Shawnette_Reid_u10a1_Case_Conseptualization

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Nov 24, 2024

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Case Conceptualization of J.W (pseudonym) Shawnette Reid COUN6302: MHC Clinical Practicum Professor Crystal Neal June 16, 2023
Demographic Description Age: 15 years Gender: Female Race: White She had a diagnosis of ADHD, PTSD and personality disorder Has received services from mental health skill building, therapeutic in school counseling and case management service
Presenting Problem Presentin g problem( s) : • Presents depression like symptoms with • No interest to teenager things • Traumatized after watching her grandfather get killed • Difficulty sleeping • Low grades • She is calm when alone and isolated • She becomes dramatic when in company of others
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History Relevant to Treatment Predisposing factors : • No significant or noticeable history of psychological disorders in the family. Precipitating factors : • J.W witnessed her grandfather get killed in his home Perpetuating factors : • Poor adherence to medication. She could spit them out when not monitored Protective factors : • Supportive Parents and Teachers
Previous Mental Health Treatment • Mental health skill building, therapeutic in school counseling and case management services. • Medication for ADHD
Family Background J.W has a supportive mother and other family members who are not highlighted in her case The family structure is strong and mindful of her condition Work/Education History • J.W is a student • She has no work history
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Medical History J.W has been on a medication for ADHD The specific medicine is not mentioned in the case presentation
Diagnosis Primary Diagnosis: (F43.10) Posttraumatic Stress Disorder (APA, 2013). J.W meets the criteria for PTSD after witnessing her grandfather killed, recurrent nightmare, avoiding sleeping at night, diminished interest in significant activities, inability to remember the aspects of her grandfather’s death, feelings of detachment from others, sleep disturbance and hypervigilance for more than one month as stipulated in the DSM-V (APA, 2013).
Diagnosis continued… Using the Decision Tree for Behavioral Problems in a Child or Adolescent, J.W does not meet the criteria for Attention- Deficit / Hyperactivity Disorder (ADHD)because she does not show impulsive behaviors or have trouble paying attention (Schillaci et al., 2009). Additionally, she doesn’t present the symptoms for personality disorder such as need for instant gratification and difficulty with relationships (Schillaci et al., 2009).
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Description of Client Functioning J.W prefers isolated lifestyle She is very calm when alone and becomes dramatic when in company of others. She is also emotionally disturbed J.W is physically fit. She prefers sleeping during the day
Client-Therapist Match • J.W is responsive to the therapeutic measures. • She likes artwork and dancing that can be integrated as part of play therapy • Therapist is culturally sensitive and appreciates the dynamics of adolescents.
Conceptualization of Client’s Difficulties and Strengths Main therapeutic goal is for J.W to adopt coping skills she will utilize when triggered Therapy also aims to build her strengths to support her education that will also enlighten her to adhere to her medication. As a white adolescent girl, mentoring her to take her medicine through mindfulness is imperative
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Conceptualization of Client’s Difficulties and Strengths continued… The counselor incorporated the Cognitive Behavioral Therapy (CBT) According to Danzi and La Greca (2021), CBT is an effective evidence-based therapeutic treatment for PTSD. The counselor used Trauma Focused cognitive behavioral therapy (TF-CBT) to help J.W overcome her trauma and embark on her nomal life. The counselor applied journaling, cognitive restructuring and mindful breathing exercises.
Client’s Progress to Date J.W has a consistent progress because she adheres to her medication She has attended three sessions and responds well to the various techniques incorporated to support her She is able to cope with nightmares while reducing her fear for regular night sleep.
Client’s Progress to Date continued… J.W used two types of SSRIs including Venlafaxine (Effexor) and Fluoxetine (Prozac) because of their effectiveness. The therapy applied created a mutual relationship based on further research for better future experiences. The counselor upheld professionalism and cultural sensitivity
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Self-Awareness Processing Being able to focus on yourself is significant in psychotherapeutic involvements The counselor learned to be mindful of personal engagements that promote physical and mental health status. The counselor also learned about emotional triggers better deal with negative emotions like anger or hate
Unanswered Questions Can self awareness speed up the recovery of a client? Does it make them embrace medication or reject the remedies provided for their problems?
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author. Danzi, B. A., & La Greca, A. M. (2021). Treating children and adolescents with posttraumatic stress disorder: Moderators of treatment response. Journal of Clinical Child & Adolescent Psychology, 50(4), 510-516. Kress, V. E., Paylo, M. J., & Stargell, N. (2019). Counseling children and adolescents. Pearson Education. Schillaci, J., Yanasak, E., Adams, J. H., Dunn, N. J., Rehm, L. P., & Hamilton, J. D. (2009). Guidelines for differential diagnoses in a population with posttraumatic stress disorder. Professional Psychology: Research and Practice, 40(1), 39.
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