Full Clinical Interview

Presenting Problem

AP, 19 years of age, comes to the reception room of Kenya Methodist University, the first contact having been the peer counsellors training. She presents her case and together we explore issues critical to her situation. We also explored her family background and the issues that brought her for counselling.

Vegetative Functions

AP eats well but has serious problems sleeping. She said that she used to suffer from stomach ulcers but the effect has been reducing especially after she joined university.

History of the presenting problem

AP has gone through a very traumatic background. Her parents had constant conflicts and abusive to each other. This made her to fear staying away from home and she has instead opted to go to schools nearby/neighbourhood.

Treatment so far

AP has never sought any help and this is the first time she is seeking help.

Medical History

AP has had a normal life but she used to suffer stomach ulcers up to the time she was in high school.

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• Family Relationship pattern
• Subsistence farmer

Subsistence farmer

AP claims to have had a secure childhood. She enjoys cordial relationship with her grandparents, parents and siblings. She has had a normal schooling, and posted relatively high marks (320 Marks in KCPE and a B in KCSE).

Family medical psychiatric history

No known condition.

Developmental history

Pregnancy, birth and milestone were all well negotiated as far as she knows. AP was a wanted baby and the mother had no problem during pregnancy. The delivery was normal and the baby cried immediately after birth.

All milestones were effectively negotiated.

Additional information

AP is a young woman of normal build. Reserved, shy but very articulate. Regards me with a level gaze; we make good contact with each other. She tells me she is a Christian and that she wants to live for Christ and lives a happy marriage life. She has since childhood been a member of the choir in her church and engaged in work in the church. Feels she has normal contact with her kinsfolk, studies, is unmarried, and lives with both her parents and siblings. Her university life has been okay and she has posted good grades.

MENTAL STATE EXAMINATION (MSE)

• Appearance: She is well groomed and clean. Appropriate posture. She is alert and responds to instructions and communication appropriately and articulately. Her body size is appropriate for her age.
• Behaviour: Normal motor activity. She is well-oriented to time and place. She however does not maintain eye contact and she does not have normal facial expressions.
• Mood and affect: She is cooperative, open but a bit shy and openly shares her story.
• Thought processes and content: Normal. She is aware of time, place and people. She has no problem of speech or thought processes. She has no overvalued or illogical thoughts.
• Perception: AP's five senses are well functioning. She does not report any difficulty with any of her senses.
• Attention and concentration: Both her attention and concentration are consistence. At times she is engaged in deep thoughts and reflections during the session.

Cognitive functions:

Memory: She has good memory. She recalled with precision her life history and the experiences she had. She did not have any problem recalling any historical information in relation to her family, education, social life and spiritual life.

Judgement: She has good ability to exercise judgement and good decision making. She is fully aware of her situation and the effects it has on her normal functioning and productivity.

Intelligence and information: AP is well informed and has high intelligence. She can understand and interpret concepts and engage in logical and coherent dialogue.

Insight: Understanding of the problem

AP understands that her condition bothers her and that it has potential to ultimately affect her happiness and contentment in marriage and in future.

Case formulation (Summary of principal findings)

AP claims to have had a secure childhood. She had grown up in a well nit family where they enjoyed cordial family relations. She had normal schooling and posted relatively high marks. She had good and healthy relations with opposite sex.

Prognosis:

AP's prognosis is good if she continues with the therapy, so as to work out her fear and make an informed decision. If she has to continue with her studies normally and deal with the relationship concerns that she has as well as her faith and spirituality. It will important for AP learn critical decision making skills and strategies and to be helped to deal with her childhood experiences and the family expectations.

Primary diagnosis:

Intellectually mobile girl with relatively well-developed ego-potency, emotionally stable with marked latent anxiety. At the same time she understands that these symptoms may "conceal" other, more deep-seated conflicts. She is therefore motivated for the insight therapy that we agreed upon suggest.

On the strength of the theory that anxiety is absorbed and retained by the symptom (primary gain) and that therefore a resistance has been mobilized (Against) insight in the source of the anxiety.

Case conceptualization

Given the diagnosis of the fear she has for the future based on her family history, we will apply the following theoretical strategies.

Eclectic approach with an emphasis on

• i. Family systems theory/therapy.
• ii. Cognitive Behavioural Therapy.