The document outlines a case analysis of a 34-year-old Hispanic woman, Liz, who is experiencing depression and anxiety stemming from negative core beliefs and an abusive relationship with her husband. It requires a thorough analysis using DSM-5 guidelines, including an assessment of her background, mental status, presenting problems, and appropriate theoretical orientation for treatment. The analysis should incorporate identified goals, interventions, legal and ethical concerns, and support with peer-reviewed sources consistent with APA formatting.

1. This has the therapist and client conversation
Case Conceptualization and Treatment Plan
Develop a clear and thorough understanding of the presented
case in the video shown in class.
Write a 2,800- to 3,500-word paper using the Clinical Case
Study Guidelines document to prepare your analysis of the
video presented in class.
Review your notes taken during the counseling session
presented in class. Use the DSM 5 and additional professional
sources as you explore the client's situation, potential diagnosis,
treatment planning, and legal and ethical concerns.
Select a theoretical orientation to complete the analysis of the
client.
Discuss the presenting problem from the theoretical perspective,
and include language from the theory throughout the case
conceptualization. Include the following:
•Summarize the client's background and present living situation,
addressing diversity and the human life cycle.
•Discuss the client's present level of functioning and provide
examples from the Unnamed Video to support your assessment.
•Identify the client's key problems and issues. Discuss which
problems the client is experiencing and why the client is having
these problems.
•Propose a theoretical orientation that would be appropriate to
use with this client and discuss the theory and application.
•Provide a logical and rational assessment of the client and a
diagnosis that is consistent with the assessment. Support the
diagnosis using the DSM 5 and other research.
•Identify appropriate goals and interventions that are consistent
with the assessment, diagnosis, and theoretical orientation.
Discuss how these might be addressed within the treatment
sessions.
•Recommend psychometric tools that would be appropriate for

2. further assessing the client's needs based on background and
diagnosis. Justify your recommendations.
•Identify thoughts and behaviors that you would use as criteria
to determine readiness for successful client termination.
•Identify important legal and ethical issues and propose
resolutions. Support your resolutions with appropriate codes of
ethics and legal statutes.
•Use peer-reviewed sources to support your ideas throughout
the paper.
Format your paper consistent with APA guidelines.
4 goals – 3 short term and 1 long term each having 3
interventions = 12 interventions. No objectives only goals and
interventions.
CLIENT NAME: LIZ
DATE OF BIRTH:
PHONE:
PRIMARY LANGUAGE: English
EDUCATION:
REFERENCE BY: Friend
OCCUPATION: Homemaker
ASSESSMENT DATE: 01/05/2017
EVALUATED BY:
DESCRIPTION OF THE CLIENT The client is a 34-year-old
woman Hispanic female, dressed casually and neat, clean
clothing. She made normal eye contact, she spoke in expressive
voice, and appeared sad manifested by tears. PRESENTING
PROBLEM The client reports for the past two months her
experiencing hopelessness, depression and anxiety because of
negative core beliefs that she is inadequate, worthless and a
failure. The client reports “I have a lot on my mind, I feel
pressure like I cannot breathe sometimes and I get angry with

3. myself because I want to please everyone”. This has resulted in
symptoms that are diminishing the enjoyment of her life. The
client’s automatic negative thoughts that she is worthless and a
failure has caused the client to stop doing things that used to
bring her pleasure. The client reports that all of these emotions
and conflict is affecting her. The client states she is tearful,
always tired; restless; unable to feel pleasure; ambivalent
suicidal ideations; anxious, unable to sleep; hopelessness; loss
of appetite; despair; and fear.
HISTORY OF PROBLEM The client reports that she and her
husband have relationship conflict and communication problems
which lead to arguing. The client states “he pushed and slapped
me, he said that he would kill me or hurt me in front of my
children. I felt the abuse was escalating so I took the children
and moved in with my mother”. For the past two years her
husband started drinking heavily and the physical abuse is
escalating. She has been living in fear that he will kill her. This
negative core belief has a caused automatic negative thoughts
that allowed years of mental, emotional, and physical abuse
from her husband. These automatic negative thoughts have
contributed to the client’s depression as a result, she has left her
husband and moved in with her mother. The experience of the
separation from her husband has triggered negative core beliefs
that she is inadequate, worthless, and undesirable, and
reinforces, or activates, her automatic negative thoughts.
MENTAL STATUS
What happened to you or made you decide to make the
appointment today as opposed to a few months ago? She has not
been feeling well don’t have the energy to do things needs more
and looking gofer answers she’s here to try to find help and
figure out what direction to go with.
What is going on with your life? About 2 months ago she moved
out of her home to her parent’s house with her 2 children oldest
is 9 boy, and 7 year old girl. Husband is a little abusive, she
does not want to be there. She feels safe at mom’s house.

4. Doesn’t know if she did the right thing. She has been married
for 10 years.
Tell me a little about the abuse?
Abuse wasn’t big he occasionally pushed her a couple of times
slapped her, verbally abusive, escalated it got worst so she
ended up leaving.
Was there abuse early on the relationship?
Early in marriage didn’t think it was abuse, we fought argued
got in my face pushed in my face didn’t think anything of it.
Got worst during the years. (Crying am sorry)
Therapist? Asked if she was afraid to move out? She said she
was slapped in front of the kids, hurt her, threatened to kill her
and hurt her. Didn’t want kids to see that anymore got scared.
Therapist? Did he abuse the kids? NO. (Seriously) But last time
the kids were scared they were yelling at their father to stop!
(She’s crying holding back) they did see that and I felt so guilty
Therapist? Good job keeping the kids safe. Has he tried to call?
Yes calling her mother’s home and mother tells her she should
return his calls and answer his calls. She doesn’t know if she’s
taking the kids away from their dad. She feels that she is taking
them away. She doesn’t know if she needs to go back home
maybe he will change.
Your mother keeps telling her she should go back home. Mother
encourages her to go back home. She wishes her mom would
stop. She feels angry every time her mother tells her to go back
home. Mother feels that kids are missing out on good parenting
if she doesn’t go back.
So she’s encouraging you to go back? A little angry at first the
more I talk about it I don’t know if it’s the best thing.
Is that what you want or your mother? Sometimes she’s not
sure. Sometimes she wants to go back home to feel like a
family. At her house she had her family, her house, her space,
time. (Crying)
Gives her credit will work to clarify what she wants and needs.

5. Tell me a little about your culture beliefs?
Culture beliefs or spirit believes that are causing you distress? –
am Mexican we have certain values, married to stay married she
was born in the US or Mexico no here... Sometimes she wonders
if her values is the reason to go back home. Her mom has
experienced this before she’s wises and has been down the road
before. Her own mother has been in an abusive marriage with
Liz father. Dad would hit her mom. At times mom would not
come out of the room because of the bruises on her body. Her
father ended up leaving her mother anyways.
Did he abuse you and how did affect you? Father never abused
Liz but witnessed mom abusive life. She plays it in her head and
she doesn’t want her kids to feel like her.
So you have been down this road before did your mom ever get
remarried? She feels like she is relieving the same story. What
if she doesn’t get remarried again Liz mother never got re
married, she works, and raised the kids. Liz mother tells her
that she thinks she still loves her husband and that is why she
should go back. Her dad was pretty abusive her dad would hit
her. Everything her mother did was about her kids.
What is one of your strengths personality something that will
get you through? I love my kids I love my mom I think I love
my husband.
Therapist? Do you have a support group? Not too many friend.
One friend her name is Karen. Pretty much there for Liz for the
past 1 year. She is funny, crazy normal woman, listens doesn’t
judge me, cares and suggested to seek counseling and I dint
want to I thought it would be a waste of time but lately I
haven’t been feel well I feel like am against the wall.
Feelings? Liz is not feeling well, she feels like she is against a
wall right now.
Sleeping? Don’t sleep, wake up can’t sleep last night up till
2am can’t sleep. Feels pressure in head, lots of thoughts, don’t
want to be at her mom’s house, feels like she’s not pleasing her
mom and her husband and hurting her kids don’t want to do that
anymore. She doesn’t want to hurt kids and everyone. (Crying

6. deeper)
Anxiety before it’s like you described it raising thoughts, heart
pounding, pressure, not feeing well? Liz stated that it sounds
about right. She can’t get up to get the kids ready for school she
falls asleep till 2am, thinking about the kid’s feelings all the
time. Don’t want to do anything, hard time getting up, feels
exhausted no energy, waking up to do the same thing over and
over again. Feels like its getting worst since she moved out. It
started with her wanting to leave when she finally left.
She wants to leave her mom house, she doesn’t know if kids are
happy, kids talk to dad over the phone and she avoids talking to
him because he can convince her to come home. So she hasn’t
really talked to him
What brings you joy during the day makes you feel good? My
Kids, family, sister, she’s cool, friends, younger sister is
independent not married with a career, no kids, lives in
Washington now. Pretty amazing life. Sister asked her to find a
job and move to Washington with her. She doesn’t know if she’s
ready for that. Sister is pretty smart and has everything.
What do you think about moving it sounds exciting? I’m not
ready for that what do I bring to the table she has a career she’s
pretty she’s smart,
Have you ever thought that about yourself? I don’t feel that am
pretty and smart like her sister. I only remember getting married
and having kids that’s her role that’s her life what will she do
out there. She doesn’t want to be extra baggage to her sister.
If you stay or move will you follow your mother’s footsteps?
She doesn’t know she didn’t get married to be alone she married
to be married and do what’s right. Liz stated if she stays with
her husband she’s afraid she will up like her mom. She didn’t
get married to have a broken home. She needs to stand up to
make it right. She mentioned that her husband Robert is
Mexican and that is the values to go by being a Hispanic family.
Husband does apologize after he abuses her and it has gotten
worst. Doesn’t know if he meant it or just saying it so she can
stay when she was living at home.

7. It almost sound like you have 2 options – to go back to him or
to follow your mom’s steps.
Any possibility of a third any hopes for that? What else could
there be, I have no options right now.
Do you have any hopes in your day to day activity that makes
you smile or think about the future? Go back to school get a job
or something
Do you get tired even when you don’t get a full night sleep you
think the fatigue is because you don’t sleep? I think it’s a lot on
my mind, even when I sleep I still feel tired, pressure that I
can’t breathe, thoughts of uncertainly am I doing the right thing
am I abusing my kids am I hurting my kids.
In what ways? I mean I took them away from home and their
dad from what they have known and their comfort zone.
When your mom younger did you wish your mom would have
stayed? YES (seriously voice)
How do you handle those thought I mean your experiencing
those things again?
Liz feels angry at herself right now if this is supposed to be life.
Now she’s wondering if this is supposed to be her life.
It sounds what you have been experiencing at childhood and
marriage you have a lot of opinions you carry that every day? I
can’t please everyone I feel it
Eating, exercise any fresh air these last two months? If it’s a
positive vie lost weight, rarely eats, no appetite, don’t feel like
eating, makes kids good but makes them eat. It’s hard to take
showers, she doesn’t put make up on anymore, feels no pleasure
in getting ready or trying to look good.
Thoughts of hurting yourself? Anyone else? My objective is for
you to be safe and built trust. She doesn’t want to be here
anymore,
If you do it, how would it be? She said what if the kids were
better off wouldn’t disappoint mom if she wasn’t here, right
now she feels like she’s hurting people she loves.
What about you hurting yourself, will you keep yourself safe?
How often are the thoughts of hurting yourself? I loved to be

8. happy could love for things to be perfect but don’t know how to
fix it. I don’t know how.
This is an important step you made an appointment and showed
up today. This shows you have hope because you’re here start to
feel the hopeful and build on it. Means possibility to feel better.
It takes a lot of courage. You being here tells me there’s hope
possibility that you can feel better and you will find the answers
that you’re needing.
I’m concern that you’re coming down pretty hard on yourself
with yourself and sounds that Robert caused the pain and you’re
trying to heal it. Robert is a good man deep inside wish I could
help him change.
Did your mom change your father? I don’t know I was little
girl. I tried to he smiled laughed and play full. I thought he was
happy then he would pick fights with mom full blown fights
next time you know she was his punching bag. (Sad)
It feels like when you were a little girl you were afraid and
weak? I never thought about it.
What was it about your sister to move to Washington why do
you think she did that? My sister moved to Washington because
she had a bigger better dreams. Always said she wanted to
explore the world she didn’t want to be like mom.
What is her relationship with her and your mother? Pretty good
relationship with mom, Mom likes to talk trash because her
sister is not around not available.
Sister calls and tells her she loves her, checks in to see if she’s
ok and if she needs anything. She supports her to move forward.
Both her sister and Karen her friend want her to live a different
life. Don’t know is she has the energy and the confidence.
Tell me about a time when you had energy and confidence? I
was much younger 18 or 19 years old more energy and
confidence. (She nods yes) Hasn’t thought of younger self till
now. (Smiles and holds back tears)
Do you ever go out with Karen? Yes for lunch we hang out of
course I have no money so they cook at her mom’s. Burritos you
know or chorizo, (she smiles) When she’s around Karen she

9. feels good she smiles and she’s a good friend. (Calm secure
about what she said)
What’s your mood day to day give me a family history are you
smoking cigarettes are you using any substance any careen to
help you cope? I suppose I probably would take up drinking or
smoking but Ican’t afford anything don’t smoke or drink only
drink coffee to stay awake during the day doesn’t help. Always
tired confused during the day and night can’t sleep.
Any history of substance abuse in family or marriage with
Robert alcohol or drugs? Robert Drinks on weekend gradually
became a problem drank during the week she was ok with him
drinking only drinking on the weekends and going out. Slowly
started to drink all the days of the week sometimes he wouldn’t
get up to go to work on time. Call him out he gets angry.
Every any relationship between the abuse and drinking? Yes he
thought it was ok, He would yell at her even for the smallest
things telling her she was worthless, wouldn’t amount to
anything, she couldn’t make it on her own, she would never
leave him.
Sorry to hear that. Anyone in the family with substance abuse?
My dad was a drinker. They knew when dad drank it would
probably turn out into a fight with her mother. Liz felt angry
with her mother because she never left her father. Right now
she doesn’t want her kids to feel the same way any with her
either.
This is understandable for all this to be a conflict. Like I said
there’s a lot of hope and we will build upon this. We will
proceed with our next appointment. (End of movie) no age was
given looks to be in mid 30’s, no education level was given
only that she would go back to school.

10. This paper was from 2015 and they used something else not the
new DSM 5 to get the diagnosis.
its old but this is what the movie was about to give you an idea.
Try to use my friends outline and different wording please as
they check
DESCRIPTION OF THE CLIENT
The client is a 34-year-old woman Hispanic female, dressed
casually and neat, clean clothing. She made normal eye contact,
she spoke in expressive voice, and appeared sad manifested by
tears.
PRESENTING PROBLEM
The client reports for the past two months she experiencing
hopelessness, depression and anxiety because of negative core
beliefs that she is inadequate, worthless and a failure.
The client reports “I have a lot on my mind, I feel pressure like
I cannot breathe sometimes and I get angry with myself because
I want to please everyone”. This has resulted in symptoms that
are diminishing the enjoyment of her life. The client’s
automatic negative thoughts that she is worthless and a failure
has caused the client to stop doing things that used to bring her
pleasure. The client reports that all of these emotions and
conflict is affecting her. The client states she is tearful, always
tired; restless; unable to feel pleasure; ambivalent suicidal
ideations; anxious, unable to sleep; hopelessness; loss of
appetite; despair; and fear.
HISTORY OF PROBLEM
The client reports that she and her husband have relationship
conflict and communication problems which lead to arguing.
The client states “he pushed and slapped me, he said that he

11. would kill me or hurt me in front of my children. I felt the
abuse was escalating so I took the children and moved in with
my mother”. For the past two years her husband started drinking
heavily and the physical abuse is escalating. She has been living
in fear that he will kill her. This negative core belief has a
caused automatic negative thoughts that allowed years of
mental, emotional, and physical abuse from her husband. These
automatic negative thoughts have contributed to the client’s
depression as a result, she has left her husband and moved in
with her mother. The experience of the separation from her
husband has triggered negative core beliefs that she is
inadequate, worthless, and undesirable, and reinforces, or
activates, her automatic negative thoughts.
MENTAL STATUS
Activity: The client displayed her attitude as open and
somewhat guarded. Motor activity level demonstrates
psychomotor regularity, frequently moving her hands to wipe
tears away. Her speech is of regular rate and rhythm; eye
contact is fair.
Mood and Affect: The client appeared sad with tearful affect,
which was congruent with mood and appropriate to content.
Thought Process, Content, and Perception: The client denies any
auditory and visual hallucinations and has coherent thought
process. The client has difficulty sleeping due to constant
preoccupation and rumination of thought of hurting her children
by taking them away from their father or should she return to
him.

12. Cognition, Insight, and Judgment: The client is oriented to time,
place, person, and situation. The client demonstrates average
intelligence, has clear cognition, and intact memory for recent
and remote items. The client has slightly impaired insight and
judgment.
Physiological Functioning: The client appeared to be in good
health but reported she has lost some weight because she does
not feel like eating. The client states “I feel pressure like I
cannot breathe, am I hurting my kids because I took them away
from their father”. She denied use of alcohol or illicit drugs
however she drinks coffee to stay awake during the day.
Suicidal and Homicidal Assessment: The client reported having
thoughts about ending her life. She voiced ruminating thoughts
“I do not want to be here because I am not pleasing my
children, husband, or mother”. She states, these ruminations are
fleeting thoughts with no plan. Therefore, she is considered a
possible danger to self. The client denied any homicidal
ideation or ruminations.
SOCIAL HISTORY
The client reported that she is separated, unemployed, and has
two children, a nine-year old boy and a seven-year-old girl. She
has been married for ten years. She states early in her marriage
they would argue and yell. The first year of marriage was fine
but her husband started emotionally and physically abusing her.
With the help of her close friend she left her husband and has
been living with her mother for the last two months. She has not
spoken to him since she left. This event has triggered negative
core beliefs that she has failed as a parent for not keeping the
family together. Her sister supports the decision to leave her
husband and wants her to come to Washington for a fresh start.
But now, the client states he continuously apologizes by
sending gifts and begs for her to come back home. The client
also reports that her mother suggest that she return home so the

13. children will not suffer from not having their dad.
The client’s family of origin lives in California and consists of
her mom and younger sister. Her father was a truck driver and
her mother was a stay at home mom. The client reported her
father past away from a heart attack over five years ago, and her
mother never remarried. The client states her father was “a
drunk and abusive towards my mother”. The client states her
mother instilled Christian and cultural values and beliefs that
family is everything. Once you get married, your husband is the
head of the
household and you are to obey and never get divorced so the
children will have both parents. These thoughts are part of the
client’s core belief from the way she was raised. The client
reported her father was would yell, call her mother names, tell
her “she is worthless and without him she is nothing”. These
thoughts and feelings are part of the clients’ negative core
beliefs that she is inadequate and worthless because of her
upbringing. The client states her “father would hit her in front
of us and she would not come out of her room for days because
of the bruises. We were afraid all the time especially when he
would drink”. The client reports her mother would blame herself
for the abuse and try harder not to make him angry and do
everything her husband would tell her to do, because he was all
she had. These faulty core beliefs followed the client into her
marriage reinforcing her faulty cognition of what a marriage is
supposed to be.
The client and her sister are very close. Her younger sister was
determined to get out of the house and not end up like her
mother. Once she graduated from high school she went away to
college in Washington and found a job after she graduated from
college and rarely returns home. The client’s younger sister is
not married and has no children. The client was an average

14. student in school. She only had a few friends with whom she
shared activities and phone calls. She had no serious illnesses
and lived in the same house all of her life. The client attended
college for about two years and received an Associate’s Degree
in Business Management. She worked as an Administrative
Assistant until she got married and had her first child then
became a stay at home mom. She has one close friend with
whom she hangs out with.
LEGAL ISSUES
The client has no legal concerns. However, client is currently
separated from her husband.
ETHICAL CONCERNS
The client was given consent forms and understands the
confidentiality, HIPPA, reporting laws, etc. The client received
a thorough risk assessment.
THEORETICAL PERSPECTIVE JUSTIFICATION
Cognitive Behavioral Therapy (CBT) is a counseling model that
increases the client’s understanding of how thoughts and
behavior are connected to emotions. The clients’ upbringing and
exposure to negative childhood experiences of seeing her
parents fight have created her cognitive distortions. The
cognitive distortions she learned from her mother in childhood
have persisted to adulthood. This faulty belief system have
created negative thinking patterns that have been evident
throughout her life creating hopelessness and despair. The
client’s family background and exposure to negative childhood
experiences have produced her cognitive distortions. The
cognitive distortions she learned from her mother in childhood
have persisted into adulthood.
DISCUSSION
CBT helps to address and change negative thinking patterns and

15. behaviors associated with depression while teaching how to
change the behavioral patterns that contribute to
her depression. Changing the behavior can lead to an increase in
thoughts and mood. CBT can help the client identify her
automatic thoughts and maladaptive behaviorism so she can
develop an accurate schema through which to filter her daily
interactions. The client should be tested for Folstein Mini
Mental Status Exam, Beck Anxiety Inventory, The Beck
Depression Inventory (BDI) this scale would be helpful to
measure his depression. Columbia-Suicide Severity Rating
Scale is a questionnaire used to assess suicide. This measure
can be used by any professional. This instrument is needed to
help determine the severity of suicide in the client. To
determine if he is just thinking about it because of the break up
with his girlfriend or was this something he has been thinking
about for a while.
DIAGNOSIS
Major Depressive Disorder
Depressed mood most of the day, nearly every day, as indicated
by either subjective report or observation made by others.
Markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day.
Significant weight loss when not dieting or weight gain, or
decrease or increase in appetite nearly every day
Insomnia or hypersomnia nearly every day. Fatigue or loss of
energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt
nearly every day.
Diminished ability to think or concentrate, or indecisiveness,

16. nearly every day (either by subjective account or as observed by
others).
Recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or
a specific plan for committing suicide.
The symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
The episode is not attributable to the physiological effects of a
substance or to another medical condition.
The occurrence of the major depressive episode is not better
explained by schizoaffective disorder, schizophrenia,
schizophreniform disorder, delusional disorder, or other
specified and unspecified schizophrenia spectrum and other
psychotic disorders.
There has never been a manic episode or a hypomanic episode.
With Melancholic features
Loss of pleasure in all, or most activities
Lack of reactivity to usually pleasurable stimuli
A distinct quality of distressed mood characterized by profound
despondency, despair, and/or moroseness or by so-called empty
mood.
Early morning awakening Significant anorexia or weight loss
Excessive or inappropriate guilt
POSTTRAUMATIC STRESS DISODER F 43.10
Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways:

17. Directly experiencing the traumatic event(s).
Witnessing, in person, the event(s) as it occurred to others.
Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the
traumatic event(s) occurred:
Recurrent, involuntary, and intrusive distressing memories of
the traumatic event(s).
Intense or prolonged psychological distress at exposure to
internal or external cues that symbolize or resemble an aspect of
the traumatic event(s).
Marked physiological reactions to internal or external cues that
symbolize or resemble an aspect of the traumatic event(s).
Persistent avoidance of stimuli associated with the traumatic
event(s), beginning after the traumatic event(s) occurred, as
evidenced by one or both of the following:
Avoidance of or efforts to avoid distressing memories, thoughts,
or feelings about or closely associated with the traumatic
event(s).
Negative alterations in cognitions and mood associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the
following:
Persistent and exaggerated negative beliefs or expectations
about oneself, others, or the world (e.g., “I am bad,” “No one
can be trusted,” “The world is completely dangerous,” “My
whole nervous system is permanently ruined”).

18. Persistent, distorted cognitions about the cause or consequences
of the traumatic event(s) that lead the individual to blame
himself/herself or others.
Persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame). Markedly diminished interest or participation
in significant activities.
Feelings of detachment or estrangement from others.
Persistent inability to experience positive emotions (e.g.,
inability to experience happiness, satisfaction, or loving
feelings).
Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the
following:
Problems with concentration.
Sleep disturbance (e.g., difficulty falling or staying asleep or
restless sleep).
The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
The disturbance is not attributable to the physiological effects
of a substance (e.g., medication, alcohol) or another medical
condition.
SPOUSE OR PARTNER VIOLENCE, PHYSICAL,
CONFIRMED
T74.11XD Subsequent Encounter

19. Psychosocial Stressors
The client has problems with primary support which is her
mother who wants her to return to the violence for the children.
RECOMMENDATIONS
1. Complete homework assignments
2. Become more active with family, friends, or social groups
3. Join a gym or start an exercise regimen
TREATMENT PLAN
Short-term Goal #1
The client will continue to decrease her frequency of automatic
negative thoughts of wanting to end it all or die.
Interventions for Goal #1
The client will decrease her frequency of these thoughts from
20 times a day to 15 times a day by journaling to identify
thoughts, feelings and behaviors before during and after
stressors.
Short-term Goal #2
The client will continue to decrease her frequency of negative
self-statements.
Interventions for Goal #2
The client will identify and alter irrational or negative self-
statement and replace them with positive statements.
The client will journal to identify thoughts, feelings, and
behaviors before, during, and after stressors.
Short-term Goal #3
The client will plan and complete one pleasant or social activity

20. per week.
Interventions for Goal #3
The client will increase the ability to find evidence to the
contrary of negative emotions with higher levels of positive
emotions through the use of mood monitoring.
Long-term Goals
The client will also continue to journal and use thought records
to identify her stressors.
REFERALS
The client will be referred to physician and psychiatrist.
EVALUATION OF COUNSELING PROGRESS/PLAN
The counselor will use a cognitive behavioral approach. The
sessions will be once a week for five weeks, then once every
two weeks if appropriate, until symptoms have improved. At
that time, the counselor and client will determine a plan for the
future course of sessions.
The client is a 34-year-old Hispanic woman in a marriage that
has experienced depressive symptoms, anxiety, ruminating
thoughts, and catastrophizing with ambivalent suicide ideations.
The goal is to help identify her automatic negative thoughts and
negative core beliefs with the process of cognitive restructuring.
Cognitive restructuring helps replacing these unhealthy thinking
patterns with positive self-statements. The client will be given
homework of journaling and completing a thought record to aid
her in identifying her stressors and prompting her positive self-
talk. The client will continue to actively participate in
approximately 20 cognitive behavioral therapy sessions one
hour a week to ensure progress with anxiety, mood, and
depression.

21. Running head: Treatment Plan: Alexandria Wright
1
Treatment Plan: Alexandria Wright
10
Example of friend’s paper on another case
you can use this outline to guide you
Treatment Plan: Alexandria Wright
Description of Client:
Alexandria Wright is a 36-year-old Caucasian female who
appears older than her stated age. She was well groomed,
average height, and overweight. She was respectful and
cooperative throughout the interview; however, at times she did
appear defensive. She is married and has two sons ages five
and seven. Her parents are both deceased with her father
passing away a year ago. Alexandria also has three sisters with
a three-year gap between them. She is also highly educated and
works as a Certified Public Accountant.
Presenting Problem:
Recently, within the last month, she has had a return of the
feelings of sadness present after her father death a year ago.
According to the client, she is experiencing this recurrence
because of issues associated with her father’s estate.
History of Problem:
Alexandria reported having been in psychotherapy a year ago
after her father’s death, and reported that it helped her.
However, in the last month she has been dealing with settling
her father’s estate, and it has brought back the feelings of
sadness. She describes her sadness as feelings of annoyance,
especially toward others. Although she initially reported
sadness as her primary issue she quickly shifted the focus to

22. family problems that months ago were not present. According
to, Alexandria the family problems began as soon as, at the
request of her father, she started functioning as the executor of
her father’s estate. She also reported that besides being
assigned the executor of her father’s estate his wish was that the
family divided everything equally to prevent any family
discord. To ensure aforementioned occurred she and her
siblings decided they would prohibit their spouse’s involvement
and input in their father’s estate.
Despite the agreement made she has been experiencing
interference from her brother in-law Bruce. She reports he is
not in agreement with the value and prices she has placed on her
father’s belongings. This is causing her to feel agitated,
annoyed, unappreciated, and insulted. It also has caused them
to argue and have conflict between them. According to
Alexandria these feelings stem from having invested a large
amount of time and effort placing value on her father’s
belongings. She also believes he is criticizing her ability to
handle being the executor of the estate even though she is an
accomplished certified public accountant (CPA).
Additionally, this has caused conflicts with Bruce’s wife
Elizabeth, who is her younger sister. She believes Elizabeth
should put a stop to his interference and criticism, and by not
doing so is choosing Bruce over the agreement they made. She
also believes Elizabeth’s behavior is inappropriate at times
because of her impulsivity, spontaneity, and growing up with no
boundaries or guidelines. Thus in effect causing her to be upset
and irritated with Elizabeth.
Mental Status:
Her eye contact was good. Her affect was appropriate to the
context and situation. She was oriented to person, time, and
place. Her motor activity was overly calm. Herattitude was
cooperative and focused; however, easily defensive. Her speech
was coherent and of normal rate, rhythm, and tone. She also
reported no past or current history of suicidal or homicidal

23. ideations or plan and intent. She did not experience visual or
auditory hallucinations. Insight and judgment appears within
normal range. Thought content was free of phobias, delusions,
and ideas of reference.
Social History:
Alexandria reported having a normal childhood with nothing
unusual occurring. Her parents had clear expectations and rules,
and they had high expectations for her. Despite their rules and
high expectations she had a good relationship with them. She
was well organized and a responsible child. She was also very
tidy, clean, and liked order. She also grew up with three sisters
with a three-year gap between them. Alexandria reported that
they were named after royalty, and her parents treated them as
such. She was closest to the oldest sister because they had
many things in common. This close relationship continues to
hold true as adults. Alexandria reported some of her proudest
achievements included becoming her high school valedictorian,
graduating magna cum laude for both her bachelors and masters
degrees, and getting her CPA on the first try.
Currently, she is married and has two sons ages five and
seven. Her husband is an automotive engineer and her children
attend elementary school. She has a CPA and currently works
as an accountant. She describes her life as very organized and
structured. For instance, they get up every day at the same
time, eat at the same time, clean their home every Monday, do
laundry only on Tuesdays, and she helps her children with
homework the same time every day. Financially they follow a
strict budget and always save 10% of their income for their
son’s college education and emergencies. According to
Alexandria, life is easier having structure and order. Even
though she reports the need of having structure and order she
denied engaging in rituals, procedures, or obsessive thoughts.
Alexandria also reported that she organizes for fun and
organizing relaxes her. For instance, when on family vacations
she finds herself organizing the kitchens in her vacation homes.

24. Additionally, at times when organizing it is hard for her to stop
intrusive thoughts; however, she is always able to complete the
task. She also stated she is a hard worker not a perfectionist;
however, her sisters tell her she is a perfectionist. For example,
when planning a family vacation she will spend a significant
amount of time organizing and structuring the trip to the point
of annoying her family. She also will not consider delegating
tasks because of the belief that no one can do as well as her.
She reported concerns about her children’s education because of
inappropriate societal influences. She believes society has
taken a nose dive for the worse and would like to control what
her children learn in regard to morality and values. In fact, this
belief has caused her to consider home schooling her children.
Strengths and Assets:
Alexandria is a hard worker, is self-disciplined, and motivated
to treatment evidenced by her self-referral. This motivation and
insight as well as her self-discipline and work ethic will prove
beneficial in the implementation of goals and interventions.
She is also assertive, which in client driven and collaborative
therapeutic modalities will be a strength.
Diagnosis:
Axis I: 309.0 Adjustment Disorder with Depressed Mood,
Acute
Axis II: 301.4 Obsessive-Compulsive Personality Disorder
Axis III: None
Axis IV: Problems with primary support group-discord with
brother-in-law/sister
Axis V: GAF 61 (present)
Diagnostic Rationale:
Alexandriameets the criteria Axis I 309.0 because substantial
criteria indicators are met. The indicators are as follows: She
developed the emotional symptoms (sadness, annoyance) in
response to the stress of pricing her father’s belongings within
three months of beginning this task. This annoyance and

25. sadness is in excess of what would be expected from exposure
to this new stress in her life (her brother-in-law interfering with
the estate). Additionally, this is causing her significant
problems interpersonally with her sister and brother in-law.
Last, with the information gathered, she did not meet the
criteria for any other mood disorder or bereavement disorder
because her symptoms are not related to mourning the loss of
her father.
She meets the criteria Axis II 301.4 because four or more of the
criteria indicators are met. They are as follows (1) is
preoccupied with details, rules, lists, order, organization, or
schedules to the extent the major point of the activity is lost, (2)
is over conscientious, scrupulous, and inflexible about matters
of morality, ethics, or values, (3) is reluctant to delegate task or
work with others unless they submit to exactly his or her way of
doing things, (4) adopts a miserly spending style toward self
and others; money is viewed as something to be hoarded for
future catastrophes, and (6) shows rigidity and stubbornness.
Treatment Plan:
Mode:
With adjustment disorder the goal of therapy would be to have
Alexandria return to the level of interpersonal functioning prior
to the conflicts associated with the estate. Also to change the
maladaptive thoughts or behaviors she is using to respond to her
current stressor. In terms of the obsessive-compulsive
personality disorder the target would be Alexandria’s need to
organize (behavior) to feel a sense of control (feelings). The
premise of Cognitive Behavioral Therapy (CBT) is the link
between a person’s thoughts, feelings, and behaviors, thus I
would recommend this approach for Alexandria.
Frequency and Duration:
CBT is recommended weekly. The sessions would be one-hour
long for 12 to 14 weeks.

26. Referrals:
1. Referral to psychiatrist for an evaluation to determine
appropriateness of medication for symptom management.
2. Referral to her primary care physician to rule out any medical
condition that could be causing the sadness, such as a thyroid
problem or diabetes.
Goals of Treatment:
Short-Term Goals:
1. Will reduce arguments with brother in-law Bruce and sister
Elizabeth from seven times a week to five times a week.
2. Will improve coping and problem-solving skills to reduce
stress when confronted with a new problem or challenge.
3. Will engage in one pleasant activity a week that does not
consist of organizing or scheduling.
4. Will decrease episodes of organizing and structuring from
seven days a week to five days a week.
Long-Term Goals:
1. Will restore positive interpersonal relationships with her
brother-in-law and sister to the previous (one year ago) level.
2. When faced with a new problem, change, or challenge will
display effective coping and problem-solving skills.
3. Will be able to engage in three pleasant activities a week that
does not consist of organizing or scheduling.
4. Will decrease episodes of organizing and structuring from
seven days a week to once a week.
Interventions:
To improve Alexandria’s relationship with her brother in-law
and sister interventions provided would be:
a) First increase her awareness of her behavioral responses in

27. the relationship, her role in the conflicts as well as their
interpretation of her behaviors.
b) Assist in identifying inappropriate responses by having her
journalize her interactions and feelings when interacting with
Bruce and Elizabeth.
c) Practice appropriate verbal and behavioral responses to a
variety of anticipated situations via the use of role-play.
To improve her coping and problem-solving skills interventions
provided would be:
a) Teach her to identify what she has control over and what she
does not.
b) Educate on effective problem-solving techniques.
To increase her pleasant activities the interventions provided
would be:
a) Help her identify activities she could participate in that do
not consist of organizing and scheduling.
b) Use a calendar to have Alexandria schedule in the day of the
week she will do the activity.
c) Teach her the link between pleasant activities and the
decrease in her stress as well as sadness.
To assist in helping decrease her episodes of organizing and
structuring interventions would include:
a) Use the cognitive triangle technique to teach how her
thoughts about orderliness and cleanliness are affecting her
behavior.
b) Implement the thought stopping technique to assist in the
reduction of the obsessive behavior and thoughts.
c) Implement the deep breathing technique so she can relax and
self-soothe while attempting to decrease the obsessive-

28. compulsive urges and behaviors.
Prognosis:
Alexandria’s prognosis is good because she not only has the
motivation for treatment but also has the cognitive ability to
understand the interventions that would be provided in session.
Ultimately, treatment outcome will not solely depend on the
recognition that a problem exist but also relinquishing some of
that control despite the emotional stress it will cause.
Person of the Therapist:
The therapist recommended neuro-linguistic programming
despite the fact the he was not competent in this technique
having attended only one seminar. As therapist we cannot treat
or use interventions beyond our scope of practice or
competencies. During this session the therapist exposed himself
in transference by saying he knew who Bruce was and even
mentioned his last name. The therapist told the client he work in
the same company and even shared personal information about
Bruce. Therefore, the client felt in her confront zone and asked
the therapist to speak to Bruce and tell him to maintain away
from her business. Even though the therapist stated he could not
do that because it was unethical this can still have some ethical
or legal concerns as it can cause a dual relationship or even risk
breaking confidentiality laws. In this situation I would have
asked the client if she had a problem with me as her therapist
because I knew her brother in-law. If she did have a problem I
would transfer the case to prevent a multiple or dual
relationship. If it was not a problem I would reinforce
confidentiality as well as setting clear boundaries.
Also, the therapist interrupted the client numerous times.
For instance, he consistently interrupted to make inferences of
what she was feeling, what she did or said. Even though
summarizing of feelings is an appropriate therapeutic technique
he did not reflect the clients feelings effectively.
I would also have liked the therapist to obtain more information

29. on the client’s sadness to assist in ruling out a mood disorder as
well exploration of indictors of associated with bereavement.
It also would have been helpful to explore impairments in an
area of life functioning other than socially/interpersonally. For
example, it was not clear if her extreme organizing is affecting
her at work, with her activities of daily living, or with her
physical health. It is assumed with the limited information we
obtained she is not. He also never asked about substance abuse,
legal history, mental health history, explored culture factors, or
assessed for trauma.
Reference
American Association for Marriage and Family Therapy
(AAMFT). (n.d.). Code of Ethics. Retrieved from
http://aamft.org
American Psychiatric Association (2000). Diagnostic and
Statistical Manual of Mental Disorders (4th ed; text rev.).
Washington, DC: Author.