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Head: CASE PRESENTATION | INTERNSHIP I 1

CASE PRESENTATION | INTERNSHIP I

ALFA RODRIGUEZ

NEW JERSEY CITY UNIVERSITY

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Number of Sessions to Date: 5

BACKGROUND INFORMATION

K.S. is a seventeen-year-old African-American female from a middle class home. The

client lives with her mother and is currently a senior in high school. Shes also

employed part-time at a super market. The client does not identify herself with any

religious organizations or spiritual organizations. Shes currently involved in a

relationship with a female school classmate and her sexual orientation is

homosexual.

PRESENTING PROBLEM

The client was referred to The Bridge by the court after she was involved in a

physical altercation with a friend nearby her school. Her initial and current problem

include her inability to control her anger. K. is in need of education about anger and

its negative consequences and she is also in need of learning anger management

skills. The treatment goal is for the client to learn coping skills to manage her anger.

The skills that the client will be introduced to during the course of treatment include

but are not limited to counting to ten, walking away, deep breathing, thinking of the

consequences and expressing the anger.

ASSESSMENT

Biopsychosocial History - The client has no history of previous counseling

treatments nor prior medical treatments.

Family and environmental factors - K. was raised by her single mother, however, her

father was actively present in the clients life until 2013 when he was incarcerated.
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The client reports having a better relationship with her father, as he understands

her better than her mother. The client also reports she has not been able to visit

her father in jail for the past 18 months due to him being moved to another jail.

However, she hopes he will be out of jail by May of 2017 so that he may be present

at her high school graduation. The client also has a half brother on her fathers side,

who she rarely sees; she also has an older sister.

Observations K. was very quick to build rapport with me. This is evident by her

verbatim during our first session. She did most of the talking during our first session

and indicated that she felt comfortable talking to me. She always has a smile on her

face when she comes to the session, even during the days she expresses how tired

she is because of all her responsibilities.

Formal an informal assessment The client appears to understand the gravity of not

managing her anger. Shes able to reflect on the consequences of her behavior after

she has already experienced anger outbursts. The three hours that she spent in jail

also made her reflect on the importance on controlling her anger. Instances of anger

and frustration mainly occur at home with her mother, in the school and sometimes

at work. She finds it easier to apply coping skills at work than at home or in school.

K. appears to be making efforts in treatment, shes always on time, rarely misses any

sessions and is fully cooperative and an active participant of her treatment.

However, K. seems to be having some resistance in completing her homework

assignment. This issue is further discussed during the self-critique portion.

Needs the client is in need of psychoeducation on anger management. The client

would also benefit from having a better support system that includes spending more
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quality time with her mother. As the client reported, some days she does not get a

chance to see her mother due to their conflicting work schedule.

CLINICAL DIAGNOSIS AND TREATMENT

The client would benefit from the use of the Cognitive Behavioral Therapy and the

Person Centered Theory. The Person Centered approach would benefit the client as

it creates a safe environment for her to discuss her anger issues by therapist use of

unconditional positive regard where The clients experiences, positive or negative,

should be accepted by the therapist without any conditions or judgment. In this way,

the client can share experiences without fear of being judged. (Good Therapy, N.D.)

Whereas the Cognitive Behavioral Therapy will enable the client to focus on

solutions to her anger management by encouraging her to challenge and change her

destructive patterns of behavior.

Based upon the presenting problem and the information provided by the client and

the counselors assessment, the clients differential diagnosis with multi-axial

assessment is as follows:

Axis I F43.24 Adjustment Disorder with Disturbance of Conduct

Axis II - V71.09 No Diagnosis on Axis II

Axis III - No medical conditions stated

Axis IV Economic Problems

Taking into consideration the adjustment disorder diagnosis, the client would also

benefit from the use of Cognitive Behavioral Therapy as this approach can help the

client in recognizing her feelings, First the therapist helps you recognize the

negative feelings and thoughts that occur. (Medlineplus, N.D.) In addition, with the
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use of CBT, the client will also learn how to change her behavior, Then the therapist

teaches you how to change these into helpful thoughts and healthy actions

(Adjustment Disorder, n.d.) Another benefit of this approach is that the client Is

encouraged to break down the thoughts, feelings and behaviors that trap them in a

negative cycle and they learn skills and strategies that can be applied in everyday

life to help them cope better. (Jerry Kennard, n.d.) According to an article by

Counseling Directory, Cognitive behavioral therapy looks at how both cognitive and

behavioral processes affect one another and aims to help you get out of negative

cycles. (n.d.). This would be particularly important for my client as this will enable

her to gain understanding of how her anger is interconnected. In addition, the use of

this approach as it relates to her current diagnosis will assist the client to Improve

age-appropriate problem solving skills and communication skills (Commomwealth

of Virginia, n.d.)

INTERVENTIONS

Goal 1: Provide client with education about anger

Interventions:

The client will be introduced to anger and will be educated on how anger can be

considered as a secondary emotion.

Goal 2: Learning of anger management skills

Interventions:

Use of CBT to teach the client the following anger management skills

1. Recognizing anger early

2. Counting to 10
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3. Take time out

4. Deep breathing

5. Expressing anger

6. Thinking about the consequences

SELF-CRITIQUE

The client seems to have a clear understanding of the detrimental consequences of

her lack of anger management. This is evident by her verbatim when discussing her

arrest and other incidents where she has not been able to control her anger.

Throughout the course of the therapy sessions, she reports she has been able to

implement the counting to ten, inhaling and exhaling and the talking out technique.

She reports she has been able to moderately control her anger at times, however,

she fails to implement the technique at instances where her anger builds up quickly.

An impediment to her progress has been her lack of commitment to completing her

homework assignments that include documenting the anger triggers, warning signs,

her response and outcome. As per the feedback received from my class instructor, I

tried to discuss her resistance to homework due to the fact that as of our last session

on November 16, the client has not been able to complete the assignment. During

the last session, she reports that she was able to complete the assignment but she

indicated she forgot the notebook in class where she wrote it and that when she

went back to the classroom, it was no longer there. I reminded her the importance of

having her homework assignment done and I gave her the suggestion one of my

clients mentioned in class of writing the note on her phone or using the phones
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audio system. The client agreed to write the note on her phone and indicated she

will bring it to our next session.

References
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Adjustment Disorder. (n.d.). in MedlinePlus. Retrieved November 10, 2016 from

https://medlineplus.gov/ency/article/000932.htm

Kennard, J. (n.d.). Benefits and limitations of cognitive behavioral therapy (CBT).

Retrieved November 10, 2016 from

http://www.healthcentral.com/anxiety/c/4182/165578/benefits-

limitations-treating/

Cognitive behavioural therapy. (n.d.) In Counseling Directory. Retrieved November

10, 2016 from http://www.counselling-directory.org.uk/cognitive-

behavioural-therapy.html

Adjustment Disorders. (n.d.) in Commomwealth of Virginia. Retrieved November 10,

2016 from

http://vcoy.virginia.gov/documents/collection/Adjustment%20Disorders_1.

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