AS533

Psychological Case Formulation

By

Yyyy Xxxx

For

R. James Little, M.Ed., M.A., C. Psych., Psy.D.

Andrea Myrie-Nurse, Psy.D., C. Psych.

July 4, 2020
Psychological Case Formulation

Name: Mr. Xxxx Xxxx

Address:
Telephone:
Date of Birth:
Age:
Date(s) of Assessment:
Date of Report:

Reason for Assessment

Mr. Xxxx is a -- -year-old man who underwent a Psychological Assessment on May 15, 2020 for
the purpose of developing a treatment plan to address feelings of low self-confidence and stress
related challenges establishing healthy boundaries at work. He tends to over extend himself and
then becomes irritable and moody. He is tiring of this pattern of behavior and does not like how
it affects his family. Therefore, he is seeking professional help to break this cycle. Mr. Xxxx was
interviewed and completed psychometric testing. The following report is based on information
derived from the interview and testing.

Procedures

 Clinical Interview
 Beck Depression Inventory-II (BDI-II)
 Beck Anxiety Inventory (BAI)
 MMPI-II-RF
 MCMI-IV
 Symptom Checklist-90-R (SCL-90-R)
 House -Tree-Person Projective Test
 Incomplete Sentence Blank
 Early Recollections
 Life Style Inventory

Background Information

Mr. Xxxx reported that he has not undergone any previous psychological assessments and has
not undergone psychological counselling. He has never taken medication for his mood.

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Relevant Personal History:

Mr. Xxxx, --- years-old, was born on ---, 1965 and raised in Toronto, Ontario. He has one older
brother, who is 56 years old. Mr. Xxxx reported that his brother received more attention than he
because of his gender and later because he became ill. Mr. Xxxx grew up in a first-generation
Italian household and led a traditional life at home. His first language is Italian, and he spoke a
combination of Italian and English at home. He grew up in a neighbourhood where most
everyone spoke English. He faced some discrimination during childhood due to his ethnicity, but
not later in life. Mr. Xxxx reported there were no complications with his birth. Also, he denied
any early significant medical or developmental difficulties.

Mr. Xxxx’s mother, 76-years-old, is a retired factory general labourer. His father, died in 2004 at
the age of 72 from heart disease, was employed at CN Rail as a cleaner. Mr. Xxxx reported a
good relationship with his parents while growing up. He knew his parents loved him, but they
would never use words of affection openly or hug their children. His mother tended to be the
disciplinarian and she was concerned with outward appearances and stressed not disclosing
family matters that could bring shame. His father was a happy-go-lucky individual who was less
concerned with what others thought. His parents spoke broken English and both had completed a
mid-elementary school level education. He was also close with his maternal aunt and his two
female cousins who lived two doors down from his home. His two cousins were considered
attractive.

Mr. Xxxx recalled they were quite poor, and he did not have many of the luxuries that other
children enjoyed such as bicycles or swimming lessons. His relatives, most of who were much
wealthier, seemed to enjoy making a point that their lot in life was better. Although this fed into
his feelings of inadequacy it also provided him, at times, with the impetus to push himself to
achieve things that their money could not buy. Nonetheless, these negative early messages
significantly impacted his self-confidence and contributed to feelings of inadequacy. His brother,
who did not handle the negative messages well, became quite depressed at the age of 16.
Subsequently, life at home changed dramatically for Mr. Xxxx who was 14 at the time and just
entering high school. The shame around his illness and the lengths his mother went to keep it
hidden for fear of bringing shame to the family was difficult to deal with. He recalls an
atmosphere of fear and unpredictability at home for the next several years due to his brother’s
volatile behavior. As mentioned earlier, all focus shifted to his brother. Mr. Xxxx and his parents
tried to help rehabilitate him. It was not until years later that he was diagnosed and properly
medicated.

Mr. Xxxx reported he married his wife of 26 years at the age of 28, which at the time, was
considered old by Italian standards. His relatives would make comments such as “It’s about
time”, rather than congratulations further feeding feelings of inadequacy. He reported a good
relationship with his wife who is employed as a programmer. The couple has two adult children,
a son age 21 and a daughter age 23. His son is in his fourth year of a Finance degree at McMaster
University. His daughter graduated McGill University with an honours B.A in Sociology and is
currently attending college in a Social Services Worker diploma program. Mr. Xxxx reported
that he has a good relationship with the children who are in good health and doing well. He
stated he tried to protect the children from his extended family as he did not want them exposed

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to the negative messages and develop the same feelings of inadequacy. Mr. Xxxx described a
longstanding problematic relationship with his mother-in-law who has always disliked him and
spoke to him in a disparaging manner. All efforts to try and win her approval proved fruitless and
after decades of doing so, he finally stopped blaming himself for her behaviour and gave up.

Mr. Xxxx described an adequate social support system comprised of his wife, children and best
friend. His best friend is one of the few people he feels will not judge him and with whom he can
be his true self.

Education and Training:

Mr. Xxxx reported that he did not learn to speak English until he started Kindergarten. He
wanted to learn English and fit in with the other students most of whom spoke English. One
example of challenges fitting in occurred at lunch times. His food looked different from most
everyone else. He had thick crusty Italian buns with veal and peppers while everyone else had
Wonder Bread with peanut butter with jelly sandwiches. He worked hard to lose his Italian
accent and speak in a soft voice so he would not be different from the other students. He recalled
no other significant difficulties in elementary school and he denied any difficulties acquiring his
basic literacy and math skills.

Subsequently, Mr. Xxxx attended --- Collegiate and graduated at the age of 18. He denied any
specific assessment for or diagnosis of a learning disability, nor was he provided with any
remedial assistance.

After completing high school, he attended the University of Toronto and completed a B.A. in
Psychology. Since 2018, he has been attending graduate school in a Masters of Psychology
program. In addition, he earned his Registered Rehabilitation Professional (RRP) designation
through VRA Canada, and his Certified Vocational Professional (CVP) through the College of
Vocational Rehabilitation Professionals (CVRP).

Employment History:

Mr. Xxxx advised his first full-time job was as a Research Assistant at ------------. He was
responsible for both clinical and research endeavours. Since 1993, he has been employed as a
vocational consultant. He has worked with a variety of clients (including clients with physical
injuries, emotional trauma, head injuries and learning disabilities).

Mr. Xxxx reported that two of his consulting contracts are with supervisors that sometimes bully
employees. At such times, he tends to think he deserves the bullying due to his low self-esteem
and lack of faith in his abilities rather than being upset with them for their behavior. He thinks
that he deserves the bullying because he could have done better and blames himself. The critique
from these two employers feed into his feelings of inadequacy and causes him to work harder to
try and prove himself in order to fix all the hurts he felt from parents, peers and relatives.
However, he would never obtain this validation from these employers as they use this as a
control tactic over their staff; nonetheless, he would continue to work harder effectively burning

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himself out and becoming moody and irritable. This vicious cycle at work and in his personal life
feeds into his feelings of inefficacy and not being good enough.

More recently, a general email was circulated at work (a different contract from the above-
mentioned employers), requesting volunteers to cover for the holiday season. He quickly
volunteered and then felt resentful for having done so. He was exhausted by the volume of extra
work he incurred, was irritable with others and angry at himself. It was after this experience in
conjunction to many similar work scenarios that he reached a breaking point and decided it was
time to stop this pattern of behaviour. Not having the confidence to do so on his own, he thought
that perhaps with the guidance and support of a professional counsellor he might be better
equipped to do so. He also feared his family was also tiring of his behaviour. Indeed, they made
several comments about his mood and urged him to reduce his workload

Recreational Activities:

Mr. Xxxx reported that he does not have much time for hobbies due to his long work hours,
attending school, and home responsibilities. He tries to attend gym classes one to two times per
week and exercise when he has the time to do so. In addition, he enjoys gardening, baking and
cooking, but rarely has the time to do so. He meets with his friends about once every two
months, but often prefers to be alone due to feeling too exhausted to socialize. Moreover, he
enjoys hosting holiday dinners with his wife in their home; however, his desire to have
everything appear perfect for his guests makes the undertaking quite stressful. He stated this
stems back to the early messages of keeping up appearances and not bringing shame to your
family by having an untidy home.

Medical History

Mr. Xxxx reported being in good general health. He denied any history of significant injuries or
accidents. He is not taking any medications currently.

Mr. Xxxx denied any psychological or psychiatric history. He stated for the past several years, he
will feel sad and possibly depressed when he over-extends himself at work because it takes a toll
on the family. More specifically, his family must take on the roles he normally would do during
those busy times and then feels guilty and inadequate. He may also be more irritable with family
members and dislikes himself and feels remorseful when he behaves this way. Mr. Xxxx denied
any history or substance use or abuse.

Psychological Complaints

Mr. Xxxx reported he has always suffered from low self-confidence and feelings of inadequacy,
which he thought might be tied to the early messages he received during childhood from his
immediate and extended family members. This spilled over into his early years at school being
an immigrant with limited language skills and where there were few ESL students. As such, he
was in an atmosphere which perpetuated the feeling of not being good enough.

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Currently, due to his self-esteem issues and feelings of inadequacy he tends to overcompensate
by over extending himself at work and sometimes in his personal relationships to the point of
mental and physical exhaustion, and thus, he ends up with feelings of resentment towards
himself and others. He would like to break out of this cycle of behavior and feel confident
enough in his abilities and self-worth so that he can say ‘no’ without fear of rejection, or guilty
feelings. Despite others giving him positive feedback at work he never quite believes he is good
enough. In fact, he often receives comments from coworkers such as “No one works as hard as
you…why do you do all that?”

Mr. Xxxx described his current mood as a “down”, as he sees himself repeating the same
behavior and cannot seem to break the cycle despite promises to himself and others to do so. he
came to this conclusion after the recent incident at work in which he quickly offered himself up
for vacation coverage.

Mr. Xxxx reported that he sometimes cries when feeling sorry for himself, but that this is not
worsening or problematic. He worries about how others at work will react if he asserts himself
and expresses his true feelings. In addition, he has always been a little short-tempered, which he
attributed to sometimes having unrealistic expectations of himself and others, and sometimes due
to fatigue. he stated that he calms down quickly and is usually remorseful, as he realizes this is
not an appropriate manner to react to stressful situations. he reported no recent changes with
regards to irritability. He denied anhedonia and reported he derives joy from spending time with
friends and family. When queried about suicidal ideation, it said that he has not considered this
as an option.

In terms of his sleep, Mr. Xxxx reported he has never been a solid sleeper. It often takes him
several hours to fall asleep due to many thoughts about various things and making to do lists for
the following day in his mind. Sometimes, he will ruminate about things he wishes he had done
differently, but this has not been a recent problem. After falling asleep, it is rare that he will sleep
through to morning. He generally wakes briefly once or twice per night usually due to hearing a
noise. Often, it is difficult for him to return to sleep as he will start thinking about something that
was bothering him in the daytime, think about the events of the next day, and resume his to do
lists. In general, he obtains five to six hours of sleep per night and he rarely finds sleep to be
restorative; nonetheless, his energy level is sufficient. Indeed, he described himself as a high-
energy person who tends to accomplish a lot throughout the day. Nonetheless, about once every
two weeks he is so exhausted that he must sleep for several hours.

In terms of cognitive functioning, Mr. Xxxx reported no recent changes to his memory and
concentration. He stated he finds it difficult to concentrate when there is too much background
noise, but this does not represent a change from his usual self. His appetite and weight are stable.

Mr. Xxxx denied any difficulties with anxiety or panic attacks. He is afraid of extreme heights,
roller coasters and certain bugs. He has never been comfortable in the dark but can tolerate it. He
denied difficulties with nightmares or bad dreams.

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Behavioural Observations

Mr. Xxxx arrived promptly for his scheduled appointment. He presented as an appropriately
attired and groomed individual of stated age. Rapport was readily established with the examiner.
He was generally open and forthright during the interview, but at times somewhat guarded and
nervous. he did not experience any difficulties understanding questions posed of him. He
demonstrated an appropriate range of affect. He was able to establish and maintain eye contact,
smile and respond to humour. He became tearful briefly when discussing his childhood
experiences but was able to quickly compose himself.

Mr. Xxx appeared to maintain a good level of motivation, co-operation, and effort throughout the
assessment. His stamina was good and he did not display any pain behaviours. As such, the
results of the current assessment are believed to provide a generally accurate reflection of his
emotional functioning.

Test Results/Emotional Functioning

Mr. Xxxx was administered the Beck Depression Inventory-II (BDI-II). The BDI II is a 21-
item Likert-scale questionnaire designed to assess the severity of depression. Mr. Xxxx obtained
a score of 2 on the BDI-II questionnaire, reflecting a minimal level of depression in the past two
weeks. he endorsed the following items as mild, “I feel more restless or wound up than usual”, and
“I have less energy than I used to have”. The remainder of the items were endorsed as minimal. He
did not endorse an item related to suicidal ideation.

Mr. Xxxx was also administered the Beck Anxiety Inventory (BAI), a 21-item Likert scale
questionnaire designed to screen for anxiety. Mr. Xxxx obtained a score of 3 on the BAI
questionnaire, reflecting a minimal level of anxiety in the past one week. he endorsed the following
panic-related symptoms on the BAI as mild, “Unable to relax”, and “Nervous”. He endorsed the
following somatic symptom on the BAI as minimal, “Feeling hot.”

The Symptom Checklist-90-R (SCL-90-R) was administered to provide an overview of Mr.

Xxxx’s mental state and presenting symptoms. It provides measures of nine symptom
dimensions, including Somatization, Obsessive-Compulsive, Interpersonal Sensitivity,
Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid ideation and Psychoticism. It also has
three global indices of distress, including Global Severity (GSI), Positive Symptoms Distress
Index (PSDI) and Positive Symptom Total (PST).

Mr. Xxxx’s responses to the symptom checklist were plotted against norms using nonpatient
males. He did not score in the clinical range on any of the nine symptom dimensions. His profile
suggested good psychological integration, and little global psychological distress. Overall
intensity of distress is unremarkable, and he has endorsed a moderate number of symptoms. The
level of somatization in this respondent's profile is at the level of the normative mean and is
essentially unremarkable. Levels of obsessive-compulsive symptoms in Mr. Xxxx’s profile are at

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normative mean levels and are essentially unremarkable. There was some evidence to suggest
that he is experiencing difficulties with feelings of personal inadequacy and considerations about
devalued self-worth; however, distress is not of a clinical magnitude. There are a few isolated
signs and symptoms of depression in the respondent's test protocol, but they appear to represent
nothing out of the ordinary and are not remarkable clinically. There is little or no evidence of
paranoid thinking in this respondent's record. No items were endorsed as “Extremely” or “Quite
a bit distressed.”

Mr. Xxxx was administered the Minnesota Multiphasic Personality Inventory-2-RF (MMPI-2-
RF). This reliable and valid inventory of personality is in a self-report and true/false format that
assesses aspects of adult personality and psychopathology.

Mr. Xxxx’s profile was considered valid. His scores on the substantive scales indicated
emotional dysfunction and feelings related to self-doubt. There were no indications of somatic or
cognitive dysfunction in his protocol. He is likely to be prone to rumination, feelings of
insecurity and inferiority, to be self-disparaging and intropunitive. There were no indications of
disordered thinking or maladaptive externalizing behaviour in his protocol. His profile suggested
that he tends to be very low in energy and disengaged from his environment. He reported an
average number of interests in activities and occupations of an aesthetic or literary nature (e.g.,
writing, music, the theater). He also reported an average number of interests in activities or
occupations of a mechanical or physical nature (e.g., fixing and building things, the outdoors,
sports). No specific psychodiagnostic recommendations were indicated by Mr. Xxxx’s MMPI-2-
RF protocol. Treatment considerations would be his low self-esteem and other manifestations of
self-doubt.

Mr. Xxxx was also administered the Millon Clinical Multiaxial Inventory-IV (MCMI-IV).
The MCMI-IV provides an in-depth analysis of personality and symptom dynamics. It provides
clinicians with a foundation for treatment planning. In addition, it lists possible DSM-V
diagnoses associated with ICD-10 codes.

Mr. Xxxx’s scores on measures of response bias showed no unusual test-taking attitude that
would distort MCMI-IV results.

Mr. Xxxx’s profile suggested he is experiencing no disorder or a minimally severe disorder. He

appeared to fit the following personality disorder classifications best: Turbulent Personality Style
and Compulsive Personality Style.

Mr. Xxxx’s profile suggested he generally presents as energetic, ambitious, and often exudes a
contagious optimism. At times appearing larger-than-life with a seemingly endless exuberance,
he tends to attract others into endeavors and exciting relationships. However, Mr. Xxxx may
suppress or otherwise disregard healthy limits and boundaries, thereby creating distress and
exhaustion in himself and others. When distressed, he will attempt to mask his frustration with a
typical air of cheerfulness but, when depleted, may become clinically depressed.

The House Tree Person Test (HTP) is a projective test used in the assessment of personality.

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Mr. Xxxx’s projective drawings reflected willingness to engage with others, but he has limited
skills to reach out. In addition, he tends to put up boundaries and is hesitant to reveal much about
himself. He tends to be a somewhat hypervigilant, tense and anxious individual. His drawings
also suggested that he is a somewhat needy, dependent individual who sometimes does not feel
secure in relationships. His drawings also suggested a tendency towards obsessive-compulsive
behaviour and a need to portray himself as acceptable.

Sentence Completion is also a projective test used in the assessment of personality.

As Mr. Xxxx is being assessed for treatment planning, the Sentence Completion Projective test
was utilized to gain some insight into various aspects of his personality. This information will be
further discussed in treatment. he demonstrated similar patterns in his responses as he did in the
remainder of the clinical measures utilized for the preparation of this report. More specifically,
he tends to have a flare for the dramatic and enjoys exciting things. He tends to worry and feel
anxious. He over-extends himself for fear of rejection and then his energy level is depleted. At
such times, he tends to feel angry at himself and others. He tends to be guarded and does not
open up easily to others. he sometimes has unrealistic expectations of himself and others. He
tends to catastrophize events.

Early Recollections is also a projective technique that was utilized to gain insight into Mr.
Xxxx’s personality and how he views others.

Early recollections reflected a similar theme. Mr. Xxxx tends to be self-sacrificing, putting others
happiness ahead of his and then feeling resentful and let down. He does not know how to tell
others how he feels when let down, but he wishes others knew how he felt. He worries about
how others see his and wants to please everyone. He tries not to be a burden or an inconvenience
in his attempt to please others.

Summary and Conclusions

In summary, Mr. Xxxx is a 54-year old male who was self-referred for a psychological
assessment to determine treatment planning. He struggles with his self-confidence. He does not
feel he is good enough for healthy relationships with supervisors at work. He is often frustrated
and sad; however, he often bottles up his emotions discussing them only with his one close
friend whom he perceives as someone he can trust and who truly understands him. He struggles
to find positive attributes about himself that will allow him to engage in healthy behavior.

Based on the information collected as part of the clinical interview and the test results, Mr. Xxxx
does not meet criteria for a DSM-V diagnosis at the present time. However, results of the clinical
measures and his self-report suggest that he is someone with feelings of inferiority, anxiety and
sadness related to perfectionism.

Treatment Recommendations

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Mr. Xxxx has not received any form of psychological treatment to date. He maintained the need
for psychological treatment and is interested in attending. An initial 16 to 24, 90-minute sessions
of mindfulness-based cognitive-behavioural therapy to address his low self-confidence and stress
related challenges establishing healthy boundaries at work. Treatment sessions would include the
following:

1. Cognitive restructuring to help him identify, challenge and modify maladaptive and
distorted beliefs so they become more adaptive.

2. Helping him learn the tools and strategies to catch his maladaptive thinking habits as they
happen by idiom techniques such as a thought record form and downward arrow
technique. 

3. Referral to an assertiveness training group to increase his knowledge, coping capacity,

and skills required to solve his problems with assertiveness.

4. Literature to read on assertiveness and building self-confidence such as; How to Stand up
for Yourself and Still Win the Respect of Others by Judy Murphy, The Assertiveness
Workbook: How to Express Your Ideas and Stand Up for Yourself at Work and in
Relationships by Randy J. Paterson, and How to be Confident and Improve your Self-
Image by Katy Richards.

5. Further exploration of early recollections and identifying patterns of behaviour.

6. Homework related to challenging his perfectionism and logging his emotional reactions
to these challenges so they can be reviewed and explored in session. 

7. Replacing his "should" and "ought to" beliefs about himself with realistic expectations. 

8. Working on establishing a healthy sleep routine and implementing self-care activities into
his daily life. 

Treatment Considerations and Potential Obstacles:

Mr. Xxxx may initially be defensive and experience difficulties opening up. It may be prudent to
first build up his depleted self-esteem first by focusing on past accomplishments to get him to
open. Doing so may prompt him to become an active partner in restoring a more balanced sense
of self-confidence by recalling and elaborating on his attributes and competencies; that is, he can
work with the therapist to adjust his relationship with these events from a more exaggerated
meaning to one that is directed at establishing a more humble but honest self-esteem. Unlikely to
remain enthusiastic and motivated over a more involved therapeutic course, he will probably
make light of difficulties unless his life experiences become increasingly discouraging.
Treatment may best be directed toward building greater empathy and impulse control, toward
focusing on here-and-now behavior, and toward helping him learn how to sustain attachments
through more integrated behavior.

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Submitted by,

Yyyy Xxxx

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