Molly Hayes Comprehensive Case Report and Treatment Plan Caap 6611 2015

Comprehensive
Case Report & Treatment Plan: Template Booklet with Directions (Sept 2015). Authored by Dawn McBride, Ph.D.
Molly Hayes, Practicum Counselling Student
Comprehensive Case Report and Treatment Plan

A Narrative Therapy Approach to Identity Exploration
By Molly Hayes
molly.hayes@uleth.ca

CAAP 6611: General Counselling Practicum
For Professor Dawn Lorraine McBride
University of Lethbridge
Master of Counselling Program

Date Submitted: November 30, 2015
Assignment Deadline: December 1, 2015

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Comprehensive Case Report & Treatment Plan: Template Booklet with Directions (Sept 2015). Authored by Dawn McBride, Ph.D.
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University of Lethbridge (U of L) CAAP 6611: General Counselling Practicum

Comprehensive Case Report and Treatment Plan

REPORT DATE:
CLIENT NAME: Lucy Hanson AGE: 11 years GENDER: female
AUTHOR OF THE REPORT: Molly Hayes
ON-SITE SUPERVISOR:
CONTEXT OF SERVICE: Specialized programming within a school district
REFERRAL SOURCE:
HOW LONG DID THE CLIENT HAVE TO WAIT BETWEEN REQUESTING AN APPOINTMENT AND
ATTENDING THE FIRST APPOINTMENT?
DATE OF IN-PERSON INTAKE/ASSESSMENT INTERVIEWS:
NUMBER OF SESSIONS TO DATE (including intake/assessment interviews):
WHO TYPICALLY ATTENDS THE SESSION:
AVERAGE LENGTH OF A COUNSELLING SESSION:
NUMBER OF SESSIONS REMAINING and/or DATE OF TERMINATION:
HAS AN ON-SITE SUPERVISOR REVIEWED THIS CASE?
HAS LIVE SUPERVISION BEEN INVOLVED IN THIS CASE?
HAS AN ON-SITE SUPERVISOR REVIEWED THIS CASE REPORT?

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PURPOSE OF THIS REPORT:

This report has been written to meet one of the students course requirements to earn a
Master of Counselling (Counselling Psychology) degree. It is required that U of L practicum
counselling students demonstrate competent skills in collecting and analyzing client assessment
data, forming case conceptualizations, and planning appropriate treatment.
Although the report is loosely based on a client case, all facts and identifying information about
the case (i.e., name, city, & demographic data) have been altered to protect the privacy of the
client. Since this report is fictional, and it has been written in fulfillment of a course
requirement, the report will not be included in the clients file. This fictional case report may be
kept by the student and supervisor for referencing purposes, such as when writing future case
reports since no information that would reveal the identity of the client is recorded.
ETHICAL BEST PRACTICE NOTES:
Consent Issues: In full adherence of the authors code of ethics (CPA), the client was informed
of her rights as a client of counselling and the risks and benefits of therapy on October 8, 2015
and of this case report on November 27, 2015. In addition, the client was informed of the limits
to confidentiality and how client files are maintained and destroyed.
Consent to receive counselling services from parents/guardian: As per the law and standards
of good practice and the expectations for consent contained in my code of ethics, each parent
have given informed consent for their youth to participate in therapy with the author. A copy of
this consent is in the clients file.
Consent for the release of the report: In full adherence to CPA code of ethics, the client has
given informed consent for this case report, albeit fictional but loosely based on the clients
experiences, to be released to the following professionals for the purposes of learning how to
write comprehensive case reports: Wes Bartel (supervisor), Dawn McBride (professor), and
students in Professor Dawns counselling program classes to whom it will be distributed at
Professor Dawns discretion. This report should not be read by any other individuals unless the
client has given permission to do so.

Lucy (and her parents) accepted the opportunity to read and provide feedback on this fictional
case report.

Additional release information: Consent to release portions of this fictional report was granted
in February 2016 by Lucy and her parents. Therefore only the desired sections remain in this
report; removed sections are noted with an absence of information and a strikethrough the
titles.
CLIENT OVERVIEW:
Family Status:
Living Situation:
School Status:
Educational Background:
Cultural Background:
Language Background:
Religious/Spiritual Background:
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ASSESSMENT OF MENTAL STATUS (observed by reporting therapist during the time frame of
October 8, 2015 to November 27, 2015):
Appearance: Lucy dresses appropriately and often has ungroomed hair.
Behaviour: Lucy presents engaged body language and minimal eye contact (note: minimal
eye contact is appropriate for her existing medical and neurological diagnoses Duanes
Retraction Syndrome and Moderate to Severe Developmental Prosopagnosia, respectively).
Affect in the Sessions: Lucy presents animated and eager in sessions displaying a range of
emotions from anger and frustration to excitement and cheery.
Cognitive Process: No difficulties noted.
Thought Process: Evidence of preoccupation with thoughts of skepticism of the intentions

of others.
Insight & Judgment: Lucy actively participates in conversations regarding her rights and role
as a counselling client including issues pertaining to consent, treatment and assessment.
Lucy reports difficulty coping with emotional regulation and perception of self.
Communication & Speech: Lucy is highly articulate (vast and diverse vocabulary) and often
speaks rapidly.
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PRESENTING PROBLEM:
Lucy has requested counselling services to gain a better understanding of her personality,
capabilities, interests, and challenges, reporting that her limited perception of self is a barrier to
interpersonal and intrapersonal happiness. Lucy explained that despite knowing of her
cognitive strengths and sensory challenges for as long as she can remember, her concerns
about the ambiguity of the other components of her identity have increased considerably in
recent months.
Lucy reports the following symptoms:
Easily irritated by classroom sounds, sights, and social interactions (for several years)
Externalized behavioural responses to frustration (for several years)
Persistent concern about her identity (for the past three months)
Persistent concern about the undiscovered nature of her abilities (for the past three
months)
Persistent concern regarding the perception that her parents are keeping information
about her abilities from her (for the past three months)
In addition to Lucys concerns presented above, Lucys mother also notes the following
symptom:
Sleeping disturbances (trouble falling asleep and staying asleep for at least the last
twelve months)
Similarly, Lucys current teachers have expressed the following concerns:
Easily fatigued (noted by the implementation of a modified school schedule that

shortens Lucys school day and the presentation of sleeping at school for the past three
months)
Work avoidance (noted by regular task defiance, frequent requests to leave the
classroom, low work output, and confirmed confessions from Lucy that she is
attempting to avoid the work asked of her for at least the past three months)
Social deficits (noted by a general intolerance of others)
History of Presenting Problem:

Lucy reported that her overall intolerance for classroom occurrences emerged when she began
attending preschool but has been effectively managed with environmental adjustments such as
headphones, motor breaks, small classroom sizes, and through the use of other sensory tools.
Lucy noted that her externalizing responses to frustrations have become less frequent over the
last school year since moving to a different specialized placement; Lucy explained that she has
learned that behavioural outbursts do not lead to better circumstances (i.e. choices, attention,
or more preferred activities) at this new placement. When asked about the symptoms noticed
by her mother and teachers, Lucy denied struggling with sleep and fatigue, but confirmed that
she avoids work because it does not interest her and agrees that she likely appears unfriendly to
others.

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With reference to her identity-related concerns, Lucy explained that she has become more
personally reflective this school year (perceived to be due to maturation), which has led to a
consideration of her perceived successes and weaknesses. According to Lucy, she displays
strengths in advanced tasks but weaknesses in more age appropriate tasks resulting in confusion
about her perceived self-efficacy and perceived sense of self. Additionally, Lucy believes that her
parents are withholding information regarding her abilities.
Impact of the Presenting Problem:
Generally speaking, Lucys sensory challenges and behavioural tendencies greatly impact her
ability to benefit from traditional classroom-based learning resulting in relational challenges and
perceived barriers to self-efficacy. However, Lucy explained that since settling into an
appropriate specialized program, her pre-existing diagnoses have become less of a barrier to
educational enjoyment. Lucys more recent identity-based concerns contribute to low quality of
interpersonal relationships with her family members and school professionals.
Differential Considerations:
It appears as though Lucy is experiencing symptoms of autism spectrum disorder (ASD), social
(pragmatic) communication disorder, unspecified anxiety disorder, oppositional-defiant
disorder (ODD), and attention-deficit/hyperactivity disorder (ADHD) (of which she holds an
existing diagnoses for). The below respective subheadings below outline the differential
considerations for these categories of symptoms.
Autism spectrum disorder (ASD) and social (pragmatic) communication disorder: Lucys
described social, sensory, and cognitive experiences prompt the consideration of ASD. Lucys
age, intellectual superiority, use of verbal communication, and physical movements rule out
Rett syndrome, selective mutism, language disorders, intellectual disabilities, and stereotypic
movement disorder. However, it is unclear at this point whether Lucy experiences highly
restricted and fixated interests of abnormal intensity, therefore it is also appropriate to
consider social (pragmatic) communication disorder, as Lucys mother and teacher described
Lucys communication style as often socially inappropriate. Additionally, although Lucy
describes herself as having a creative imagination it cannot be determined at this time whether
her imaginational experiences are related to hallucinations or delusions so child onset
schizophrenia cannot be ruled out.
Unspecified anxiety disorder: Lucys expression of worries, irritability, and displayed sleep
disturbances prompt a consideration of anxiety disorders. Lucy denies that her anxious
presentation is related to interpersonal separation (ruling out separation anxiety disorder),
specific events including social situations (ruling out phobias, social anxiety disorder, and
agorophobia) and that results in a negative change in verbal output (ruling out selective
mutism), and presentation of symptoms of panic (ruling out panic disorder). Additionally, the
recent onset and narrowed scope Lucys experiences with anxiety (within the last three months
pertaining only to ambiguity of identity) make a consideration of generalized anxiety disorder
inappropriate at this time. Lucy denies the use of medication or substances, and does not
believe her existing conditions (sensory processing challenges, and food sensitiveness)
contribute to her worries therefore ruling out medically and/or illness related anxiety disorders.
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Oppositional-defiant disorder (ODD) and attention-deficit/hyperactivity disorder (ADHD):

Lucys described behavioural presentations of anger outbursts, irritability, argumentativeness,
resentfulness, hyperactivity tendencies, and impulsivity make a consideration of ODD and
ADHD appropriate. Lucy has explained that her defiance is related to an intention of
nonconformity and not due to the difficulty of the task required, prompting a combined
consideration of both disorders.

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BACKGROUND (History):
The following section addresses the relevant familial, medical, developmental, and other
contextual factors that might be causing, contributing and/or affecting the clients stated
presenting problems.
Genogram:
Relevant family of origin history:
Relevant developmental history:
Relevant academic history:
Relevant medical history:
Relevant psychiatric history:
Counselling history:

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GENERAL ASSESSMENT OF FUNCTIONING:

The following self-report, informal assessments were administered during the first four
sessions. They were selected to gain further insight into the clients background, resources and
level of overall stress. The results of these measures were processed with the client in a
therapeutic manner extracting meaning and building resiliency.
Relevant life stressors:
Lucy has described the following main life stressors as likely to be relevant to her existing
concern: school and teacher related tensions, frequent school or classroom changes, ongoing
familial tension, and normal adolescent development leading to a preoccupation in personal
qualities.
Extent of stress in the clients life:
In addition to the relevant life stressors listed above, in the last twelve months Lucy has also
experienced a brief hospitalization of her sister and increased absence of her father in the
home due to his work schedule as indicated by the Holmes Stress Scale (for non-adults) Lucys
Holmes and Rahe Stress Scale (for non-adults)1 scores are considered average, putting her at
moderate risk for stress-related illnesses (scoring 188, with scores between 150 and 299
ranging the moderate risk category) (see Appendix B).

Because Lucy believed that the values placed on the stressors listed in the Holmes Stress Scale
(for non-adults) were not accurately aligned with her perception of impact, the Child and
Adolescent Survey of Experiences: Child Version (CASE)2 (see Appendix C) was administered.
The CASE revealed stress related to the experience of mixed-emotions linked to Lucys sisters
brief hospitalization (quite good experiences associated with the absence of her parents to a
little bit bad experiences associated with the sickness of her sister), extremely negative stress
related to the death of a family pet, and very positive experiences associated with the changing
of schools, resulting in the decrease of overall stress. Lucy reported that her perception of her
overall stress is low with the only significant stressor being her personal identity concerns; Lucy
noted that the stressors indicated in the Holmes Stress Scale (for non-adults) and the CASE are
managed with self-care.
Extent and Quality of Social Support:
RISK ASSESSMENT, Current and Historical:

Pedagogy Incorporated (2012). Holmes & Rahe Non-Adult Stress Scale. Retrieved from https://www.pedagogyinc.com/Home/Resources/General/Non-Adult-Stress-Scale.aspx
2
Macquarie University Centre for Emotional Health (2015). Child and Adolescent Survey of Experiences. Retrieved from
http://www.centreforemotionalhealth.com.au/pages/questionaire-child-and-adolescent-survey.aspx
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CASE CONCEPTUALIZATION:
Narrative therapy, the chosen orientation adopted by the author of this report, recognizes the
importance of considering the clients perspective of their experiences when engaging in therapeutic
endeavours. The narrative therapy approach explains that people create stories about themselves
that they use to explain their experiences; problems occur when their lived experiences contradict the
dominate narrative that they have created or that exists for them. From the narrative therapy
perspective, Lucys persistent concern about the ambiguity of her identity reflects a possible gap
between Lucys dominate narrative and her lived experience. Elements of Lucys existing dominate
narrative is defined by her awareness of her diagnoses and features themes of being different than her
peers and family resulting in a narrowed venue for self-exploration, low self-efficacy, increased rigidity
and anxiety.

From the narrative therapy approach, Lucy is experiencing challenges with self-exploration and selfactualization because her diagnoses (or perceived traits) lack the flexibility needed to create new
stories; in other words, she only understands herself as a student with significant challenges and of
superior intelligence. Therefore from this orientation, Lucy will need to engage in a self-learning
process that adds non-diagnostic content to her narrative in order to allow for a positive reauthoring of her experience. With a deeper understanding of herself, Lucy may be in a better position
to make sense of and address the interpersonal and intrapersonal anxieties she experiences as barriers
to trying new things, setting goals, and engaging in interpersonal relationships.

Based on Lucys profile and interests, narrative therapy is an appropriate approach to addressing her
concerns. Lucys superior language skills, interest and strengths in reading and creating stories make
the concepts of therapeutic storytelling through narrative therapy relatable, strength-based, and
suitable. Additionally, the non-formulaic nature of narrative therapy allows the process to be clientdriven, meeting Lucys unique learning and behaviour needs and permitting for the integration of other
therapeutic practices that Lucy may be exposed to by other professionals in her life at this time (or the
coming months).

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TREATMENT PLAN:
Lucy will be offered approximately 10 weekly 1 hour narrative therapy sessions under the
supervision of Mr. Wes Bartel, registered psychologist.

Lucy is a good candidate for narrative therapy because the self-discovery and re-discovery
premise and verbal nature of the approach caters to her interests, strengths, and desired
outcome of counselling.

It is the firm belief of the author of this report that it will be important to maintain a balance
between process- and content-based therapeutic skills to motivate client change, while
maintaining the working alliance. The following are the goals that were set by the client and
articulated in specific form by the author of this report.

Main Goals
1. Improve self-efficacy
2. Re-authoring of existing
narrative through selfexploration
3. Development of new stories
Main Intended
Interventions
Self-efficacy project
Comfort zone
mapping
Goal-setting
activities (within and
outside of comfort
zone including self
and others)
Values cards
Self and others
masks
Storytelling of past
personal events or
personal current
events
Exploration of
diagnostic content
of identity
Possible selves
mapping
Goal-setting
Behavioural
rehearsal and
experimentation
Some of the
Major Indicators of Change
Pre- and post-scaling of selfefficacy project
Scaling with use of comfort zone
mapping
Changes in behaviour goal-setting
Changes in perception of self and
others as noted by narratives
Addition of non-diagnostic content
to narrative of self (discovery of
values, sense of self, sense of
others, etc.)
The existence of new positive

personal goals
The existence of new positive
stories
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PROGRESS TO DATE:
Number of Sessions Held:

Therapeutic Relationship:

Client Motivation:

Treatment Plan Progress:

Goal 1: Improve self-efficacy
Lucys first therapeutic project included a personal and literal exploration of self-efficacy
(i.e. how it is defined and how does that relate to your experiences). As a result of this
project, Lucy determined that her quality of self-efficacy has been previously defined by
her psychological, educational, and neurological assessment scores that gave her a predetermined notion of her sense of self. Lucy deduced that with this notion of selfefficacy, left little hope for change and therefore required a re-exploration of selfefficacy. Lucys conceptual change has created therapeutic space for re-definition of her
abilities and interests resulting in increased hope for self-efficacy.

Goal 2: Re-authoring of existing narrative through self-exploration
No notable progress at this time.

Goal 3: Development of new stories
No notable progress at this time.

Treatment Plan Modification: There have been no modifications made to the treatment plan at
this time.

RECOMMENDATIONS:

Molly Hayes, Master Counselling Practicum Student
University of Lethbridge
Practicum site not disclosed for this report
Contact information not disclosed for this report

Wes Bartel, M.C, R. Psych.
Employment site not disclosed for this report
Contact information not disclosed for this report

Date signed
Date signed
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Appendix A: Genogram

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Appendix B: Holme and Rahe Stress Scale for Non-Adults
Appendix C: Child and Adolescent Scale of Experiences

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Appendix D: Ecomap Adaptation
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Comprehensive

Comprehensive Case Report and Treatment Plan

University of Lethbridge (U of L) CAAP 6611: General Counselling Practicum

PURPOSE OF THIS REPORT:

Appearance: Lucy dresses appropriately and often has ungroomed hair.

Cognitive Process: No difficulties noted.

Thought Process: Evidence of preoccupation with thoughts of skepticism of the intentions

Similarly, Lucys current teachers have expressed the following concerns:

Easily fatigued (noted by the implementation of a modified school schedule that

History of Presenting Problem:

Oppositional-defiant disorder (ODD) and attention-deficit/hyperactivity disorder (ADHD):

GENERAL ASSESSMENT OF FUNCTIONING:

3. Development of new stories

The existence of new positive

Appendix B: Holme and Rahe Stress Scale for Non-Adults

Appendix C: Child and Adolescent Scale of Experiences

Appendix D: Ecomap Adaptation

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