II

Date: 09/14/2011

Orientation: x4 and Alert
Behavior: Cooperative and Polite
Posture: Fair

Speech: Slower
Tone: Quieter
Volume: Soft

Eye Contact: Minimal
Mood: Dysphoric
Concentration: Impaired

 

Current Situation: Patient stated he was a voluntary patient and his command wanted him to come. He stated to be under an extreme amount of stress and that he has been struggling to hide signs of this for as long as he can remember. Patient stated that he is no longer able to keep his despair a secret.

 

Content of Session: Patient sighed heavily as he was coming into the office and provider asked about the sigh. He said he was stressed out at work, he just found out he was having a baby and that he has been getting calls from a detective. He said that having a baby wasn’t registering with him. He stated that he feels ‘weird’ and that his ‘world is shaking’ and that he eats once a day. Patient said that he wakes up 4 times a night, going to bed a lot earlier than usual. He stated that he does not know how he feels about having a baby but that he wanted to be very happy and that it wasn’t a big deal.

 

Patient began to talk about his biological father whom he’s never met. He stated that he received a phone call from him on his 20th birthday only to tell him bad news regarding his mother. Patient said that his mother has been having problems with drugs but he did not care about it. He says he couldn’t force himself to care or be mad. When asked about his goals in life and what would he like to achieve from therapy, patient stated that for the first time in his life he would like to feel normal and be like everyone else. When asked about why he joined the armed services and what we expected from it, he said that he had to get away. Patient stated that he felt extremely isolated constantly throughout his childhood and adolescent years and that he moved around constantly. He stated that due to his constantly shifting environment it has become almost impossible for him to gain ‘closeness’ with his peers. He stated that his middle school and high school years had created many rifts in his thought process and made it hard for him to find an identity. Provider asked patient to go into detail and he told provider about he felt ashamed through his school years that he wasn’t able to do things that a normal teenager in his neighborhood had the luxury of doing. He envied the kids around him and was deeply ashamed of his household so he decided to ‘create’ another identity for himself so that he could hide from his teachers and fellow classmates how he really felt. Patient stated that he didn’t know how to act, being a ‘class clown’ caused him to get into trouble but gained friends but he didn’t like the attention he was getting from his teachers.

 

Patient wanted to get to the source of his depression and believed it started in the 1st grade when his teachers pulled him out of class and told him that he could not speak to a fellow girl (classmate) because he was not worthy of her because of the color of his skin. He also claimed that the parents contacted the teachers and his mother to tell him to stay away from their daughter. Patient said that he didn’t understand why he was told this being that he was too young to understand what was going on around him but that he has been carrying the weight of that incident for years.

 

Patient said that his mother and legal father fought over him during his childhood and that he would cry himself to sleep because he didn’t like the way he was treated with his father. Patient stated that he has been sexually abused by several members of his family as a child but that at the time he didn’t think it was a big deal or had anything to do with his depression. He said at some point in his life he stopped caring. He said whenever something good happens to him, he gets dragged back into the ‘darkness’.

 

Impression: Patient is sharing more about his life history which has alot of physical and sexual abuse. He also appears to have periods of dissociation. He describes feeling out of his body after a session when he talked about some of the abuse and his feelings. Patients presents as very depressed, he has a blank stare and he talks in a monotone. Prolong exposure therapy was described to patient for consideration. He agreed to think about it.

Reviews

[Coyote Poetry]

I like the way you are writing the story. Like a real hospital trying to get into the mind of a patience. No weakness in this chapter. Just powerful description and story. A excellent chapter.
Coyote

[Calypso]

I have learned some of this so far though!