DESCRIPTION OF THE CLIENT
The client is a 34-year-old woman Hispanic female, dressed casually and neat, clean clothing. She made normal eye contact, she spoke in expressive voice, and appeared sad manifested by tears.
The client reports for the past two months she experiencing hopelessness, depression and anxiety because of negative core beliefs that she is inadequate, worthless and a failure. The client reports “I have a lot on my mind, I feel pressure like I cannot breathe sometimes and I get angry with myself because I want to please everyone”. This has resulted in symptoms that are diminishing the enjoyment of her life. The client’s automatic negative thoughts that she is worthless and a failure has caused the client to stop doing things that used to bring her pleasure. The client reports that all of these emotions and conflict is affecting her. The client states she is tearful, always tired; restless; unable to feel pleasure; ambivalent suicidal ideations; anxious, unable to sleep; hopelessness; loss of appetite; despair; and fear.
HISTORY OF PROBLEM
The client reports that she and her husband have relationship conflict and communication problems which lead to arguing. The client states “he pushed and slapped me, he said that he would kill me or hurt me in front of my children. I felt the abuse was escalating so I took the children and moved in with my mother”. For the past two years her husband started drinking heavily and the physical abuse is escalating. She has been living in fear that he will kill her. This negative core belief has a caused automatic negative thoughts that allowed years of mental, emotional, and physical abuse from her husband. These automatic negative thoughts have contributed to the client’s depression as a result, she has left her husband and moved in with her mother. The experience of the separation from her husband has triggered negative core beliefs that she is inadequate, worthless, and undesirable, and reinforces, or activates, her automatic negative thoughts.
Activity: The client displayed her attitude as open and somewhat guarded. Motor activity level demonstrates psychomotor regularity, frequently moving her hands to wipe tears away. Her speech is of regular rate and rhythm; eye contact is fair.
Mood and Affect: The client appeared sad with tearful affect, which was congruent with mood and appropriate to content.
Thought Process, Content, and Perception: The client denies any auditory and visual hallucinations and has coherent thought process. The client has difficulty sleeping due to constant preoccupation and rumination of thought of hurting her children by taking them away from their father or should she return to him.
Cognition, Insight, and Judgment: The client is oriented to time, place, person, and situation. The client demonstrates average intelligence, has clear cognition, and intact memory for recent and remote items. The client has slightly impaired insight and judgment.
Physiological Functioning: The client appeared to be in good health but reported she has lost some weight because she does not feel like eating. The client states “I feel pressure like I cannot breathe, am I hurting my kids because I took them away from their father”. She denied use of alcohol or illicit drugs however she drinks coffee to stay awake during the day.
Suicidal and Homicidal Assessment: The client reported having thoughts about ending her life. She voiced ruminating thoughts “I do not want to be here because I am not pleasing my children, husband, or mother”. She states, these ruminations are fleeting thoughts with no plan. Therefore, she is considered a possible danger to self. The client denied any homicidal ideation or ruminations.
The client reported that she is separated, unemployed, and has two children, a nine-year old boy and a seven-year-old girl. She has been married for ten years. She states early in her marriage they would argue and yell. The first year of marriage was fine but her husband started emotionally and physically abusing her. With the help of her close friend she left her husband and has been living with her mother for the last two months. She has not spoken to him since she left. This event has triggered negative core beliefs that she has failed as a parent for not keeping the family together. Her sister supports the decision to leave her husband and wants her to come to Washington for a fresh start. But now, the client states he continuously apologizes by sending gifts and begs for her to come back home. The client also reports that her mother suggest that she return home so the children will not suffer from not having their dad.
The client’s family of origin lives in California and consists of her mom and younger sister. Her father was a truck driver and her mother was a stay at home mom. The client reported her father past away from a heart attack over five years ago, and her mother never remarried. The client states her father was “a drunk and abusive towards my mother”. The client states her mother instilled Christian and cultural values and beliefs that family is everything. Once you get married, your husband is the head of the household and you are to obey and never get divorced so the children will have both parents. These thoughts are part of the client’s core belief from the way she was raised.
The client reported her father was would yell, call her mother names, tell her “she is worthless and without him she is nothing”. These thoughts and feelings are part of the clients’ negative core beliefs that she is inadequate and worthless because of her upbringing. The client states her “father would hit her in front of us and she would not come out of her room for days because of the bruises. We were afraid all the time especially when he would drink”. The client reports her mother would blame herself for the abuse and try harder not to make him angry and do everything her husband would tell her to do, because he was all she had. These faulty core beliefs followed the client into her marriage reinforcing her faulty cognition of what a marriage is supposed to be.
The client and her sister are very close. Her younger sister was determined to get out of the house and not end up like her mother. Once she graduated from high school she went away to college in Washington and found a job after she graduated from college and rarely returns home. The client’s younger sister is not married and has no children. The client was an average student in school. She only had a few friends with whom she shared activities and phone calls. She had no serious illnesses and lived in the same house all of her life. The client attended college for about two years and received an Associate’s Degree in Business Management. She worked as an Administrative Assistant until she got married and had her first child then became a stay at home mom. She has one close friend with whom she hangs out with.
The client has no legal concerns. However, client is currently separated from her husband.
The client was given consent forms and understands the confidentiality, HIPPA, reporting laws, etc. The client received a thorough risk assessment.
THEORETICAL PERSPECTIVE JUSTIFICATION
Cognitive Behavioral Therapy (CBT) is a counseling model that increases the client’s understanding of how thoughts and behavior are connected to emotions. The clients’ upbringing and exposure to negative childhood experiences of seeing her parents fight have created her cognitive distortions. The cognitive distortions she learned from her mother in childhood have persisted to adulthood. This faulty belief system have created negative thinking patterns that have been evident throughout her life creating hopelessness and despair. The client’s family background and exposure to negative childhood experiences have produced her cognitive distortions. The cognitive distortions she learned from her mother in childhood have persisted into adulthood.
CBT helps to address and change negative thinking patterns and behaviors associated with depression while teaching how to change the behavioral patterns that contribute to her depression. Changing the behavior can lead to an increase in thoughts and mood. CBT can help the client identify her automatic thoughts and maladaptive behaviorism so she can develop an accurate schema through which to filter her daily interactions. The client should be tested for Folstein Mini Mental Status Exam, Beck Anxiety Inventory, The Beck Depression Inventory (BDI) this scale would be helpful to measure his depression. Columbia-Suicide Severity Rating Scale is a questionnaire used to assess suicide. This measure can be used by any professional. This instrument is needed to help determine the severity of suicide in the client. To determine if he is just thinking about it because of the break up with his girlfriend or was this something he has been thinking about for a while.
Major Depressive Disorder
Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others.
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day.
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).
Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The episode is not attributable to the physiological effects of a substance or to another medical condition.
The occurrence of the major depressive episode is not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified and unspecified schizophrenia spectrum and other psychotic disorders.
There has never been a manic episode or a hypomanic episode.
With Melancholic features
Loss of pleasure in all, or most activities
Lack of reactivity to usually pleasurable stimuli
A distinct quality of distressed mood characterized by profound despondency, despair, and/or moroseness or by so-called empty mood.
Early morning awakening
Significant anorexia or weight loss
Excessive or inappropriate guilt
POSTTRAUMATIC STRESS DISODER
Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways: Directly experiencing the traumatic event(s).
Witnessing, in person, the event(s) as it occurred to others.
Presence of one (or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred:
Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s).
Intense or prolonged psychological distress at exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Marked physiological reactions to internal or external cues that symbolize or resemble an aspect of the traumatic event(s).
Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic event(s) occurred, as evidenced by one or both of the following:
Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).
Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world (e.g., “I am bad,” “No one can be trusted,” “The world is completely dangerous,” “My whole nervous system is permanently ruined”).
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others.
Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).
Markedly diminished interest or participation in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings).
Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following:
Problems with concentration.
Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).
The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
The disturbance is not attributable to the physiological effects of a substance (e.g., medication, alcohol) or another medical condition.
SPOUSE OR PARTNER VIOLENCE, PHYSICAL, CONFIRMED
T74.11XD Subsequent Encounter
The client has problems with primary support which is her mother who wants her to return to the violence for the children.
1. Complete homework assignments
2. Become more active with family, friends, or social groups
3. Join a gym or start an exercise regimen
Short-term Goal #1
The client will continue to decrease her frequency of automatic negative thoughts of wanting to end it all or die.
Interventions for Goal #1
The client will decrease her frequency of these thoughts from 20 times a day to 15 times a day by journaling to identify thoughts, feelings and behaviors before during and after stressors.
Short-term Goal #2
The client will continue to decrease her frequency of negative self-statements.
Interventions for Goal #2
The client will identify and alter irrational or negative self-statement and replace them with positive statements. The client will journal to identify thoughts, feelings, and behaviors before, during, and after stressors.
Short-term Goal #3
The client will plan and complete one pleasant or social activity per week.
Interventions for Goal #3
The client will increase the ability to find evidence to the contrary of negative emotions with higher levels of positive emotions through the use of mood monitoring.
The client will also continue to journal and use thought records to identify her stressors.
The client will be referred to physician and psychiatrist.
EVALUATION OF COUNSELING PROGRESS/PLAN
The counselor will use a cognitive behavioral approach. The sessions will be once a week for five weeks, then once every two weeks if appropriate, until symptoms have improved. At that time, the counselor and client will determine a plan for the future course of sessions.
The client is a 34-year-old Hispanic woman in a marriage that has experienced depressive symptoms, anxiety, ruminating thoughts, and catastrophizing with ambivalent suicide ideations. The goal is to help identify her automatic negative thoughts and negative core beliefs with the process of cognitive restructuring. Cognitive restructuring helps replacing these unhealthy thinking patterns with positive self-statements. The client will be given homework of journaling and completing a thought record to aid her in identifying her stressors and prompting her positive self-talk. The client will continue to actively participate in approximately 20 cognitive behavioral therapy sessions one hour a week to ensure progress with anxiety, mood, and depression.
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