CALMSCIOUS · CASE STUDY 02
Reconnecting with
Everyday Life.
A personal account of seeking greater clarity, connection and hope in everyday life.
Illustrative image; does not depict the client. Name changed for privacy.
Clinical-format summary adapted from a client account supplied by Calmscious. This is not a complete clinical record. “Not documented” means the information was absent from the supplied account; it does not mean an assessment was not performed.
SECTION 01Identifying Data
Karthik is a pseudonym used for this public case study. The original name is not published. Age, gender identity, occupation, marital status and ethnicity are omitted to protect privacy. Referral source is not documented. Names and identifying photographs are omitted.
SECTION 02Chief Complaint / Presenting Problem
Karthik described difficulty feeling stable and connected in everyday life while living with schizophrenia. Karthik sought a safe, non-judgemental environment in which to discuss difficult experiences. Specific symptoms, onset, frequency, severity and detailed effects on occupational or social functioning were not documented.
SECTION 03Client History (Anamnesis)
Schizophrenia is mentioned in Karthik account. The source does not establish when, how or by whom this diagnosis was made. Developmental, medical, medication, hospitalisation, family, substance-use, legal and detailed social histories were not provided.
SECTION 04Mental Status Examination (MSE)
| MSE record | No clinician-recorded mental status examination was supplied. Appearance and behaviour, speech, thought process and content, mood and affect, insight and judgement, alertness, orientation, attention and memory cannot be assessed from this narrative or its illustrative image. |
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SECTION 05Behavioural Observations
| Session observations | No contemporaneous clinician observations of non-verbal behaviour, cooperation, rapport or session interactions were supplied. Client descriptions of feeling supported are reported experiences, not substitutes for clinical observations. |
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SECTION 06Psychological Evaluation / Assessment Tools
| Assessment evidence | No assessment instruments, screening results, standardised scores or projective-test findings were supplied. Baseline severity and measured change cannot therefore be established from this account. |
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SECTION 07Clinical Formulation & Diagnosis
Schizophrenia is a reported condition in the source account; it is not independently established here. Diagnostic criteria, clinician assessment, differential diagnosis and rule-outs were not supplied.
5 Ps: information available
- Presenting: The reported concerns are summarised in section II.
- Predisposing: Not documented.
- Precipitating: No clearly established onset event was documented.
- Perpetuating: No clinician-supported maintaining factors were supplied.
- Protective: Karthik’s help-seeking and reported experience of a supportive, non-judgemental therapy relationship are described.
This is an account of available information, not a completed clinical formulation.
SECTION 08Treatment Plan
- Goals described
Karthik wanted greater stability, clarity and connection. These priorities are reflected in the account; a formal treatment plan with agreed short-term and long-term goals was not provided.
- Support described
The account describes a supportive environment and opportunities to work through difficult experiences at Karthik’s own pace. A session-by-session record and sufficient details to identify specific clinical interventions were not provided.
- Available detail
The account does not provide sufficient detail to attribute CBT, ACT, DBT, exposure tasks or other named interventions, or to establish a specific protocol.
SECTION 09Course of Therapy & Discussion
Client-reported course and outcomes
Karthik reported greater clarity, connection to self and hope for the future. These statements describe subjective experience; no symptom ratings, independent assessment, functional measures or follow-up findings were supplied.
Therapist reflections, transference/countertransference observations, discharge criteria and a formal final evaluation were not supplied. This narrative cannot establish treatment efficacy or be generalised to other clients.
Name changed for privacy. Identifying personal details are omitted. Experiences, outcomes and timelines vary.
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