Case study, Sam:

Sam came to see you at the insistence of his girlfriend, Astrid. You have had two counselling sessions with Sam, and you are starting to build the picture of what is going on for him. Here is the information you have so far: Sam is a 22-year-old male from Western Australia (WA), now living in Victoria with a friend. Sam has only one family member here in Victoria. He is in the third year of his apprenticeship.

Sam had an accident at work, resulting in ongoing chronic lower back pain. Sam was asked to carry a 40kg bag of cement with urgency without a wheelbarrow, Sam felt he could not say no. It was initially a serious injury however scans now indicate the injury has mostly healed. Six months later, chronic pain persists.

Sam has also recently been diagnosed with depression by his GP. Sam has low mood, is listless, bored, in pain most days, and is withdrawn. Sam is currently engaged with a physiotherapist and a pain specialist clinic; however, he reports this is treatment is "not helpful". Sam reports that Workcover are pushing him to return to work, which he is highly apprehensive about.

Sam recently returned to work and felt pushed to do more than he was able to by his boss, resulting in a pain flare up. Sam's pain specialist has indicated that he is "likely to experience some residual pain" and has attempted to discuss the neuropsychology of pain. Sam was too polite to say directly to his pain specialist, that from his perspective he needs the pain gone entirely.

Sam has been trying to "fix" his pain, as the idea of a slow and steady recovery feels unacceptable. Sam and his girlfriend have been exploring all the options, including seeking a surgical opinion and receiving treatment from a chiropractor. Sam's girlfriend, Astrid, is very sympathetic, often telling Sam not to "let others push you around, you have a serious injury. They don't understand that. This whole thing is their fault." / "Don't let them take advantage of you Sam".

Sam has become withdrawn and isn't leaving his room much. He is not returning calls from his mum and has bills piling up. Sam's cousin who lives in Melbourne has tried to reach out and he hasn't responded to her texts.

Astrid insists on getting out and about i.e. for a coffee, lunch, and has tried to drag Sam to a movie recently. Sam said he was in too much pain to sit there the whole time and they had to leave. Sam's diet has gone downhill - eating only convenience foods. He's more sedentary than before as he only moves when he must - by extension of this, he's getting minimal sunlight.

For the first time in his life, Sam is not sleeping properly - he falls asleep okay but wakes up at 4am every morning. Tiredness makes it hard to focus on activities during the day. Sam lies in bed for hours, trying really hard to get back to sleep. The harder he tries, the further away sleep feels. Sam finds himself napping during the day and does not care much because "there is nothing to do anyway". Prior to his injury, Sam moved to take up a VFL (Victorian Football League) position as a player in Victoria. Sam hasn't returned to football since his injury. This was one of two major social outlets, the other one being his workplace.

Sam was raised in a family where the emphasis was on feeling positive and having a "good attitude". He was rewarded for being optimistic. Sam's father is seen as "strong" and not letting things get to him - he played football at the highest level in Western Australia, his grandfather was a footballer also. Sam's mother says, "every day is a gift". She also prioritises an optimistic outlook and finds difficulty in being with challenging feeling states. Sam's younger sister is an ice-skating champion - further supporting a family culture of achievement and physical mastery.

Sam feels he doesn't know how to be around them whilst feeling like he is, both physically and mentally. Sam's older brother dropped out of high school and has criminal charges for robbery with a weapon. He associates with a bad crowd, and his family suspects he is dealing drugs. He is now rarely talked about within the family. Sam remembers his brother as an important figure that he looked up to and described him as being fun and rebellious - but for the last five years it doesn't seem like his brother has any time for him.

Sam's Grandmother was a special person in his life, who he felt really 'saw' him. It surprised his family when Sam spent afternoons in the kitchen with his grandmother just being together and baking. Sam didn't want to let others know the depth and duration of his sadness when she died unexpectedly last year. Sam finds it difficult to let those feelings in and tries to block them out and not think about her at all. Sam has one friend, Dave, who is a long-term friend from childhood. He moved over from WA about 5 years ago and has a thriving social circle, who he continues to try to link Sam in with. Dave persists in visiting Sam and is not rebuffed by Sam's lack of enthusiasm.

During Sam's school years, he was highly praised for his sporting prowess as he was good at multiple sports (cricket, football, athletics, and swimming). He had unremarkable grades but was particularly skilled with woodworking and other practical subjects. In school, Sam was part of a bigger social crowd, he was well liked, invited to parties, and loved having lots of people around him as he felt energised by the company of others. Sam was known by his teachers as quiet but a pleasant student, popular with peers, and easy-going.

Since his injury, Sam has started drinking to distract and escape his pain. He pushed himself to do things with his friends initially but is now drinking alone in the evening, while watching tv.

Part 1: Case formulation :

Case conceptualisation assists therapists to understand and organise a client's presenting issues and background information in meaningful way. This then helps inform treatment planning.

- a. Develop your case formulation for Sam (using the 5 P's plus template provided)

-b. Within the case formulation outline the factors relevant to Sam's mental health as well as the key areas you might assist him with in counselling.