Case conceptualization and counseling process documentation format

 

Counselor Name: Pooza Shrestha

 

Client’s name: Rita (Name changed)

 

Client’s socio demographic information:

 

Age:   23

Gender: Female

Marital status: Single mother

Education: Primary level of education

Profession: Singer

Family:

Any significant mental illness in family: None

Clinician’s questions or concerns regarding this case:

Presenting issues/symptoms/clinical picture

Presenting problem(s)/ symptoms (include duration):

 

Ms. Rita had come with some personal problem. While assessing the problem, it was identified that she had been going through hypertension since a year and was under medication. As per the client, her health condition was not improved by the medicines so she left taking them. It was also identified that she had once attempted to commit suicide due to her personal matter during the course of her hypertension. At counseling room, her blood pressure was monitored in all three positions (supine, standing and sitting), but her blood pressure in all three positions was found to be extremely high. Therefore, she was referred to Bir Hospital for emergency health support. She was given some medicines there. Later, her sister took her to Shahid Gangalal National Heart Center. As per the informant (client’s sister), the cardiologist of the respective hospital has suggested to take the client to a Psychiatrist (Patan Hospital) for consultation. The cardiologist has suspected that the client might be going through some mental health issue associated with her hypertension.

Symptoms: Sad, hesitant, dysthymic, tremors.

Findings based on the checklist of client selection criteria

• Poor economic condition
• Single mother
• Works at entertainment sector

 

 

 

Dissociative symptoms:

• Detachment

 

Other assessment data:

• Legal issues

Current stability (note any impulse control problems with alcohol, drugs, violence, sexual acting out, self-injurious behaviors, etc.):

• self-injurious

 

Client’s additional socio demographic information:

Current family support:

Her elder sister is the one in her family who supports her. She had taken the client to hospital for consultation.

 

Social support available:

None

 

History taking and treatment plan:

History:  Three pronged approach including past and present life issues, traumatic events, childhood attachment status, significant health history (lifetime)

She was traumatized when her husband whom she loved so much betrayed her.

 

Current concerns/symptoms:

(Current symptoms are caused by earlier experiences that were not adequately processed due to trauma or insufficient information)

Dominant Symptom:

Sad, crying, blaming oneself (even for being dumped by her husband), suppressive

Dominant irrational belief

The client has an irrational belief that;

• My past is the most important part of my life and it will keep on reminding me what I am now and how I was before.
• A girl of poor family background can never have a good and sustained life.

 

Positive Cognition

• The client was aware of her current responsibility (especially towards her children)

Past incidents (Negative): touchstones memory or other experiential contributors

First: Poverty, lack of education

Worst: Gender discrimination

Other past events:_______________________________________________________________

Present triggers: The client got ready for marriage without her interest. However, after getting married she loved her husband more than anything. But he betrayed her. So this event triggers her at present leading to health problems.

Future challenges and desired outcomes:

• Economic challenge
• Health problem Future challenges
• Unsafe workplace

 

• Getting citizenship and birth certificates of her children
• Healthy life Desired outcomes

 

 

Treatment planning: (incident chosen for reprocessing that is contributing to the present problems)

• Treatment for hypertension
• Psychiatric treatment
• Psychotherapy

 

Past Incidents (Positive)___________________________________________________________

 

Strengths and resources: She realizes that she has to survive.

 

Resources including ego strengths, coping skills, positive experiences, self-capacities:

Not obvious

 

Past treatment episodes and diagnoses:

She was diagnosed of hypertension and was under medication.

 

 

Preparation notes:

Client education for response:

 

 

 

 

The expected feedback for this case:

The client needs psychiatric support. Hope to get information regarding this.