Case Presentation 1 And Treatment Plan Counseling Case Presentation Paper

2734 words - 11 pages

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COUN 699 – Case Presentation 1 – “Ann”
__________________ University
Case Presentation 1 – “Ann”
Demographic Information
“Ann” is a 29-year-old, white female who is a single mother of three children ages 9, 3, and 18 months. She has never been married but lived with the father of her two youngest children until approximately a year ago and is now living with her mother and younger brother. Her youngest two children visit their father every other weekend, but client states she has not seen the father of her oldest child since 2009. Client states she does not have many close friends, “does not like people”, and spends most of her time, when she is not working, at home with her mother and children. When she does go off anywhere it is with her mother. Client works in a factory in an assembly line position and reports “this suits me just fine because I don’t like people anyway”. Ann is one of the main financial supporters of the home along with her younger brother. Her mother does not work outside of the home, but cares for the children while client works.
Client reports she does not have any significant health history. According to her mother she met all her developmental milestones. Client states she did not have any problems in school except with reading, which was due to her inability to focus. Client reports her three pregnancies were normal and uneventful and her children were born healthy.
Presenting Problem
Client was first referred approximately a year ago by her Primary Care Physician due to her not responding well to Zoloft and her increasing symptoms of anxiety and depression. Her PCP started her on 50 mg of Zoloft, titrating up to 100 mg and client continued to experience irritability, anxiety, and increasing depression. PCP lowered the client’s dose back down to 50 mg and referred her for mental health evaluation. Client’s previous PCP had prescribed Celexa, which client took for about a year without positive effect. Client reports she feels hopeless about not only finding a medication that will work for her, but getting answers as to why she feels the way she does.
On intake interview client states her present concerns are “mostly issues with anger, anxiety, and depressed moods that started when I was younger”. Client complains of the following symptoms: Aggression (anger outbursts, racing thoughts), depression (difficulty concentrating, difficulty thinking, easily distracted, irritability), anxiety (dizziness with panic attacks), loneliness, poor self-esteem, social isolation, feelings of worthlessness, hopelessness, headaches, and muscle tension.
Client’s current stressors include conflicts with her mother typically regarding money or client’s high levels of irritability, financial problems, long hours at work, and difficulty managing her 3-year-old daughter’s behavior. Client’s main anxiety trigger seems to be an increa...


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