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An Example Psychological Case Formulation: PTSD Treatment Using CBT [C7548]

An Example Psychological Case Formulation: PTSD Treatment Using CBT [C7548]

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The course professor for C7548, Diagnosis and Treatment, provides an example case formulation for the childhood survivor of trauma who is now suffering from the dual disorder of PTSD and addiction
The course professor for C7548, Diagnosis and Treatment, provides an example case formulation for the childhood survivor of trauma who is now suffering from the dual disorder of PTSD and addiction

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Published by: David Moore, PhD CDP on May 22, 2010
Copyright:Attribution Non-commercial


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C7458 Diagnosis and Treatment Planning
Dr. David Moore
Argosy University-Seattle
Page 1
A Case Formulation Example
The Dual Disorder CBT Treatment of a Childhood Trauma Survivor
I. Introduction to the Theoretical Model
The approach to this client’s evaluation and therapy is within the Behavioral Therapy domain of counseling theory. Within the behaviorist strand of counseling theory, Cognitive Behavior Therapy (CBT)
has been successfully used to treat Anxiety Disorders.
In this case study, theclient has Post Traumatic Stress Disorder [PTSD]; which is one of the most multi-problemmental health categories in the Anxiety Disorder cluster. The clinician uses CBT methodology.A leading CBT Theorist, Albert Ellis, has developed an enriched CBT model called RationalEmotional Behavioral Therapy (REBT)
that fit this client’s treatment needs. The client’ssubstance use disorder, separate but entwined with her PTSD, is the second component of her “dual disorder”. REBT is an effective behavioral therapy model for addressing thedevelopmental history model of addictions treatment; which is more commonly treated from aPsychodynamic Therapy domain of counseling theory. In REBT, like a Psychodynamic[sometimes called Psychoanalytic] method, the client’s historical awareness of her progressivedisease and its distortions in thinking [i.e. “problem denial”] is addressed through what Ellis callsthe ABC’s of irrational thinking.
The therapist assists the client with an REBT problem self-assessment; which is called a “First Step” in Minnesota Model chemical dependency treatment.
 In the example transcript of the third session, used for explanatory purpose, the client brings her daughter to the therapist’s office which creates an enactment of mother—daughter dynamics.The therapist allows the family dyad to derail naturally between the multiple subjects of dysfunction that have existed within the family addiction and multi-generational trauma. In thesession, the therapist uses the framing model of REBT to exhibit the inability of the dyad toresolve here-and-now decisions due to long-standing irrational beliefs about their relationship.
II. Basic Demographic Client Information
 Name: Laura ClientAge: 42Race: Bi-racial
 Sex: FemaleMarital Status: Single, DivorcedEmployment: Pedicure, Cosmetology without formal educationReferral: Tacoma Indian Center Treatment: Outpatient Clinic, Individual counseling
Native American and European American
C7458 Diagnosis and Treatment Planning
Dr. David Moore
Argosy University-Seattle
Page 2
The key presenting issues are Ms. Client’s efforts to develop a sustained addiction recovery thatincludes the level of behavioral health necessary to parent a 14 year old daughter who is on theWashington State early intervention program for truancy and delinquency [i.e. the BECCA law].
III. Client Background Summary
3.A. Substance Use History 
Laura Client was introduced to alcohol use by her family when she was in her pre-school years.An anecdotal description told in her family is a joke about when the client was a baby and could“suck down her bottle of beer”—but had a hard time drinking her bottle of milk. She remembersthe ongoing consumption of alcohol from age five when she would drink with her grandmother.Her substance abuse was established in her elementary years and, by the beginning of junior highyears, she was consuming marijuana, alcohol and hallucinogens [“LSD”]. Prior to reachingadulthood, dropping out of high school in her senior year, her poly-drug abuse escalated toadding cocaine [including the highly addictive smoked version called “crack”] andmethamphetamine. As she entered early adulthood years, her memory is clouded by the poly-drug nature of her drug abuse, but she had further added the highly toxic combined use of heroinand methamphetamine to her addictive behavior.
3.B. Psychological Functioning and History 
Along with childhood neglect through the use of alcohol provided by her family, she wasverbally and physically abused by her parents and grandparents. The middle of three children,she was the only adopted child. She perceives this difference resulted in her parents treating her more poorly than her siblings, not feeling accepted by her parents, and even questioning whether her parents wanted her as a child.Her mother is an alcoholic. Aside from her very early exposure to alcohol, her mother’salcoholic behavior created an environment that she describes as being a “self-medication” reasonfor her own teenage and adult alcohol use. At this level, she is able to connect the genetic andenvironmental influences on her dependence. She has an inaccurate perception that, outside of the substance use, she didn’t really have any behavioral health problems. She also fails toconnect her own mother—daughter narrative to her current situation with her daughter.Once her addictions began to include more expensive and neurochemically addictive drugs[methamphetamine, heroin and cocaine] she began to engage in prostitution and theft to financeher lifestyle. She has also experienced psychotic symptoms in her adult life. She does not hear command voices, but she does hear and see negative auditory and visual hallucinations. Anexplanatory anecdote provided by Ms. Client was an incident about 3 years ago when she believed Satan was talking to her through her cheek. As a result of this psychotic delusion, shetook a scissors and cut out a substantial chunk of her cheek to “remove Satan’s influence.”Currently, she presents with very low self-esteem, high levels of anxiety, and mood swingswhich have been diagnosed as a Bipolar disorder. She is now abstinent from substance use with
C7458 Diagnosis and Treatment Planning
Dr. David Moore
Argosy University-Seattle
Page 3
continuing care in support groups; but has a very hard time dealing with anger and frustrationthat she would historically sedate with one or more drugs. In developing services for Laura,social and health agencies are assisting her develop life skills when she has little or no prior learning. These deficits are further aggravated by sleeplessness created by dreams similar to thehallucinations noted above. While abstinent from addictive use of drugs at this time, she reportsthe beginning of compulsive overeating late at night [“binge eating”].
3.C. Education
Ms. Client reports to having good grades prior to dropping out in 12
Grade. She reports nohistory of Special Education needs. She plans on further education to complete her GED and isconsidering post-GED business studies. She reports vocational interests in cosmetology and pedicure services [“applying make-up and being a nail artist]. She has had no formal education ineither activity.
3.D. Legal History 
Ms. Client has been arrested in the past for prostitution and possession of narcotics. In light of her extensive adult lifestyle of admitted criminal behavior, her time of incarceration appears lessthan might be expected.She was a crime victim with two extensive situations of rape. During the second rape, at age 19,she was held captive for three days by a man who raped her repeatedly while he put a gun to her head.In other areas of contacts with law enforcement, either as a violator or victim, she cannotremember a lot of her past. She knows that she has had numerous legal interactions, but cannotrecall specifics. She identifies her drug of choice for the last 30 years as beingMethamphetamine, which has extensive connections to the illegal community of drugmanufacture and distribution. It also left her, as she notes, in an ongoing “fog.”Currently, her major legal issues are in the role of a parent. Her 14 year-old daughter, Jericah, isinvolved with the state truancy system [BECCA Bill]. Jericah has stopped attending school andLaura can’t figure out how to intervene successfully on this behavior. Jericah has a history of suffering from depression and self-injury [cutting] behavior. Client does believe that asubstantial amount of Jericah’s emotional pain and behavioral health problems are the result of Laura’s drug abuse and her parallel parental absence during Jericah’s childhood years.
3.E. Social History 
In addition to her drug addiction, she also reports her overall lifestyle has been influenced by problem gambling during periods of active substance use. She reports the assumption that if shegambled she could get more money for drugs. During the past one year period abstinence fromalcohol and drugs, she has not engaged in gambling behavior.

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