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EarlGrasshopper375
She was dressed appropriately, with obvious meticulous attention…
She was dressed appropriately, with obvious meticulous attention to peer-group fashion conventions
regarding hair, makeup, and dress. She appeared the appropriate weight for her height.
Claire is highly accomplished with above-average academic grades and PSAT scores as well as social
successes, including student council president, honor council representative, prom committee, and prom queen
candidate. According to referral notes, she maintained good discipline and performance until several weeks ago;
then, on March 24, 1984, she served 1 day of in-school Saturday detention for skipping school to go shopping
with friends. As a result of the attention focused on her behavior leading up to, during, and following her
detention, several additional behavioral concerns were raised.
Presenting Concern.
Claire came to her school counselor’s attention on several occasions following her 1-day
detention. On the first occasion, a school security guard identified Claire as one of several students repeatedly
found smoking marijuana under the football field bleachers during lunch breaks. A school janitor confirmed that
he had suspected from odors and debris he found that she had also smoked marijuana in the school building
during her Saturday detention. Because there was no definitive evidence, a note was made in her school records,
and Claire was found in the cafeteria as assigned during subsequent lunch periods.
On the next occasion, the same security guard reported that she had overheard Claire vomiting in the
girls’ bathroom on several occasions; however, Claire denied this as well as any health problems. When
consulting with her father, the school counselor learned that the father also had heard her vomiting in the
bathroom at home, but “assumed that’s what girls do when they are 17, right?”
The father also noted that he thought she seemed overly preoccupied with her eyebrows and eyelashes
and arm hair, which all seemed to be becoming sparse. Again he said his perception was that “that’s what
teenage girls do.”
Background, Family Information, and Relevant History.
Claire has one older brother, an adult who has
graduated from college and is an architect who lives in urban Chicago. Her father is a highly successful
physician who is chief of radiology at Sherman Hospital in Elgin. Her mother does not work outside the home;
she participates in a large number of charitable efforts throughout the Midwest region. In spite of their
respective successes, Claire’s parents described a historically weak marital relationship and poor
communication with their children. Regarding medical histories, her mother has been in treatment as an
outpatient and inpatient for alcohol abuse and prescription-drug dependence on an ongoing basis over the past
10 years. Both parents are highly recognized patrons of the arts and humanitarian efforts and perceived to be
community leaders.
Regarding school history, reports indicate that Claire has been consistently recognized for her above-
average academic performance, leadership in school, extracurricular organized activities, social success among
her peers, and skill as both a gymnast and cheerleader throughout her elementary, middle school, and high
school years. It is unclear whether Claire’s presenting concerns have been present for some time but
overlooked, or alternatively, have emerged only in the past year.
Problem and Counseling History.
Claire has been seen three times with the goals of conducting an extended
assessment and establishing a therapeutic alliance. She appeared quite resistant during the initial meeting, with a
special concern that her parents would have access to her records. A working agreement was established among
Claire and her father that although her attendance at counseling sessions will be reported to her father, no
information about session contents will be shared without Claire’s permission (within the “normal” limits of
confidentiality). Claire also is aware that suspension from school might result should she not pursue counseling
as agreed. Her concerns appear in three areas.
First, Claire admits to regular marijuana use during and immediately after school. She reports that her
use began only recently, in March, but admits that she is aware her use has resulted in late papers and missed
homework. At the same time, she has said that “it doesn’t really matter, because my teachers always give me a
break.” She is aware that she risks school suspension at this late point in her school career and responds that
“I’m coming to counseling, and they’ll leave me alone.” She also admits she has begun associating with
unfamiliar boys of peer age and boys in their early 20s “so I can bum some pot. All you have to do is flirt a little
to go home with a few free joints!”
Identify and List Client Concerns And Any Other Problem Areas:
This can include behaviors, thoughts, affect, physiology, life role
adjustment, institutional adjustment, family roles, relationships conflicts, work problems,
school problems, clinical problems such as self-harm, medical problems, meds, developmental
problems, cultural social influences, psychological assessment results, MSE concerns,
maintaining factors (anxiety but working from home as a safety behavior).
Step 2: Organize Concerns Into Logical Thematic Groupings
using the Clinical Targets Approach , Formed according to four aspects of experience: thoughts, feelings , behavior and physiology.
Step 3: Theoretical Inferences: Attach
thematic groupings to Inferred Areas of
Difficulty
Theoretically identify groupings and offer data
to support the groupings.
For example, CBT has two primary groupings
– maladaptive thoughts and behaviors. For
each grouping offer case data to support it, and
theoretical constructs such as specific
cognitive distortions (e.g., all or nothing,
mental filter, etc).
Step 4: Narrowed
Inferences and Deeper
Difficulties
Offer the deeper core issue
using Cognitive Behavioral therapy
