Presenting problem: M.B. is a 53 year old, Caucasian, married x3/divorced x2, part time employed female with reported history of depression for 7 years. Client states she has never sought treatment for depression as she has been able to manage “fine” on her own. In the past she attempted marriage counseling with her first husband but only attended a couple of sessions. A few months ago she and spouse saw a marriage counselor one time and did not return. Client states that husband of 11 years initiated on line sex 5 years ago after she “pulled away” from him. Client states that her depression became worse after she was laid off from her job. She admits struggling with depression prior to but things got worse because she was struggling financially. She felt guilty burdening spouse so withdrew emotionally and physically from him. She was not interested at the time in getting on medication for depression as she is not a “fan” of taking medication. She reports that she thought things had gotten better in their relationship but found out a couple years ago that spouse went on a sex website that was a scam and spent thousands of dollars. She claims it has taken 2 years to help him understand that the relationship is a scam. She that had been dealt with and that he had blocked contact with the woman he was Internet dating earlier this year. Unfortunately, she found in March 2018 after what she refers to as “snooping” that spouse had gone on another dating site and connected with a supposed 34 year old Colombian woman. She confronted him and he admitted that he had been seeing this woman via the Internet. He also, admitted that he had been sending gifts and money to her and her family. She claims that he spent $10,000.00 in 6 weeks on this woman and her family. After the attempted marriage counseling session, spouse told client that he had purchased a plane ticket to Bogotá Columbia for 9/14/18. Client fears that spouse is being scammed. He also told client that he has a 2 year plan which consists of him retiring, divorcing client and moving to Columbia to be with his Internet girlfriend. Client is hurt by this and states that they no longer have any trust in their relationship. They are struggling financially and he is the main breadwinner as she works part time. Client is working on becoming a massage therapy instructor so that she can teach massage therapy. She is currently a certified massage therapist. She reports crying spells daily, hopelessness, and loss of interest with passive SI. Client states she thinks about “going away” or “not being here anymore”. She denies any intent. Client denies HI, AH and VH. She was born and raised in Johnston County by parents. Mother is deceased. She reports having been close with both parents. She has an older brother. Relationship with brother is fair. She and spouse live on family farm next door to her father. Father has bipolar d/o and history of 1 suicide attempt in 1984. She denies any family history of substance abuse. She attended college but quit after father had his first “nervous breakdown”. She obtained massage therapy certification. Client married first at age 20. She has been married to current spouse for 11 years. Client reports past history of physical, emotional and sexual abuse by an ex-boyfriend.
Major Psychosocial issues:
Types of service rendered: (i.e., individual, couple/family therapy, group therapy, etc.)
Overview of treatment process:
Goals: Client states she is still having crying spells and is quite depressed but is able to manage without medications. She states she has friends that are very supportive. Client has made arrangements to have a friend with her the first couple of days after spouse leaves for Columbia. In addition she is planning a weekend get together at her home on the 21st with a few lady friends. Client is interested in continuing therapy while she is trying to work through marital issues.
Treatment limitations: No treatment limitations
Remaining difficulties: Financial Limitations and marital problems.
Recommendations: Individual therapy recommended. Client is willing to consider medication management in the future but not at this time.
Follow-up plan: No follow-up plan needed.
Instructions for future contact: She was told to contact our office at any time. A list of crisis numbers was given to her also.
Signature:
Assignment
• Identify a client who may be ready to terminate therapy.
The Assignment
• Identifying information of client
• Date the client initially contacted therapist, date therapy began, duration of therapy, and date therapy will end
• Total number of sessions, including number of missed sessions
• Whether termination was planned or unplanned
• Presenting problem
• Major psychosocial issues
• Types of services rendered (e.g., individual, couple/family therapy, group therapy ) You can choose
• Overview of treatment process
• Goal status (goals met, partially met, unmet)
• Treatment limitations (if any)
• Remaining difficulties and/or concerns
• Recommendations
• Follow-up plan (if indicated)
• Instructions for future contact
Sample Solution
