CASE STUDY

Dylan attended his first session accompanied by his 42-year-old mother, Brenda. According to her,
as a 16-year-old freshman in Cyber High school, Dylan was incredibly attached to his family and
relied on his mom as his primary support. A week prior to his initial appointment, Brenda called
for a phone consultation to discuss Dylan’s primary symptoms. At the time of the call, Dylan was
not eating a majority of foods that were prepared at home. He was struggling to leave the house
and seemed affected by preoccupation with thoughts around getting the stomach flu. Dylan was
fearful that eating anything that was prepared at home would result in vomiting and prolonged
illness. He would routinely inspect utensils at home to ensure cleanliness and oversee his parents
and siblings as they participated in preparing meals. With the severity of symptoms increasing over
the course of 60 days, Dylan had lost 17 pounds as a result of the eating restrictions. As Dylan
entered the office, he slipped his sleeve over his hand to open the door from the lobby to the main
office but then quickly recovered and extended his hand to accept the clipboard of paperwork and
pencil to finish the logistics of the intake appointment. He made very little eye contact throughout
the session, and his responses were literal. Questions such as, “Tell me what has been going on”
required extensive further clarification because the lack of clarity in the initial question caused
intense anxiety. He was able to discuss his interests in video gaming and design, online
role- playing games, and Lego building. Although Dylan wants peer interaction and friendships,
his experience has been such that he now avoids the inevitable rejection that comes with attempting
social interactions. Dylan discussed a recent argument over “rocking the bed,” he coughed
repetitively. Brenda discussed that Dylan has always “rocked” himself to sleep, and although this
would not be much of an issue in and of itself, it poses quite an issue being on the bottom of a bunk
bed. The intake progressed to discuss more of the symptoms related to his weight loss. Dylan
discussed feeling that the weight loss now was likely unhealthier than any stomach flu he could
ever contract. He had no rational reason for fearing vomiting, nor could he describe a situation in
which someone died from profuse vomiting. When asked, “What is the worst thing that could
happen to you?” he was speechless and yet, strangely enough, a sense of calmness overcame him
realizing he did not know the worst-case scenario. Dylan coughed again. And again. And again.
Brenda reported that it has not always been coughing; he has had sniffling episodes during which
he has sounded sick but was perfectly healthy. More social history from Dylan’s past reveals that
he has struggled with appropriate communication that is relevant to his peer group. He has
a difficult time dealing with rule breakers and has always been incredibly literal. When asked,
“What would you say if I told you it was raining cats and dogs outside?” He responded, “I would
first look outside to see what you were referring to and make sure there were not cats or dogs
outside.” Brenda agreed that his inability to connect to other kids his age in socially appropriate
activities has caused a tremendous amount of isolation in his life.

Tentative diagnosis: Obsessive Compulsive Disorder

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CASE CONCEPTUALIZATION

• Fixation on anal stage of psychosexual development. Harsh toilet training at this stage may
have caused feelings of guilt and shame in the client, which transferred into obsessions and
compulsions.
• The use of repression as a defense mechanism to unconsciously push away thoughts that
may be causing anxiety and reaction formation, by portraying the opposite behavior of what
the unconscious is suggesting.
• A conflict between id and ego may lead to symptoms of obsessive-compulsive disorder.
• Over-attachment with mother.
SESSION PLAN

SESSION 1

Goal: To know about client’s presenting problem, history, nature of the problem and other
important information which will further help in designing the treatment plan in upcoming
sessions.

Technique used: Intake interview

Rationale: The rationales for using this technique are:

• To know about client’s demographic information, presenting complaints, nature of

the problem, events which might have caused that problem, history of the problem, duration
of the problem, prior treatment that he was taking for the treatment of the presenting
problems and its details, medicine or drugs consumption (if he is taking any), medical
history (history of physical exams, current medicine and health conditions since childhood
which includes details of the serious illness. As this information will help in the designing
the future treatment plan and interventions.
• Intake will provide us (therapist) information like client’s orientation, his insight towards
his problem and how much he is willing to change.
• Intake interview will help in building rapport and breaking the ice with the client as it is the
first formal interaction between client and the therapist.
Note: The client was asked to maintain a dream journal, in which he recorded anything
and everything he remembered about his dreams.

SESSION 2

Goal: Going to use the broad-band instrument used to psychologically evaluate adolescents. To
assess the mental health of patients. To remove doubt as to what is really wrong with the patient.

Technique used: MMPI-A-RF

Rationale: This test has been selected due to its extensive advantages:

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 • It makes it very difficult for subjects to ‘fake’ responses, deny problems or give a
particular
impression.
• The test is based on empirical research and not on a clinician's assumptions about what
answers indicate particular personality traits.
• Address issues specific to adolescent problems.
• This should normally be able to detect unconsciously somatizing or
consciously malingering in patients.
SESSION 3

Goal: Free association is a technique used in psychoanalytic therapy to help patients learn more
about what they are thinking and feeling. It helps patients discover unconscious thoughts
and feelings that had been repressed or ignored. When patients become aware of these unconscious
thoughts or feelings, they are better able to manage them or change problematic behaviors. The
goal of free association is not primarily to uncover hidden memories but to identify genuine
thoughts and feelings about life situations that might be problematic, yet not be self-evident. Free
association would be a helpful technique to explore the conflict or tension.
Technique used: Free association

Rationale:

• Categorize the association by labeling whether each word prompted a positive or negative
association.
• Then attempt to explain why those specific association were made
• The previously unconscious thoughts and feelings become conscious as they are
discussed.
This new awareness can be used to make deliberate changes in behavior.
Goal: katharsis means "purification" or "cleansing". Catharsis therapy is based on the idea that
bringing painful memories to consciousness with emotional discharge is the best way to recover
from old wounds.

Technique used: Catharsis

Rationale: Commonly use catharsis and cathartic techniques as part of their clinical practice to
enable clients and themselves to release emotion, to feel better and to facilitate coping.

SESSION 4

Goal: To interpret the client’s dream to get a glimpse of the unconscious, portrayed in the form of
dreams. Interpretation of his dreams will provide a different perspective to the client’s struggles.

Technique used: Dream analysis

Rationale: This technique has been selected due to several reasons:

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 • Dream analysis will play a vital role in helping the client realize things about himself that
he subconsciously already knows
• It can help confront things that the client needs to resolve
• The interpretation will provide valuable information that will further help in the therapy
sessions.
SESSION 5

Goal: To deal with the client’s repressed memories. We can see what the client had said related to
his dreams in previous session and what he will indicate to the therapist about his recovered
memory.

Technique Used: Recovered memory

Rationale:

• It describes the client’s emotional or painful events that were blocked out of conscious
awareness.
• It may help him confront the person whom they remembered abusing them. In some cases,
people have ended up in criminal courts with successful prosecution.
SESSION 6

Goal: Hypnotherapy is a proven tool to get rid of bad habits and to develop new ones. It can also
be used to remove anything from your sub-conscious mind. It serves to change the way how
our mind works and reacts. Unfortunately, if you try to override the unconscious ’ natural way of
behaving, the ‘change’ will eventually wear off and the old patterns will emerge once again.

Technique used: Hypnotherapy

Rationale:

• It promotes healing or positive development in any way but eventually the unthinking,
subconscious part of the mind will override your attempts and your normal instinctive and
emotional responses will take over automatically. Direct hypnosis suggestion can be used
to suppress or change the thoughts and behaviors.
• Hypnotherapy can also be used to control the sensations of pain, and hypnosis has been
used to perform surgery on fully conscious patients who would be in obvious agony if not
for the use of hypnosis.
• It is the key to unleashing potential, changing unwanted habits and behaviors and finding
solutions to problems and concerns.
• It allows the unconscious mind to become receptive to therapy without any conscious
interference.

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• Hypnosis is the induction of a deeply relaxed state, with increased suggestibility and
suspension of critical faculties. Once in this state, sometimes called a hypnotic
trance, patients are given therapeutic suggestions to encourage changes in behavior or relief
of symptoms. Some practitioners use hypnosis as an aid to psychotherapy. The rationale is
that in the hypnotized state, the conscious mind presents fewer barriers to effective
psychotherapeutic exploration, leading to an increased likelihood of psychological insight.

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