Case Presentation Outline, in the spirit of the Structural Interview, for TFP course.
1 – Identifying data (age, sex, ethnicity, sexual orientation, marital status, work/employment status) 2 – problem for which patient came for treatment
来访寻求治疗所针对的问题
3 – other problems that patient describes (if any)
来访提及的其它问题(如果有)
4 – problems that we see that patient didn’t describe (if any)
治疗师发现的对方所未提及的问题(如果有)
5 - information from prior therapist, if available
来自前任治疗师的一些讯息,如果有
6 – description of patient’s current functioning in life
描述来访目前生活中的功能
- vocation, meaningful activities
7 – relevant personal/developmental history 8 – psychiatric history 有无精神科病史 9 - mental status in terms of appearance and way of presenting self
从外貌和呈现自我的方式中展现的精神状态
10 – diagnostic impression and impression of patient’s defensive functioning.
诊断性印象和对来访的防御功能初始印象
11 - description of treatment contract 治疗合约的描述 12 - description of dominant transferences 对占主导性的移情的描述 13 - course of treatment so far 至今为止的治疗历程 |