john sales scs

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Social Case Study

March 7, 2013

I. Identification of Data:Name: John Sales

Age: 21

Gender: Male

Address: Bicol

Birthdate: September 20, 1991

Civil Status: Single

Religion: Roman Catholic

Nationality: Filipino

II. Reason For Referral:The client was admitted due to schizophrenia. The purpose for the current

evaluation is to screen out and clarify the nature of the underlying schizophrenia.

III. Present Situation:Presently subject has maintenance of medication for his psychological condition.

He is under the gentle T.C program. He is a crew in zoo/grounds department. He is

looking forward to meet his family and friends.


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IV. History:He graduated High School at Immaculate Concepcion School in Bicol at the age of 18

and then he wants to take up a vocational course at TESDA, but because of peer pressure

he never gets enrolled in tertiary level. That time his parents went to Taytay, Rizal to get

a job and his Kuya Elmer is the one who took care for them. His Kuya Elmer was very

close to him and also whos the one take him to the rehabilitation center. According to

him he has no problem with his siblings. He found joy taking marijuana and talampunay

due of the influence of his friends and media. He got his first rehab in Bicol, and it lasts

for six months and then he move here in BDRFI after a year due to continuing taking

drugs and other mental problems.

At first his thought was not that accurate especially in his family background and

marital data. He can also demonstrate how to use the drug and the tools that he used in

inhaling it. He can immediately answer the questions from the interviewer.

V. Recreation and Interest:Mr. Sales likes to play basketball. He loves to have a conversation with the girls

OJTs.

VI. Psychosexual Development:His childhood was very happy and enjoy, he can clean up by himself. According

to him he never had a girlfriend, and he never had sexual intercourse with a girl but he

experienced sex with a homosexuals. He also had insecurities with his friends because he

never had sexual intercourse thats why every time he lies in his bed he thinks about

something especially a girl that makes him do masturbating. He does it many times.


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VII. Choice and Turning Points in Life:Mr. Sales regrets the time he was doing wrong things and taking drugs that makes

his life miserable. It gives him moral lesson that life was very important. He always

thinks about if he gets out in the rehab he wants to go back in school and finish it to have

a better life.

VIII. Recommendations:It is recommended that efforts to establish a trusting relationship with this client be

continued, in order to help him cultivate a more adaptive and coping pattern. For him he has

no problem regarding in his family. The environment has a big factor in his behavior. He can

easily influence and trust his friends that bring him to be miserable. Through the help of his

family especially his Kuya Elmer and an effective intervention he can easily recover.

IX. Impressions:Mr. Sales is having schizophrenia due to substance abuse. He is properly trained to obey

and function well in his duties on grounds/zoo and his daily tasks.


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Psychological Test Evaluation

March 7, 2013

I. Identification of Data:Name: John Sales

Age: 21

Gender: Male

Address: Bicol

Civil Status: Single

Religion: Roman Catholic

Nationality: Filipino

II. Reason for Referral:To confirm Mr. Sales schizophrenia and assures his intellectual and emotional

functioning including personality traits, attitudes, intelligence and emotional concerns. To

create appropriate intervention program that will help and guide him.

III. Evaluation Procedure:Sacks Sentence Completion Test January 04, 2013

Draw a person test January 07, 2013

House, Tree, Person January 07, 2013

Bender Gestalt January 07, 2013

Raven Progressive Matrices January 09, 2013


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General Observation/Mental Status Examination:

During the interview Mr. Sales was glad because he meets new people and he

wants to have a conversation with others. His mood was open. Orientation was intact for

person, time and place. Eye contact was appropriate. He was cooperative. During the test

he was eager to know what will be the result of the test. Sometimes he talks a lot but he

immediately answers again the questions.

IV. Tests Result and Interpretation:

The result of the test shows that Mr. Sales has inhibited tendencies. Mr. Sales also

appears to remain delusional, paranoid with low intellectual capacity and poor

intrapersonal as well as interpersonal relationships. It shows that there is possibility for

heightened sensitivity to environmental changes. There are a withdrawal tendencies,

insecurity, inhibited and constructed personality and dull conditions and psychotic

conditions. Also seen the feature of paranoid subtype of schizophrenia which was the

presence auditory hallucinations and prominent delusional thoughts about persecution or

conspiracy. There is a possibility for masturbating guilt and defensiveness against sexual

approaches. The client seems to be a schizophrenic condition. He has a limited

intelligence.

V. Clinical/Diagnostic Impressions:Mr. Sales is having schizophrenia due to substance abuse. He is properly trained

to obey and function well in his duties on grounds/zoo and his daily tasks.


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VI. Recommendations:It is recommended that efforts to establish a trusting relationship with this client

be continued, in order to help him cultivate a more adaptive and coping pattern. For him

he has no problem regarding in his family. The environment has a big factor in his

behavior. He can easily influence and trust his friends that bring him to be miserable.

Through the help of his family especially his Kuya Elmer and an effective intervention he

can easily recover.


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Case Treatment Plan

Chief Complain/Area

of Concern

Psychosis

(hallucination, delusion,paranoid beliefs)

Paranoid Schizophrenia

Intervention

Cognitive behavioral

Therapy for Psychosis

(CBT-P)The client is encouraged

The treatment focuses on

thought patterns that causedistress and also on

developing more realistic

interpretations of events.This also help him to

understand and change

patterns that tend tointerfere with his ability to

interact with others and

otherwise function.

Individual TherapyAs part of this process,

your therapist will help

him look back on yourpersonal history. Together

you're likely to gain

insights into when, andwhy, you may have started

to form those ideas and

behaviors. Then, buildingfrom this new

understanding, your

therapist can help him start

to change those patterns.

Family therapyBoth he and his family maybenefit from therapy that

provides support and

education to families. His

symptoms have a better

Objectives

To identify his

delusional orparanoid beliefs

and to explore how

these beliefs

negatively impactin his life.

To cope with the

distress and daily

life challenges

brought on byparanoid

schizophrenia.

Remarks/

Recommendations

Continue the medication

he intake.When the client talks

about his hallucinations,

delusional or paranoid

beliefs, encourage him todescribe what he sees,

hears or feel and tried as

much as possible a realisticinterpretation or

explanation of what is

really happening.

This can help reduce the

severity of his symptoms

and improve

communication skills,relationships, his ability to

work and his motivation to

stick to this treatment plan.

This therapy can help

him and his familycommunicates better and

understands family

conflicts. Family therapy

can also help family


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chance of improving if hisfamily members

understand his illness, can

recognize stressful

situations that might triggera relapse and can help him

stick to his treatment plan.Family therapy can also

help you and your family

communicate better and

understand familyconflicts. Family therapy

can also help family

members cope and reduce

their distress about your

condition.

members cope and reducetheir distress about his

condition.


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The evidence for the efficacy of CBT in treating patients with persistent symptoms ofschizophrenia has progressed from case studies, case series, and uncontrolled trials tomethodologically rigorous, randomized, controlled trials that include patients from both theacute4 and the chronic end of the schizophrenia spectrum.5-7 Subsequent meta-analysis8 andsystematic reviews have further strengthened the evidence base.CBT is now recognized as an effective intervention for schizophrenia in clinical guidelines

developed in the United States9 and in Europe.10 In spite of the evidence base and absence ofside effects, however, the general availability of this treatment approach within communitysettings is still low.11 This article will examine the procedure of CBT for psychosis, theevidence for its use, and the implications for practicing psychiatrists.PROCEDURE

The therapeutic techniques used for patients with schizophrenia are based on the generalprinciples of CBT. Links are established between thoughts, feelings, and actions in acollaborative and accepting atmosphere. Agendas are set and used but are generally moreflexibly developed than in traditional CBT. The duration of therapy varies according to theindividual's need, generally between 12 and 20 sessions, but often with an option of ongoingbooster sessions. CBT for psychosis usually proceeds through the following phases.Assessment

The assessment begins by allowing the patient to express his or her own thoughts about hisexperiences while the therapist listens actively. The use of rating scalesboth specific andgeneralis encouraged to monitor progress, and the results are shared with the patient.Diagrams and written material can be most useful, especially for patients with chaoticlifestyles. The formulation of symptom causation and maintenance is also shared with thepatient and evolves throughout the therapy as new information is considered.

Interpretation Guide

Attitude towards Mother (14, 29, 44, 59) 2 = Completely rejects and depreciates motherwhom he considers over demanding. 1 = Sees mothers fault but accepts and tolerates

differences. 0 = express only positive feelings towards the mother.

Attitude towards Father (1, 16, 31, 46) 2 = feels extreme hostility and contempt with overtdeath wishes. 1 = admires father but wishes that their relationship were closer. 0 = expressescomplete satisfaction with fathers personality.

Attitude towards Family Unit (2, 27, 42, 57) 2 = feels rejected by the family which lackssolidarity and which has constantly contended with difficulties. 1 = aware that the familydoes not recognize him as a mature person but has no difficulty in relating with them. 0 =instability of the family domicile has had little effect on his favorable feeling towards them.

Attitude towards Women ( 10, 25, 40, 55) 2 = extremely suspicious, possible homosexual

tendency 1 = high ideas but ambivalent feelings. 0 = only minor or superficial criticisms

Attitude towards Heterosexual Relationship (11,26,41,56) 2 = appears to have given upachieving good sexual adjustment 1 = deserved sexual experiences but reservation about hisability to maintain marital relationship. 0 = indicates satisfaction towards this area

Attitude towards Friends and Acquaintances (8,23,38,53) 2 = suspicious and apparentlyseclusive 1= seems to wait approval of others before committing himself emotionally 0 =


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express mutual relationship with friends and self

Attitude towards People Supervised (4,19,34,58) 2 = feels he can handle or control hostility inhandling others 1 = feels capable of doing good supervisory but has misgivings about assumingan authoritarian role. 0 = feels controllable and well accepted by subordinates.

Attitude towards Supervisors at work or School (6,21,36,51) 2 = resents or fear authority 1 =mild difficulty in accepting difficulty 0 =

Attitude towards Colleague at work/school (13,28,43,58) 2 = feels rejected by colleagues, andcondemns them 1 = has some difficulty at work and depends on colleagues 0 = expresses goodmutual feelings

Fear (7,22,37,52) 2 = disturbed by the apparent fear of loving, possibility to control hisfeelings 1 = fear of self-assertion which is fairly common and not pervasive. 0 = lack of fear

Guilt Feelings (15,30,45,60) 2 = concerned with spiritual feeling and physical sex drives 1 =has regret over past and seems mildly disturbed by his failure to control his trouble. 0 = does

not seem to be aware of guilt feelings

Attitude towards Own Ability (2,7,32,47) 2 = feels completely incompetent and hopeless 1 =feels he has a specific ability but tends to fear difficulty 0 = confident on his ability toovercome obstacles

Attitude towards Past (9,24,39,54) 2 = feels rejected and isolated 1 = 0 = feels well adjusted,no significant disturbance in the past

Attitude towards the Future (5, 20, 35, 50) 2 = pessimistic, no hope in his own resources forhappiness and success 1 = unsure of himself but tries to be optimistic 0 = seems confident inachieving his goals

Goals (3, 18,53,49) 2 = lack of motivation for achievement 1 = desires material things forfamily as well as for himself 0 =


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Bulacan State University

City of Malolos, Bulacan

College of Social Sciences and Philosophy

Department of Psychology

Bulacan Drug Rehabilitation Foundation Inc.

Social Case Study, Psychological Evaluation Report and Case Treatment Plan

Jefrey C. Tamayo

BS Psychology 4B

March 7, 2013


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