10a1 Brandy Carter - Unit 10 mandatory assignment format. PDF

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Running head: CASE FORMULATION WITH TREATMENT PLAN

U10a1 Case Formulation with Treatment Plan Brandy S. Carter Capella University CES8760-Advanced Clinical Practice

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Case Formulation with Treatment Plan Client Demographics and Sociocultural Background Lauren is a twenty-five year old Haitian-American female who moved to the United States with her parents at the age of eight. Lauren is married to Jason, a twenty-two year old Caucasian male. The couple has been married for a little over a year. Together they have a twoyear old daughter. Lauren is currently enrolled in school, she is finishing her Bachelors degree in health care management. Lauren is also a full-time nurse at a local hospital. Jason has a Bachelor’s degree in business administration and is currently employed as financial advisor at a Fortune 500 company. The couple currently lives with Lauren’s mom in her basement. The household also includes Lauren’s ninety year old grandmother. Lauren has one older brother that lives in the area. Lauren is estranged from her father but states that she has a decent relationship with her mother and grandmother. Jason’s parents live near the couple, he describes his relationship with his parents as normal; Jason has no siblings. When Lauren described the living arrangement, Jason appeared very agitated. Presenting Issues/Reasons for Referral The client has come to counseling due to increasingly negative communication. Lauren, states, “if we don’t get help…this marriage won’t last. Nothing ever gets resolved because Jason is such a jerk and doesn’t know how to talk to me”. Lauren often refers to Jason as very negative. Jason states, “all we do is argue. We don’t talk, we just yell and I am sick of it”. During the session, Jason and Lauren often cut one another off, not allowing the other person to finish their statement. When either is talking, the other can be seen making negative facial expressions by rolling of the eyes and frowning. The couple displayed no positive emotion and sat separately on the couch. At one point Jason attempted to touch Lauren’s hand and she moved away. Anderson

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and Gehart (2006) note that each client discusses their perspective of the problem and not how they may contribute to the problem. For example, Lauren feels Jason’s sarcasm and rude remarks make it difficult to talk to him. Jason feels that Lauren is always nagging and negative and it makes it difficult to discuss anything. Jason also feels that Laure over exaggerates small things. The therapist listens to how both Lauren and Jason describe the problem, how and why both Lauren and Jason think the problem started, how each person defines their role in the problem, and the best way to address the problem. Clinical Evaluation Problem 1 Excessive Negative Communication Outcome Goal: The client will be able to verbalize needs, wants and emotions in a positive manner Subjective Data: Lauren states she was raised in a very strict and religious home and does not understand how Jason could not believe in any higher being. She was raised in a single parent household along with her older brother. Lauren recalls times where her mother would discipline her and her brother harshly for not cleaning the dishes. Lauren and her brother were never able to express feelings to her mother or ask questions when they didn’t understand something. Lauren remembers that her mother would often communicate by yelling. Lauren doesn’t remember her mother saying kind things or even expressing love to her and her brother. Jason refers to Lauren’s mother as a, “Haitian Nazi”. Lauren is very uncomfortable living in her mom’s house. Jason can be very messy and this causes strife between Lauren and her mother. Lauren’s mom will often complain to her about Jason’s lack of cleanliness, Lauren often finds herself having to scold Jason like a child and beg him to clean up. Jason comes from a religious household but he refuses to subscribe to any religion. Jason shares that everyone in his household used sarcasm as

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a form of communication and he doesn’t see it as an issue. Jason describes Lauren as being too sensitive and feels she should toughen up, especially after hearing how her mother speaks to her. Lauren strengths, as described by her are, smart, caring, loving. Her weaknesses, selfish, easily annoyed and too nice. Jason describes his strengths as, work ethic, common sense, communication and understanding the big picture. He listed his weaknesses as, lack of attention to detail and high sex drive.

Pr obl em Ti t l e:Ex cess i veNegat i veCommuni cat i on Dat a

Hypot heses

Pl an

The client was married shortly Developmental Tran- Assist the client with creating a after they started dating. They sition-(CS3) timeline thatlevels will allow them dissatto Objective Data: As noted by Rogosch, Cicchetti and Toth (2004),“high of marital are transitioning from living inmove and transition to living on dependently on their are owncommon to liv- among couples with a depressed their own. In order for thisafter timeisfaction and conflict spouse, especially the ing with Lauren’s mom and line to be created, the client must grandmother a very traditional work and use birth of a child.inThis leads to the spousal subsystem appearing rigidcollaboratively and disengaged (Faber, household and they are tasked positive communication skills. with raising their finds child itwhile 2004). The client difficult to verbalize needs, wants and concerns; when a discussion is trying to create new traditions. held, it typically results in a lot of screaming and use of profanity. There appear to be major trust The client willbeing need avoided. to be LaurenFamily Identify and create issues that are won’tSystem-(SC1) allow Jason to watch theirinteractions daughter alone, she degenogram to discover what patviewed systemically. Gehart terns exist. (2014)him notes it is important scribes asthat irresponsible and child like. Both Jason and Lauren show difficulty when expressto identify interactional and relational patterns within family as avoidant behavior. ing emotion. Jason usesthe sarcasm unit. Working Hypothesis Ingram (2011) highlights, “cul- Cultural Issues-(SC2) Utilize identified coping strategies that allow for positive comtural Issues must be directly admunication and a safe to express dressed for problems related to Plan needs, wants and verbalize emocultural group membership actions. culturation, cultural identity, and intercultural conflicts” (p. 331). Lauren’s family or origin differs great from Jason’s. This issue is prevalent in the way they individually handle discipline. It is also a point of contention when they attempt to communicate. Lauren feels that Jason is very dismissive and disrespectful in his approach. Jason describes Lauren as, “hardheaded and stubborn”. Jason is accustomed to this because his father spoke to his mother the same way. Lauren’s parents weren't married Problem Title: Excessive Negative Communication but where her dad was around she never heard him speak to her Outcome goal: The client will be able to verbalize needs, wants and emotions in a positive manmother in a disrespectful mannerner.

While observing the client during the session, it is clear that the clients have difficulty separating from their family of origin. There are poor parenting skills that have been displayed

Deficits in Self and Relational Capacities(P3)

Creating an exercise where the client explores their partners family of origin. Assessing attachment style of previous caretakers.

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While observing the client dur- Deficits in Self and ing the session, it is clear that Relational Capacitiesthe clients have difficulty sepa- (P3) rating from their family of origin. There are poor parenting skills that have been displayed with the marijuana smoking around their daughter. Jason consistently shows a lack of empathy for Lauren’s emotional well being. Jason also shows difficulty with understanding and accepting his own emotions.

Creating an exercise where the client explores their partners family of origin. Assessing attachment style of previous caretakers.

Living with Lauren’s mother causes a lot of tension for the client.

Environmental Factors-(SCE7)

Moving into their own space may help take the pressure off the couple. This will help to create a closer attachment.

Lack of sex and intimacy are difficult to discuss due to communication issues.

Biological Cause(BE2)

Lauren would benefit from a physical exam with her PCP/GYN to rule out any medical issues related to her level of sexual arousal. Medical issues such as hypothyroidism can decrease libido which affects the sex drive (Godfrey, 2007). Positive communication will need to be used to discuss such a sensitive topic.

Strategy-Therapist will use the family systems model, emotionally focused therapy to increase positive communication and encourage the client to openly express emotion and verbalize needs. Goals are used in EFT to target change and develop new interactions patterns that nurture and support each partner (Gehart, 2014). The therapist will monitor behavioral interactions to assess attachment style. EFT therapists often do this by inquiring about the client’s attachment history to caretakers and previous adult relationships. The therapist is also listening to attachment in-

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juries that have happened in the relationship. These injuries must be specifically addressed in order for the process to work (Johnson, 2008). The therapist will learn about the client’s culture in order to build trust and rapport in during the therapeutic process; joining with the client by using reflection, validation, empathetic conjecture and evocative responding (Hinkle, Radomski & Decker, 2015). Long range goal(s)- Increase the client’s awareness of their negative interactions and identify the primary emotions that fuel them. Client will be able to express emotions, verbalize needs and communicate in a positive manner. Client will reduce negative interactions 1 time a week for 3 consecutive weeks; reducing arguments. Client will report at least one positive interaction on a daily basis for four-weeks. Sexton (2011) notes that EFT’s softening emotions technique assists the client to become less critical, allowing vulnerability and the ability to express any underlying fears. This will encourage the client to speak openly, allowing for a flow of positive communication. Short range goal(s) - Client will develop three alternative ways to verbally communicate when angry. This is directly related to promoting acceptance. These alternative communication skills can assist the client to reshape interactions. Client will be able to verbalize emotions, needs and wants without the use of foul language (late-phase goal). This will be measured by the client demonstrating the skills, without the assistance of the therapist in 2-3 consecutive sessions. In order to determine effectiveness, the client will be administered the Marital Satisfaction Inventory (MSI-R). Process Goals - The therapist will attend to nonverbal communication by closely monitoring for signs of unexpressed primary emotions, these often provide valuable clues (Furrow, Ruderman, & Woolley, 2011). While observing interactions during the session, the therapist will track pat-

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terns and cycles of interactions and then reflect these patterns onto the client to help them understand their relationship (Johnson, 2004). Assessing the strength of the current attachment and listening for history of the relationship and any key factors is essential. This can take place when the therapist is assessing for any past attachment injuries (Johnson, 2008). The therapist will reflect both primary and secondary emotions by reflecting them back to the client by showing empathetic understanding. Reflecting back secondary emotions involve helping the client identify their feelings during the negative interaction cycle (Gehart, 2014). The client will attend scheduled sessions, develop and utilize coping strategies that will assist in decreasing negative communication as well as comply with any assignments or exercises given as homework or during the session. Participate in role play activities that demonstrate positive communication skills Techniques or Procedures - Emotionally Focused Therapy (EFT) is comprised of a three-structure process (Hanna, 2007). The therapist will identify problematic cycles, emotional experiences and related emotional states. This step is de-escalation of conflict. The next step is for the therapist to restructure the attachment bond, the cycle of negative communication is viewed as the enemy, taking the blame of either partner. Consolidated gains is the step where new communication patterns are reinforced. Setting-The client will meet in a private office that has a casual atmosphere. This will help to make the client comfortable with the therapeutic process. Modality (format)-The client will participate in couple sessions. If the client decides they would like to also do individual sessions, the therapist and client will discuss and the therapist may choose to refer the client to a colleague in the office. The therapist will not incorporate family members into sessions. It is important that the client use the sessions as a time to connect and

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make progress towards the specified goals. Duration and Frequency-Family therapy is often looked at as brief and problem focused. If a client is using insurance to pay for sessions, the insurance company often determines the number of sessions. Ultimately, the client and the nature of the problem should guide the therapist and the best modality of treatment (Patterson, Williams, Edwards, Chamow & Grauf-Grounds, 2009). Client and therapist have agreed to begin with twelve sessions. The sessions will be 45-50 minutes in length and will be held on a biweekly basis. During the 11th or 12th session, the therapist and client will assess progress to determine if future sessions are needed. Client and therapist may opt to have maintenance sessions after the initial twelve sessions. Maintenance would be a monthly session with the client. Ingram (2011) highlights that in order to remain ethical, the therapist should know the following-(a) the client’s insurance coverage limits for the number of sessions (b) if the clinician’s plan of employment uses a short-term therapy model (c) duration of the therapist’s intended training or employment at the clinical setting (p. 107). Case Management Discussion Client-Therapist Relationship In order for treatment to be successful, there must be a positive client-therapist relationship. The therapist is viewed as a consultant that assist the client in reprocessing their emotional experiences. Johnson (2005) also refers to this as, “a choreographer who helps the client restructure their relationship dance” (p. 62). The therapist must join the system to build an alliance with the relationship. Joining the system includes, identifying relational patterns, and reflecting them back so the client can understand the relationship. The therapist will also utilize the following in order to build rapport: 1. Empathic Attunement-the client must feel understood and heard; acknowledging the previous

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history between African Americans and Caucasian will be essential in this process. Jason (Caucasian male) will need to feel just as connected to the therapist (African American female) as Lauren (Haitian American female) does. The therapist can also use this opportunity to explore resources in the community and connect the client with them for additional support. 2. Johnson (2005) suggests that when using emotionally focused therapy (EFT) the therapist employ RISSSC: repeat, images, simple, slow, soft and client’s words. 3. Acceptance and maintaining a nonjudgmental stance is essential. Acceptance involves honoring the client where they are in their journey. The therapist is not to be viewed as someone attempting to reteach the client communication. Problem Titles, Priorities and Sequencing Outcome assessments Throughout the therapeutic process, the therapist anticipates that the client will start to see improvements in daily communication. The client will start to a decrease in blaming and an increase in conflict resolution. The client will start to feel more supportive and connected to one another. As the positive communication increases, the session will spread out to monthly. The client needs to utilize the coping strategies without any prompting from the therapist. During the first session the client was administered the Marital Satisfaction Inventory, Revised (MSI-R) At the end of therapy, the client will be given the same assessment and the score should show and increase in marital satisfaction. Cultural and Relationship Factors Emotionally Focused Therapy (EFT) is one of the most researched couples therapy . Research indicates that there is between a 70-73% success rate when used with couples from different cultural backgrounds (Johnson, 2005). According to, Soleimani, Najafi, Ahmadi, Javidi, Ho-

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seini,Kamkar & Mahboubi, (2015), marital couples have an overall higher rate of marital satisfaction when the therapist uses EFT. Couples are able to create a safe environment. In order to ensure an effective therapeutic relationship, the therapist will conduct research on the Haitian culture; especially as it relates to communication. One possible issue to consider is that Jason may see the therapist as being more connected to Lauren because she is an African American female. The therapist also identifies as a Christian and has to be careful not to pass judgment onto Jason because he identifies as an atheist. The therapist will need to pay close attention Jason’s verbal and nonverbal gestures to gauge his level of comfort during times where religion and race may come up during the session. Ethical and Legal Considerations The therapist should also consider any ethical and legal issues that may arise when creating or implementing the treatment plan. Gerhart and Tuttle (2003) suggest that treatment plans serve both legal and ethical purposes by documenting competent services. “Current ethics guidelines require therapists to maintain adequate records of treatment” (p. 4). The therapist should take into consideration how motivated the client is in reaching their goals. If the client is not in agreement with the goals, the therapist should be open to revising them so the client feels comfortable and is willing to work towards the goals. The plan should be diverse; the client’s culture, gender, ethnicity, race, religion and family structure should be taken into account. Using the client’s language, concepts and boundaries can help to ensure this is done (Ingram, 2011).

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References

Anderson, H., & Gehart, D. R. (2006). Collaborative therapy: Relationships and conversations that male a difference. New York, NY: Brunner-Routledge. Faber, A. J. (2004). Examining remarried couples through a bowenian family systems lens. Journal of Divorce & Remarriage, 40(3), 121-133. doi:10.1300/J087v40n03_08 Furrow, J., Rudderman, L., & Woolley, S. (2011). Emotionally focused therapy four-day externship. Santa Barbara, CA. Gehart, D. (2014). Mastering competencies in family therapy: A practical approach in theories

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