PART ONE: INTAKE INFORMATION
IDENTIFYING INFORMATION AT INTAKE:
Name: -
Age: 49
Gender Identity and Sexual Orientation: female, heterosexual
Employment Status: - employed as the secretariat at a university.
Socioeconomic Status: -
CHIEF COMPLAINT, MAJOR SYMPTOMS, MENTAL STATUS, AND
DIAGNOSIS:
Chief Complaint: she has a complain of concomitant disorders. She is referred to psychologist
for low mood, lack of energy and sleep problems
Major Symptoms
Emotional: depressed, low mood, sadness, negative emotions
Cognitive: hopelessness, organizational difficulties, difficulties with planning, postponing until
last moment.
Behavioral: avoiding unpleasant and difficult activities, engaging in substitute activities,
difficulties in regulation of emotion and avoidance behavior
Physiological: low immune system, intense symptoms of concomitant diseases.
Mental Status: Diagnosis (from the Diagnostic and Statistical Manual or International
Classification of Disease): The client is diagnosed with depressive disorders by a psychiatrist.
She was referred to psychologist for low mood, lack of energy and sleep problems.
CURRENT PSYCHIATRIC MEDICATIONS, ADHERENCE AND SIDE EFFECTS;
CONCURRENT TREATMENT: Client is currently not taking any medications.
CURRENT SIGNIFICANT RELATIONSHIPS: Client is currently not in a relationship.
PART TWO: HISTORICAL INFORMATION
BEST LIFETIME FUNCTIONING (INCLUDING STRENGTHS, ASSETS AND
RESOURCES):
HISTORY OF PRESENT ILLNESS: The client is suffering from depressive disorder and from
childhood she has been treated for anxiety- depressive disorders.
At the age of 3, the patients remembers that she was fastened by belt and between 3 to 6, the
patient was sexually harassed by her uncle. She started to feel that she was less important
when her mother adopted her sister. The patient made 2 suicidal attempt at 16 and 1 at 17. Due
to the suicidal thoughts l, the patient wad psychiatrically treated and received a course of
psychotherapy as well.
The recent stressful in her life was her mother's and grandmother's death. The patient's
relationship with her mother was not good but before her death, they reconciled
HISTORY OF PSYCHIATRIC, PSYCHOLOGICAL OR SUBSTANCE USE
PROBLEMS AND IMPACT ON FUNCTIONING: The client has taken drugs and alcohol when
she was 17, tried to attempt suicide with it.
HISTORY OF PSYCHIATRIC, PSYCHOLOGICAL OR SUBSTANCE ABUSE
TREATMENT, TYPE, LEVEL OF CARE AND RESPONSE: The client reported that she was
psychiatrically treated for suicidal attempts in hospital, she has received pharmacological
treatment and also psychotherapy.
PERSONAL, SOCIAL, EDUCATIONAL AND VOCATIONAL HISTORY: The client is currently
employed at university as secretariat. when she was 13, she felt diminished and less important
than her adopted sister.
MEDICAL HISTORY AND LIMITATIONS: The client is having concomitant disorders such as
ulcerative colitis, cataract, osteopenia, tachycardia, inflammatory infections, etc and she
received treatment for all of these. She was given steroids, vitamin D, mesalazine and
omeprazole.
CURRENT NON-PSYCHIATRIC MEDICATIONS, TREATMENT, ADHERENCE
AND SIDE EFFECTS :- . She was given steroids, vitamin D, mesalazine and omeprazole.
RELEVANT CHILDHOOD DATA :-
Client did not have a good relationship with her mother. At the of 3, she remembers that she
was fastened by belt. between age 3 to 6, she was sexually harassed by her uncle. She felt less
Important at the 13 because of her adopted sister. She has attempted suicide for 3 times and
had received psychiatric treatment for several times at hospital. From childhood she has been
treated for anxiety depressive disorders.
CORE BELIEFS :-
I am helpless.
nothing has any sense.
I am insufficient.
I am worthless.
CONDITIONAL ASSUMPTIONS/ATTITUDES/RULES
I do not fulfill my parents.
I let others down.
Even if I try hard, nothing will change.
When I suffer nobody can help me, so I would be better off dead.
Situation#1
When she was 13, her aunt died and her mother adopted the aunt's daughter.
Automatic Thoughts
I am not important.
Meaning of A.T
No one loves me
Emotions
sadness
Behaviour
Not having good relation with her mother.
Situation#2
When she felt less important than her sister, she attempted suicide for 3 times.
Automatic thoughts
I’m not necessary
Meaning of A.T
I should better die a no cares about me.
Emotions:-
worthless, sad
Behavior:-
Crying, suicide attempts.
Situation #3
When her mother died.
Automatic thoughts
I am alone
Meaning of A.T
I was not able to fulfill my parents dream
Emotions
Sadness, grief
Behaviour
Difficulties in regulating emotions and avoidance.
PART FOUR: THE CASE CONCEPTUALIZATION SUMMARY
HISTORY OF CURRENT ILLNESS, PRECIPITANTS AND LIFE STRESSORS: Client did not
have a good relationship with her mother. At the of 3, she remembers that she was fastened by
belt. between age 3 to 6, she was sexually harassed by her uncle. She felt less Important at the
13 because of her adopted sister. She has attempted suicide for 3 times and had received
psychiatric treatment for several times at hospital. From childhood she has been treated for
anxiety depressive disorders
MAINTAINING FACTORS:
Maintaining factors include the feeling of less Important than her sister when she was a kid, she
was sexually harassed and there was a strong feeling of guilt of not being able to satisfy her
parents ambition.
VALUES AND ASPIRATIONS: The client feel like that she was not sufficiently good and there
was a sense of not satisfying her father's ambitions.
NARRATIVE SUMMARY, INCORPORATING HISTORICAL INFORMATION,
PRECIPITANTS, MAINTAINING FACTORS AND COGNITIVE
CONCEPTUALIZATION DIAGRAM INFORMATION: : Client did not have a good relationship
with her mother. At the of 3, she remembers that she was fastened by belt. between age 3 to 6,
she was sexually harassed by her uncle. She felt less Important at the 13 because of her
adopted sister. She has attempted suicide for 3 times and had received psychiatric treatment for
several times at hospital. From childhood she has been treated for anxiety depressive disorders.
Maintaining factors include the feeling of less Important than her sister when she was a kid, she
was sexually harassed and there was a strong feeling of guilt of not being able to satisfy her
parents ambition. The client become avoidant towards her emotions. she was facing difficulties
in planning and was being procrastinator. The avoidance in her life brought anxiety issues.
PART FIVE: TREATMENT PLAN
OVERALL TREATMENT PLAN: The treatment plan is designed in a way so that it helps the
client to be assertive, not avoiding the important task in her life. The plan should be able to help
the client in resolving the sleeping issues and guilt. The plan will also involve working on
organizing the life, confronting emotions and difficult life situations.
PROBLEM LIST/CLIENT’S GOALS AND EVIDENCE-BASED
INTERVENTIONS:
During the initial sessions of the therapy, The client's conceptualization was taken and the
therapy was planned according to the goal.
Behavioral techniques were used of using action plan and evaluation of the plan. The technique
was able to help patient in not postponing the activities. The client was trained for dealing with
the matters in the current life. overall this technique helped I n improving the self esteem of the
client.
Psycho education was used in order to give the client for understanding the depressive
disorder. As she felt the abandonment by her parents, the technique of daily action plan was
used so that her life can be more planned and better. The client was able to meet her
acquaintances more often.
During the therapy, paradoxical technique was used of immersing I n negative thoughts. This
helps the client to think negative for 20 minutes instead of the whole day. The goal is to avoid
the negative thinking for whole day.
The client was expected to read the self help books on assertiveness and the patient's beliefs
was analyzed .
Traumatic experiences of sexual harassment in childhood were worked out with the client
using the exposure therapy by talking about the traumatic experiences of life. The goal was non
avoidance, weaving the traumatic experience into the patient's own system of cognitive
representation
PART SIX: COURSE OF TREATMENT AND OUTCOME
THERAPEUTIC RELATIONSHIP:
The treatment plan was focused on reducing the client's depressive symptoms and anxiety. By
the end of the sessions her anxiety was reduced and she started thinking positively. The client
was able to communicate about her problems. The client's thinking pattern became more
adaptive.
NUMBER AND FREQUENCY OF TREATMENT SESSIONS, LENGTH OF
TREATMENT: 12 sessions of CBT were given
MEASURES OF PROGRESS:
The client was showing improvement in her thinking patterns, assertiveness and was able to
communicating her thoughts in a better manner. The client was able to solve the problem on
her own.
OUTCOME OF TREATMENT:
The client learned to control her own thoughts ,express her personal opinions and communicate
with others. She worked on solving her problems as they arise. the treatment plan helped her in
Improving her self esteem. The traumatic experience of sexual harassment was reduced by the
exposure therapy. At the end of therapy the client's mood was balanced.
