Case Analysis - Jet and Alex

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Apr 3, 2024

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Case Analysis Jet Kofoot and Alex Wirtz 21 March 2024 Potential System Services Alcoholics/Narcotics Anonymous Medication Education/Tutor Services Medical Specialist Family Therapy Occupational Therapy Individual Therapy Primary Care Provider Informal Support School Counselor/Support Job Seeking Services Substance Abuse Counseling PTSD/Abuse Support Groups Clubs/Teams/Interest-aligned groups Case Analysis Elements of Case Analysis The school counselor has referred James Reid. James is the target client system for this analysis. The main presenting problem for James are symptoms of post-traumatic stress disorder (PTSD) that he has been experiencing. These symptoms have been brought on by living with abuse and conflict between his father and mother, and his mother’s ongoing issues with (PTSD) and substance abuse. James is a 17-year-old white male who lives with his mother, Maria, in an urban area. He appears to be well nourished and in good physical condition. His height and weight are average for his age. He is clean and his clothing is suitable for the setting. James avoids eye contact and complains of the lights being too bright in the room. He states that he has been suffering from frequent headaches. He also complains of intrusive memories and nightmares that occur every night. He shuffles his feet when he walks and slouches while sitting. His affect is flat, his mood is gloomy, and he is hypervigilant. There is an edge in his voice and the volume of his speech is

Case Analysis Jet Kofoot and Alex Wirtz 21 March 2024 low. He expresses no thoughts of harming himself or others. His responses to questions are logical and relevant. He appears to easily lose focus but responds quickly when redirected. He is oriented to time and place. He expresses a coherent understanding of his situation. He acknowledges the impact his parent’s relationship and his mother’s subsequent struggles have had on him. His father abused his mother for a number of years, and she left him two years ago. He now lives with his mother and has no contact with his father. He is an only child and there is no extended family in his life. James has a few acquaintances that he “hangs out” with but no close friendships. He expresses feelings of guilt and helplessness for not being able to protect his mother during the abusive episodes in their lives. To cope with his own emotional pain, James has turned to substance abuse, primarily marijuana and alcohol, which he uses as a way to numb his feelings and escape reality. James' academic performance has suffered, and he has become increasingly withdrawn from social activities. He reports that he once enjoyed sporting activities but has lost interest in them. He struggles to concentrate in school and his grades have suffered. This has also affected his relationship with his teachers. He believes many of his teachers treat him as a lost cause. He rarely completes his homework which often means he spends an abundant amount of time in detention. James reports that he feels a profound sense of isolation and hopelessness about his future. He has been talking to the school counselor about his thoughts and feelings, and the counselor has expressed a concern that James needs additional support. At the Micro level James has been impacted by the issues that his mother is dealing with which makes it difficult for him to communicate with her about his own needs. His ability to develop relationships with his peers is also impacted at this level. The lack of a reliable male role

Case Analysis Jet Kofoot and Alex Wirtz 21 March 2024 model in his life makes it difficult for James to develop a secure sense of self at the micro level. James was once involved in sports, however, his current circumstances have made this type of Mezzo level activity problematic for him. His grades and relationships with teacher have suffered at the Macro level. James’ adolescent role performance has been stunted. Managing his emotions is harder than it would normally be for an average teen. He is juggling complex emotions that he is ill prepared to experience at this stage in his life. Hallmarks of adolescent role development are expanding one’s social circle and taking on new and varied social roles. James’ social circle is shrinking as he backs out of social activities like sports. Because he is backing out of social activities he is unable to expand his roles in adolescent society. He does not have the opportunities to interact with his peers like he once did. This also creates barriers to developing new friendships and becoming a part of group activities centered around mutual friendships. A primary DSM-5 diagnosis of Post-traumatic stress disorder, chronic (F4312) is suitable for James. Secondary diagnoses of Emotional lability (R4586) and Nightmare disorder (F515) are also appropriate. Additional attention should be paid to his physical complaint of headaches. Many factors are having an impact on James’ mental health at this time. Abuse and trauma in the home have caused him to experience delayed emotional and social development. James no longer has a relationship with his father, and his relationship with his mother is strained. He is having difficulty maintaining peer friendships and is unable to develop new ones. His grades have suffered as have his relationships with his teachers. He has lost interest in activities he once enjoyed. His adolescent role performance has been stunted. He has turned to the abuse of substances in the hope of finding relief. It is vital to James’ recovery that his treatment includes the collaboration of his therapist, AA, primary care physician, and a

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