Confidential Psychological Report free essay sample

The client was instructed to take a battery of psychological projective personality tests that examine and evaluate his personality which will then make a critical analysis of his psychological case report as well as provide basis for treatment of his problem. The client, Mr. Valdez will also be involved in a comprehensive and detailed interview about his background information and personal history. II- Intake Interview Case History A. Family History On March 19, 2005, 15 yrs old Michael Anthony Valdez ran and rushed to his dying father’s side. Lying down on his death bed, He held his hand and told him something he wanted and waited to say all his life. He asked his father one final request- A father’s approval and acceptance as his Gay son. His final words were 8 letters, 3 syllables and a chance for his son to live a new life. Thonie or Mick-Mick was born Michael Anthony Cisneros Valdez on January 28, 1990, the eldest son and the second of Cesar and Fe Valdez. We will write a custom essay sample on Confidential Psychological Report or any similar topic specifically for you Do Not WasteYour Time HIRE WRITER Only 13.90 / page He never knew his mother and had no past memories of her but was often the topic of father’s stories and tall tales. Thonie is one of Cesar’s 5 children- The first and the eldest daughter, Lucille, Macky, Kevin and Sophia. The client, Mr. Valdez grew up and was raised by his father’s side of family relatives, while his other siblings went to the province to live with the mother’s side of extended family. Because of increasing financial problems and failing grades in his subjects, he chose to put his education to halt. Nevertheless, he was loved and was treated as a real son by his adopted and extended family. 1. Parents According to the gathered data and information from the pre-intake and intake interview, His father and mother met as co-workers working as budget employees at Manila city hall. Sometime during the client, Mr. Valdez’s birth, his father had a big fight with his mother that ended up leaving them for another family. Unknown to her husband, the wife has been living and sleeping with another man that drove the family apart. It took a long time for them to recover and move on from what happened nevertheless his father found a way to take care and raise 5 children by playing the role of a mother and a father. The client, Mr. Valdez’s upbringing which is marked by an absence of central and core parent figures which constitute the lack of love and attention may be one of the major factors that influence his depressive and suicidal tendencies. 2. Siblings The client, Michael Anthony is the eldest son of Mr. and Mrs Valdez and the second of five siblings: The first and the eldest daughter-Lucille, younger brother-Macky, Kevin and 11 years old half sister, Sophia which he never met. Based on our intake interview, the client and his brother, Macky lives in Manila with their father, while their other siblings currently reside with their Mother’s extended family. One time he was supposed to see and meet her for the first time but he declined and rejected the invitation as he’s better off without her. He would often act tough and hard whenever having conversations about his mother but displays a mask to hide his repressed anger and depression. 3. Larger Family Circle Mr. Valdez, the client’s siblings and extended family relatives from both sides would rarely come over and see each other because of long distance relationships, thus, the only means of communication and connection is through social networking sites in the internet. At least once a year on special occasions, family reunions and barrio fiestas they would meet and visit each other’s homes except, Mrs. Valdez who is hated and shunned away from the family. For most part of Michael Anthony’s childhood, He was raised by Aunt Malou, a family relative and grew up in the company of a female controlled household. During the time when his father was forced to work for 18 hours just enough to sustain the family’s basic needs, the client would sometimes hang out and bond with his female aunts and cousins; strolling and frolicking by the baywalk and having picnic at the province. . Physical Surroundings of Youth Early on his childhood to pre-adolescence, he began to display and show signs of homosexuality when he unconsciously acquired and copied the mannerisms of his female family relatives. During this time, that he also felt the love and care from a family that he can call home. At an early age, he was forced to be independent and to w ork hard in a struggling and financially unstable environment. He is a hardworking, tough but emotionally drained and withdrawn kind of person. Sometimes he would try to fake a smile and act numb to put on a facade to everyone. His struggle to find a family and a home for a normal childhood may have caused him to have a quiet and mild mannered demeanour which represents repressive anger and anxieties. General Home Atmosphere a. As a Family Member: He is trustworthy, hardworking and always puts the needs of others first before her own. He never had a home to call his own so much that he never felt the love and care from a family. b. The Father: They have a very loving and caring relationship to the point that they’re dependent and reliant to each other. It took a long time for the father to recover and cope up with the mother’s departure and had taken the dual role of a mother and father to the children. This dark and unfortunate moment in their lives made them realize that all they have is each other. c. The Mother: The case client, Mr. Valdez briefly stated that he never knew his mother and had felt intense pain and anger for a while because of never having a maternal figure in his life. Time and the lessons he learned taught him to forgive and forget. If ever God permits him to have the chance to meet his mother, he would gladly accept it. d. Among Siblings: According to the client, Mr. Valdez’s interview, when he left and got separated from his brothers and sisters was one of the most painful and heartbreaking moment in his childhood. From then on he got his first bittersweet tast of life. e. Towards Relatives: Mr. Valdez, the client briefly states that he grew up and spent most of his childhood with his father’s side of family relatives. Though constantly struggling with finances and trying to find a job, they never fall short of loving and treating him like a real son. B. Personal History 1. Developmental History (From Pre-Natal to Present) From early on his childhood up to now, it was briefly mentioned by the test subject, Mr. Valdez that he grew up and was raised by his aunt Malou and other relatives from the father’s side of family. There was no definite or major parent figure but through the unconditional love of single father and to his adopted family he was able to find a home he could call his own. Somehow he felt weak and lost, and all that anger, pain and depression was repressed and he entered into a rebellious phase which provoked him to have suicidal attempts and run away from home. He remembered the times he would get drunk and pass out in the streets on the way home and let himself go because of those repressed and bottled up emotions that were not released. During the latter part of his adolescent stage, he realized his mistakes and learned his lessons but not before his father passed away from Cardiac Arrest. His father’s death opened new doors for him and showed him the way to forgiveness. . School History His Education and School were never his first priority. Growing up in a struggling and financially unstable middle class family with a single father, he lost focus and lacked motivation or driving force in his studies. He would let himself get influenced by his peers to skip school and cut classes. Around middle childhood to pre-adolescence, he studied Grade school and enrolled at a local educational institution named Fernando Ma. Guerrero public school at Herran, Pedro Gil. He would often get average to below average grades. Right after his father died of a heart attack; he voluntarily decided to put an end to his education while in the intermediate level of his high school and chose not to get a degree in college. He did this to lessen their expenses and take away the burden and the load off his father and family. 3. Peer Relationship At 10 years old, during his middle childhood to adolescence, He had friends that mostly consist of boys. They would often run around and play normal boy-ish games but the client’s homosexual tendencies were already gradually visible and evident. Having learned and felt comfortable in his sexuality in high school, He began to establish and make friends with the girls in his school and they would often roam and wander the streets at night. Those were one of the most rebellious times in his life. During his early adulthood he learned to become more mature and socially conscious about himself and the environment. He gained a few close friends that were true and loyal to him and they would go out, drink and party like a group of consenting adults. 4. Employment History During Mr. Valdez’s pre-intake and intake interview, he stated that being a peer health educator and volunteer at the Department of Health (DOH) has made him realize and learn a better and deeper understanding about the value of life. He was able to educate and impart to others the lessons and mistakes learned in the past and at the same time learn from other people. He also points out that he became aware with other’s problems and issues. 5. Romantic Relationship History Love is like a burning candle in the wind, it always ends and it never lasts, the client quoted. Throughout Mr. Valdez’s life, his past was filled with constant and countless goodbyes and heartaches that he almost forgot how to say hello and stand up for love. He became hardened and toughened by time but withdrawn and exhausted in life. He briefly stated that he had lots of loves in his life that had broken him apart. One night, because of a recent heartbreak which turned into an obsession, he grabbed a bottle of chemical in his medicine cabinet and took 2 rounds and immediately felt unconscious as he passed out. In a matter of minutes his Aunt Malou found him lying on the floor and was taken to a nearby hospital right away. He believes that the longest a homosexual relationship could last is within a year. The longest relationship he had was 6 months and 2 weeks. 6. Sex History On regular nights, Partying and hooking-up with guys in clubs and gay bars are his past time. He would have sex and sleep in other people’s beds, sneak out of the house and forget it the next morning. Even though he tries not to get emotionally attached to them, he can’t help but fall in love in a short period of time. Because of financial problems and the lack of a stable and well-paying job, he recently resorted to going out and dating older, rich foreigners. Having a job and working in Department of Health (DOH) have made him completely change and influence his views towards homosexuality and sexual intercourse. He actively supports and is in favour of same-sex marriage and the passage of the reproductive health bill. He believes that all men should be treated equal and safe sex should be implemented. 7. Aggressive History According to test subject’s formal and in-depth interview, Mr. Valdez’s aggressive and reckless behaviour rarely gets him into a fight with others but regularly gets him in trouble until now. Whenever he is under influence of alcohol his aggression reaches a maximum level so as his lack for control of his anger. He is promiscuous and sexually aggressive when flirting and hooking-up with guys. He is a moody type of person and is often defensive and protective of his friends. 8. Medical and Health History One of his major medical or clinical records is his confinement with his suicidal attempt last 2009, other than that he has minor to moderate medical conditions that include, chicken pox, dry cough, minor headaches and stomach pains and chronic toothache. . Alcohol and Drug History His repressed anger or emotions and his depression may affect or influence his alcohol addiction and aggression. He briefly admits to have a rough estimation of 10 to 15 bottles of beer until he passes out and his alcohol intake often goes beyond his limit. During partying with friends and having sex, he can’t resist consuming more bottles of beer than he could actually take and whenever he gets drunk and lose himself; he enters into this unconscious and reckless state and becomes aggressively promiscuous. 10. Major Experiences During the intake interview, the client was asked to enumerate and recall the past major events in that serve as turning points, rites of passage and signs of change in his life as generalization of his background information as well as data gathering. These events could either cause positive or negative effects to the person. One of the major events in his life is his Father’s death it changed him a lot and viewed the world in a different perspective. He also reminisced and remembered one of the darkest moments in his life when attempt to commit suicide. Another turning point in his life is his 21st birthday which his Aunt Malou and his relatives planned for his debut. 11. Aims and Aspirations Even though the future seems so far and tomorrow can wait, He always has hope and faith that everything will turn out right for him and to his loved ones. One thing he learned in life is to never let go of his goals and aspirations and also not to give up the people you love. He dreams of becoming a rich man and go abroad. He also wants to have a family of his own with the man or the woman he will love. He expects that by 39 years old, he would have become stable, settled down with a home to call his own. 12. Self Perception and Perception on Environment According to Mr. Valdez’s point of view to himself and to the world, He used signs and symbols and explained Life as a large blank piece of paper and every person is a pen that never runs out of ink, we write our own history and we give life and meaning to each other. III- Psychological Testing Atmosphere A. Psychological Tests and Date Administered Psychological Tests Administered| Date Administered| Draw a Human FigureProjective Personality Test| October 7, 2011| Draw a House-Tree Projective Personality Test(H-T-P Drawing)| October 7, 2011| Sack’s Sentence Completion Test (SSCT)| October 10, 2011| HEXACO Personality Inventory Revised Test (HEXACO PI-R)| October 10, 2011| B. Observational Data Prior to administering the battery of projective personality tests to Mr. Valdez, the subject, a Pre-intake and Intake interview was conducted by a psychology trainee last October 7, 2011, Friday in a private and formal setting. Having agreed and signed the formal consent for confidentiality, specific and categorical questions with topics of common and general interest to the most complex and confidential issues were asked by the interviewer. The interviewee was then required to answer in all honesty and in detail. While asking for more information and taking down notes, the interviewer simultaneously make an observation to the subject’s behaviour and mannerism throughout the entire interview. The MSE or the mental status examination and evaluation serve as basis for observation and interpretation. There are 15 components that comprise the MSE which gives the observer/interviewer a systematic and organized manual for effective observation. Based on an empirical and comprehensive observation Mr. Valdez, the client’s external appearance is casual but dishevelled and worn-out; he is seating in an angular position and wearing a plain blue shirt, blue denim jeans and blue sneakers. It can be assumed and implied that he knows how to mix and match but not enough to please and be presentable. He’s sitting in a slumped position with one foot bending at the metal bar of the chair. There are evident signs of rigidity and tension. He tends to have unusual movement. During the first part of the interview, the interviewer takes note of his blank and empty face which shows lack of focus and direction. He displays no interest and is easily distracted by external forces. His irritated and unsteady mood swings is visible throughout the interview. He has low level of cognitive ability and comprehension to the questions in the interview. The client, Valdez shows that while he is interested and eager to answer questions and if ever give additional information, He is unable to answer straight to the point and often strays from the actual questions being asked. Based on acquired data and gathered information from the client’s case, it is stated that there was too many abstract and intangible information to be organized and formulated. Test Behaviour The psychology trainee administered and conducted a private psychological exam with a battery of projective personality tests to Mr. Michael Anthony Valdez, the client. He was then asked to listen and follow the instruction said orally by the trainee. Tests including a Human Figure Drawing and House-Tree-Person Drawing analyze and interpret the qualities and details of the drawing to a person’s personality. Sentence Completion Tests gives a statistical and logical approach to verbal reasoning and implication to feelings and thoughts. The final easy and simple survey test is a HEXACO projective inventory-revised test which uses the HEXACO model of interpretation. During the testing process, Mr. Valdez seems withdrawn and exhausted while answering; he was slumped and slouching posture when he was reading the questions. While he loses focus and attention throughout the testing, he glimpses at the room every now and then and has wide open but tensed legs as if in an uptight seating position. The silence but the feeling of tension in taking the tests is indeed visible. A straight and blank face is shown and his tired and weary eyes wander around as if lost. This show signs of drained and withdrawn emotions- his depression and anxiety level is evident. C. Test Interpretations, Test Summaries and Protocols Draw a Human Figure Test The Human figure drawing test is the first of the battery of projective personality psychology tests that was conducted and administered to Mr. Michael Anthony Valdez by a psychology trainee in San Beda College. Mr. Valdez was instructed to draw and illustrate a full body image of a male and female human being then was asked to conceptualize and formulate a brief info about the drawing at the back of the paper. Based on interpretation of the features and the traits in Valdez’s drawing, one of the evident details present is the thick, heavy lines and the dark shading of the drawings. Both hands of the male and the female were omitted and drawn out of existence. This uncommon characteristic implies that there is positive withdrawal from the environment and felt rejected and alienated from the mother figure which in turn affects his point of view towards female. While both men and women have thin and small bodies, the larger male figure is shown which implies that male figures are more powerful sex. A small and square-shaped figure means feeling of rejection and reacts negatively to the demands of the environment. Consistencies of both male and female drawings have small dotted eyes, pointed shoulders and small neck which show withdrawal, fearful hostile feelings and impulsive behaviour. Broken and unsteady lines denote alcoholic tendencies. Both male and female facial expressions are fairly emphasized the hair of both male and female is heavily shaded and emphasized which connotes narcissism and aggression. Draw a House-Tree-Person Test (H-T-P) Mr. Michael Anthony Valdez, 21 years old Department of Health (DOH) peer volunteer took part as a client in a House-Tree-Person Drawing test last October 7, 2011 and was conducted and administered by a psychology trainee in San Beda College. Having signed a written formal consent and agreed to be a test subject, Mr. Valdez was asked to draw and illustrate 3 figures in 3 separate sheets of paper. The first drawing is the test subject’s own idea of a perfect home, a house the he or she wishes to live. The second drawing is nature-oriented and represents his own point of view towards self and the environment by making a Tree or a plant. The last figure to be drawn is a complete full body image of person. According to the interpretation based on the set of attribute and traits, the first drawing, the House is marked by an overemphasized chimney and doorknob which represents male sex symbol and phallic preoccupation of doors. The doors placed at the back and side which represents need to satisfy fantasy and escape to consequences and problems. The house is composed of a single open window with a thin line that indicates a piece of window pane. This specific feature of the house drawing implies that there is fixation of female sexual organs and have a tendency to burst out emotions and react aggressively but with minimal discretion. The second drawing, The Tree is characterized by irregular and indefinite shaped holes in the trunk, apple fruits hanging in the trees display childish behaviour and dependence. The last drawing, the person is a direct reflection of self and his desire and wants. The arms show broad and a muscular feature with wing-like form which means lack of control and compulsive tendencies but maintain striving for strength. The eyes are drawn hollow which signifies hostility and aggressive qualities. His image of the person is cartoon-like and comical which imply depreciating and pessimistic mood swings. Sack’s Sentence Completion Test (SSCT) Mr. Michael Anthony Valdez, a 21 years old volunteer peer educator in Department of Health (DOH) signed up to be one of the first client of the Sack’s sentence completion test. He was asked to fill up sentences of a 60 items test in 15 variables involving the test subject’s attitude toward parents and his or her attitude toward the past, future and everyday life. According to the overall interpretation of data, the client, Mr. Valdez shows significantly high level of attitude towards past. The test also shows that the client is unaware and frustrated in relation to his strengths and weaknesses and lives a problematic life cloaked in darkness. He fails to handle problematic situations and may act negatively when things don’t go his way. Based on the test subject’s results, the test variables related to family background influence his personality and points of view in life. The client, Mr. Valdez shows that there is strong feeling of rejection and isolation but displays independent and liberated attitude towards environment. HEXACO Personality Inventory-Revised Test (HEXACO PI-R) The final and easiest projective personality test was conducted and administered last September 19, 2011. This specific test follow the HEXACO model of personality structure and requires summation of raw scores to produce greatest common factor and consistency in all the attributes present. Mr. Valdez’s numerical interpretation and statistical analysis of raw scores show the highest total in Extraversion level. The Extraversion facet level scale has 4 subcategories that cover topics like individual’s self esteem, boldness, sociability and liveliness towards people. The social self esteem set of items receive the highest score of the 4 facets. IV- Summary Formulation (Consistent Findings and Conclusion) Mr. Michael Anthony C. Valdez, a 21 years old peer health educator and facilitator and also the client and the central focus of our psychological case report have successfully accomplished and complied with every requirement and phase of the test procedure. Having found and discovered consistent finding and key details in the results of all the tests and the interviews that form the solution and treatment for the test subject. The psychology trainee shall be able to make their own summary and conclusion. His pre-intake and intake interview suggests and opens up different dimensions and corners of his thoughts and feelings. Michael Anthony’s past experiences are important as much as the present and his aims and aspirations toward the future. During the first two set of psychological tests which is a projective drawing of a male and female human figure and the House-Tree-Person test, consistency and substantial information were noted and recorded. The second test which challenges the verbal ability to construct words and sentences and to fill up incomplete sentences according the interests and mood swings of the person. According the Sack’s sentence completion test there are uestions belonging to subcategories and variables which discusses different parts of our emotions and feelings these items is arranged in random order. The final projective psychological test is the easiest which is the HEXACO Model of personality structure and just give a clear understanding of who the subject is. The highest facet level receives a grade of 62 which is the Extraversion level and under that category he received an 18 in self esteem level. The second highest grade he gained was Honesty- Humility, a score 57 and got 15 in sincerity subcategory. V- Diagnostic Impression (DSM IV-TR) Axis I- Major Clinical Disorder Dysthymic Disorder The client, Michael Anthony has sudden outbursts of aggression and repressed emotions. He often feels lack of self esteem and pessimistic attitude. He is often pressured by his environment and influences through his substance and alcohol abuse. Axis II- Personality Disorder/ Mental Disorder Borderline Personality Disorder Based on the overall interpretation and summary of data, The case report conclude that the test subject has Borderline personality disorder manifested by his depressive and preoccupied qualities, his frantic and desperate efforts to avoid loneliness and abandonment. His projective personality tests also show results that show consistent recurrent suicidal behaviour and chronic emptiness. The client also has history of homosexual relationships with men and evokes promiscuity and lack of family and home. Axis III- Medical and Clinical Conditions N/A Axis IV- Environment Factors Problems with Primary Support Group The test subject has problems within the family because of the dysfunctional and the lack of specific and definite parent figure. The product of a broken family, his mother left them and never knew his siblings. Axis V- Global Assessment Functioning Global Mass Index of 45- Serious Symptoms This indicates factors like suicidal ideation and severe obsessional rituals or any serious impairment in social, occupational, or school functioning. VI- Case Formulation and Treatment Plan There are several and various psychological treatments that can be administered and conducted to the client especially with borderline personality disorder and gender identity disorders. We can treat the client’s problem with Alfred Adler’s Adlerian Therapy, Rollo May’s person centered therapy and Gestalt’s Empty Chair Technique