GENIAL CV II

Referral

Identifying Information

TheresaOriginally: Akron, Ohio. Currently: San Fransico, CA

criteria

35 yearsWhiteHeterosexualCisgenderFemaleUnemployed BA in Business & Finance High SESLives with a roommateSingle

Case Presentation

(F10.20) Alcohol Use Disorder, severe.

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

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

Diagnostic Impression

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

Assessment

Case Formulation

Culltural Consideration

Theoretical Consideration

Oro House of Recovery - CA

Residential Treatment Center

Ethical and Legal

rule out

Psychosocial History

Treatment Plan

Assessment of Progress

Bipolar II: was ruled out due to no evidence of hypomanic or manic episodes. Borderline Personality Disorder: the client lacks the core patterns of unstable relationships, intense emotions, and SI.

(F41.9) Anxiety Disorder, unspecified

(F10.20) Alcohol Use Disorder, Severe

Continued

Dysfunction of work, social

Large amounts

Daily use

C. Irritability

B. Unable to control worry

A. Excessive Worry

Fatigue

B. loss job

Anhedonia

A. 5 sad mood

(F33.2) Major depressive disorder, recurrent severe

C. sleep disturbance

Worthlessness

What Causes Distress: Negative thought patterns. Caused by Cognitive Distortions and SchemasWhat 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).

Cognitive Behavioral Therapy

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 brandsCulturally Adaptive Intervention: Used meditation and grounding techniques, catering to her spiritual but non-religious beliefs, emphasizing Cultural Values in Goal-setting

Cultural Consideration

• 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

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

Referral Questions

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.

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.

Case Formulation

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

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

• The Minnesota Multiphasic Personality Inventory (MMPI)

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

Assessment

Proposed

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.

Ethical &Legal

• 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.

• 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.

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.

Initital

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.

Middle

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.

End

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.

Assessment of Progress & Prognosis