Case Vignette, Diagnosis and Treatment Plan
Final Paper Case Vignette
The client is a 44 year old Jewish white male who is coming in to therapy due to of his two year relationship with his 32 year old girlfriend. He appears quite distressed, and says he just can’t take the pain, and is crying intermittently throughout the session. He appears younger than his age and is dressed casually in a t shirt and shorts and doc martin boots. He is oriented x 4, is above average in intelligence and the mental status reveals no organic or psychotic process. His mood is depressed and his behavior is agitated. In attempting to respond to the client during the initial interview, the client says he is not done talking and stops the therapist from speaking. He also indicates that he wishes that he had come to therapy a year ago with his girlfriend and that would have saved the relationship. He indicated that his girlfriend wanted someone who was more responsible with his life.
The client’s history reveals that he is a freelance graphic artist and works mostly under table as he has not filed taxes in over ten years. He spends most of his time playing volleyball on the beach, salsa dancing in the evening, and computer games. He lives in a run down studio apartment, his car is 13 years old and in bad need of repair and he makes just enough money to cover his bills. His father holds an inheritance for him from a relative where he can request $500 a month if he wants to, often getting into arguments with his Dad to get more money. His mother passed away when he was 21 years old due to cancer and he has one younger sister who is 42 years old, who lives in another state and they have a conflictual relationship because she believes their parents indulged him and she got the short end of the stick. He attended college but never finished, short 3 classes. His work history reveals that he has held a number of jobs but has difficulty holding on to them as he starts out as their best employee and then eventually gets fired as he doesn’t perform. The client has never been married and most of his relationships last about 6 months. He has been in therapy for brief periods of time but has never sustained after 2 or 3 sessions.
The client requested that be able to tape record the sessions so that in his long drive to therapy that on the way home he could listen to them.
Provide the following information in your papers:
Diagnosis:
Provide a DSM-V diagnosis, noting the criteria and what you ruled out.
Treatment Plan:
Provide a treatment plan reflecting goals, objectives, and activities Conceptualization:
Utilizing at least one theoretical basis, provide a conceptualization of the case including etiology and present understanding of the client’s difficulties.
Treatment:
Provide a response how you would work with this patient, different interventions and techniques you would use, difficulties in working with this client, and transference and counter-transference issues
