Case Analysis : Chief Complaint Essay

864 WordsNov 17, 20154 Pages
Chief Complaint Client has been feeling angry at home and school, but mostly at home; client lashes out at home and at her classmates. Client is experiencing low self-esteem, low energy, and low motivation. Client has been feeling sad and experiencing difficulty falling asleep and staying asleep. Client has been unable to complete tasks and has been unable to focus. Case Summary (13 year old female) Client dines SI. Client was cutting; the last time client cut was eight months ago. Client disclosed engaging in cutting when she was angry. Client becomes upset when parents are fighting with younger brother. Client feels that her brother is treated unfairly and she wants to be able to stand up for him, but is unable to. Client also becomes upset with the injustices at school and in society. Client wants to be able to stand up for and protect the less fortunate. Client has always been an A and B student and is expected to be so by her parents. Case Assessment Diagnosis Axis I: 311 Depressive disorder, 300 Anxiety Disorder Axis II: Deferred Axis III: None Axis IV: Family Hx of ADHD and Anxiety symptoms Axis V: 60 Establish Goals for Therapy Goal #1. Align mother and father in the hierarchy. obj. 1) Therapist will use a positional intervention to get the father more engaged in the conversation. obj. 2) Therapist will highlight strengths when the father supports mother in setting boundaries. obj. 3) Therapist will assist parents in talking to one another directly and will
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