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Includes Pre-Intake interview, Intake interview (Case History: Family, Personal History), Psychological Testing Atmosphere (Tests administered, Observational data, Test Behavior, Test results and interpretation), Findings and Conclusion (Summary Formulation, Diagnostic formulation) and Recommendation. **For educational purposes only.
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CASE STUDY CASE STUDY I. Pre-Intake Interview Male patient 000, 22, is seeking treatment for anxiety and trauma. He is a single Filipino college graduate who resides in the Metropolitan Manila neighborhood of Camarin, Kalookan. In a tertiary hospital, he is employed as a hospital employee and performs the duties of an admitting associate. He communicates with doctors, nurses, patients, and their loved ones here while assisting them with their inpatient needs. Everyone has experienced a significant change since the epidemic began, but 000 was particularly affected because he is a frontliner and had particular difficulties. He is a son and a brother to his family in addition to playing the part. While he pretends to be a helpful buddy to his buddies, he is actually struggling with his love life. Despite having solid relationships with his family and friends, he is guarded and uncomfortable discussing his concerns with them. This is so that they know how much he values them and how much their opinions matter to him personally. He made an effort to meet new individuals through a dating app in August 2020 and tried his luck with dating. He felt frightened and sexually harassed as a result of this bad outcome. He was uneasy after the experience and considered injuring himself to the point of killing himself. He doesn't feel comfortable telling his family and friends about this. His primary worry is that he will be triggered and will once more have trouble falling asleep and experiencing flashbacks to his tragedy. During this time, he also considered self-harm and suicide. He made the decision to call a crisis hotline for assistance, which provided him with advice on how to address his circumstance. He received some temporary assistance from it, but he still wishes he had a supporter. STRICTLY CONFIDENTIAL
CASE STUDY II. Intake Interview Case History
1. Family The patient's parents are 000 and 000. The customer is one of six children, the fourth in order. His family is what drives him to achieve his objectives. They are very close, just like a normal Filipino family who adheres to the "utang na loob'' culture. During the discussion, he made it clear that he will only invest his time and effort in endeavors that will ultimately be profitable for him or that have a good chance of paying off for him and his family. He has supportive friends at work and at college, but although enjoying a close friendship with them, he does not feel comfortable discussing his love life, specifically his sexual life, with them. They put pressure on him, so he decided to try his luck at dating and meeting new people using a dating app. His parents and other members of his family are aware of his gender preference, but he notices that his father doesn't seem to like LGBTQIA+ persons in general. He does not feel comfortable sharing sensitive information with them because of this when he meets new individuals. 2. Personal History College graduation is the client's greatest level of education. When questioned about his accomplishments, he included earning a degree at the young age of 19 at the top of the list. He recently completed 18 teaching units in preparation for the Professional Teacher Licensure Exam. The interviewer elicited three responses from the examinee when he was asked about the values and beliefs he upholds. The first is the "one word rule," according to which he will keep any commitment made. The second is to never compare yourself to others and, if you must, draw motivation from their accomplishments. Last but not least, he checks every penny and always thinks carefully before spending it. He confronts his issues in order to solve them, but first he needs time to reflect and recuperate. When he is unable to complete a task within the day, 000 is depressed. He models the behavior of performing your work and completing it as quickly as you can. His family is what drives him to achieve his objectives. He concluded by saying that he will only invest his time and effort in endeavors that will ultimately be profitable for him or that have STRICTLY CONFIDENTIAL
CASE STUDY C. Test Behavior The patient asked only a few questions during the test and did not have any trouble following directions. He carefully considered his answers and completed the test in the allotted time. D. Test Results and interpretation The subject has a minimal to not visible at all errors. This indicates an absence of visuoconstructive deficits or brain impairment in the respondent. The examinee has a fear of self-assertion and this fear is becoming pervasive. 000 is troubled by his regrets from the past, which he feels he should have been able to handle. He initially turns to sleep as a coping mechanism when he feels helpless or problematic and does not feel like dealing with his problems, but soon he switches to keeping himself active. He considers his options carefully and takes his time making decisions. The respondent had a good upbringing, but his early adulthood was marked by serious disruption. Over the past two years, patient 000 had trouble sleeping and felt exhausted most of the time. He is feeling tense and persistent in feelings of sadness. He had a change in appetite, which is what caused him to lose weight. When he was upset, one of his ideas was to damage himself or commit suicide. He makes the decision to suppress his feelings. Compared to his father, 000 is more attached to her mother. Even though there are moments when the respondent recognizes his mother's wrongdoing, he accepts and tolerates it. The respondent solely expresses favorable thoughts for his mother. His family is his primary focus and the reason he strives to accomplish his life's objectives. They are unaware of his trauma because he holds his family in high regard but finds it difficult to share his feelings with them about it. He heavily considers his family's perspective while making decisions, and he waits for their acceptance and approach before committing to others. He does express relationships with others on a mutual basis, but he stands to gain from them. At the moment, 000 is having issues at work, specifically with his boss and coworkers. He behaves professionally, but in terms of the connection, he is not the same jovial and approachable coworker he once was. STRICTLY CONFIDENTIAL
CASE STUDY In the past, the respondent's approach toward his work has been commended because he puts his all into whatever he does. This is due to the fact that in his opinion, when discussing work, a person should act professionally. Due to his early graduation relative to the typical range of ages, his attitude toward education while still a student is especially noteworthy. He showed his parents that despite earning a meager salary, he is capable of supporting the family or perhaps acting as the primary provider. His sexual urge is one example of how his prior experiences have influenced the way he lives. His ability to have a good relationship with his family, who serve as his source of motivation, is one of his talents. His top aim is to pursue his ideal career while also providing for his family's necessities and making a difference in the world. When faced with a challenge, his weakness is running away from it. In defense of him, this is his technique of keeping from becoming overwhelmed by what is going on. He would rather sleep or do random things than come up with a solution. Recently, he has been keeping himself occupied to keep his mind off worrying thoughts. IV. Findings and Conclusion A. Summary Formulation Mr. 000 took the psychological tests while wearing business clothes. He seems clean and well-groomed. According to the test results and interpretation, the respondent's decision-making is significantly influenced by his family and he only acts in ways that are beneficial to them. The results of his tests revealed indicators of worry and sadness but no evidence of cognitive impairment. Even though he has close relationships with his family, the patient is greatly impacted by their opinions on matters that are personal to him. Over the past two years, patient 000 had trouble sleeping and felt exhausted most of the time. He is feeling tense and persistent in feelings of sadness whenever he remembers his past trauma. STRICTLY CONFIDENTIAL
CASE STUDY V. Recommendation In order for 000 to learn to manage urges or thoughts of self-harm or extinguish them altogether, a safety plan was developed. The patient was also asked to sign a no-harm contract or safety contract which can be used to assess the nature and severity of suicidality in 000, identify specific troubling issues that are causing suicidal thoughts, and determine the client’s ability to contract. The contract allows for the formation of a therapeutic alliance, the definition of the psychotherapeutic framework, and the reduction of anxiety in both the patient and the clinician. Whenever he is in the said situation, he is suggested to create a “Reasons to Live Worksheet” wherein he will write his thoughts on why it is worth living. In identifying history of trauma exposure and assessing level of PTSD symptoms, standardized measures like Trauma Screening Questionnaire were given to 000 and must be filled up. This is designed and is concerned with the patient’s reactions to the traumatic event that happened to him. When it comes to learning skills to reduce distress in the moment, mindfulness practice is recommended. This can be Progressive Muscle Relaxation, Grounding Techniques or Controlled Breathing. Existing coping skills of 000 like writing in his journal should also be strengthened. Ranking the order of the trauma is one of the ways to help 000 to be able to talk about the trauma, especially hotspots or worst moments. Another way also is to acknowledge and validate the trauma that happened to him and his feelings. Mindfulness practice such as Journal Therapy or Rainy Day Letters from the self is also a great help for 000 to learn how to catch and challenge negative thoughts that are bothering him. And lastly, learning about communication styles is a big step for 000 to learn how to communicate his thoughts to others better. These thoughts can either be needs or wants and learning about Dialectical Behavior Therapy Skills can be of great help in addressing. Listing the enjoyable activities and responsibilities is a great exercise also to increase feelings of self-worth, which would mean being able to assert the things 000 wants for himself. 000 Psychologist STRICTLY CONFIDENTIAL