Case conceptualization

 

write a case conceptualization that integrates their chosen theoretical orientation(s) and techniques into a cohesive treatment plan.

 

Case Vignette #1
Theories and Methods of Counseling – Spring 2015
Case Vignette #1
Jane Doe is a 41-year-old Caucasian female who called your office to schedule a counseling
appointment. In her voicemail, she stated that she has been feeling very sad and overwhelmed lately,
especially since she lost custody of her two children (ages 3 and 5) by CPS. After your office manager
schedules her for an initial visit, you meet with her in the first session and gather the following
information:
Jane reports that she has been “court ordered” to participate in counseling because “of my
mental issues.” She stated that she has always felt very sad and is easily overwhelmed by stress. When
asked about her primary reason for seeking therapy, she noted that she has been experiencing a very
low mood, having trouble concentrating, feeling very anxious, having difficulty initiating and staying
asleep at night, and occasionally has suicidal thoughts. She also reported that she feels “panicky” on
occasion and during which times she often has difficulty breathing, feels “shaky,” and feels “like my
heart is stopping up my throat and I can’t breathe.” She stated that she copes with her panic attacks by
smoking marijuana but that she often feels very ashamed afterwards, which makes her feel more sad.
You also gather the following information about her background from a background questionnaire:
Developmental/Social History: Jane was born and raised in west Texas in a small rural farm town. She
was born 2 weeks early and weighed 6lbs at birth. Her mother smoked while she was pregnant with
Jane, but she was reportedly born without any complications. All milestones were reportedly met on
time. Early behavioral history is remarkable for being very shy and having difficulty making friends in day
care. No major childhood illnesses or injuries are reported. Jane has two older siblings, and her parents
divorced when she was 8 years old. She lived with her mother during her childhood but noted that her
mother frequently abused prescription medication and alcohol. Jane’s mother’s boyfriends would often
lock Jane in a room at night. She noted that she was the victim of sexual abuse by her mother’s
boyfriends from age 8-16. Jane left home at the age of 16 and moved into an apartment with “an older
man.” She subsequently “got into drugs and alcohol” and was incarcerated a few times during her early
20’s for possession of drugs. Jane got married at the age of 35 and later had two children in her early
40’s. One of her children has autism. Most recently, she lost custody of her children to CPS because she
was found to be “neglectful” due to leaving her children alone at home for “five or six hours.” Jane
denies that this is true, but noted that she needs to “learn how to be a good momma.”
Medical History: Jane reported that she is diagnosed with high blood pressure, diabetes, obesity, and
endometriosis. Her current medications include blood pressure and diabetes medication. She has
Medicaid as her primary insurance. All other medical history is unremarkable. Substance abuse history is
reportedly notable for use of meth from age 18-35 and marijuana from 35-present.
Psychiatric History: Jane reported that she has been hospitalized as an inpatient on one previous
occasion for “bipolar disorder with psychotic features.” She stated that she was intoxicated with meth
during this hospitalization. Jane has been in counseling in the past for substance abuse. She denied any
previous suicide attempts. When she was hospitalized, she was prescribed an antipsychotic medication
and “Valium.” She has not seen a psychiatrist since her late 30’s.
Academic History: Jane dropped out of high school in the 10th grade. She later earned her GED. She
denied any history of learning disorders or special education services. She noted that she would like to
attend college someday to get “a real job.”
Case Vignette #1
Theories and Methods of Counseling – Spring 2015
Vocational History: Jane reported that she has been on Social Security Disability for “bipolar” since she
was 35. Prior to that, she reportedly worked off and on at gas stations as a cashier. She stated that she
“always had difficulty getting along with her co-workers and supervisors” and that she would frequently
“go off on them” when she was angered.
Family Medical/Psych History: Reportedly positive for depression, anxiety, bipolar, schizophrenia,
ADHD, OCD, learning disabilities, dementia, stroke, and substance abuse.
Legal History: Jane reported that she has been arrested four times since her early 20’s for drug
possession. She stated that she is currently on probation.

 

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