INTAKE REPORT
Client Name: Carl Freud Therapist’s Name
Date of Birth: 12/10/1973 Intake Date: 03/15/2016
IDENTIFYING INFORMATION:
Carl Freud is a 29-year-old, divorced, Caucasian male, who is the branch manager of a local bank. He owns a condominium in Atlanta where he lives with a female roommate. His workout partner, a primary care physician, referred Carl for an evaluation.
PRESENTING PROBLEM/SYMPTOMS/HISTORY:
Carl indicated that he felt “really down” for the past month. He believes he began feeling this way after a significant account took their business to another bank. Carl said that afterwards he began questioning his performance and management abilities. He felt very guilty about losing the account, even though it appears he had little to do with the actual circumstances that led the account to leave his branch. He began feeling increasingly insecure in other areas of his life and started questioning his own worth as a person. He started wondering if he had any “real” friends and began to withdraw from social activities he once enjoyed. He soon began having trouble falling asleep at night and found himself very tired in the morning and had trouble getting up. Over the past few weeks, he reports having no appetite and has had to “force” himself to eat. While he has not weighed himself, he has noticed his clothes fitting more loosely. He said it takes all his energy to make it through the day and he has discontinued his regular habit of working out at the health club. The past few days he has called in sick to work, due to increasing difficulty in concentrating and lack of motivation. He rarely called in sick more than a couple times per year prior to the last month. When questioned about suicidal ideation, he indicated that for the first time in his life he has considered suicide as an option, though he quickly denied any intent to do so. He also denied thinking about methods or having a specific plan. He was very worried about having the thoughts at all, and this, in part, motivated him to follow up on his friend’s referral to seek treatment. Carl stated he had similar symptoms (feeling down, questioning self worth) after his divorce, about 4 years ago, but believes he “got over it” by throwing himself into work and exercise. He has never sought treatment previously and admits that is why he is even “more down” now because he cannot seem to “get over it” like he did before.
PSYCHOSOCIAL HISTORY:
Family History: Carl is the second of three children born to his parents. His parents have been married for 36 years and reside in Cincinnati, Ohio. His father, age 61, works as senior accountant in a large accounting firm and his mother, age 59, works as a chef. His older sister, age 34, is a homemaker, married to an attorney, and they have four children. His younger brother, age 26, is completing his third year of optometry school and has recently become engaged. Carl describes his family as close, although he only sees them once or twice a year. His sister lives close to his parents in Ohio and his brother is in Boston.
Carl describes his father as emotionally distant, but always available to him in “practical” ways. He states his father always pushed him to his best and Carl indicates that he always felt like he needed to work hard in order to earn and keep his father’s approval. He states his mother is the one with whom he would discuss emotional and relational issues. He states that she has a history of at least two (that he is aware of) periods of depression for which she was prescribed medication (he does not remember what). He indicates she had not had any problems with depression since she began chef school after his younger brother went to college.
Carl said he and his brother and sister have always been pretty close with just the normal “sibling squabbles.” He describes his sister as the “perfect mother” and says that he feels somewhat inadequate as a family man when he compares himself to her. He describes his relationship with his brother as competitive. Carl states that his brother was the “smart one” and he was the athletic one.
Carl was not aware of any significant psychiatric problems in other members of his family. He says that his paternal grandfather was “pretty harsh” on his father and might have had a drinking problem. He said neither of his parents drink alcohol and he denied any history of emotional, physical, or sexual abuse. He said his parents were strict, but never spanked him.
Carl described his family as “moderately religious.” He said they went to a fairly liberal Protestant church a couple times per month. Carl said he was involved in the youth group throughout high school. When he went to college, he stopped going to church unless he was visiting at home. Carl said that he still believes in God and follows a strict ethical code, but states he does not have an active spiritual life.
Social History: Carl described having one or two close friends throughout his school years. He was active in little league sports as a kid. He lettered in junior varsity and then varsity athletics in high school, where he played soccer and baseball. He described himself as shy with girls and did not start dating until his senior year in high school. He had a steady girlfriend throughout his senior year of high school and his first semester of college. They went to different colleges and she broke up with him over Thanksgiving holiday, because she wanted “more freedom to enjoy her college experience.” Carl described the break-up as “devastating.” He said he was pretty down for about three months after the break-up. Carl dated off and on during his freshman and sophomore years in college, without getting involved in any serious relationships.
During the summer between sophomore and junior year, Carl met Amanda, a recent college graduate who was working in the office of Carl’s physical therapist. They began dating and were engaged by Christmas. They married the following summer. Carl said that their first year of marriage was “rough,” as he was taking a very heavy load at school so that he could graduate on time. After Carl graduated and began his career, he continued working long hours. At the time, he felt the need to work hard in order to “prove himself” at work. He said Amanda frequently complained about his long hours. She told Carl that she had expected that after he graduated things would improve. Instead, their relationship became increasingly distant and after two years of marriage, they separated. Amanda filed for divorce six months later.
Since the divorce Carl has avoided any serious relationships. He has spent most of his time working, exercising, and playing in a softball league. He has close “acquaintances” in each of the settings where he spends his time. His closest friend was recently transferred overseas. He says that he and his roommate are becoming “pretty good” friends, though “strictly platonic.”
Academic and Employment History: Carl said he was always an “average” student. He was never particularly interested in school until his junior year in high school. At that point, he began taking it more seriously and began getting B’s and some A’s. He remembers his teachers always comparing his sister’s performance (she was always an excellent student) with his. He thinks that they were trying to motivate him to improve, however, he recalls that in middle school this made him less interested in his schoolwork and more motivated to find an area where he could excel (baseball). When he began to do well in high school, he found the comparisons did not bother him anymore. He went to a small private college where he received a partial scholarship to play baseball. He was injured at the end of his sophomore year and was unable to play at the college level anymore. After he lost his scholarship, he began working part-time at a local bank. He continued going to college full-time and graduated with an economics degree. After graduation he began working full-time for the bank. He was transferred into the commercial lending department. After a year-and-a-half at the bank, he was made a commercial loan officer. Two years later, he was promoted to assistant branch manager and in another two years he was made the branch manager, which is the position he currently holds.
THERAPY/PSYCHIATRIC EXPERIENCE:
Carl saw a college counselor for depression two months during his freshman year of college after his girlfriend broke up with him. When questioned about this, he stated that it was not as serious as this present episode. He did not remember having any problems with his sleep or appetite. He found the therapy helpful at the time.
MEDICAL HISTORY:
Carl ruptured his achilles tendon playing baseball his sophomore year in college. He required surgical repair followed by 12 weeks in a series of casts. He then had to wear a heel lift for 9 months. Carl went through significant physical rehabilitation to get to the point where he could run again. Carl denied any other significant history of injuries, medical illness, or surgeries. He is not currently on any medication and reported no current health concerns.
Carl started to drink his freshman year in college. He denied any significant problems or legal incidents secondary to drinking. After his injury, he said he “mellowed out with the drinking” and only drank socially (no more than three drinks per occasion). At present, he says that he rarely drinks more than two beers or glasses of wine in an evening. He denied any history of drug or tobacco use. He said he is “obsessive” about exercise; he works out every night and plays softball on the weekends, at least until the last month.
MENTAL STATUS EXAM/BEHAVIORAL OBSERVATIONS:
Carl is a 29-year old male who appeared his stated age. He was dressed casually in blue jeans and a sweatshirt. He was unshaven but was otherwise clean and well groomed. He had difficulty maintaining eye contact with eyes downcast but otherwise seemed comfortable with the examiner. He was cooperative, discussed his problems freely and openly, and responded to the examiner’s questions. He spoke clearly but softly in a coherent and relevant manner. He described his mood as depressed and his affect was consistent with his mood. He briefly became tearful on two occasions (discussing his divorce and his relationship with his father). Thought content was notable for a self-derogatory tone. He denied having any hallucinations. The client had a couple lapses in attention, but otherwise cognitive functioning (orientation, memory, concentration) appeared normal. His judgment was intact and his insight was good. His intelligence was estimated to be in the average range. He acknowledged passing thoughts about death and suicide, however, he denied seriously considering an actual plan or method and he denied intent. He readily signed a written safety contract.
CURRENT SITUATION and FUNCTIONING:
Carl has previously been “obsessive” about exercise and playing softball regularly but in the last month he has rarely engaged in these activities. Carl used to go out with friends about once a week but stated this has diminished greatly since his current mood and since his closest friend was transferred overseas. Now his day most often begins after a fitful, if at all, night’s sleep. He has difficulty rising in the morning, runs late to work or calls in sick and watches TV most of the day. He avoids many phone calls, including his sister’s, and has little to no appetite. Carl indicated that he is anxious about all of this because he is normally a hard, diligent worker, is very active and enjoys being close to his family.
Carl’s own perceived strengths include good insight and reasoning, hard worker, ambitious, athletic, confident and successful. His perceived weaknesses include currently feeling out of control and unable to “snap out of it,” not as smart as he should be, not having a family/being a family man, and feelings of loneliness.
DIAGNOSTIC IMPRESSIONS/DIAGNOSIS:
Depression: Carl reports feeling down, unable to sleep and wake up, not participating in activities (working out, softball, social gatherings) that used to bring him pleasure, calling in sick to work, lack of motivation, no appetite, possible weight loss, questioning self worth, some suicidal thoughts but no plan.
Phase of Life Problem: Carl reports comparing self to siblings, especially his sister in regards to not being a family man. Feelings regarding the divorce may be re-surfacing, questioning self worth.
296.22 Major Depressive Disorder, Single Episode, Moderate
V62.89 Phase of life problem
CASE FORMULATION:
Carl was raised in a fairly competitive family with a strong work ethic. He came to believe that hard work and success was the way to earn approval from others. He has developed a strong workaholic/perfectionistic streak. Biologically, he may have inherited a pre-disposition to depression from his mother. The recent perceived failure at work served as the catalyst for Carl’s downward spiral of self-doubt and depression and feelings related to his divorce may be resurfacing. He has begun negatively comparing himself to his siblings (e.g., feels less intelligent than his brother, feels he has failed as family man compared to his sister). Due to his negative self-regard, increasing anhedonia and lack of energy, Carl has begun to withdraw from his usual activities and thus does not benefit from his social support system. Additionally, his best friend recently moved which has left him with fewer resources. Carl has used this isolation and loss as confirmation of his failures. However, given his resources and his prior level of functioning and self noted strengths, such as insight, the prognosis appears very good.
TREATMENT RECOMMENDATIONS:
Carl is depressed to the point that it is interfering with his social and occupational functioning. Treatment is indicated to resolve his depressive episode, return him to his previous level of social and occupational functioning, and to address underlying constructs, which lead Carl to feel inferior and driven. To this end, Carl would likely benefit from individual psychotherapy addressing his misattributions regarding his problems at work, his obsessive-compulsive personality traits, and the family dynamics, which lead Carl to feel so driven and inferior. Carl may need interventions to help enhance his social support network. A psychiatric consult for evaluation of pharmacotherapy is also strongly recommended.
TREATMENT PLAN:
Goal 1: Client will not engage in any self- harming behavior
Objectives: Client will write a contract in regards to suicidal ideation. Client will discuss any further thoughts of suicide or suicidal intention that arise, as soon as they arise. Eventually state he has no more suicidal thoughts.
Interventions: Individual therapy one time per week for one hour. Check in with client regarding ideation, monitor level of harm, increase support network.
Goal 2: Client will receive a psychiatric evaluation to assess for medication need.
Objectives: Client will set up appointment with psychiatrist. Client will cooperate with evaluation. Client will take medication if and as prescribed.
Interventions: Individual therapy one time per week for one hour. Monitor client response to medication.
Goal 3: Develop ability to recognize, accept and cope with feelings of depression and underlying feelings of inferiority, perfectionism and workaholism.
Objectives: Identify source of depression. Explore other times that similar feelings occurred. Identify negative self- talk and internal messages. Reframe messages.
Interventions: Educate about depression. Normalize feelings. Encourage sharing feelings of depression in order to clarify them and gain insights to the causes. Assist in developing coping strategies such as: exercise, less internal focus, feeling expression, strength focusing. Assist in exploration of feelings underlying depression and family dynamics.
Goal 4: Alleviate depressed mood and return to previous level of functioning
Objectives: Set up self- care plan. Set up ways to achieve better sleep. Make positive statements regarding self and ability to cope with stresses of life. Develop healthy cognitive patterns and beliefs about self that lead to alleviation of depressive symptoms. Identify cognitive self- talk that supports depression, negative feelings and replace with healthy cognitions. Engage in activities that reflect increased energy and interest. Participate n social contacts.
Interventions: Assist in developing awareness of cognitive messages. Reinforce social activities and social skills that support more intimacy in relationships. Assign recreational activities.
Therapist Signature: _________________________________
Therapist’s Name
Licensed Professional Counselor
