Intake Report and Treatment Plan: Obsessive-Compulsive Disorder (OCD) Report

Identifying Information

Joan is a 49-year-old married lady of Caucasian origin. She was referred to the present facility by her Medical physician for an extra analysis regarding her points with somatic signs. Upon session, Joan had different underlying health-related experiences. For occasion, she narrates experiencing “anxiety attacks” within the week after an entire full month; she recounts having elevated coronary heart palpitations and different chest-related pains (Sperry & Sperry, 2012). Furthermore, she complained of a number of points about her presenting well being issues. First, although she states that she may be very fantastic, she recounts how her job as a supervisor is difficult. Second, at her place of residence, she is the main father or mother in virtually each chore and monetary obligation. Lastly, her two daughters have more and more complained about her incapacity to emotionally attend to them now that they’re youngsters.

We will write a customized Report on Intake Report and Treatment Plan: Obsessive-Compulsive Disorder (OCD) particularly for you
for less than $16.05 $11/web page

807 licensed writers on-line

Learn More

Behavioral Observations and Mental Status Exam

Joan seems okay along with her habits regarding her consuming about 5-7 cups of espresso and consuming a full darkish chocolate each different day. Being that she is affected by insomnia perpetuated by her historical past of overworking each at her job and at house, an analysis of her sleep patterns exhibits poor sleep hygiene, thus making her persona type throughout analysis look like obsessive obligatory type (Sperry & Sperry, 2012). Moreover, their look is said to her psychological standing as conscientiousness and the sensation of avoidance depicted by each her workers and her two daughters.

In this case, her temper seems dysphoric for her rising anxiousness and emotional distancing. Though she blames herself for all of the criticism, she doesn’t have any suicidal and homicidal ideation indicated primarily based on the observable information. As such, she is corporative and signifies an inherent ability for any remedy for her state of affairs. The information introduced is due to this fact enough for a scientific therapeutic plan.

History of Presenting Problem

The presenting issues appear to have originated from previous scientific occasions. According to Joan, her complete life from childhood has been accompanied by her overambitious to attain in each activity, her conscientious nature, never-making errors habits, and her avoidance to point the presence of a mistake in her endeavors imposed by her controlling and significant father (Sperry & Sperry, 2012). Moreover, she has utilized the usage of crossword puzzles, studying books, and enjoying solitaire throughout her childhood to deal with her anxiousness points.

Past Treatment History

Joan describes utilizing a psychotherapy medicine that features such diversion methods as crossword puzzles, fixing solitaire video games, and studying as an answer to her anxiousness. She additionally narratives utilizing such therapeutic-related options as managed respiratory charges and ignoring sure vital statements from others to make sure her anxiousness doesn’t overweigh her feelings. She was not in every other previous medicine prescriptions. In addition, no household medical historical past associated to her psychological well being situation.

Relevant Medical History

A chemical imbalance of the mind is related to the mind containing both much less or extra of the neurotransmitter chemical substances. In essence, the mind doesn’t have a transparent communication pathway due to the lack of nerve cells accountable for making a connection between info and the synthesis of the data. Relevant to this evaluation, such medical situations as anxiousness, persona dynamics operative, and the chemical imbalance of the mind are vital for additional therapeutic evaluation (Sperry & Sperry, 2012). The practitioner attending to her has a non-disclosed contact however is a psychotherapist, primarily based on the interviewing questions imposed on Joan.

Developmental History

Cognitive growth contains alterations in thought processes via childhood. This cognitive habits change was induced in her by her father, who was a lot controlling and demanding (Sperry & Sperry, 2012). In this case, she developed excessive problem-solving skills with minimal probabilities of making a mistake in her duties. As an adolescent and missing the father or mother determine indicated by her distant mom and over-controlling father, her social expertise have been significantly affected.

Get your 100% unique paper on any matter accomplished
in as little as 3 hours
Learn More

Social and Family History

Her social studying expertise have been additionally interfered with as she was rising up. In this case, Joan doesn’t have the abilities to narrate with others due to the detrimental social expertise induced on her by her father, which contain her independently performing duties. Because of her potential to handle time and meet set deadlines, her language and tutorial growth have been hypothetically nice, thus giving her a supervisor position in her present firm. She has no navy background or any associated authorized points regarding her employment. However, she has a dysfunctional and poisonous relationship along with her members of the family.

For occasion, she has a distant mom and a controlling father. Moreover, her two daughters really feel that their mom doesn’t assist them emotionally. She has no verifiable romantic relationship along with her husband, as exacerbated by her frequent travels by her husband. Spiritually, she doesn’t imagine in miracles, therefore giving it a score of three when requested about probabilities of getting higher via miracles. Joan doesn’t present any circumstances of alcohol use, however as a result of overuse of espresso and darkish chocolate, her state of affairs may be described as a substance abuse dysfunction.

Joan doesn’t present any aggression or violence to each her household and workers however signifies a peaceful blended demeanor.

Current Functioning

Joan can attend to each her household and worker duties. In essence, her situation has not lowered her work productiveness. For occasion, she will be able to handle her boss’s demand to extend manufacturing and, on the identical time, addresses each her house’s monetary and family chores. As such, her self-care capability to attend to non-public facilities is very rated, a power wanted for psychological care intervention. However, she admits to not having the ability to delegate all of the duties to her workers, a vice that may result in extra stress if the boss’s calls for are to be primarily based upon. Moreover, that incapacity has made her not be ready to assist her workers emotionally.

Formal Assessment Data (if any)

Joan studies a poor score of three out of 10 with reference to believing in a miracle to occur to her in order that she will be able to get nicely and free from the life stressors she is present process. Her score is predicated on the truth that she doesn’t really feel any anxiousness throughout weekends and believes it isn’t all about miracles for her. Interestingly, she notes that she can provide it a score of 6, simply because throughout work, she will be able to relax and never consider any job and household stressors.

Diagnostic Impression

One of the foremost underlying diagnoses on this case of Joan is Obsessive Compulsory Disorder (OCD). It is a psychological illness that causes recurrent undesirable ideas or perceptions (obsessions) or the impulse to do one thing time and again (coercions). In the case of Joan, her want for being a perfectionist, conscientiousness, and criticalness is an indication of OCD. As a diagnostic code, it may also have resulted in anxiousness, particularly when one is obsessive with a activity however find yourself not carrying out them. In such conditions, stress and anxiousness develop. Also, with a number of duties to do, most sufferers with OCD shouldn’t have time to sleep, leading to insomnia.

Case Formulation

In psychoanalysis, Adlerian concept can be utilized to know a shopper’s case formulation and evaluation. According to Adlerian, one can perceive the foundation of a shopper’s behaviors, how they will alter their notion of themselves, and the way they will modify their opinion of their childhoods (Sperry & Sperry, 2012). Based on this evaluation, Joan presents with anxiousness dysfunction, lack of sleep hygiene, coronary heart palpitation, and subsequent pains in her chest. Case formulation is a crucial facet within the characterization of illnesses and their codes for the simple therapeutic plan (Sommers-Flanagan & Sommers-Flanagan, 2017). In addition, Adlerian posits that an individual can interpret the circumstances of their existence and make them their way of life. As such, Joan biologically predisposes to such components as taking a excessive quantity of espresso and darkish chocolate.

We will write a customized Report on Intake Report and Treatment Plan: Obsessive-Compulsive Disorder (OCD) particularly for you!
Get your first paper with 15% OFF
Learn More

Psychologically, she is predisposed to traits of perfectionism, criticalness, the feeling of avoidant, and conscientiousness. This is predicated on Adlerian notion of Psychopathology, through which he compares behaviors to the way in which an individual logically manifests its signs from extreme excuses for failure to perform sure life duties (Sperry & Sperry, 2012). Using this evaluation, Joan’s social circle features a hectic working atmosphere, emotionally unsupportive to each her daughters and her workers, and exacerbated by her distinct mom and controlling father.

Moreover, being overly conscientious and having an emotionally distant mom is the foremost pattern-maladaptive. In this case, organic, social, and psychological components are perpetuated by occasions similar to perfectionism, little time for each household and workers, and task-focused habits, respectively.

XII: Cultural Formulation

Joan’s cultural id is that of a Caucasian id, upper-middle-class WASP lady. She doesn’t have any culturally-related stress, thus extremely acculturated. Based on Adlerian perspective, issues may be comprehended by an individual not possessing a sense of belonging to a given group or tradition. Specifically, Ratts and Pederson (2014) posit that the understanding of a multicultural train can logically result in advocacy for social impartiality. In this case, the counselor and the affected person contain themselves in understanding one’s cultural background, thus creating systemic-level interventions.

Preliminary Treatment Plan

Crisis Management/Stabilization

Since Joan is affected by chest pains and coronary heart palpitation, the counselor ought to carry out disaster administration by transferring Joan to a heart specialist to take care of her chest and coronary heart issues. This motion can solely be efficient after the client-therapist engagement is achieved primarily based on Adlerian first stage of therapeutic objectives. This ought to be accomplished instantly to keep away from health-related medical errors.

Medical/Somatic Referral (If Any)

Apart from the chest and coronary heart palpitation, Joan doesn’t have any somatic referrals that require rapid intervention.

Treatment Specifics and Goals

The first remedy encompasses the scientific remedy plan for Obsessive-Compulsive dysfunction.

Goal#1: To scale back obsessive ideas and compulsive behaviors associated to the dysfunction


  1. Cognitive-behavioral and habits remedy particularly in the direction of the identification and modification of distorted behaviors.
  2. Psychoeducation and processing: This is the place the affected person is psychologically educated on methods through which she will be able to handle her behaviors, particularly the obsession to take excessive quantities of espresso and darkish chocolate.
  3. Exposure and response remedy. In the case of Joan, it’s evident that she has poor social expertise due to her restricted time to work together with others and the household. For this remedy intervention, contain the affected person in outside actions the place she will get to see the opposite model of the world the place persons are extra socially interactive.

Goal#2: To enhance the household relationship and connection between Joan and her household


  1. Using the third stage of Adlerian concept in remedy (perception), a family-based intervention is crucial. In this technique, remedy entails inspecting hectic family-related points,
  2. Organizing household actions the place Joan participates in enjoying video games along with her two daughters and her husband. According to Reichenberg and Seligman (2016), a household alliance is established to extend the success of family-mediated remedy. Therefore, the therapist ought to solely search to take away all obstacles that may make the affiliation not useful.
  3. Another family-related intervention contains the creation of time throughout busy schedules. In this fashion, the members of the family will really feel a way of belonging and acts to reassure Joan that her remedy will probably be optimistic.

Goal #3: To scale back overworking on the job and within the household due to her perfectionism and conscientiousness resulting in anxiousness


  1. Distraction method: This this diversion technique, Joan will in a position to assist her household and workers emotionally, slightly than proceed along with her endless duties that don’t give her time for the employees and her daughters. This is the reorientation stage as deployed from the fourth stage of Adlerian perspective.
  2. Involve the affected person in answering presuppositional questions, thus are leading to Joan accepting outcomes as they’re in her job as a supervisor and imagine that it isn’t solely via perfectionism that duties are accomplished successfully. This communication will create a hyperlink with the, subsequently resulting in excessive manufacturing when they’re listened to. In such a means, the stress in Joan will probably be lowered due to lowered life stressors, particularly these associated to work.
  3. Controlled publicity and ritual prevention may be sued to cut back the general anxiousness in Joan. For all of the objectives and interventions, the situation of the care plan is an outpatient setting. The timing and frequency contain utilizing a reasonably spaced timing, with about 8-10 classes carried out weekly. During this time, Selective serotonin reuptake inhibitors (SSRIs) may be administered to cut back the obsession and compulsions.

Ancillary Services

In the state of affairs the place Joan is transferred to a heart specialist for chest ache and coronary heart palpitation, Ambulance providers are required for fast transport, and on the heart specialist facility, cardiac monitoring providers are carried out. In this case, the heart specialist can contain the providers of a radiologist for diagnostic imaging. In addition to the acknowledged ancillary providers, the counselor ought to search the providers of substance-­abuse dysfunction providers for scientific and adversary care plans directed in the direction of her excessive espresso and darkish chocolate consumption.

Cultural Considerations and potential Social Justice Intervention

With regards to the Biopsychosocial evaluation in Joan’s case, there are not any culturally centered remedy issues.

Not positive when you can write a paper on Intake Report and Treatment Plan: Obsessive-Compulsive Disorder (OCD) by your self? We may help you
for less than $16.05 $11/web page
Learn More

Potential Obstacles

Joan’s feeling of avoidance and along with her perfectionistic character, her excessive expectation to achieve each activity underpins a medical impediment. Having little time for household can also be an impediment, particularly when a care plan is underpinned via the presence of a household proxy.

Therapist Characteristics

The therapist is supportive via the evaluation and requested questions successfully, thus enabling Joan to reply them effectively. The therapist can also be multiculturally competent when she builds a rapport with Joan to ask about her cultural variety and issues. According to Reichenberg and Seligman (2016), a therapist ought to be self-aware about their notion of life points and people associated to the affected person to assist them form their experiences and assumptions. Moreover, a therapist ought to be cognizant of particular person traits to assist them establish purchasers who’re too demanding and people who are defensively vital.


Sperry, L., & Sperry, J. (2012). Case Conceptualization: Mastering this competency with ease and confidence (1st ed.). Routledge.

Ratts, M. J., & Pedersen, P. B. (2014). Counseling for multiculturalism and social justice: Integration, concept, and software (4th ed.). John Wiley & Sons, Inc.

Reichenberg, L. W., & Seligman, L. (2016). Selecting efficient remedies: A complete systematic information to treating psychological issues (5th ed.). John Wiley & Sons, Inc.

Sommers-Flanagan, J., & Sommers-Flanagan, R. (2017). Clinical interviewing (6th ed.). John Wiley & Sons, Inc.

Looking for this or a Similar Assignment? Order a Paper Now