This section of the intake report focuses on three main topics: (a) usual daily activities, (b) client self-perception of personal strengths, and (c) apparent ability to adequately perform usual age-appropriate activities of daily living. Depending on your setting and preference, it is also possible to expand on this section by including a description of the client's psychological functioning, cognitive functioning, emotional functioning, or personality functioning. This provides the interviewer with an opportunity to use more of a subjective appraisal of current client functioning in a variety of areas.
Currently, during a typical day, Mr. Smith rises at about 7 a.m., has coffee and breakfast with his wife, reads the newspaper, and then moves to the living room to watch the morning news. He indicated that he usually reads the "classified" section closely for job opportunities, circling the positions he may be interested in. However, after moving into the living room, he reports doing everything he can to avoid having to go out and seek employment. Sometimes he watches television, but he reports being too "pent up" to sit around too long, so he goes out to the garage or into his backyard and "putters around." He usually makes himself a sandwich or a bowl of soup for lunch and then continues his puttering. At about 5:30 p.m., his wife returns home from her job as an administrator at a local nonprofit corporation. Occasionally, she reminds him of his plans to get a new job, but Mr. Smith indicated that he usually responds with irritation ("It's like I try to bite her head off") and then she retreats to the kitchen and makes dinner. After dinner with his wife, he "continues to waste time" by watching television, until it's time to retire. His usual routine is interrupted on the weekends, often by visits from his children and grandchildren and sometimes when he and his wife venture out to a local casino to "spend a few nickels" (however, he indicated their weekend activities are diminishing because of tightening finances).
Mr. Smith sees himself as ordinarily having numerous personal strengths, although he needed prompting to elaborate on his positive qualities. For example, he considers himself an honest man, a hard worker, and a devoted husband and father. He further believes he is a good buddy to several friends and fun to be around ("back when I was working and had a life"). In terms of intelligence, Mr. Smith claimed he is "no dummy" but that he is having some trouble concentrating and "remembering anything" lately. When asked about personal weaknesses, Mr. Smith stated, "I hope you got lotsa ink left in that pen of yours, Doc," but primarily focused on his current state of mind, which he described as "being a problem of not having the guts to get back on that horse that bucked me off."
Despite his poor hygiene and general lack of productiveness, Mr. Smith seems capable of adequately performing most activities of daily living. He reported occasionally cooking dinner, fixing the lawnmower, and taking care of other household and maintenance tasks. His perception, and it may be accurate, is that he is less efficient with most tasks because of distractibility and intermittent forgetfulness. His interpersonal functioning appears somewhat limited, as he described relatively few current outside involvements.
For good reason, students are often reluctant to assign a diagnosis to clients. Nonetheless, most intake reports should include some discussion of diagnostic issues, even if you discuss only broad diagnostic categories, such as depression, anxiety, substance use, eating disorders, and so on. Although simply listing your diagnostic considerations is acceptable in some circumstances and including only a multiaxial diagnosis is preferred by managed care companies, our preference is for a brief discussion of diagnostic issues followed by a DSM multiaxial diagnosis. The brief discussion orients the reader to how you conceptualized your diagnosis, and it can even include an explanation of why you chose one particular diagnostic label over another. In the following description, we use Morrison's (1993) guidelines of assigning the least severe label that adequately explains the symptom pattern.
This 53-year-old man is clearly suffering from an adjustment disorder. Although he also meets the diagnostic criteria for major depression, I am reluctant to assign this diagnosis because his depressive symptoms are so strongly associated with his recent life change, and he has no personal and minimal family history of a mood disorder. Mr. Smith is also experiencing numerous significant anxiety symptoms, which may actually be more central than his depressive symptoms in interfering with his ability to seek new employment. Similarly, a case could also be made for assigning him an anxiety disorder diagnosis, but again, the abrupt onset of these symptoms in direct association with his job loss suggests that his current mental state is better accounted for with a less severe diagnostic label. His provisional DSM-IV-TR multiaxial diagnosis follows:
Axis I: 309.28 Adjustment Disorder with Features of Anxiety and Depression (Provisional)
Rule Out (R/O) 296.21 Major Depressive Disorder, Single Episode, Mild Axis II: No Diagnosis on Axis II (V71.09) Axis III: None
Axis IV: Severe: Recent job loss after 31 years of employment Axis V: GAF = 51-60
Note that in the preceding multiaxial diagnosis, we used a number of procedures provided by the DSM for indicating diagnostic uncertainty. Specifically, we used the "provisional" tag and included a "rule out" diagnostic possibility (major depression). Additionally, for the Global Assessment of Functioning (GAF) rating, we used a range (which we often recommend because of the inherent subjectivity of GAF ratings; Piersma & Boes, 1997).
For this section, include a paragraph description of how you conceptualize the case. This description provides you an opportunity to describe how you view the case and how you are likely to proceed in working therapeutically with this client. Not surprisingly, behaviorists describe their cases in behavioral terminology, while psychoanalyti-cally oriented therapists describe their cases using psychoanalytic terminology. Generally, keep your theoretical jargon to a minimum, in case your client requests a copy of your intake report.
Mr. Smith is a stable and reliable individual who is currently suffering from severe adjustment to sudden unemployment. It appears that, for many years, much of his identity has been associated with his work life. Consequently, he feels depressed and anxious without the structure of his usual workday. Furthermore, his depression, anxiety, and lack of perceived constructive activities have considerably shaken his confidence. For a variety of reasons, he feels unable to go out and pursue employment, which, especially because of his strong value of normality and employment, further reduces his confidence in and respect for himself.
Psychotherapy with Mr. Smith should focus on two simultaneous goals. First, although it is impossible to provide him with new employment, it is crucial that Mr. Smith begin making a consistent effort to seek and obtain employment. It seems unrealistic to simply suggest to him (after 31 years of employment) that he reconstruct his identity and begin valuing himself as an unemployed person. The treatment objectives associated with this general goal include:
1. Analyze factors preventing Mr. Smith from following through on his daily job searches.
2. Develop physical anxiety coping strategies (including relaxation and daily exercise).
3. Develop and implement cognitive coping strategies (including cognitive restructuring and self-instructional techniques).
4. Develop and implement social coping strategies (including peer or spousal support for job-seeking behaviors).
5. Develop and implement social-emotional coping strategies. (Mr. Smith needs to learn to express his feelings about his personal situation to close friends and family without pushing them away through irritable or socially aversive behaviors).
The second general goal for Mr. Smith is to help him expand his identity beyond that of a man who is a long-term employee at a wood products company. Objectives associated with this second goal include:
1. Helping Mr. Smith recognize valuable aspects of relationships and activities outside an employment situation.
2. Helping Mr. Smith identify how he would talk with a person in a similar situation, and then have him translate that attitude and "talk" into a self-talk strategy with himself.
3. Exploring with Mr. Smith his eventual plans for retirement.
Although Mr. Smith's therapy will be primarily individually oriented treatment, it is recommended that his spouse accompany him to some sessions for assessment and support purposes. As he noted, there have been increasing conflicts in their relationship and it should prove beneficial for them to work together to help him cope more effectively with this difficult and sudden life change.
Overall, it is important to encourage Mr. Smith to use his already-existing positive personal skills and resources to address this new challenge in his life. If, after 6 to 10 sessions using this approach, no progress has been attained, I will discuss the possibility of medication treatment and/or an alternative change in approach to his treatment.
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