Identifying Information

Jane Doe [real name withheld] is a XX-year old Caucasian female.  She has a X-year old son.  She is engaged to be married in March.  Both she and her son live with her fiancé.

Chief Complaint

Jane Doe is court-recommended for counseling to address anger issues related to her divorce.

Presenting Problem

Jane Doe is experiencing the following problems:

1. Nightmares about previous abuse and experiences.
2. Anxiety toward relationship status with fiancé.
3. Stress about current life situation.
4. Anger toward ex-husband.

Background Information

Jane Doe was born in the United States.  When she was 8-years old, her parents divorced.  At that time she was sent to live with her "Aunt" (family friend) in England.  Once there, Jane Doe was immediately placed in a boarding school.  She transferred to 8 different boarding schools in 5 years.  This was due to acting out behaviors (e.g., blowing up toilets with cherry bombs, setting fire to a desk).  During the summers, Jane Doe lived with her "brother" John Doe [real name withheld], who was about 20 years older than her.  She stayed with him on and off until she graduated high school.  Jane Doe was sexually abused by John Doe, as well as his friends.  She was frequently flown back and forth between the US and England - Jane Doe reported that "nobody wanted her".

When Jane Doe was about 19-years old, she became pregnant and married the father, Harry [real name withheld].  The October after they were married, Harry was killed.  Shortly after, Jane Doe gave birth to stillborn twins.  The following December, she married Tom [real name withheld].  They were married for 11 years and have a son together, Bob [real name withheld].  Tom was physically abusive toward Jane Doe.  They have been separated for 5 years and the divorce was final two years ago.  Jane Doe is court-recommended to attend counseling.  This was a recommendation upon her divorce from her second husband, Tom.  Jane Doe and Bob, who is now X years old, are currently living with Fred [real name withheld], her fiancé.  Jane Doe and Fred plan to be married in March.

Jane Doe suffered from Cervical Cancer last year.  While she is currently in remission, she returns to the doctor for blood tests every three months.
 

Treatment Plan

Assessment

While in counseling previously, Jane Doe was diagnosed with Major Depressive Disorder - Recurrent.  However, she is exhibiting symptoms of Posttraumatic Stress Disorder.  For example, she has nightmares throughout the entire month of October about traumatic events that have occurred in her past.  She experiences intense psychological distress at exposure to cues that symbolize an aspect of the traumatic events.  Jane Doe has an inability to recall various aspects of the trauma and appears to be demonstrating a restricted range of affect.  She has difficulty sleeping due to her nightmares and reports an exaggerated startle response.
Jane Doe has and is currently experiencing a number of significant life stressors.  There have been problems with her primary support systems (e.g., removal from the home, physical and sexual abuse, death of first husband, divorce from second husband), problems related to interaction with the legal system (e.g., court-recommended counseling), and other psychosocial and environmental problems (e.g., discord with second husband).  Due to previous traumatic life events, Jane Doe was previously diagnosed with Major Depression-Recurrent.  I believe any underlying symptoms of depression to be secondary to her PTSD.  Her current functioning is within the moderate range.

Goals

Jane Doe and I worked together in a collaborative manner to decide upon the issues to be addressed within the counseling sessions.  The topic of most pressing concern was her nightmares about previous abuse and experiences.  Our first goal was to work toward alleviating these nightmares.  In order to do this, we are trying to gain some understanding about why the dreams are occurring.  Gestalt techniques have been utilized to explore her dreams about sexual abuse (Ratican, 1992).  The following steps were utilized:

1. Tell the dream in present tense.
2. Notice what stands out
3. Become part of the dream.
4. Formulate existential statements.

The second most important issue was her anxiety toward the status of her relationship with fiancé.  My second therapeutic goal was to help Jane Doe to build a satisfactory relationship with her fiancé.  We are working toward her being able to express her needs and wants in a conducive manner.  We first explore and practice this through an elaboration of needs and wants within the therapy session.  We also discussed her emotional responses to various interactions (Reynolds & Brewin, 1998).

Jane Doe is experiencing stress about her current life situation.  She is looking to develop support systems in order to help relieve this stress. The third goal within the therapy setting, we are exploring options for managing day-to-day stress.

Jane Doe is court-recommended for counseling due to reported anger toward her second husband.  Our fourth goal in regards to this was to develop a means to interact in a neutral way with her ex-husband.  To do this, we are discussing options for how to deal with her ex-husband in various situations without causing Jane Doe undue stress (Jaycox, Foa, & Morral, 1998).
 

Case Summary

Jane Doe has demonstrated insight and a genuine interest in addressing the previously stated issues.  She became more focused and better able to stay on topic as the sessions went on.  While stating the she was not sure how in-depth she wanted to explore her nightmares, Jane Doe readily shared the details of what she could remember.  She appeared to become more willing to discuss her feelings and to show her emotions within the therapy sessions.  In doing this, she became more focused on herself and aware that she was guarding her feelings both in and out of therapy.  At the time that this was written, Jane Doe appeared to be coping better with the thoughts and memories of her first husband and feeling more positive about the status of her relationship with her fiancé.  I believe that this will continue to improve through further exploration of her feelings, needs, and experiences.  A continued discussion about coping skills, etc may prove to be beneficial.  This process should take six months.

Hill, C. (unknown).  A cognitive-experiential model of dream formation and dream interpretation.  Working with Dreams in Psychotherapy.

Jaycox, L., Foa, E., & Morral, A. (1998).  Influence of emotional engagement and habituation on exposure therapy for PTSD. Journal of Counseling and Clinical Psychology, 66(1), 185-192.

Reynolds, M. & Brewin, C. (1998).  Intrusive cognitions, coping strategies and emotional responses in depression, post-traumatic stress disorder and a non-clinical population.  Behaviour Research and Therapy, 36(2), 135-147.