RANZCP Psychological Methods Case History

RANZCP Psychological Methods Case History
“Grace Willa”: The Conversational Model of Psychotherapy Informed by Psychodynamic
Psychotherapy and Other Key Principles
Submitted under RANZCP guidelines
De-identification and Confidentiality Declaration
In accordance with RANZCP requirements, this case history has been de-identified. This
includes all data that could identify the patient, their family and other individuals, such as name,
location, names of hospitals, supervisor and dates of admission. Data that are de-identified are
initially marked with an asterisk (*) the first time they appear.
Word Count (excluding the de-identification disclaimer, cover sheet, index/table of contents
and references/bibliography): 9,574 words
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TABLE OF CONTENTS
Contents 2-4
Synopsis 5
Identifying Data 5
Referral 5
Presenting Complaint 5
History of the Presenting Illness 6-7
Extensive Past History 7-8
Medical History 9
Medications 9
Allergies 9
Alcohol and Drug History 9
Family History 10
Personal History 10-13
Spiritual Beliefs 14
Premorbid Personality 14
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Mental Status Examination 14-15
Risk Assessment 15-16
Physical Examination and Initial Investigations 16
Initial Psychodynamic Formulation 16-18
Provisional DSM 5 Diagnosis 18
Differential Diagnoses 18-21
Management 21
 Initial Agreement and Plan 21
 Decision to Employ Psychotherapy 22
 Consideration of Alternative Treatment Strategies 22
 Goals of Psychotherapy 24
 Treatment Contract 24
 Liaison with Other Professionals 25
 Supervision 25
Progress in Psychotherapy 25
 The Initial Phase 25-28
 The Middle Phase 29-33
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 The Final Phase 34
 Termination 34-35
Reformulation 35-37
Discussion and Final Reflections 37-39
Bibliography 40-41
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Synopsis
This case describes Grace, a 60-year-old woman who suffered from a long-standing history of
depressive and anxiety syndrome associated with borderline, anxious and avoidant personality
traits. She underwent psychotherapy to explore the source of her anxiety and low selfesteem.
During the therapy, it was established that ongoing interpersonal issues and social stressors
relating to money, job and accommodation, as well as a history of sexual and domestic violence
by her father, contributed to her condition.
Identifying data
Grace was a 60-year-old woman and a mother of two children. She lives in a regional town,
which is several hundreds of kilometers away from any major city. She was unemployed and
living with her male partner, Kennedy, whom was also unemployed. Grace had undergone two
divorces with her first husband, Michael, and second husband, William.
Referral
Grace was referred to me on March 10th, 2017, by Community Mental Health Team
Psychologist Ms. Smith*. Ms. Smith felt that long-term psychotherapy would help Grace
overcome her low selfesteem issues and trauma. I presented the case to my supervisor, Dr.
Erickson*, who agreed that psychotherapy sessions were necessary for Grace. Ms. Smith, who
was Grace’s Psychologist for more than two years, was also convinced that the psychotherapy
was essential for her.
Presenting Complaint
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“I feel anxious, hopeless and depressed. I need help”.
History of the presenting illness
In 2017, the Community Mental Health Team Psychologist referred Grace to me for long-term
psychotherapy.
Grace reported symptoms of sadness, anhedonia, guilt, hopelessness, energy loss, concentration
loss, appetite change, slowing of psychomotor activity, sleep change and fleeting suicidal ideas
of more than two weeks in duration – this indicated a major depressive disorder with a recurrent
nature and moderate intensity. Grace reported feeling sad most days for over two years,
manifested by sleep change, hopelessness, appetite change, low self-esteem and concentration
loss and associated with significant distress – this indicated a persistent depressive disorder.
She reported ongoing lower-back pain, which impacted on her thoughts, feelings and behavior
when severe – this demonstrated somatic symptom disorder. She reported having reading and
writing difficulties from an early age and that she struggled enormously at school and left due to
these difficulties at the age of 9 – this indicated a learning disorder.
She reported intermittent ongoing worry, concentration loss, sleep change and impairment with
functioning. She reported drinking several glasses of wine on days when she felt overwhelmed.
She reported having intermittent nightmares from previous abuse by her father. She reported
feeling emotionally deregulated sometimes, associating this with crying, feeling hopeless about
her situation, having intermittent suicidal ideas and a history of past impulsive suicide attempts
and feeling rejected in her relationships. She reported becoming anxious and avoidant
sometimes, due to her complex circumstances, a difficult upbringing and reading and writing
problems.
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She described some social anxiety. She described becoming anxious occasionally, based on the
situation. She reported that, when she was unwell, she was unable to go shopping. Grace did not
report any symptoms of eating disorders, mania or psychosis.
Extensive Past History
Grace reported a long-standing history of anxiety and depression since childhood, due to paternal
physical and sexual abuse. She was also exposed to bullying at school, which intensified her
depression and anxiety. Additionally, Grace had a learning disorder, which involved the inability
to read and write. She had to abandon school and get married to escape the bullying at school
and her abusive father. Grace has also tried to commit suicide several times: the last time, she
tried to run in front of a truck in 2013.
She reported worrying about her inability to find proper work, and that she will never be able to
do so because of her limited education and ongoing back pain. She reported fleeting nightmares
of abuse from her father. She reported a long-standing history of back pain due to a bulging disc.
She reported that her engagement in volunteer work at the hydrotherapy pool and cardiac
rehabilitation was fluctuating, although she loves this work.
She reported spending most of her time in bed, feeling depressed and anxious. It appeared to be
related to her suppressed anger with her partner not finding work and spending all day at home.
She reported initial and middle insomnia (sleeping only a few hours a day), poor energy and
anhedonia, which have been fluctuating. She reported living a life associated with shame and
guilt and reported intermittently feeling helpless, worthless and hopeless.
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She reported a long-standing history of fleeting suicidal ideation and a few suicide attempts. She
described the difficulty in regulating her moods and worrying about what others think of her. She
reported difficulty in coping with separations and losses.
Grace had to see a counselor as a child because she had difficulties coping at school and home.
These difficulties were mainly due to domestic problems – abuse by her father and siblings.
However, her father found out about the counseling sessions and ended them. She also tried to
commit suicide or conceived suicidal plans at various times. The first time was when her father
victimised her through physical violence and sexual harassment. However, she didn’t act on
those thoughts. She had thought of committing suicide after her second marriage ended,
combined with difficulties concentrating, resulting in her GP prescribing sertraline. The third
suicidal attempt was the most severe because she tried to walk in front of a moving truck when
her husband had to undergo heart bypass surgery.
Grace has been reviewed by three psychiatrists, who have monitored her mental state and
progress and treated her with psychotropic medications. She is well known to the Community
Mental Health Team and she was referred by her GP in 2013. She had psychology sessions
through her GP’s mental health plan. Grace has responded poorly to sertraline. Recently she took
a combination of duloxetine and quetiapine, which has helped to reduce her anxiety and improve
her sleep. Grace has been case managed since December 2014. She received treatment from the
Community Mental Health Team Psychologist from March to July 2017 and admitted feeling
sad, rejected and abandoned when he ceased psychotherapy.
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