Initial Case Conceptualization


Initial Case Conceptualization

Nichole Hairston-Purvis

Dr. Stephanie Warren


Capella University

February 12, 2018


Part One: Client Information

This paper focuses on S. H., a client that the therapist has been speaking with in counselling sessions over a couple of weeks since they met during an internship program in the field. S.H. is 25 years of age. The client resides in Detroit City in Michigan, United States of America as a first generation immigrant, her country of origin being Nigeria in Africa. Having migrated into the U.S with her parents, 2 brothers and a sister when she was 11 years old, she is an African American citizen. She speaks both fluent English and Spanish. The client is a staunch Muslim and her wealthy parents live in New Jersey, U.S. S.H. has been working as a credit officer at a locally based bank until she was dimissed a few months ago .She rarely asks for financial support from her parents despite the fact that she is out of job.

The client does not portray any signs of physical disability and appears physically healthy. S.H. did not complete her college education after she got pregnant, arguing that she could not properly manage college, full time job and raising a baby. S.H.’s siblings are graduates having professional careers. The client has a son who is 2 years old and she claims that sometimes she feels ‘overwhelmed’ because of raising him all alone as her husband serves in the military and has been away for nine months. Client reveals that it has now been two years since she saw her family. Furthermore, she states that her relationship with her parents is ‘close’ despite mentioning that her father is an excessive drinker. Her father and mother are a banker and an educator respectively.

While presenting her concerns and problems the client said, “I lost my job a few months ago which has brought a feeling of hopelessness. I am having sleepless nights and I have lost my appetite.” Over the past two months, the client reported having lost eight pounds. Despite worrying about being a solo parent, she also fears that she might become homeless. S.H stated, “I am always worried. I am completely stressed out. My husband has been away for nine months serving in the military .I am always worried about him.” During her various appointments, S.H. has been arriving thirty minutes earlier. She also reported that she had never attended any counselling in the past. The client appeared to be suffering from depression and anxiety due to the fact that the client presented with shaky hands and was tearful during while completing her intake paperwork. During the description of her problems and her decision to seek out therapy, she made limited eye contact .She had a halting speech. The client seemed pretty willing and commitment to the nine treatment sessions recommended by her insurance company.

Part 2: Theoretical Framework

The counsellor utilizes the Individual Psychology Theory which asserts that the key motives regarding human behavior and though involves individual person’s striving for power and superiority, that partly compensates inferiority feeling. From this perspective, every person is considered to be unique in which his unique goals and methods of achieving them find expression in his/her life style- a life style that is an outcome of his/her creativity. Nonetheless, the person is not considered as separate from the society since all the significant problems that include problems emanating from general human relationships, love and occupation are considered to be social. Individual Psychology theory put more emphasis on three significant factors which influence the personality of an individual (Ogdeu & Adler, 2012). The theory emphasizes on social factors which include; love, occupation as well as societal factors. It should be noted that people’s personalities are strongly derived from the said factors. From the issues presented by S.H. during the interview, it’s clear that she is encountering societal issues of insufficient support from friends and family, loneliness, joblessness among others. The theory also posits that people usually derive their individual character through their response towards the influence of external factors (Fall & Holden, 2013).

The rationale behind the application of individual psychology theory in S.H.’s case is her that she portrays an underdeveloped interest in social matters, for example her failure to meet her family for two years even though they are living in the same country. As a matter of fact, she has an uncooperative and exaggerated superiority complex as she neither explains her financial crisis to her wealthy parents nor asks for their financial support. The mixed feelings of superiority and inferiority are manifested through anxiety and aggression. This has prompted the client into solving her problems through a private and self-centered fashion as opposed to a common sense task centered fashion. This has resulted to her failure to the extent that she is worried that she might soon become homeless.

The individual psychology theory saves her situation effectively since the therapy and counselling will involve the provision of the patient with insight particularly on her mistaken style of life through the use of the material or information presented during the interview. Since this theory focuses more on social economic factors and their influence on an individual’s personality, it was imperative to gather information relating to the client’s family background; social-economic status, job status, occupations and relationships. The application of the theory significantly influenced the type of the questions that the therapist posed with the aim of obtaining the information that would be used throughout the therapy treatment sessions.

Part 3: Assessment and Diagnosis

In the U.S., ICD-10-CM is used as a coding for diagnosis. As for S.H.’s case, the diagnosis results revealed that suffering from; stress, depression, behavioral and mental disorders.

The ICD-10 code for the S.H.’s problems would be defined by chapter V, blocks F00-F99.Under DSM-5 diagnostic criteria, the client problems fall under the depressive disorders and anxiety disorders categories. The reason behind such diagnosis is that; first of all, the client seems to panic because of the possibility of becoming homeless and difficulty in raising her son alone. The fact that S.H. recognizes her fears and worries especially when she confesses that she is worried about her husband in addition to the possibility of becoming homeless is a clear justification that her case could easily be diagnosed as an anxiety disorder under DSM-5.

The process used in the formulation of assessment and diagnosis involved the application of simple interview-type questions. The questions used were intended to gather information of education background, religion, social-economic status, family background, health status and other relevant materials for assessment and diagnosis. After the collection of information, an analysis was done followed by an evaluation. Consequently, the counsellor applied the DM-5 specifically to arrive at an accurate diagnosis. The diagnosis was formulated through the utilization of self-report instruments e.g. symptom and signs checklist alongside depression and anxiety scales (Davis, Miller, & Dowd, 2015). The counsellor applied DSM-5 diagnostic procedure in achieving the diagnostic outcomes. The degree of depression, anxiety and the severity of the symptoms were the basis on which the DSM-5 was employed. With the consent of S.H., the therapist was able to consult her younger sister as well as her elder brother in an attempt to discover more relevant information about the client. The DSM-5 diagnostic procedure applied, significantly contributed to the effectiveness of individual psychology theory employed in the counselling. This is because the diagnostic results assisted the counsellor in coming up with the most effective treatment.

Part 4: Counselling goals

One of the counselling goals that the counsellor has formulated is the reduction of loneliness. S.H. is lonely with her husband in the military, raising her son alone alongside her unwillingness to meet her family. This reduction will be assessed through extension of the client social circle of friends in addition to seeking out her family members. Another goal involves the eradication of hopelessness which will be measured through the client’s commitment in attending the therapy sessions and her attempts to secure another job to boost her independence. She could also be measured through her efforts in recovering her appetite and sleep. The third goal entails the improvement of the physical health which will be realized through addition of the nine pounds lost since the problems started.

The above goals were set after a thorough assessment of the information and the resultant diagnosis. The formulation of the goals was done in a way that the information presented would be sufficient to achieve them without the need for further investigation. In other words, the choice of the goals was purely based on the honesty and quality of information. The counsellor was certain that the material could be used effectively in providing treatment to the client.

When selecting the goals, the social-cultural background of the client as well as her personal history was considered through the enquiry into her family social-economic status, her job status, her religion, race, age, family relationships, educational background, marriage among others (Schwartz & Waldo, 2014). The goals formulated reflect the concepts and assumptions of the individual psychology theory in that all of them will be achieved by making recommendations which are related to increasing the interaction of the client with the society. This is to deal with any superiority and inferiority issues that are present in the life of the client.

References Davis, T., Miller, J., & Dowd, T. (2015). Adlerian psychology and Cognitive-Behavior Therapy:Convergencies. J Individ Psychol, 36(2),119-135. Fall, K., & Holden, J. (2013). Theorretical Models of Counselling and Psychotherapy. New York,NY: Brunner-Routledge. Ogdeu, C., & Adler, A. (2012). The Practice and Theory of Individual Psychology. New Je

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