Sample Case Conceptualization

PLEASE NOTE: THIS CASE CONCEPTUALIZATION IS JUST A SAMPLE AND DOES NOT REPRESENT A REAL
CLIENT IN ANY WAY.

Case Presentation

Sex: Female

Age: 19

Race: Caucasian

School classification: College freshman-local university student

Client Profile: The client is a nineteen-year-old late adolescent, who is currently in her first year of her
college and classified as a freshman. She is a child of divorced parents at the age of 13, and reports that
she rarely speaks to her father, and has a strong, bonded relationship with her mother. She has fair
complexion and blonde hair, and has a thin build. She is quiet and shy among strangers, and reports that
she is uncomfortable expressing her true feelings with others. She states that she often bottles up her
emotions in order to keep peace in her relationships, but if she has a serious issue she consults with her
mother for guidance. She works hard to do well in school, but has been referred for heavy sexual activity
and trouble in her relationships.

Reason for Referral: Client entered counseling because her mother was concerned about
communication between her and her father, and requested individual counseling. Her mother is also
worried about the frequency that her daughter is out late and hangs around older college men, and
suspects the possibility that her daughter is pregnant. The client frequently discusses unhappiness
within her personal relationships, and states that she often feels lonely and frustrated that she struggles
socially at school. She reports being sexually involved with multiple partners outside of a monogamous
relationship. The client has recently been sick with nausea, fatigue, and headaches. She reports being
worried of pregnancy as well as not knowing how to have a proper relationship with a male due to the
strain of the relationship with her father. She has also presented for counseling to establish healthy
interpersonal relationships with others to make the social college experience healthy and consistent.

Mental Health History: Client has had no previous mental health history.

Medical History: No significant medical history has been reported. The client is being referred to an
obstetrician and gynecologist for a pregnancy test and annual check-up.

Areas Contributing to Counseling Success: Client and counselor have established a working, therapeutic
relationship throughout the course of counseling. The client has discussed issues after her parents’
divorce as well as her sexual activity with this counselor more than she reports talking about with her
mother . The counselor aims to recognize the client’s positive attributes well as general potential for
change and growth. This counselor works to help the client find positive self-worth as well as healthy
boundaries for others, especially within potentially harmful situations. The client continues to work on
her personal goals and still desires to repair her relationship with her father. Additionally, the client has
begun to work with this counselor on identifying her own emotions and taking with the counselor about
difficult issues rather than avoiding them.

Areas Possibly Impeding Growth: Although client has high standards and boundaries for herself and her
peers, she struggles with her self-esteem and confidence. The client does not feel that she is good
enough for multiple friends or a healthy romantic relationship.She feels that while the possibility of
pregnancy is intimidating, she also sees a child as an opportunity to not be alone and have consistent
company. She is consistently frustrated and sad; however, she reports to this counselor that she often
bottles her emotions up because she has no peers to trust and can only trust her mother at this time.
Client is still hesitant identifying her unhealthy behavior patterns due to the fact that she struggles
finding positive attributes that will allow her to engage in healthy behaviors. The client often rationalizes
her actions as well as uses silence to prolong the process of engaging in the deeper emotional work
during the session.

Role as a Therapist: Counselor will act as a fellow traveler with the client and establish a therapeutic
relationship based on the core conditions of counseling. Counseling will attempt to develop a safe
environment for the client to create congruence within herself and seek self-actualization within all
aspects of her life. This process will occur with unconditional positive regard and healthy, therapeutic
transference between the counselor and the client to enhance genuineness throughout the relationship.
Counselor will “guide” the session through reflections, observations of the client’s words, emotions, and
physical behaviors. Counselor will also incorporate activities such as Sand Tray therapy as well as goal
setting in each session to help the client progress in reaching her counseling goals.

Theory Conceptualization: According to Person-Centered theory, the client is experiencing severe

maladjustment through incongruence. She lacks a positive organismic experience in identifying and
embracing her basic everyday needs due to a poor self-concept. She frequently discusses with this
counselor her concern for how people view her. Her ideal self is built on the basis that she will never be
good enough for anyone’s standards and that she is always alone, so no matter how hard she tries or
how good she is, she will come up short. Because of this incongruence, the client experiences difficulty
in her daily psychosocial stressors. She struggles to establish a positive identity and self-worth.

The client and counselor work to help the client find congruence. This begins with the client’s organismic
experience. The client has begun to identity the need to be loved and accepted and the need to trust
others no matter what she shares with them. She has recently expressed the need to not be alone at all
time and find a companion with whom she can share her experiences. It has been crucial in this
therapeutic experience that the counselor displays unconditional positive regard for the client in order
to allow the client to have a model of what it looks like to have her organismic needs met in the
therapeutic time together. The first ten sessions with this counselor established basic needs and wants
of the client in order to re-establish a healthy, congruent, self-concept.

Multiaxial Assessment:

Axis I-309.9 Adjustment Disorder Unspecified

Axis II-None present at this time

Axis III-None present at this time

Axis IV-Psychosocial Stressors

· Potential of pregnancy
· Parent’s divorce

· father-daughter relationship

· college social and academic pressures

· Emotional strain of late adolescence

Axis V-GAF

· Initial entry –50; client entered counseling with tears and severe stress over the academic
pressures of her first year in college, her sexual behavior, and the risk of pregnancy. She also presented
as frustrated with her current relationship with her father and the inability to effectively communicate
with others.

· Current functioning-65; client has been able to identify and express various feelings with her
current stressors. She has begun to identify standards and needs for herself in her everyday life as well
as boundaries with certain social groups. Client maintains stable functioning from day to day, but is still
experiencing maladjustment that warrants continuous therapeutic work at this time. The client has
identified her past unhealthy sexual behaviors, and has begun to identify healthy standards for herself
as well as healthy boundaries when engaging in relationships with others.

Becoming a Counselor: In future sessions, the client and this counselor will continue to work toward
congruence and the self-actualization process. In the next few sessions, the counselor intends to help
guide the client towards a positive self-concept. In accomplishing the future goals for this therapeutic
relationship, the client will work on developing a confidence within herself regardless of other’s opinions
or views. Additionally, the client will establish conditions of worth based on who she is and would like to
become, as opposed to her current conditions of worth that are based upon her experiences with
others. The client will also be able to set healthy but respectful boundaries with her father, and will be
able to establish clear standards for herself and be able to communicate them to others in the midst of
difficult situations. The client will hopefully be able to speak with her father in a positive manner when
communication occurs. The client will also be able to deal the potential possibility of being a mother, as
well as be able to express healthy sexual behaviors. The client will learn components of healthy
interpersonal relationships and how to implement her personal standards within those personal
relationships. Ultimately, the goals for this therapeutic relationship will result in congruence and the
establishment of a concept of her ideal self not limited by conditions to be whoever she would like to
become. The client will also develop lasting conditions of worth that align with her three selves. This
counselor’s goal is that the therapeutic relationship will result in termination and the client’s ability to
handle daily life circumstances with confidence and strength.