Case Assessment

In: Social Issues

Submitted By acaciasky
Words 1297
Pages 6
Cognitive-Behavioral Case Formulation

Client Name: Ms.
Date:
Identifying Information: middle-aged female, married with two children

Mental Status Examination

She appeared neatly dressed in an outfit, which was age-appropriate. She was alert and oriented to person, place, and time. The client made every effort to be open and honest. Furthermore, she maintained a cooperative attitude toward the examiner. Her mood and affect were depressed and anxious. Speech was coherent and relevant. There were no signs of a formal thought disorder as observed. Memory was intact as observed. Insight was estimated as fair to good.

Problem List

1. Feeling angry, resentful, anxious

•Include score on BAI at intake •Thoughts
-“She knew we were going to be late and deliberately stayed in the closet”
-“She runs this house”
-“I might as well not be married” •Behaviors -yelled at daughter and husband -stomach tensed up •Recent Situations -late for school and daughter was hiding in the closet -daughter refused to go to bed -husband went upstairs to play with model trains

2. Feeling depressed, helpless

•Include score on BDI at intake •Thoughts -“She doesn’t care about what I’m going through” -“She doesn’t care about what I need” -“He leaves me with all the responsibility and doesn’t care” •Behaviors -blamed daughter and husband •Recent Situations -late for school and daughter was hiding in the closet -daughter refused to go to bed -husband went upstairs to play with model trains

3. Lack of effective communication skills

•Thoughts -“She knew we were late and deliberately stayed in the closet” -“He deliberately leaves me with all of the work” •Emotions -angry -resentful -anxious •Behaviors -anger outbursts with daughter and husband
-attempted to bottle up feelings…...

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