Physical and Rehabilitation Medicine Paper

Physical and Rehabilitation Medicine Paper

The client is a 32 year-old African American man. He currently lives with his girlfriend. The client presents to the clinic seeking for help in addressing his difficulties in expressing himself and social discomfort feelings which have persisted all his life. The client reports that the condition affects his professional and social functioning thus interfering with his daily life. He is worried that the situation would limit his professional and personal development. This causes him intense anxiety which occasionally results in panic attacks. The client’s decision to live with his girlfriend before marriage went against the African traditions from which his family was deeply rooted and it triggered conflict between him, his girlfriend and his parents. He reports that the anxiety and panic episodes began immediately after moving in with his girlfriend whom he seeks to get married to in the future. He has never sought or received any psychological service and this marked the first mental health professional consultation. Physical and Rehabilitation Medicine Paper


Major psychosocial issues

The client experiences serious insomnia as observed during the course of the treatment. The treatment focused on addressing the insomnia problem which affected his sleeping patterns. The client is also depressed following the loss of his brother two years ago through a road accident. He has been in constant grief and mourning throughout the session which has shifted the focus of the therapy to addressing this psychological issue too. Physical and Rehabilitation Medicine Paper

Types of services rendered: Individual

Overview of treatment process

The session took place once per week whereby the client received a combination of cognitive-behavioral techniques and supportive-dynamic psychotherapy (Dunlop, 2016). These therapies and techniques sought to manage the client’s insomnia and panic attacks experienced. Throughout the entire therapeutic session, a good alliance was established easily between the client and the psychologist. The client however demonstrated difficulties in expression of emotions and thoughts which was attributed to emotional sensitivity. Further interaction revealed that when given the opportunity and trust, he was a quite expressive and insightful person. He was able to clearly open up effectively and articulate his inner state with sufficient space and understanding. This helped him in expressing his desires and personal needs.

The initial treatment phase was characterized by creation of relevant awareness to the client concerning his emotional state within his social spheres and how it was reflected in the diverse triangular relationships causing stress in his life (Boden & Thompson, 2015). These included the girlfriend, mother, father, uncle and himself relations which triggered conflicts once in a while. The client was able to tend for his personal needs and free himself from the influence of these people as well as attain independent thinking by working through his sense of responsibility. During this face, his interaction with the family and friends improved.

The next treatment focus addressed the psychological independence and emotional autonomy of the client. This sought to help the client detangle himself from the family traditions and beliefs and create his own sense of identity as an adult without the influence of his family. This helped him in handling the pressure associated with meeting the expectations of his family as well as their aspirations at the expense of his own. This revealed that the client had abandoned his desires and wishes to fulfill those of others. He was experiencing a dilemma of leaving his home to live with his girlfriend and that of his family demanding a marriage before that attempt following the governing traditions. His moving out resulted in guilt, anxiety and panic attacks considering the differences he had with his family. The attacks were addressed using the psycho-education approach which involved the application of breathing techniques, self-monitoring of precipitating emotional responses and thoughts as well as panic response. Relaxation of muscles and deep breathing exercises supported the relaxation techniques (Kerr, 2017). With time the client managed to differentiate between authentic wishes and desires from the other people’s expectations. He was also able to see things clearly and in an open-minded manner. The client was also able to re-evaluate his career goals (Maree & Di Fabio, 2018). He got to understand his job dissatisfaction and discovered that he was overqualified for the position he held in the family business and thus decided to utilize his full potential in positions that he was qualified for even if not within the family organization (Russell, Ferris, Thompson & Sikora, 2016). Physical and Rehabilitation Medicine Paper

The treatment also focused on supporting the client in self-care and coping. This sought to help him in coping with the loss of his brother whom he was very much attached to. During these sessions, he was able to explore and express his grief and receive social support on how to manage the loss of a loved one in the future. Fear of death and feelings of sadness were evident in the client as well as the difficulty to accept and let go of the lost brother. This condition had also significantly contributed to the presence of insomnia. The client often felt restless and could only sleep for a maximum of 4 hours in a night. Anxiety and guilt related to his decisions of choosing his girlfriend over the family wishes also increased stress which consequently affected his sleep patterns. In order to manage the situation, the client received information regarding relaxation techniques and sleep hygiene. He was also directed using combined progressive muscle relaxation and imagery as well as started on a self-initiated work regime. These approaches have produced positive outcome on the client including his facilitating sleep quickly.

Nature of Termination

Throughout the treatment, the client demonstrated notable gains and improvement. The termination of the session followed his report that he was satisfied with the degree of improvement he had experienced throughout the sessions. He expressed that his life had changed positively and he liked the direction through which he was ended. He had begun and was able to sustain multiple personal projects without the interference of his family, was able to speak about his brother without feeling sad, fearful and anxious and was also pursuing a career that suited his qualifications. He also expressed that the increased responsibilities in career and personal development as well as her planned marriage among other projects would demand increased financial and time resources which will limit his adherence to the treatment therapy. The official date of termination of the psychological therapy was expected to take place on January 25th 2019. The client missed the last planned termination session. However, he communicated and expressed his gratitude for our combined efforts in improving his wellbeing. He also appreciated the services and said a good bye.

Goal Status

The main goal of therapy was t treat the major psychological issues of the client. The client made notable improvement during the treatment course. He expressed satisfaction with his progress. He reported to have managed to appreciate the value of opening up and expressing his feelings and thoughts as well as his needs.  He has also gained positive socialization capabilities. He has also learned self-care and the need to place his aspirations above the expectations of other people. The client has also managed to overcome sadness and grief and thus been able to get over his brother’s death. He was also able to become responsible and explore his career choices with clarity.  He completely recovered from insomnia, panic attacks and social difficulties, gained confidence and improved self-esteem in the course of treatment.

Treatment Limitations

The therapy did not effectively address the underlying cultural identity conflicts held by the client even though it tried to explore the issue to a larger extent during the sessions.

Remaining Difficulties and/or Concerns

The client expresses no significant remaining difficulties /or concerns. By the end of treatment no remaining difficulties or concerns were observed. Physical and Rehabilitation Medicine Paper



The client has made significant positive progress which has optimized the attainment of his self-understanding and psychological wellbeing goals. However, ongoing analytical/ exploratory psychodynamic therapy could further benefit the client in the future.

Follow-up plan

There is no specific follow-up that was indicated for the client.

Instructions for Future Contact

The client was asked to contact the therapists in case of any consultation need. ______________________                                                            _______________

Counselor’s Signature                                                             Date


______________________                                                    _______________

Supervisor’s Signature                                                            Date


Boden, M. T., & Thompson, R. J. (2015). Facets of emotional awareness and associations with emotion regulation and depression. Emotion15(3), 399.

Dunlop, B. W. (2016). Evidence-based applications of combination psychotherapy and pharmacotherapy for depression. Focus14(2), 156-173.

Kerr, K. (2017). Critical Review on Relaxation Techniques. Critical Reviews™ in Physical and Rehabilitation Medicine29(1-4).

Maree, J., & Di Fabio, A. (2018). Integrating Personal and Career Counseling to Promote Sustainable Development and Change. Sustainability10(11), 4176.

Russell, Z. A., Ferris, G. R., Thompson, K. W., & Sikora, D. M. (2016). Overqualified human resources, career development experiences, and work outcomes: Leveraging an underutilized resource with political skill. Human Resource Management Review26(2), 125-135. Physical and Rehabilitation Medicine Paper

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