Case 8.1 199

Nicole has severed all ties with her family of origin since if she speaks with them she will only end up "feeling like dirt and getting real mad." Al-though Nicole is not involved at the present time in an intimate relationship, she does nd support ather job with coworkers and has one close friend,Vickie, in whom she can conde.Nicole has had difficulties at her job, however.She stated that she gets very upset when anyone gets "in her space." When the pressures at work become more than Nicole can handle, she feels angry and panicky and "just wants to be left alone."During the rest of the session, Nicole stated that she didn't want to do anything but lie in bed. She stated that she often cries all weekend, becomes easily angered by her children, and often resorts to yelling and spanking them.Nicole also stated that she was having difficulty doing chores (e.g., going to the Laundromat or grocery store, cooking, cleaning). There were piles of laundry in her bedroom and trash everywhere,including old food, which reeked. She stated she has had difficulty sleeping at night due to recurrent nightmares of "childhood stuff" and always feels"too tired." She avoids any situation that reminds her of "family stuff" but is afraid that she's turning out just like her mother.Nicole possesses a great deal of intelligence and has the ability to seek out support and help when it's needed. She also has a very good sense of humor that she displayed throughout the interview

Second Session with Nicole

Nicole begins the second session with you by describing a situation that occurred during the week at work. A male coworker asked her if she would like to go out for dinner after work one evening,and when Nicole declined the invitation, the co-worker lightly touched her shoulder and said, "Oh,come on Nicole, you need a little fun in your life."Nicole states that she overreacted to this gesture by swinging at the man and striking him on his chest.She tells you she doesn't know what came over her,but she felt like she was warding off an attack of some kind and couldn't tolerate having this man touch her.When you ask her if this type of thing has hap-pened on other occasions, she admits that she doesn't like to be touched by anyone. "It even bothers me sometimes if my own kids grab me when I'm not prepared for it."Nicole states that she was so upset by this inci-dent that she stayed home from work the next day because she was just "too tired" to get there on time. "My supervisor gets real mad when I'm late,even though I tell him I can't do anything about it if the bus isn't running on time. I just didn't want to deal with it the other day."You ask her why she thinks she reacted so strongly to her coworker touching her the other day. Nicole pauses for several moments and then sighs deeply. "I think it's related to all that 'child-hood stuff' with my father. I just can't get it out of my head. I think it's going to haunt me for the rest of my life."Nicole describes several depressive episodes to you in which she felt she just couldn't move because it took too much energy. During those times, she would forget to eat and would be unable to get to sleep until early in the morning. Her children would constantly ask her, "What's wrong, Mommy? Whycan't you play with us?" Nicole states that herchildren's comments made her feel like a "terrible mother."When you ask her about her goals for the fu-ture, Nicole states that she really doesn't have any goals, although she would like to go to college and become a teacher. She says she isn't sure she'll live long enough to complete an education.

Use this form to guide your questions during a client interview and to take cursory notes.

Delete the instructions and examples in each section before adding your client's information. The given examples are provided only for your reference to help you complete this form.

Client Interview

Identifying Information

basic demographic information for your client.

Name(s):

Date of birth:

Primary language:

Referred by:

Intake date:

Evaluated by:

Description of Client(s)

Briefly describe what you observe about the client's physical status, such as age, gender, ethnicity, appearance, behaviors, and any impressions that stand out to you.

Example: Client is a single Hispanic female in her mid-thirties. She is dressed appropriately for the weather, is well groomed, and appears to be her stated age. She appears slightly anxious as evidenced by her restless fidgeting.

Presenting Problem

Briefly describe why the client is seeking counseling.

It is appropriate to start the session with a question like, "What is the reason for your visit today?" or "What brings you in today?" Summarize the client's response in a few sentences.

Example: Client reports seeking counseling because she is sad, lonely, unmotivated, and feels tired most of the time. She states that this has been getting worse, and she doesn't want to get out of bed in the morning. Her symptoms began about 3 months ago after she broke up with her boyfriend. She recently has called out of work a few days because she didn't have the energy or motivation to go to work.

History of Problem

Describe the symptoms, experiences and background of the problem, previous occurrences, and interventions in a brief paragraph.

Get the client's full story. Be as conversational as possible and listen carefully to what your client is saying. Your goal is to build a friendly relationship, have the client feel comfortable with you, keep the focus on the client and their story, and gather informationnot to sound like this is an interrogation. A release of information to obtain discharge notes from other providers may be appropriate.

Consider using questions or statements that prompt the client to provide details about important topics:

How long this has been a problem?

When did you first notice this problem?

Tell me more about your problem.

How long has this issue been a concern to you?

Have others been concerned or noticed the symptoms?

How often does this problem occur?

How often have the symptoms occurred in the past?

I'd like to hear more about how often this happens.

Have interventions worked?

Have you had counseling for this issue before? If so, what was the outcome of your counseling?

Could you walk me through all the things that you have done in the past, including any previous counseling?

What differences have you had in physical health or emotional mood?

Summarize the client's responses.

Example: Client has a history of these types of symptoms when things in her life change suddenly. She reports she has had feelings of sadness and loneliness often over the past several years, even when she was with her boyfriend. She has times of crying spells, low energy, and lack of interest in activities and in socializing after changing jobs, after moving to a new city, and after her best friend got married and moved away. Client reports that she has never gone to counseling for it in the past, and it usually went away after a month or so. She would sometimes talk to her mom about it, or she has tried reading some self-help books on improving her happiness. This time is different because she needs to keep her job and she can't keep calling out sick.

Social History

Describe the client's social support system in a few sentences, including the following:

where the client lives and with whom

quality of relationships with family and friends

support received from others

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Tell me about where you live and with whom.

What are your relationships like?

Who do you get along with well, and who are you not close with?

Summarize the client's responses.

Example: Client recently moved into her own condo after breaking up with her boyfriend of 6 years. They had shared a residence and 2 dogs. Client has 2 close girlfriends whom she has been friends with since grade school, and she can tell her 2 friends anything. Client's mother lives a few miles away and they have a close relationship, although client feels that she can't burden her mother with relationship problems.

Copyright 2021 by University of Phoenix. All rights reserved.

Copyright 2021 by University of Phoenix. All rights reserved.

Biopsychosocial Assessment

Page 3 of 16

Family History

Describe the client's family of origin and relationships with family in the past and present in a few sentences.

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Tell me about your family of origin. Who did you live with growing up?

What were the relationships like in your family?

What are your family relationships like now?

Summarize the client's responses.

Example: Client states that she grew up with her dad, mom, and older sister. She describes her family as "an all-American family" with her dad working and bringing home most of the income and her mom having a part-time job for additional "fun money." She recalls her mom and dad having a happy marriage, and she felt that her years growing up were happy. She denies any domestic violence or abuse in the home. Her sister is 3 years older, and she describes her as "bossy." She says that they basically got along fine but her sister always wanted to be the "boss of her" and "tell her what to do." She still has regular contact with her sister, brother-in-law, niece, and nephew, but they don't get together very often due to geographical distance.

School History

Briefly describe the client's educational background and any relevant school history or experiences, including the following:

where the client went to school

years of education completed

positive or negative school experiences

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

How was your school experience growing up?

Did you have friends in school?

Did you go on for post-high school education? If so, what was that experience like?

Summarize the client's responses.

Example: Client describes her experiences in grade school and high school positively, stating that she remembers enjoying learning and her friend group. She attended the state university and obtained a bachelor's degree in marketing. She thought that college would be more fun than it was based on the stories she had been told. She found the rigor difficult and was glad she graduated.

Work History

Describe the client's relevant work history and experiences in a few sentences, including the following:

current employment situation

time spent in the career/profession

positive or negative experiences of work

any sporadic work history or frequent job changes

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Tell me about your job. Do you enjoy what you do?

How long have you been in this position?

What types of jobs have you had previously?

Summarize the client's responses.

Example: Client works as an advertising manager at a small firm. She has been there for about 5 years and finds the work unsatisfying. She keeps her position because it pays her bills, and she doesn't have the energy to find something else. Client reports having a few jobs prior in customer service that she didn't enjoy much, either. She states that she has never enjoyed working but always kept a job.

Spiritual

Briefly describe the client's stated spiritual beliefs.

Remember to keep the conversation flowing and not to overwhelm your client with questions.

Clients may choose not to talk about their beliefs or to avoid this topic. Remember that spirituality and religion are not necessarily the same thing. Clients may ask, "Are you asking my religion?" You are not. You are asking for their views of what they believe is greater than themselves, what connects them to the larger universe, or what brings them a sense of peace and purpose.

Consider using questions or statements that prompt the client to provide details about their history:

Do you have a spiritual belief? (You can expect at this point that the client may ask for clarification as to what you are asking. Clarify that having personal spiritual beliefs are not the same as belonging to a church or a religion.)

Summarize the client's responses.

Example: Client states that she does not belong to an organized religion and doesn't attend church but does believe that there is a higher power. In times of stress, she meditates or prays.

Legal

Indicate whether the client has current or previous legal issues. If current, what is the status? Is the client on probation, etc.?

If there are no legal issues, simply state "N/A" to indicate that they are not applicable here.

Trauma History/Abuse

Describe any past or current traumatic events or abusive situations that the client may have experienced. Indicate whether this is ongoing and if the client has received counseling in the past for it.

Keep in mind that the client may not want to disclose their history of trauma or talk about their abuse in depth, especially in the first session. Be sensitive to a client's hesitation to discuss it and remain aware of their discomfort around these topics and questions. Allow them time to respond or respect their silence and the choice to not respond at this time.

Remember to keep the conversation compassionate and flowingdo not overwhelm your client with questions.

Consider using questions or statements that prompt the client to provide details about their history:

Have you experienced any type of traumatic events?

Have you been a victim of abuse?

Summarize the client's responses.

Example: Client denies any abuse in her family and does not feel that she has experienced any trauma. Client hesitates when recalling an incident at college, stating, "It was kind of traumatic, I guess." Client does not want to disclose the details of the event at this time.

Suicidal/Homicidal

Indicate if the client has had any suicidal or homicidal thoughts, plans, or attempts. Note if these are in the past or present and if they are passive or active. If client currently has suicidal or homicidal thoughts, complete a full suicide risk assessment. If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.

Be sensitive and aware of a client's hesitation to discuss. Risk assessment is necessary if there are any indicators of suicide or homicide. Be direct when asking questions about these topics.

Consider using questions or statements that prompt the client to provide their thoughts:

Have you thought about suicide (or homicide)? (If client says anything other than "no," continue with direct questions or prompts.)

Tell me what you were thinking about.

Do you have a plan?

When is the last time you had this thought?

Summarize the client's responses.

Example: Client denies suicidal or homicidal thoughts.

Example: Client has been having some passive suicidal thoughts. She has not had this in the past. The last time she thought about this was a week ago. She has no plan, no means, and today has no intent.

Example: Client has thought about suicide. Full assessment completed. Client is at moderate risk.

Health and Wellness History

Discuss client's past and present substance use, sleep habits, and exercise and eating habits. Ask direct questions to gather this self-explanatory information.

Substance Use

Includes alcohol, drugs, tobacco, and caffeine intake

Note frequency of use, amount, and duration

Sleep Habits

Exercise Habits

Eating Habits and Appetite

Include any recent weight loss or weight gain.

Mental Status

Assess your client's mental status by discussing what you observe about the client in your session.

Activity

Describe the client's behaviors, especially the client's physical movements.

What did you notice about the client's movements?

Summarize the client's responses.

Example: Client appeared restless and fidgety during the session. She played with her purse strings, engaged in hand wringing, and swung her feet during most of the session.

Mood and Affect

Describe the client's mood and affect (visible expression of feelings and emotions).

What was the client's overall mood?

How did the client show that mood non-verbally (the affect)?

Were these congruent? (Did the client's affect align with the stated mood?)

Summarize the client's responses.

Example: Client said that she was sad and depressed. Her affect during the session was tearful and she often looked down, avoiding eye contact. Her mood and affect were congruent.

Thought Process, Content, and Perception

Describe the client's thought process, content, and perception in how they respond to questions and tell their story.

Listen to how the client responds to questions and presents their story to assess their thought process. Describe their thought process in the telling of their story using terms like logical, illogical, linear, tangential, circumstantial, rational, etc.

Listen for the content of their story and responses to assess their content. Describe their content with words like negative, depressive, obsessive, hopeful, etc.

Listen to their descriptions of reality in their story to assess their perception. Describe whether there are any perceptual disturbances, such as:

Hallucinations - hearing, seeing, or feeling things that are not there

Delusions - thoughts or beliefs that conflict with reality

Illusions - misperceptions, such as hearing the wind and thinking it is someone crying, or seeing a shadow and thinking it is a person

Summarize the client's responses.

Example: Client responded to questions and prompts with a logical and linear thought process. Her story followed a timeline of events and she was easily able to respond to questions directly. Her thought content was negative and depressive. She has difficulty finding anything hopeful in her life. She did not report harmful thoughts. She denied perceptual disturbances.

Cognition, Insight, and Judgment

If completed, indicate any results of a Mini Mental Status Exam (MMSE) in this section. Discuss whether the client appears to understand the symptoms and issues being experienced.

How is the client's insight (ability to recognize the issues and why these issues are occurring)?

How is the client's judgment (ability to make good decisions and behaviors)?

Did you get a sense that the client understands why these things are occurring?

Does the client think about choices and decisions before acting? Has the client been aware of behavioral consequences?

Summarize the client's responses.

Example: Client completed a Mini Mental Status Exam and scored well within the normal range, indicating no cognitive impairments, and estimated average to above average intelligence. It is noted, however, that she had some difficulty in concentration as evidenced by her ability to remember 3 unrelated objects after being distracted and counting backward by 7s. This is consistent with her reports of having a difficult time focusing. Client had good insight and recognized that she is depressed, which she has experienced before under circumstances of change and adjustment. Her judgement is fair, as she does consider her choices and decisions, but also, she is risking her job by choosing to stay in bed for the past few days.

Case Summary

Legal and Ethical

Discuss any potential legal or ethical issues you need to consider as the counselor. This is not about the client having a legal issue.

Consider these factors after you are finished with your intake and are thinking about the case:

Is there a need to break confidentiality due to danger to self or others?

Is there any child or elder abuse or neglect occurring?

What cultural values and considerations should be made with this client?

Are there any dual relationships?

What is your scope of practice?

Use the American Counseling Association (ACA) Code of Ethics as a guide for recognizing and discussing any potential legal and ethical situations.

Summarize the client's responses.

Example: Client stated that she passively thinks about suicide since her breakup, but hasn't had a plan, means, or intent, and has not had a thought in over a week. No risk assessment completed. Client reminded that in the case of danger to self or others, that confidentiality would need to be broken to keep her safe. Client was given numbers for crisis lines and after-hours warm line. Client will be asked at the beginning of each session about suicidal thoughts.

Strengths

Describe assets that will facilitate progress and change, such as motivation, intelligence, self-discipline, and willingness to use resources.

Challenges

Describe aspects of the client's life circumstances that may impede progress or change, such as homelessness, major psychiatric disorder, financial hardship, etc.

Discussion

Summarize the presenting problem and symptoms, along with any pertinent history and social factors that lead to a diagnosis. This section justifies your diagnosis; include any differential diagnoses here.

Consider these factors when writing the discussion:

the symptoms that brought the client in to counseling

the history of the presenting problem

any social, environmental, or medical factors

Summarize the client's responses.

Example: Client presented with sadness, depressed mood, low energy and motivation, loss of appetite, and sleep disturbance. Although she wants to sleep most of the day and does believe that she is sleeping at least 10 hours a day, she does not feel rested. Client has broken up with her long-term boyfriend of 6 years and moved to a new residence. She has lost her boyfriend and the 2 dogs that they owned together. She has a history of feeling lonely, sad, and depressed when there is a major change in her life. She is experiencing more symptoms than she has in the past, primarily evidenced by not going to work, isolating from her best friends, and not eating. These

symptoms have been getting worse over the past 3 months. Adjustment disorder is considered due to the recent changes in her life within the past 3 months. Her symptoms are not out of proportion to the stressor; therefore, ruling out adjustment disorder. Her symptoms meet the criteria for major depressive disorder as evidenced by her sadness, diminished interest in activities, loss of appetite, hypersomnia, and diminished ability to concentrate. Her symptoms are moderate, as evidenced by the interference in her occupational and social functioning. She has had symptoms like these in the past, therefore this is recurrent.

Diagnosis

Using the information gathered thus far, make a diagnosis using the DSM-5. Include the diagnostic title and code as well as any specifiers.

Example: 296.32 - Major Depressive Disorder, moderate, recurrent

Assessments to Support Diagnosis

Identify any assessments that have been used or that you might use to support a diagnosis or rule out a differential diagnosis.

Practice within your scope as a counselor with a master's degree. Remember that you are limited in which assessments you can legally use; you can use the ones in the DSM Library, but not the ones that require a doctorate degree and training outside of your scope.

Example: PHQ-9 and Beck Depression Inventory

Case Conceptualization

Explain the issues, symptoms, and diagnosis of the case through the lens of a theoretical perspective.

Consider these factors when writing the case conceptualization:

the biopsychosocial aspects of the case the theory applied in this case: cognitive behavioral therapy (CBT), humanistic, Adlerian, psychodynamic, or behavioral

how the concepts of the theory explain the client's symptoms and issues

Summarize the client's responses.

Example: The client presented with major depressive disorder symptoms following a triggering event of ending the relationship with her long-time boyfriend and moving to a new residence. Client is lonely and sad but isolating from her friends and not disclosing her depth of sadness to her mom. Client typically enjoys being with her few girlfriends but is now retreating to her bed and avoiding social contact. She has never really enjoyed her work but has been responsible with maintaining her job until recently, when she has called out several days just to stay in bed and sleep all day. This is unlike the client who has been responsible and self-sufficient in the past. Client needs increased social support to help bolster her sense of self and redirect her toward a healthier lifestyle, as she has had in the past. Healthier behavioral choices, challenging negative self-perceptions, and reconnecting with those who care about her would reduce the intensity of the symptoms she is experiencing.