Social Case Study March 7, 2013 I.

Identification of Data: Name: John Sales Age: 21 Gender: Male Address: Bicol Birthdate: September 20, 1991 Civil Status: Single Religion: Roman Catholic Nationality: Filipino II. Reason For Referral: The client was admitted due to schizophrenia. The purpose for the current evaluation is to screen out and clarify the nature of the underlying schizophrenia. III. Present Situation: Presently subject has maintenance of medication for his psychological condition. He is under the gentle T.C program. He is a crew in zoo/grounds department. He is looking forward to meet his family and friends.

IV.

History: He graduated High School at Immaculate Concepcion School in Bicol at the age of 18 and then he wants to take up a vocational course at TESDA, but because of peer pressure he never gets enrolled in tertiary level. That time his parents went to Taytay, Rizal to get a job and his Kuya Elmer is the one who took care for them. His Kuya Elmer was very close to him and also whos the one take him to the rehabilitation center. According to him he has no problem with his siblings. He found joy taking marijuana and talampunay due of the influence of his friends and media. He got his first rehab in Bicol, and it lasts for six months and then he move here in BDRFI after a year due to continuing taking drugs and other mental problems. At first his thought was not that accurate especially in his family background and marital data. He can also demonstrate how to use the drug and the tools that he used in inhaling it. He can immediately answer the questions from the interviewer.

V.

Recreation and Interest: Mr. Sales likes to play basketball. He loves to have a conversation with the girls OJTs.

VI.

Psychosexual Development: His childhood was very happy and enjoy, he can clean up by himself. According to him he never had a girlfriend, and he never had sexual intercourse with a girl but he experienced sex with a homosexuals. He also had insecurities with his friends because he never had sexual intercourse thats why every time he lies in his bed he thinks about something especially a girl that makes him do masturbating. He does it many times.

VII.

Choice and Turning Points in Life: Mr. Sales regrets the time he was doing wrong things and taking drugs that makes

his life miserable. It gives him moral lesson that life was very important. He always thinks about if he gets out in the rehab he wants to go back in school and finish it to have a better life. VIII. Recommendations: It is recommended that efforts to establish a trusting relationship with this client be continued, in order to help him cultivate a more adaptive and coping pattern. For him he has no problem regarding in his family. The environment has a big factor in his behavior. He can easily influence and trust his friends that bring him to be miserable. Through the help of his family especially his Kuya Elmer and an effective intervention he can easily recover. IX. Impressions: Mr. Sales is having schizophrenia due to substance abuse. He is properly trained to obey and function well in his duties on grounds/zoo and his daily tasks.

Psychological Test Evaluation March 7, 2013 I. Identification of Data: Name: John Sales Age: 21 Gender: Male Address: Bicol Civil Status: Single Religion: Roman Catholic Nationality: Filipino II. Reason for Referral: To confirm Mr. Sales schizophrenia and assures his intellectual and emotional functioning including personality traits, attitudes, intelligence and emotional concerns. To create appropriate intervention program that will help and guide him. III. Evaluation Procedure: Sacks Sentence Completion Test Draw a person test House, Tree, Person Bender Gestalt Raven Progressive Matrices January 04, 2013 January 07, 2013 January 07, 2013 January 07, 2013 January 09, 2013

General Observation/Mental Status Examination: During the interview Mr. Sales was glad because he meets new people and he wants to have a conversation with others. His mood was open. Orientation was intact for person, time and place. Eye contact was appropriate. He was cooperative. During the test he was eager to know what will be the result of the test. Sometimes he talks a lot but he immediately answers again the questions. IV. Tests Result and Interpretation: The result of the test shows that Mr. Sales has inhibited tendencies. Mr. Sales also appears to remain delusional, paranoid with low intellectual capacity and poor intrapersonal as well as interpersonal relationships. It shows that there is possibility for heightened sensitivity to environmental changes. There are a withdrawal tendencies, insecurity, inhibited and constructed personality and dull conditions and psychotic conditions. Also seen the feature of paranoid subtype of schizophrenia which was the presence auditory hallucinations and prominent delusional thoughts about persecution or conspiracy. There is a possibility for masturbating guilt and defensiveness against sexual approaches. The client seems to be a schizophrenic condition. He has a limited intelligence. V. Clinical/Diagnostic Impressions: Mr. Sales is having schizophrenia due to substance abuse. He is properly trained to obey and function well in his duties on grounds/zoo and his daily tasks.

VI.

Recommendations: It is recommended that efforts to establish a trusting relationship with this client

be continued, in order to help him cultivate a more adaptive and coping pattern. For him he has no problem regarding in his family. The environment has a big factor in his behavior. He can easily influence and trust his friends that bring him to be miserable. Through the help of his family especially his Kuya Elmer and an effective intervention he can easily recover.

Case Treatment Plan

Chief Complain/Area of Concern

Intervention

Objectives

Remarks/ Recommendations

Psychosis (hallucination, delusion, paranoid beliefs)

Cognitive behavioral Therapy for Psychosis (CBT-P) The client is encouraged The treatment focuses on thought patterns that cause distress and also on developing more realistic interpretations of events. This also help him to understand and change patterns that tend to interfere with his ability to interact with others and otherwise function. Individual Therapy As part of this process, your therapist will help him look back on your personal history. Together you're likely to gain insights into when, and why, you may have started to form those ideas and behaviors. Then, building from this new understanding, your therapist can help him start to change those patterns. Family therapy Both he and his family may benefit from therapy that provides support and education to families. His symptoms have a better

To identify his delusional or paranoid beliefs and to explore how these beliefs negatively impact in his life.

Continue the medication he intake. When the client talks about his hallucinations, delusional or paranoid beliefs, encourage him to describe what he sees, hears or feel and tried as much as possible a realistic interpretation or explanation of what is really happening.

Paranoid Schizophrenia

To cope with the distress and daily life challenges brought on by paranoid schizophrenia.

This can help reduce the severity of his symptoms and improve communication skills, relationships, his ability to work and his motivation to stick to this treatment plan.

This therapy can help him and his family communicates better and understands family conflicts. Family therapy can also help family

chance of improving if his family members understand his illness, can recognize stressful situations that might trigger a relapse and can help him stick to his treatment plan. Family therapy can also help you and your family communicate better and understand family conflicts. Family therapy can also help family members cope and reduce their distress about your condition.

members cope and reduce their distress about his condition.

The evidence for the efficacy of CBT in treating patients with persistent symptoms of schizophrenia has progressed from case studies, case series, and uncontrolled trials to methodologically rigorous, randomized, controlled trials that include patients from both the acute4 and the chronic end of the schizophrenia spectrum.5-7 Subsequent meta-analysis8 and systematic reviews have further strengthened the evidence base. CBT is now recognized as an effective intervention for schizophrenia in clinical guidelines developed in the United States9 and in Europe.10 In spite of the evidence base and absence of side effects, however, the general availability of this treatment approach within community settings is still low.11 This article will examine the procedure of CBT for psychosis, the evidence for its use, and the implications for practicing psychiatrists. PROCEDURE The therapeutic techniques used for patients with schizophrenia are based on the general principles of CBT. Links are established between thoughts, feelings, and actions in a collaborative and accepting atmosphere. Agendas are set and used but are generally more flexibly developed than in traditional CBT. The duration of therapy varies according to the individual's need, generally between 12 and 20 sessions, but often with an option of ongoing booster sessions. CBT for psychosis usually proceeds through the following phases. Assessment The assessment begins by allowing the patient to express his or her own thoughts about his experiences while the therapist listens actively. The use of rating scalesboth specific and generalis encouraged to monitor progress, and the results are shared with the patient. Diagrams and written material can be most useful, especially for patients with chaotic lifestyles. The formulation of symptom causation and maintenance is also shared with the patient and evolves throughout the therapy as new information is considered. Interpretation Guide

Attitude towards Mother (14, 29, 44, 59) 2 = Completely rejects and depreciates mother whom he considers over demanding. 1 = Sees mothers fault but accepts and tolerates differences. 0 = express only positive feelings towards the mother. Attitude towards Father (1, 16, 31, 46) 2 = feels extreme hostility and contempt with overt death wishes. 1 = admires father but wishes that their relationship were closer. 0 = expresses complete satisfaction with fathers personality. Attitude towards Family Unit (2, 27, 42, 57) 2 = feels rejected by the family which lacks solidarity and which has constantly contended with difficulties. 1 = aware that the family does not recognize him as a mature person but has no difficulty in relating with them. 0 = instability of the family domicile has had little effect on his favorable feeling towards them. Attitude towards Women ( 10, 25, 40, 55) 2 = extremely suspicious, possible homosexual tendency 1 = high ideas but ambivalent feelings. 0 = only minor or superficial criticisms Attitude towards Heterosexual Relationship (11,26,41,56) 2 = appears to have given up achieving good sexual adjustment 1 = deserved sexual experiences but reservation about his ability to maintain marital relationship. 0 = indicates satisfaction towards this area Attitude towards Friends and Acquaintances (8,23,38,53) 2 = suspicious and apparently seclusive 1= seems to wait approval of others before committing himself emotionally 0 =

express

mutual

relationship

with

friends

and

self

Attitude towards People Supervised (4,19,34,58) 2 = feels he can handle or control hostility in handling others 1 = feels capable of doing good supervisory but has misgivings about assuming an authoritarian role. 0 = feels controllable and well accepted by subordinates. Attitude towards Supervisors at work or School (6,21,36,51) 2 = resents or fear authority 1 = mild difficulty in accepting difficulty 0 = Attitude towards Colleague at work/school (13,28,43,58) 2 = feels rejected by colleagues, and condemns them 1 = has some difficulty at work and depends on colleagues 0 = expresses good mutual feelings Fear (7,22,37,52) 2 = disturbed by the apparent fear of loving, possibility to control his feelings 1 = fear of self-assertion which is fairly common and not pervasive. 0 = lack of fear Guilt Feelings (15,30,45,60) 2 = concerned with spiritual feeling and physical sex drives 1 = has regret over past and seems mildly disturbed by his failure to control his trouble. 0 = does not seem to be aware of guilt feelings Attitude towards Own Ability (2,7,32,47) 2 = feels completely incompetent and hopeless 1 = feels he has a specific ability but tends to fear difficulty 0 = confident on his ability to overcome obstacles Attitude towards Past (9,24,39,54) 2 = feels rejected and isolated 1 = 0 = feels well adjusted, no significant disturbance in the past Attitude towards the Future (5, 20, 35, 50) 2 = pessimistic, no hope in his own resources for happiness and success 1 = unsure of himself but tries to be optimistic 0 = seems confident in achieving his goals Goals (3, 18,53,49) 2 = lack of motivation for achievement 1 = desires material things for family as well as for himself 0 =

Bulacan State University City of Malolos, Bulacan College of Social Sciences and Philosophy Department of Psychology

Bulacan Drug Rehabilitation Foundation Inc. Social Case Study, Psychological Evaluation Report and Case Treatment Plan

Jefrey C. Tamayo
BS Psychology 4B

March 7, 2013