I. Client Background and referral information
Anna is an 18-year-old Caucasian female who sought help on her own. She lives with her parents in a small rural area in North Carolina. Anna is dealing with toxic parental issues. Her parents continuously belittle her and call her vulgar names. She is dealing with her parent's constant fighting: her dad is abusive to her mother, and in turn, they are both abusive to her. Because of her parent's constant emotional abuse, she is dealing with severe trauma. She is displaying negative coping skills where she is cutting to relieve her stress and anxiety.
Anna often feels unworthy. She becomes distant from her friends and tries to stay invisible at home with her parents. Anna does not have a religious background. She is open to religion and believes in a higher power, but she is not known to be more of a diagnostic.
II. Strengths and Client Supportive Factors
Anna is seeking emotional support on her own, which shows she is concerned about her mental stability and well-being. She is tired of feeling alone and invisible in her feelings. She stated she wants to change but her living arrangement with her parents is very toxic and financially she is unable to live on her own. She is in school at a local community college not far from her home.
She wants to get her education and pursue a four-year degree once she completes her associate degree. She is doing very well in school despite the turmoil she is dealing with at home. However, she feels that may change if she can’t find a way to cope with her negative emotions and feelings. That is her rationale for seeking mental and emotional support.
1. Supportive Health Factors:
Anna had a physical before our first session. She is in good physical health based on the report on January 5, 2023. She is due for her next physical in 2023.
2. Social Supports:
She has several good friends that are in support of her seeking professional help. Her
friend Liza is her accountability partner. She lets her know when she is feeling
overwhelmed. They have been friends since middle school.
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3. Financial Resources:
Anna lives with her parents due to financial issues. She is paying her way through
college by working a part-time job and financial aid. She is not able to live on her
own. She is paying for her therapy sessions based on a sliding scale.
4. Emotional-Behavioral Strengths:
Anna’s emotional strength is her ability to bounce back quickly (resilience). She is self-aware based on her ability to ask for help, by referring herself for therapy. She appears to have good self-control and a stable mood during our first two
sessions. However, she is exhibiting di`iculty with emotional regulation and her inability to manage her own di`icult inner emotional struggles.
5. Anna is organized, and she likes structure.
She doesn’t like to be a burden or cause
conflicts. She goes into freeze mode when she feels she is not able to control her
environment.
6. Cognitive Strengths:
Anna does not exhibit any learning disabilities or deficits. Her grades in college are above
average. She doesn’t exhibit any areas of di`iculty with memory. She is mentally able to
function normally.
III. Client Symptoms or Concerns
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1. Health Problems: None
2. Social Di`iculties: None
3. Financial Problems: Anna is having financial di`iculty. She lives with her parents and
is paying her way through school (college). She doesn’t make enough money to live
on her own at this time.
4. Emotional-Behavioral Difficulty: Anna is not able to self-regulate healthily.
When she becomes overwhelmed, she wants to cut. She has di`iculty emotionally
when her parents continue to demean her and belittle her abilities. She is living in a
toxic parental environment. She at times feels invisible as if she doesn’t matter. She is
showing signs of trauma due to her childhood. Her parents continue to fight and hurt
each other as well as her.
5. Cognitive Deficits: Anna is having difficulty focusing when she is at home. The
environment is so toxic according to Anna; she can’t do her homework at home. Her
home environment seems to be the trigger for her negative emotions.
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IV. Timeline and Priority of Symptoms/Concerns
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When Anna was a child, she would go to her room and hide when her parents were arguing. Her father would physically assault her mother and that scared her. She began cutting when she was 12 years old. She learned this behavior from her friend, and she watched others on social media cutting. She did not want to commit suicide however she did want the pain to go away and cutting she stated helped her relieve the pressure even though it hurt it also was calming. Her symptoms of panic and fear, isolation, and feelings of hopelessness arose. Her traumatic events as a child have shaped her emotional instability, which led to cutting and her frozen response to people arguing. Because of her inability to focus on home and her cutting, I asked her to complete a level 1 Cross-Cutting Symptom Measure Assessment for Adults to determine any feelings of stress, anxiety, or suicidal ideation. Based on her Level 1 assessment her rating fell in the (low range) which determined a Level 2 assessment was not needed at this time. We will revisit this in the next few weeks.
V. Diagnostic Impressions:
1. Possible Primary Diagnosis:
a. Generalized Anxiety Disorder (300.02); F41.1; (ICD 10 CM) based on the DSM-V. I selected to go with Generalize Anxiety Disorder based on not enough evidence to determine a more specific trauma diagnosis, but that the effects of her experience have led to difficulties in multiple domains.
Overall Case Conceptualization (Narrative Summary) Anna demonstrates her ability to bounce back or show resilience when she is faced with difficult situations. However, if the situation persists for longer than a few days she results back to what is comfortable and soothing for her, which is cutting. Her home environmentis toxic. Her parents are constantly arguing, and she feels if she says anything she will be their next target, so she becomes invisible in her emotions and ability to cope. She goes
into freeze mode when her parents are having a physical fight or throwing each other verbal insults. Anna has been dealing with this toxic environment for most of her young life. It became unbearable when she turned 10, and at the age of 12, she began to cut. A negative coping strategy she learned on social media. She has said she doesn’t want to cut
anymore, but she doesn’t know how to stop. She said she hasn’t cut in a while, and she is, at times, seeing some progress. She realized she needed outside therapeutic support, and that is when she called our office for an appointment. She was able financially to afford our services based on a slider scale and our contract with her college campus to help college
students in need of therapeutic counseling. Anna has strong organizational skills, and she enjoys structure. She can concentrate on her schoolwork when she is away from her home environment. She desperately would love to earn a living that would afford her the ability to live on her own. Although it is not feasible for her to afford to live on her own at this time,
she is working towards a goal for her future living arrangements. Anna does not have a religious background; she did not go to church as a child. However, she is open to talking about God but doesn’t know if she wants to incorporate it into
her therapeutic sessions. Because Anna is having a difficult time at home, she is vulnerable to having negative beliefs and negative emotional instability that may cause her to revert to her unhealthy ways of coping (cutting). Her parents belittle her, she feels less than her, and she is dealing with unwanted negative emotions. Anna took the level 1 cross-cutting
assessment as stated, and at this time, she does not show any symptoms of long-term depression, stress, or suicidal ideation. However, based on her information and diagnosis, I will conduct another assessment in the next few weeks to see if it stays the same or changes. Anna, on the other hand, enjoys listening to music, taking walks outside, and hanging out with her friends. But when she is in a down mode, she will withdraw from her friends and become a loner for a while. Anna has just started therapy; we are on our second session. During our first session, we completed intake paperwork and discussed
informed consent, payment, and the therapeutic relationship. During our second session, we began discussing Amy’s issues and concerns and other topics of her distress. I started by gauging Anna’s feelings by giving her a scale from 1 to 10, select the number that best fits how you are feeling. 1- I feel down, and 10, I feel great. Amy selected a four and
explained why she felt this way. This was how we began our conversation. She told me about how she felt at home and how her parents continued to treat her as less than others. Her main dilemma is about her parents and why she feels so unworthy. She mentioned shame and guilt.
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Recommendations:
Short-Term Objectives – Describe what it is like to grow up in a home environment. Intervention - Build a positive, trusting relationship with Anna in sessions through consistent eye contact, active listening, etc. Identify feelings associated with major
traumatic incidents in childhood and with parental childhood patterns. Support Anna and encourage her to begin to express feelings of rage sadness, fear, and rejection relating to family abuse. Decrease feelings of shame by being able to verbally affirm self as not responsible for the abuse. Assign writing a letter to both parents individually to express her feelings about their abuse. Possibly use the empty chair technique if necessary to help Anna deal with the feelings. Help Anna to identify positive aspects for the self of being able to show forgiveness to all involved in the abusive relationship. Give her alternative options for cutting instead of cutting use an ice cube in the palm of her hand, and hold it until it soothes her emotions, which has the same effect as cutting but is less harmful.
Sessions: We will meet a total of 8 – 1-hour sessions per week virtually. We will reassess her progress at the end of the 8 weeks.
Sharon H. Beatty - LCMHC