Reason for referral:
Sally was self-referred for an evaluation and possible counseling as she was extremely concerned about her physical health and her personal problems, including failed marriages, guilt, lack of sleep and energy, excessive alcohol intake, poor concentration, and decreased interest in activities.
Background information:
Sally is 38 years old, married Caucasian female, currently being seen for depression and physical complaint. Sally has a long history of depression since childhood, with an onset after her father left the family when she was 10. Sally’s family has a history of alcohol use. Despite the complex family dynamics, she graduated from…show more content… Further, despite that she scored lower on the Alcohol (ALC) scale, based on Sally’s report about the history of alcoholism, indicates that her use of alcohol has had a number of adverse consequences in her life, including difficulties in interpersonal relationships, difficulties on the job, and an indication of health complications. Sally is likely to be unable to cut down or quit on her drinking despite repeated attempts at sobriety. Given this pattern, it is increasingly likely that she is alcohol-dependent and has suffered the consequences in terms of physiological signs of withdrawal, lost employment, strained family relationships, and financial hardship. This distress appears to be manifested in mood…show more content… She appears to be an excellent candidate for individual counseling in that she demonstrated interest and motivation for treatment. She is aware of her internal experiences. Sally has provided three general areas that relevant to treatment: anxiety, depression, and hopelessness. The combination of problems that she reported suggests that treatment would be Substance Abuse Treatment along with Cognitive Behavior Therapy with following goals:
Alcohol Dependence
Goal: Be free of alcohol use/abuse
• Avoid people, places and situations where temptation might be overwhelming
• Learn five triggers for alcohol and drug use
Physical Health Issues
Goal: Cope with stress of physical health issues and chronic pain
• Explore and resolve thoughts and feelings that arise as a result of medical conditions and medications
• Learn two new strategies for coping with the above thoughts and feelings
Health, Stress Issues
Goal: Manage physical healthcare conditions and cope with related stress
• Learn as much as possible about the condition(s) and needed treatment
• Attend all scheduled appointments with doctors and therapist
• Maintain good overall physical health and healthcare practices
• Report any medication concerns to the prescribing doctor ASAP
Parenting
