Case Study Review and Psychotherapy Note

Case Study Review and Psychotherapy Note

Sally contacts 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


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.

Case Study Review and Psychotherapy Note

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.


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


Case Study Review and Psychotherapy Note Essay Sample

Conceptualization of the Case Using the Systemic Model

The systemic model looks at individuals in the context of their relationships and the larger systems in which they exist. It emphasizes the importance of understanding the larger context in which an individual exists and how this context influences their behavior and relationships. In Sally’s case, understanding her childhood experiences, current circumstances, and beliefs about the world are all crucial factors in understanding her substance use and related problems (Dydyk et al., 2022).

Sally’s childhood experiences, particularly her father’s untreated bipolar disorder and her mother’s depression, likely significantly impacted her development, behavior patterns, and relationships. She had frequently moved to escape her father, which may have contributed to her difficulty in having deeper relationships and feeling isolated. Her mother’s hospitalizations and need for care may have forced Sally into a parental role, leading to her belief that she can and should be in control of her own life without needing assistance from others.

In addition, Sally’s current circumstances, such as her recent move to New York and her infidelity, are also factors that contribute to her substance use and related problems. Sally’s belief that she is an “existential thinker” who questions her life’s purpose may also indicate a sense of isolation and disconnection from others (Dydyk et al., 2022). Her lack of belief in a higher power or any energy influencing her existence may further contribute to her isolation and lack of connection with others.

Clinical Considerations Using the Systemic Model

The systemic model emphasizes the importance of addressing the more extensive system in which an individual exists and how this system may contribute to their problems. In Sally’s case, some clinical considerations using the systemic model may include addressing her relationships with family members. Sally’s experiences with her parents likely significantly impacted her development and the formation of her patterns of behavior and relationships.

Addressing her relationship with her mother, as well as her feelings towards her father and his untreated bipolar disorder, may be necessary for helping her to understand and cope with her current difficulties. Addressing her relationships with others is also significant; Sally’s difficulty forming more profound relationships and feeling isolated may contribute to her substance use and related problems (Bell & Strang, 2020). Addressing her behavior patterns in relationships and helping her develop stronger connections with others may be necessary for addressing her substance use.

The second clinical consideration based on the systemic model is to address her beliefs. Sally’s lack of belief in a higher power or any energy that influences her existence may indicate her isolation and disconnection from others. Helping her explore and challenge these beliefs may be critical in helping her feel more connected to others.

Thirdly it is crucial to look at her current circumstances. Sally’s difficulty with self-control and poor boundaries may contribute to her substance use and related problems. Helping her develop better self-regulation and boundaries patterns may be necessary for addressing her substance use (Dydyk et al., 2022). Sally’s overwhelming sense of guilt and shame about her substance use may contribute to her difficulty addressing her problems. Helping her to explore and address these feelings may be necessary for supporting her in her recovery.

Psychotherapy S.O.A.P. Note Based on a Hypothetical Session


Top of Form

Subjective data  Sally reported feeling guilty and ashamed about being addicted to prescription opioids. She shared her struggles with self-control and past attempts at abstinence, which resulted in relapse and further guilt and shame. Sally expressed difficulty managing her medication regimen and poor boundaries, often approaching me as her co-worker rather than her therapist. She also talked about her childhood experiences, including her father’s untreated bipolar disorder and her mother’s frequent hospitalizations for decompensations, which resulted in her assuming a parental role (Dydyk et al., 2022).  
Objective dataSally appeared anxious and tense throughout the session. She reported a history of prescription opioid use for the past decade, which began as a treatment for migraine headaches. She denied any other substance use or psychiatric history. Sally presented as a high-functioning individual with a bachelor’s degree in psychology and working as an executive producer of a well-known real-life television series on addictions. She appeared to have a tough exterior facade and limited social support.  
AssessmentSally presented with symptoms consistent with opioid addiction and poor self-regulation skills. She expressed guilt and shame about her addiction and difficulty managing her medication regimen, resulting in relapse. Sally also exhibited poor boundaries and limited social support, possibly related to her childhood experiences.  
PlanEducate Sally to develop healthier coping skills and strategies for managing her addiction. I recommended that Sally consider attending a support group or seeking the help of a sponsor to help her maintain abstinence. To address her underlying emotional issues related to her childhood experiences, it is essential to set realistic goals and develop an appropriate treatment plan that suits her needs (Patterson Silver Wolf & Gold, 2020). Establishing clear boundaries and reinforcing the therapist’s role as a therapist, not a co-worker, is essential. It may also be beneficial to explore Sally’s beliefs about her life’s purpose and any existential issues she may be experiencing. Cognitive-behavioral therapy may be essential to change negative thought patterns and behaviors that contribute to opioid use, such as her childhood experiences and her current circumstances (Patterson Silver Wolf & Gold, 2020). Naltrexone is an opioid antagonist that blocks the effects of opioids, can reduce cravings, and can be prescribed as a medication of choice (Bell & Strang, 2020). Monitor for signs of relapse and work collaboratively with Sally to develop a plan to manage cravings and avoid future relapse. Top of Form  


Bell, J., & Strang, J. (2020). Medication Treatment of Opioid Use Disorder. Biological Psychiatry, 87(1), 82–88.

Patterson Silver Wolf, D. A., & Gold, M. (2020). Treatment-resistant opioid use disorder (T.R.O.U.D.T.R.O.U.D.): Definition, rationale, and recommendations. Journal of the Neurological Sciences, 411, 116718.

Dydyk, A. M., Jain, N. K., & Gupta, M. (2022, June 21). Opioid Use Disorder. PubMed; StatPearls Publishing.

Share your love