Case Study Jamie Maria and Sofia Luna

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Counselor’s Name: Date:

Case Conceptualization Form

I. Assessment

Discuss background characteristics, presenting complaints, history of the problem, and social and cultural considerations. Describe the differential diagnosis, including any related diagnoses that were considered and ruled out. Explain the legal and ethical considerations that are relevant to the client situation.

II. Case Conceptualization

Use your theoretical orientation to provide a concise summation of the client’s psychological strengths and difficulties. Integrate your client’s history with the theoretical orientation you have selected to support your explanation.

III. Treatment Plan

List two long-term treatment goals for client issues with at least two short-term objectives that are steps in how you plan to meet each goal. The objectives need to be specific and measurable and are driven by your theoretical orientation and the element you are asking the client to change (e.g., thoughts, feelings, actions, etc.)

Problem, Issue, Challenge, Obstacle, Symptom:

Treatment Goal 1:

Objective:

Objective:

Problem, Issue, Challenge, Obstacle, Symptom:

Treatment Goal 2:

Objective:

Objective:

IV. Interventions

Discuss how you will work toward the treatment plan goals. Base your interventions on the theoretical orientation you discussed in your case conceptualization. Be sure to use evidence-based practices that are supported by your research. Describe any referrals that you believe will be beneficial.

Jamie, Maria, and Sofia Luna

You are working at an outpatient clinic when a family is referred to you for an intake session. Last night, the police were called to the Luna household for a domestic disturbance. Since the family is working on the immigration process to become American citizens, their case worker recommended that they seek counseling to address the family issues.

Jamie is 28 years old and speaks moderate English. He grew up in Honduras with his parents, eight brothers and sisters, and grandparents. His father frequently went on “drinking binges” and would “put his mom in her place.” It was a patriarchy system in which they did not have a lot of income and his father had numerous mistresses. He reports that he was raised with a strong Catholic background, and he continues to practice today. His uncle sexually abused him from ages 6 to 13 when Jamie reports he was able to beat him up enough to get away. He did not want to appear “gay,” so he had numerous sexual partners and got in lots of fights to prove his masculinity. In his late teens, his brother got involved with the Mara Salvatrucha gang and tried to recruit Jamie. This was around the time he met Maria, and they decided to illegally enter the States at Maria’s urging since she was pregnant and wanted to raise their child in a better life. Case Study Jamie Maria and Sofia Luna

Maria is 26 years old and speaks little English. She grew up in Honduras as well with her mother, grandmother, and nine brothers and sisters. She never knew her father who abandoned the family when she was an infant. Her mother had several other long-term relationships but never married. Her family was “very poor” and she did not finish school past fifth grade. Maria was raped when she was 10 and then began a life of prostitution to help her mom with feeding the rest of the family. She met Jamie when she was 18 and quickly got pregnant. She illegally entered the States and began to work in a home in Texas. After she had the baby, Jamie was able to illegally enter the States and began working odd construction jobs to pay their bills since Maria no longer was working to care for Sofia.

Jamie and Maria report that they have not been successful in having any more children, which Jamie blames on Maria’s previous sexual history. He is ashamed since in his culture, “men are supposed to have many children.” Maria reports that she had many difficulties in having Sofia and did not get the proper medical care she needed. Sofia was born premature and has speech and other motor skill delays. Both Jamie and Maria admit they used drugs in the past but adamantly deny any current drug use because they know it would affect their immigration status. The police found drug paraphernalia in the household, but Jamie and Maria stay in a condo with two other families and reported the material was not their own even though Jamie appeared intoxicated and smelled of marijuana when the police arrived last night.

They both admit that when they get angry with each other, they hit and punch each other. Maria says that she will not be kept in a system like the one in which she was raised in Honduras where she is supposed to be subordinate and just take whatever Jamie gives her. She accuses him of having affairs and sleeping around with everyone. They report that they have arguments at least two to three times a week and have separated several times to get away from each other. Maria says that she is dependent on him since she is not working, and he needs to step up and be a man to take care of his family.

Maria says that on the night of the police incident, she caught him with another woman at the corner store, and when he got home, she threw a pot at him. They fought, and at one point, he grabbed a knife and threatened to cut her if she did not calm down. Sofia witnessed all of this and saw both of her parents put in handcuffs in the front yard.

Sofia is 8 years old. She is very shy but speaks English well. She is in the second grade and was held back in kindergarten due to her developmental delays. She is currently at risk of being held back again, and her attendance record is very poor. She reports that she hates to see her mom and dad fight all the time. She gets very scared, has trouble sleeping, and hides in her closet. She does not have many friends because the kids “pick on me for being dirty and a ‘spic.’” She mentions that one of the other male children living in the condo does come to “comfort her” at night and gives her “lots of hugs and squeezes.” Maria reports that she has caught Sofia “rubbing her private parts” on the couch arm and trying to kiss all the other little boys in the house. She denies that Sofia has been sexually abused and blames it all on Sofia.

After completing the intake on the family, your supervisor tells you that you can decide which person in the family system you want to focus on for individual counseling sessions—Jamie, Marie, or Sofia—with the understanding that the other family members will work with your colleagues with possible joint family sessions in the future. For the assignment, select one member of the family to complete your case conceptualization, understanding that this family member is a part of the overall family system.