Case Study
Sally contact you as a referral from a colleague who felt Sally needed psychotherapy to
address her problematic substance use. An overdose on prescription opioids was the
precipitating event that pushed Sally to seek professional care although she had been in
denial about her problem for many years. Sally was a high-functioning client with a
bachelor’s degree in psychology working as an executive producer of a well-known real-
life television series on addictions. She had just moved to New York City from the West
Coast after a failed marriage in which she and her husband had engaged in infidelity.
Sally had no children and felt relatively isolated given that her only living relatives were
her mother and father—both of whom had mental illness—living 2,000 miles away. Sally
had many resentments from her childhood as her father had untreated bipolar disorder
and “put us through hell.” Throughout the course of treatment, Sally came to share with
you that much of her adolescence was spent moving around the country with her
depressed mother in an attempt to escape her father. She developed rather superficial
relationships with people and had very few friends; that pattern followed Sally to New
York.
At the time you meet Sally, she is 38 years old and identifies herself as an “existential
thinker” who questioned “the purpose” of her life. She had no higher power and did not
believe in God, nor did she suspect that the universe had any sort of energy that
influenced her existence. Sally had an overwhelming sense of guilt and shame about
being addicted to prescription opioids, which she had started using about a decade prior
to treat her migraine headaches. She would commonly refer to herself as an
“undercover addict.” There was a degree of paranoia that she would be “found out for a
fraud” and had even requested that the initial screening be performed via a private,
untraceable application on a smartphone.
At the beginning of treatment, it was clear that Sally did not like who she was at her
core. Although her mother was physically present, she was overly anxious and
controlling during her childhood. Sally often assumed the parental role given that her
mother had frequent decompensations for which her mother was hospitalized. Sally
developed poor patterns of self-regulation yet wanted to control her life without any
assistance. She was a lonely person with a tough exterior facade. Sally felt guilty about
her infidelity and more guilty about not being able to control the substances she
consumed. In fact, during her course of treatment, she would try to manage her own
medication regimen by changing her doses and had poor boundaries, often
approaching me as her coworker rather than her therapist.
Sally reports having difficulty with self-control, has made attempts to abstain-believing
that abstinence is the ultimate self-control, experienced relapse, struggled with further
guilt and shame, and suffered the consequences of subsequent use. Throughout the
course of treatment, the door was never closed and Sally has left treatment with you
and returned about five times.
Instructions:
1. Using your selected model(please use systemic model) describe how you would conceptualize this case
2. Identify clinical considerations using your model of choice (please use systemic model)
3. Construct a Psychotherapy S.O.A.P. Note based on one hypothetical session with this
client
**Please use reference article less than 5 years old
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