Sample Case Note

Intern: Charnetta R. Waters

site supervisor

Supervisor: Whitney Gooch,

Dr. Carter, Professor

Session date: 12/2/2015

Session # 4

Individual/Group: Individual

Brief client background information (demographics, presenting concern):

Individual is a 32 year old African American female from Petersburg, Virginia.
She came to Richmond by way of assisted living facilities and judicial
systems. Individual has a long history of substance abuse including crack
cocaine and alcohol. She reports having frequent relapses especially when
stressed. Individual has been using drugs since the age of 16 years old and
has also engaged in prostitution for money. Individual now resides with her
younger sister and her family. Presenting concern is having trouble adjusting
and sitting with the distress without resorting to use of substances. Individual
reports a continuous challenge with using healthy coping skills when she is
angry, which has impacted her overall growing and well-being since
childhood.
Brief summary of the session:
Individual presented with rapid speech as she addressed the challenges she
was having with staying in control while living with her family. Individual
expressed difficulties in getting along with her sister as she often felt
pressured with having to do as her sister wanted. Individual identified that
aspect such as even shopping for her own clothes was an argument when
she felt as if her sister ridiculed her about her style. Individual exhibited
tangential thinking patterns and loud tone when speaking. She presented to
be highly agitated yet was able to maintain some control as she talked about
her problems with intern. Individual expressed the anger that she often felt
towards both her sister and her brother causes her to think about relapsing
or even engaging in dangerous behaviors. Individual to homicidal thoughts
when her brother threatened her for not giving him money that he said she
owed. Individual expressed a detailed plan if she was the same person, yet
resorted to going to her bedroom and calming off. Intern assisted individual
in identifying challenges with self-esteem that presented as the common
issue in both situations. Intern assessed how client really felt about herself as
she often felt pressured when people asked her to do things that she did

not want to do. Intern assessed the last time individual used illegal
substances. Intern celebrated that individual avoided resorting to using
drugs or alcohol while experiencing conflict this weekend.
Your

focus (goals) in this session:

Using I statements
Conceptualizing the root of conflicts
Self-reflection and coping skills

Conceptualization:
Individual presents with this anger as a secondary emotion to the conflict she
has with her family. After exploring the resentment that individual, claims her
sister has towards her, it appears that much of the problem also rest with the
low self-esteem of client. She often feels pressured as well of the simple.
Individual experiences stress and anxiety more when at home as she feels
that she is being treated like a child staying with her younger sister.
Individual family dynamics appears to be a central source of stress in her life,
which impacts her choice to use drugs.
What you feel went well in this session, and why:
Self-reflection of what goals to identify : improve self-esteem and
improve anger management
There was active listening and reflection used
What you would have done differently, and why? What do you feel like you
struggled with in the session or questioned after the session, and why:
Addressing the brother who stays with her and also sales drug
Issues you would like to discuss in supervision:
Clients with substance use dual diagnosis