Identifying Information
Joan is a 49-year-old married woman of Caucasian origin. She was referred to the current facility by her Medical doctor for a further evaluation concerning her issues with somatic symptoms. Upon consultation, Joan had other underlying health-related experiences. For instance, she narrates experiencing “anxiety attacks” in the week after a complete full month; she recounts having increased heart palpitations and other chest-related pains (Sperry & Sperry, 2012). Furthermore, she complained of several issues about her presenting health concerns. First, though she states that she is very fine, she recounts how her job as a manager is challenging. Second, at her place of residence, she is the leading parent in almost every chore and financial obligation. Lastly, her two daughters have increasingly complained about her inability to emotionally attend to them now that they are teenagers.
Behavioral Observations and Mental Status Exam
Joan appears okay with her behavior concerning her drinking about 5-7 cups of coffee and eating a full dark chocolate every other day. Being that she is suffering from insomnia perpetuated by her history of overworking both at her job and at home, an evaluation of her sleep patterns shows poor sleep hygiene, thus making her personality style during evaluation appear to be obsessive compulsory style (Sperry & Sperry, 2012). Moreover, their appearance is related to her mental status as conscientiousness and the feeling of avoidance depicted by both her employees and her two daughters.
In this case, her mood appears dysphoric for her growing anxiety and emotional distancing. Though she blames herself for all the criticism, she does not have any suicidal and homicidal ideation indicated based on the observable data. As such, she is corporative and indicates an aptitude for any treatment for her situation. The data presented is therefore adequate for a clinical therapeutic plan.
History of Presenting Problem
The presenting problems seem to have originated from past clinical events. According to Joan, her whole life from childhood has been accompanied by her overambitious to achieve in every task, her conscientious nature, never-making mistakes behavior, and her avoidance to indicate the presence of a mistake in her endeavors imposed by her controlling and critical father (Sperry & Sperry, 2012). Moreover, she has applied the use of crossword puzzles, reading books, and playing solitaire during her childhood to cope with her anxiety issues.
Past Treatment History
Joan describes using a psychotherapy medication that includes such diversion techniques as crossword puzzles, solving solitaire games, and reading as a solution to her anxiety. She also narratives using such therapeutic-related solutions as controlled breathing rates and ignoring certain critical statements from others to ensure her anxiety does not overweigh her emotions. She was not in any other past medication prescriptions. In addition, no family medical history related to her mental health condition.
Relevant Medical History
A chemical imbalance of the brain is associated with the brain containing either less or more of the neurotransmitter chemicals. In essence, the brain does not have a clear communication pathway because of the loss of nerve cells responsible for creating a connection between information and the synthesis of the information. Relevant to this assessment, such medical conditions as anxiety, personality dynamics operative, and the chemical imbalance of the brain are critical for further therapeutic assessment (Sperry & Sperry, 2012). The practitioner attending to her has a non-disclosed contact but is a psychotherapist, based on the interviewing questions imposed on Joan.
Developmental History
Cognitive development includes alterations in thought processes through childhood. This cognitive behavior change was induced in her by her father, who was much controlling and demanding (Sperry & Sperry, 2012). In this case, she developed high problem-solving abilities with minimal chances of making a mistake in her tasks. As an adolescent and lacking the parent figure indicated by her distant mother and over-controlling father, her social skills were greatly affected.
Social and Family History
Her social learning skills were also interfered with as she was growing up. In this case, Joan does not have the skills to relate with others because of the negative social skills induced on her by her father, which involve her independently performing tasks. Because of her ability to manage time and meet set deadlines, her language and academic development were hypothetically great, thus giving her a manager role in her current company. She has no military background or any related legal issues concerning her employment. However, she has a dysfunctional and toxic relationship with her family members.
For instance, she has a distant mother and a controlling father. Moreover, her two daughters feel that their mother does not support them emotionally. She has no verifiable romantic relationship with her husband, as exacerbated by her frequent travels by her husband. Spiritually, she does not believe in miracles, hence giving it a rating of 3 when asked about chances of getting better through miracles. Joan does not show any cases of alcohol use, but due to the overuse of coffee and dark chocolate, her situation can be described as a substance abuse disorder.
Joan does not show any aggression or violence to both her family and employees but indicates a calm mixed demeanor.
Current Functioning
Joan can attend to both her family and employee tasks. In essence, her condition has not reduced her work productivity. For instance, she can address her boss’s demand to increase production and, at the same time, addresses both her home’s financial and household chores. As such, her self-care capacity to attend to personal amenities is highly rated, a strength needed for mental care intervention. However, she admits to not being able to delegate all the tasks to her employees, a vice that can lead to more stress if the boss’s demands are to be based upon. Moreover, that incapacity has made her not be in a position to support her employees emotionally.
Formal Assessment Data (if any)
Joan reports a poor rating of 3 out of 10 with regards to believing in a miracle to happen to her so that she can get well and free from the life stressors she is undergoing. Her rating is based on the fact that she does not feel any anxiety during weekends and believes it is not all about miracles for her. Interestingly, she notes that she can give it a rating of 6, just because during work, she can calm down and not think of any job and family stressors.
Diagnostic Impression
One of the major underlying diagnoses in this case of Joan is Obsessive Compulsory Disorder (OCD). It is a mental disease that causes recurrent undesirable thoughts or perceptions (obsessions) or the impulse to do something over and over again (coercions). In the case of Joan, her need for being a perfectionist, conscientiousness, and criticalness is a sign of OCD. As a diagnostic code, it might also have resulted in anxiety, especially when one is obsessive with a task but end up not accomplishing them. In such situations, stress and anxiety develop. Also, with several tasks to do, most patients with OCD do not have time to sleep, resulting in insomnia.
Case Formulation
In psychoanalysis, Adlerian theory can be used to understand a client’s case formulation and assessment. According to Adlerian, one can understand the root of a client’s behaviors, how they can alter their perception of themselves, and how they can modify their opinion of their childhoods (Sperry & Sperry, 2012). Based on this assessment, Joan presents with anxiety disorder, lack of sleep hygiene, heart palpitation, and subsequent pains in her chest. Case formulation is an important aspect in the characterization of diseases and their codes for the easy therapeutic plan (Sommers-Flanagan & Sommers-Flanagan, 2017). In addition, Adlerian posits that a person can interpret the circumstances of their existence and make them their lifestyle. As such, Joan biologically predisposes to such factors as taking a high volume of coffee and dark chocolate.
Psychologically, she is predisposed to characteristics of perfectionism, criticalness, the sensation of avoidant, and conscientiousness. This is based on Adlerian perception of Psychopathology, in which he compares behaviors to the way a person logically manifests its symptoms from excessive excuses for failure to accomplish certain life tasks (Sperry & Sperry, 2012). Using this analysis, Joan’s social circle includes a stressful working environment, emotionally unsupportive to both her daughters and her employees, and exacerbated by her distinct mother and controlling father.
Moreover, being overly conscientious and having an emotionally distant mother is the major pattern-maladaptive. In this case, biological, social, and psychological factors are perpetuated by events such as perfectionism, little time for both family and employees, and task-focused behavior, respectively.
XII: Cultural Formulation
Joan’s cultural identity is that of a Caucasian identity, upper-middle-class WASP woman. She does not have any culturally-related stress, thus highly acculturated. Based on Adlerian perspective, problems can be comprehended by a person not possessing a feeling of belonging to a given group or culture. Specifically, Ratts and Pederson (2014) posit that the understanding of a multicultural exercise can logically lead to advocacy for social impartiality. In this case, the counselor and the patient involve themselves in understanding one’s cultural background, thus creating systemic-level interventions.
Preliminary Treatment Plan
Crisis Management/Stabilization
Since Joan is suffering from chest pains and heart palpitation, the counselor should perform crisis management by transferring Joan to a cardiologist to attend to her chest and heart problems. This action can only be effective after the client-therapist engagement is achieved based on Adlerian first stage of therapeutic goals. This should be done immediately to avoid health-related medical errors.
Medical/Somatic Referral (If Any)
Apart from the chest and heart palpitation, Joan does not have any somatic referrals that require immediate intervention.
Treatment Specifics and Goals
The first treatment encompasses the clinical treatment plan for Obsessive-Compulsive disorder.
Goal#1: To reduce obsessive thoughts and compulsive behaviors related to the disorder
Intervention
- Cognitive-behavioral and behavior therapy specifically towards the identification and modification of distorted behaviors.
- Psychoeducation and processing: This is where the patient is psychologically educated on ways in which she can manage her behaviors, especially the obsession to take high amounts of coffee and dark chocolate.
- Exposure and response therapy. In the case of Joan, it is evident that she has poor social skills because of her limited time to interact with others and the family. For this therapy intervention, involve the patient in outdoor activities where she gets to see the other version of the world where people are more socially interactive.
Goal#2: To increase the family relationship and connection between Joan and her family
Intervention
- Using the third stage of Adlerian theory in therapy (insight), a family-based intervention is imperative. In this method, treatment involves examining stressful family-related issues,
- Organizing family activities where Joan participates in playing games with her two daughters and her husband. According to Reichenberg and Seligman (2016), a family alliance is established to increase the success of family-mediated therapy. Therefore, the therapist should only seek to remove all obstacles that can make the association not functional.
- Another family-related intervention includes the creation of time during busy schedules. In this way, the family members will feel a sense of belonging and acts to reassure Joan that her treatment will be positive.
Goal #3: To reduce overworking at the job and in the family because of her perfectionism and conscientiousness leading to anxiety
Intervention
- Distraction technique: This this diversion method, Joan will able to support her family and employees emotionally, rather than continue with her unending tasks that do not give her time for the workers and her daughters. This is the reorientation stage as deployed from the fourth stage of Adlerian perspective.
- Involve the patient in answering presuppositional questions, thus are resulting in Joan accepting outcomes as they are in her job as a manager and believe that it is not only through perfectionism that tasks are completed effectively. This communication will create a link with the, subsequently leading to high production when they are listened to. In such a way, the stress in Joan will be reduced because of lowered life stressors, especially those related to work.
- Controlled exposure and ritual prevention can be sued to reduce the overall anxiety in Joan. For all the goals and interventions, the location of the care plan is an outpatient setting. The timing and frequency involve using a moderately spaced timing, with about 8-10 sessions performed weekly. During this time, Selective serotonin reuptake inhibitors (SSRIs) can be administered to reduce the obsession and compulsions.
Ancillary Services
In the situation where Joan is transferred to a cardiologist for chest pain and heart palpitation, Ambulance services are required for quick transport, and at the cardiologist facility, cardiac monitoring services are performed. In this case, the cardiologist can involve the services of a radiologist for diagnostic imaging. In addition to the stated ancillary services, the counselor should seek the services of substance-abuse disorder services for clinical and adversary care plans directed towards her high coffee and dark chocolate intake.
Cultural Considerations and potential Social Justice Intervention
With regards to the Biopsychosocial assessment in Joan’s case, there are no culturally focused treatment considerations.
Potential Obstacles
Joan’s feeling of avoidance and with her perfectionistic character, her high expectation to succeed in every task underpins a medical obstacle. Having little time for family is also an obstacle, especially when a care plan is underpinned through the presence of a family proxy.
Therapist Characteristics
The therapist is supportive through the assessment and asked questions effectively, thus enabling Joan to answer them efficiently. The therapist is also multiculturally competent when she builds a rapport with Joan to ask about her cultural diversity and considerations. According to Reichenberg and Seligman (2016), a therapist should be self-aware about their perception of life issues and those related to the patient to help them shape their experiences and assumptions. Moreover, a therapist should be cognizant of individual traits to help them identify clients who are too demanding and those who are defensively critical.
References
Sperry, L., & Sperry, J. (2012). Case Conceptualization: Mastering this competency with ease and confidence (1st ed.). Routledge.
Ratts, M. J., & Pedersen, P. B. (2014). Counseling for multiculturalism and social justice: Integration, theory, and application (4th ed.). John Wiley & Sons, Inc.
Reichenberg, L. W., & Seligman, L. (2016). Selecting effective treatments: A comprehensive systematic guide to treating mental disorders (5th ed.). John Wiley & Sons, Inc.
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical interviewing (6th ed.). John Wiley & Sons, Inc.