GENIAL CV II

Assessment of Progress

Treatment Plan

Psychosocial History

rule out

Ethical and Legal

Residential Treatment Center

Oro House of Recovery - CA

Theoretical Consideration

Culltural Consideration

Case Formulation

Assessment

Aya Almukhtar, MA, Clin. Psych. & Ed. Psych.Department of Clinical PsychologyThe Chicago School Spring 2024

Diagnostic Impression

(F33.2) Major depressive disorder, recurrent severe without psychotic features

(F41.9) Anxiety disorder, unspecified (300.00)

(F10.20) Alcohol Use Disorder, severe.

Case Presentation

35 yearsWhite Heterosexual CisgenderFemale Unemployed BA in Business & Finance High SES Lives with a roommate Single

criteria

Theresa Originally: Akron, Ohio. Currently: San Fransico, CA

Identifying Information

Referral

Worthlessness

C. sleep disturbance

(F33.2) Major depressive disorder, recurrent severe

A. 5 sad mood

Anhedonia

B. loss job

Fatigue

A. Excessive Worry

B. Unable to control worry

C. Irritability

Daily use

Large amounts

Dysfunction of work, social

Continued

(F10.20) Alcohol Use Disorder, Severe

(F41.9) Anxiety Disorder, unspecified

Cognitive Behavioral Therapy

What Causes Distress: Negative thought patterns. Caused by Cognitive Distortions and Schemas What Facilitates recovery: Cognitive restructuring, reframing, and behavioral activation. What is The Therapist's role: Collaborative, helps guide and support change. CBT helps individuals recognize and restructure maladaptive cognitive distortions, core beliefs, and automatic thoughts, which can lead to emotional and behavioral difficulties (Beck, 1976).

End

Focus on maintaining the progress made, enhancing resilience, and preventing relapse. This involved aftercare planning (AA, PHP, Sponsor) for dealing with potential stressors or triggers that may threaten her sobriety and mental well-being.

Middle

Implement cognitive restructuring, and Socratic questioning to change negative thought patterns. Coping skills: deep breathing, meditation, and journaling. Assign HW and conjoint session with family.

Initital

Establish a therapeutic alliance, assess the client's alcohol use, anxiety, and depression, and psychoeducation. Help Ct understand and identify cognitive distortions related to her failed relationships, job loss, and DUI and how those impact her symptoms. teach Coping skills.

Assessment of Progress & Prognosis

Given the client's commitment to full treatment, including PHP and IOP, desire to cease drinking, strong family support, and financial stability, the prognosis is cautiously optimistic. Although the ongoing DUI court case and single status may trigger anxiety and depression, these supportive factors significantly enhance her likelihood of successful recovery.

• Psychiatric History: Depression and anxiety in early 2023. Father had depression.
• Substance Abuse: the client initially reported socially and occasionally drinking in 2022, which escalated due to her dating life and failed relationships. The situation worsened after losing her job in May 2023, culminating in a DUI in November 2023. Consumption of 6 drinks a day in the past year.

• History of Presenting Problems: Early 2023: Symptoms began after failed relationships. May 2023: Worsened after job loss. Post-DUI: Further escalated following DUI incident.
• Social and Family: her mother's past alcoholism and profession as a therapist, a great relationship, her parent's divorce at age 7, emotional abuse from her father who is deceased, past alcoholic and coke addict, and a pattern of emotionally abusive partners, DV between parents in the past, despite maintaining friendships. Lives with a roommate. Single, no kids, and she is the oldest sister.
• Education & Occupation: BA in business and finance and served as Director of Revenue Operations at a tech company.
• Medical History: Chlamydia and HPV positive in college. Treated.
• Medication: Zoloft 100 mg for depression, Trazodone 50mg for sleep, and Gabapentin 300 mg for anxiety during residential treatment x1 daily.

Cultural Consideration

Intersectionality: a 35-year-old, millennial, heterosexual, able-bodied woman from Ohio, she faces challenges adapting to the dating culture in San Francisco, which contrasts with her expectations of stability and commitment, Moving Beyond Categorical Assumptions: same age, Misjudged as seeking casual relationships; she was pursuing serious connections, showing the need to reassess initial impressions. Issues of Power, Privilege, and Oppression: High SES with inherited wealth, allowing for significant treatment access and lifestyle maintenance, emphasizing socioeconomic influence on her opportunities. Afford good attorney, she didn't work for months. wearing brands Culturally Adaptive Intervention: Used meditation and grounding techniques, catering to her spiritual but non-religious beliefs, emphasizing Cultural Values in Goal-setting

Referral Questions

The client was self-referred and encouraged by her mother and sister.

• Seek treatment for alcohol use disorder, 6 drinks daily in the past year. "I am a mess, can't stop drinking."
• Manage anxiety and depression-related symptoms almost every day in the past year. (hopelessness, worthlessness, sad mood, weight gain, difficulty sleeping, concentrating, restlessness, excessive worry)
• Following a DUI in November 2023

Theresa

• Schemas: Defectiveness shame, mistrust, pessimism
• Automatic Thoughts: "I can trust men," "I am a mess."

• Core beliefs: "I am not good enough," "It is my fault," "I am a failure"
• Cognitive Distortions: Overgeneralizing, catastrophizing, personalization, minimization

Case Formulation

The client's alcohol use, anxiety, and depression, which became noticeable in early 2023, are largely driven by failed relationships, and these issues intensified following job loss and a DUI incident. Her coping strategies, including alcohol use, likely maintain and exacerbate her depressive and anxious symptoms, creating a cycle that necessitates therapeutic intervention.

Predisposition: The client has a predisposition to addiction, influenced by both of her parents. Early experiences of DV between parents. Precipitants: Her mental health symptoms and alcoholism were triggered by failed relationships, engagement in hookup culture and partying, job loss in May, and a subsequent DUI in November. Perpetuants: She perpetuates her mental symptoms through frequenting social gatherings, parties, and dates where alcohol is prevalent, and drinking daily to alleviate negative feelings. quitting job.

Proposed

Assessment

• Psychosocial Intake & Psych eval.
• PHQ 9
• GAD 7
• Brief Addiction Monitor (BAM)
• The Columbia Suicide Severity Rating Scale (C-SSRS)

• Bipolar Spectrum Diagnostic Scale (BSDS), OR Mood Disorder Questionnaire (MDQ)
• Borderline Symptom List (BSL-23):

• The Minnesota Multiphasic Personality Inventory (MMPI)

Ethical &Legal

Legal Considerations: Risk of DUI and self-harm requires monitoring and possible legal intervention to prevent harm (The Tarasoff California Civil Code 43.92., Ethical Standard 4.05, "Disclosures) Ethical Considerations: Duty to Protect (Ethical Standard 4.05): If the client is at risk of driving under the influence, the therapist may need to break confidentiality to prevent harm. Confidentiality (Ethical Standard 4.01): Must be upheld during family sessions unless consent is given to share specific information. Competence (Ethical Standard 2.01): Therapist must be competent in family therapy to effectively manage sessions. Informed Consent (Ethical Standard 3.10): Necessary for discussing client's issues with family members, outlining the scope and limits of what will be shared.