Psychotherapeutic Case Formulation
Salomon has clearly evidenced educational and emotional problems at least since the 6th grade; however, this 9th grader has apparently neither been thoroughly physically and psychiatrically evaluated, nor received an Individual Education Plan, evincing a stunning level of neglect by his educators, the school psychologist and his Nurse-mother, all of whom theoretically know better. The system for identification, triage, referral and management of care will be followed. His case formulation will be approached from the “Underlying Factors Orientation” and from the “Observable Factors Orientation.”
Initial Problem Identification
There is not enough available information to understand the problem. Therefore, Salomon will be referred for several sources of additional data. First, Salomon should be referred for a complete physical examination to determine if there are any physical factors contributing to his educational and emotional problems. He should also be referred for assessments by a neurologist and a psychiatrist. Assessments by the mother and school psychologist will be considered but not heavily relied upon due to the possibilities of inaccuracy due to “distorted samples of child behavior influenced by their own adult agendas” as well as the fact that they are “apt to reflect beliefs, values, practices, and social ideals of [their] cultural groups”(Weisz, 2004, p. 9). Salomon should also receive Neuro-psychiatric testing to define and specifying subtle abnormalities in “calculation, memory, language function, abstraction, visual-motor ability, and specific aspects of intelligence,” as well as the Minnesota Multiphasic Personality Inventory (UBM Medica, LLC, 2010). Salomon should also receive a complete psychiatric evaluation, including the Psychiatrist’s report on: Salomon’s problems and descriptions; physical and psychiatric health, illness and treatment, including any current psychotropic medications; health and psychiatric histories of Salomon and his family; information about the school and his friends; information about his familial relationships; the psychiatrist’s interview with Salomon; the psychiatrist’s interview with Salomon’s mother (and father, though unlikely); laboratory results of blood tests, x-rays and special assessments of his psychological, educational, speech and language evaluation(s) (American Academy of Child Adolescent Psychiatry, 2010).
After receipt and review of results from his physical examination, neuro-psychiatric testing, and psychiatric evaluation, Salomon’s case should be formulated per the format presented by Yeung and Chang (Yeung & Chang, 2002), though placing “diagnostic formulation” before “course and outcome,” simply because it flows logically:
a. CLINICAL HISTORY
1) Patient Identification
Salomon is a 15-year-old 9th grade student at a public high school in San Francisco. His primary language is Spanish but he is also fluent in English. Salomon was accompanied by his mother, who is a Nurse. He presents as shy with coherent and thoughtful speech. Salomon was referred by his high school psychologist.
2) History of Present Illness
His teachers describe him as highly imaginative, kind, and often insightful, yet also extremely shy, unmotivated and hopelessly disorganized with a pervasively defeatist attitude in regard to academic tasks he finds challenging, especially mathematics. His homework binders and backpack are stuffed haphazardly with reams of crumpled paper in no discernible organizational pattern. Although he lives only a few blocks from school, he is frequently tardy. He rarely delivers homework assignments on time, claiming that he forgot, despite daily email reminders from his teachers to his mother. While his spoken English is coherent and thoughtful, his handwriting is a virtually indecipherable scrawl, and even when given the opportunity to complete assignments on computer his typing is so slow he generally abandons assignments in the middle of the first page. When directed to answer questions orally in class, he often appears panic-stricken, and unable to speak. His reading comprehension has remained at the sixth grade level since sixth grade. His mathematical ability has similarly stalled at the sixth grade level.
Salomon lives with his mother, who is employed as a nurse. Approximately three years ago, his mother and father divorced following the revelation that his father had been involved for several months in an extramarital affair. Salomon’s father often travels out of state on business, and often cancels meetings with Salomon with minimal advance warning. Salomon’s school psychologist noted symptoms of moderate depression, possible deficits in attention, and possible impairments in visual and/or auditory processing. In the evaluation, the psychologist cites a fragment of a short story written by Salomon in the previous month in his English class about a boy abducted by federal agents on arbitrary and unwarranted suspicion of terrorism. In the story, the agents replace the boy with a doppelganger, who purports to be the boy, yet whose behavior eventually alerts his mother to the fact of the abduction. The story follows the mother’s attempts to retrieve her real son. Salomon’s mother’s principal concern is that because Salomon appears chronically sad, unmotivated, and unable to sustain attention on challenging academic tasks, his prospects of successfully graduating from high school appear to be diminishing by the day. She understands that the lack of a consistent father figure in Salomon’s life has been a significant stressor for him. At the same time, she says she has exhausted all potential means of convincing her ex-husband to maintain his paternal role more consistently. She would like a therapist to help Salomon move forward with his life.
3) Psychiatric History and Previous Treatment
4) Social and Development History
Salomon was born on January 1, 1997 in San Francisco. He is the only child of John, a businessman, and Mary, a nurse. Salomon is Hispanic and his first language is Spanish, though he also speaks English fluently. Salomon appeared to perform satisfactorily in school until his parents divorced, approximately 3 years ago, allegedly due to his father’s extramarital affair. Since that time, Salomon has lived with his mother at 1 Main Street, San Francisco, CA. His father lives nearby; however, Salomon’s father often travels out of state on business, and often cancels meetings with Salomon with minimal advance warning.
5) Family History
There is no family history of mental disorder.
b. CULTURAL FORMULATION
1) Cultural Identity
i. Cultural reference group
Salomon is second generation Hispanic, born and raised in San Francisco, CA.
ii. Language Salomon’s first language is Spanish, though he also speaks English fluently.
iii. Cultural factors in development
The immigration story of Salomon’s parents dovetails with the popular trend of voluntary migration from Mexico to the United States for educational and occupational opportunities. Having relatives in the San Francisco area, Salomon’s parents settled there and assimilated the culture without much difficulty. Salomon was raised as an American and is culturally similar to his American peers.
iv. Involvement with culture of origin
Salomon reports no specific involvement with his Hispanic Culture.
v. Involvement with host culture
Salomon is essentially an American teenager. When he socializes at all, it is with American peers.
2) Cultural Explanation of the Illness
Per self-reports by Salomon, an interview of his mother (Duncan & Arntson, 2004, p. 60), plus review of results from physical, neurological and psychiatric testing, there is no culturally-related explanation for Salomon’s illness (Lewis-Fernandez & Diaz, Winter 2002, p. 275).
c. DIAGNOSTIC FORMULATION
In formulating a diagnosis, Weisz’s assertion is valuable. A high number of referrals for young people stem from four clusters: “Anxiety Disorders (Social Phobia, Separation Anxiety Disorder, Generalized Anxiety Disorder, and others); Depressive Disorders (i.e., Dysthymic Disorder, Major Depressive Disorder); Attention Deficit Hyperactivity Disorder (ADHD); Conduct Related Disorders (Oppositional Defiant Disorder, Conduct Disorder) (Weisz, 2004, p. 8).
In addition, the diagram to examine primary and secondary instigating factors, originally set forth by H.S. Adelman and L. Taylor (1993), should be used. Learning problems and learning disabilities. Pacific Grove. Brooks/Cole, and later espoused by the Center for Mental Health in Schools at UCLA (Center for Mental Health in Schools at UCLA, 2010, p. 9). The therapist should also check for stressors (Center for Mental Health in Schools at UCLA, 2010, p. 10). Finally, the therapist should check common behavioral responses to environmental situations and potentially stressful events (Center for Mental Health in Schools at UCLA, 2010).
1) The resulting diagnosis would be:
Axis I: 309.21 Separation Anxiety Disorder
309.28 Adjustment Disorder, With Mixed Anxiety and Depressed Mood
315.00 Reading Disorder
315.2 Disorder of Written Expression
315.9 Learning Disorder NOS
Axis II: 301.82 Avoidant Personality Disorder
Axis III: None
Axis IV: V61.9 Parent-Child Relational Problem
V62.3 Academic Problem
Axis V: Current GAF = 40 (presentation at clinic)
2) Differential Diagnosis
Goals for Salomon’s treatment would be: effective treatment of his anxiety, adjustment and learning disorders; effective treatment of his home environment by working with both Salomon and his mother; remedial education significantly improving his reading skills; a transitional program preparing Salomon for life in school and beyond.
i. Underlying Factors Orientation
The “underlying factors orientation” (Center for Mental Health in Schools at UCLA, 2010, p. 24) is used, seeking “motivational and development differences and disabilities that disrupt desired functioning” (Center for Mental Health in Schools at UCLA, 2010, p. 25). An attempt was made to find motivational and development problems through referrals to a general physician for a complete physical, neuro-psychiatric testing and psychiatric testing.
ii. Metacognitive Strategy
Salomon should receive evidence-based intervention (Center for Mental Health in Schools at UCLA, 2010, p. 2). That would include solo therapy sessions with Rational-Emotive Behavior Therapy with the ABCDE method, in which the therapist teaches the client that external events are not causing his emotional/psychological disturbances; rather, ” ‘A’ actual external events automatically/habitually elicit ‘B’ beliefs and irrational thoughts (perceptions and interpretations of the external events) that entail ‘C’ consequent emotions that may be irrational (maladaptive, inappropriate, unrealistic), and that must be ‘D’ disputed, attacked, challenged so that ‘E’ effective rational thoughts (perceptions and interpretations of the external events) may take their place (Rosner, 2011, p. 83). As part of his treatment, Salomon should also: “Keep a daily log of problematic emotional states; for each occasion of a problematic emotional state, record the apparently activating external event; figure out the irrational beliefs/self-talk/thoughts that constituted the (mis)perception and (mis)interpretation of the actual activating external event; dispute the irrational beliefs/self-talk/thoughts; figure out more effective rational beliefs/self-talk / thoughts to replace the disputed irrational thoughts” (Rosner, 2011, pp. 83-84). In addition to solo treatments with Salomon: Salomon would also benefit from family treatment sessions, at least with Salomon’s mother present, as this would have the most effective impact on his home environment; the therapist also arrange Salomon’s participation in an in-school Rational Emotive Mental Health Program (Center for Mental Health in Schools at UCLA, 2010, p. 81).
The final step in assisting Salomon should be the development of an Individual Education Plan prepared by an interdisciplinary team including me. The U.S. Department of Justice has developed a series of 7 (realistically, 8) steps using “Consultation Theory” for the IEP’s development: first, the student is recognized as a possible candidate for special education and complementary services; secondly, he/she is evaluated by the multi-disciplinary team; third, a team comprised of the student’s parents and professionals, including but not limited to teachers and school administrators, reviews the evaluation results; fourth, the team determines whether the student requires special education and attendant services; fifth, a meeting between the student’s parents and school staff is set; sixth, the initial IEP meeting occurs between appropriate school staff and the student’s parents; sixth, another IEP meeting is held, this time including the student, and this collaborative team develops the IEP; seventh, the services mapped by the IEP are provided to the student; eighth, the IEP is re-evaluated and adjusted as required for every placement change, normally every year and certainly at least every three years. It is the collaboration of this support team, including the student, which is able to incorporate the student’s knowledge, skills and interests into the IEP, including a comprehensive transitional program for the student’s post-school life (National Dissemination Center for Children with Disabilities, 2010). Focusing on the transitional aspect of the IEP, each state has laws determining the minimum age at which a student’s IEP must including transitional planning. This transitional planning is backed by IDEA of 2004, which determined areas that should be examined when determining the student’s post-school life: post-secondary school, vocational school, employment, continuing education, services for adults with disabilities, independent living and participation in the community (Bullano, 2009).
Salomon is struggling with anxiety, depression, adjustment disorders and learning disabilities within an environment that has neglected him for far too long. At the age of 15, Salomon will ideally receive the solo counseling, family counseling, school counseling, remedial education and transitional planning to effectively assist him in dealing with his difficult circumstances. In fact, Salomon may prove to be a cautionary tale and model for his educators’ administrators’ and school psychologist’s more enlightened treatment of students who exhibit problems at an earlier stage of their education.
American Academy of Child Adolescent Psychiatry. (2010). Comprehensive Psychiatric Evaluation . Retrieved February 14, 2012 from AACAP Web site: http://www.aacap.org/cs/root/facts_for_families/comprehensive_psychiatric_evaluation
Bullano, R.Z. (2009, September 17). Transition services prepare students for life beyond high school. Retrieved February 14, 2012 from Virginia Commonwealth University Web site: http://www.ttacnews.vcu.edu/2009/09/design-transition-services-that-prepare-students-for-life-beyond-high-school.html
Center for Mental Health in Schools at UCLA. (2010). Common psychosocial problems of school aged youth: Developmental variations, problems, disorders and perspectives for prevention and treatment. Los Angeles, CA: Center for Mental Health in Schools at UCLA.
Center for Mental Health in Schools at UCLA. (Summer, 2007). Addressing barriers to learning: Evidence-based practices in schools: Concerns about fit and implementation. School Mental Health Project/Center for Mental Health in Schools, 12(3), 1-12.
Dettmer, P., Thurston, L.P., & Dyck, N. (2005). Consultation, collaboration, and teamwork for students with special needs (5th ed.). Boston, MA: Pearson/Allyn and Bacon.
Duncan, J., & Arntson, L. (2004). Children in crisis: Good practices in evaluating psychosocial programming. New York, NY: Save the Children Federation, Inc.
Kupper, L. (2000). My child’s special needs: a guide to the individualized education program. Retrieved February 14, 2012 from U.S. Department of Education Web site: http://ed.gov/parents/needs/speced/iepguide/index.html
Lewis-Fernandez, R., & Diaz, N. (Winter 2002). The cultural formulation: A method for assessing cultural factors affecting the clinical encounter. Psychiatric Quarterly, 73(4), 271-295.
National Dissemination Center for Children with Disabilities. (2010, September 24). Subpart D: evaluations, eligibility, IEPs, and placement. Retrieved February 14, 2012 from National Dissemination Center for Children With Disablities Web site: http://nichcy.org/laws/idea/partb/subpartd
National Resource Center on AD/HD. (2012, January 5). IDEA (the Individuals with disabilities education act). Retrieved February 14, 2012 from National Resource Center on AD/HD Web site: http://www.help4adhd.org/education/rights/idea
Rosner, R. (2011). Albert Ellis’ rational-emotive behavior therapy. Adolescent Psychiatry, 1(1), 82-87.
UBM Medica, LLC. (2010). Psychologist vs. neurologist testing. Retrieved February 14, 2012 from Healthier You Web site: http://www.healthieryou.com/mhexpert/exp1090301b.html
Weisz, J.R. (2004). Psychotherapy for children and adolescents: Evidence-based treatments and case examples. New York, NY: Cambridge University Press.
Yeung, A.S., & Chang, D.F. (2002). Clinical Case Study: Adjustment disorder: Intergenerational conflict in a Chinese immigrant family. Culture, Medicine and Psychiatry, 26, 509-525.