Case Scenario 2

Complete the Counseling Biopsychosocial Assessment based on the trauma scenario attached

Case 8.1

Identifying Information Client Name: Nicole Gibson

Age: 25 years old

Ethnicity: African American

Marital Status: Single mother

Children: 2 children, ages 5 and 6

Background Information Nicole Gibson is a 25-year-old single mother who has two children, a boy and a girl, aged 5 and 6, respectively. Nicole works for a nonprofit organization supported by AmeriCorp that offers self-improvement programs for at-risk youth. Green House is an organization designed to teach young people home-building skills while they earn minimum-wage salary and an annual stipend of $4,000 to pay for college tuition and books. Additionally, the program provides paid time off to pursue a GED or high school diploma along with individual or group counseling opportunities several times a week. Nicole also participates in a program that allows her to live independently in a low-income housing unit while attending school and working. Nicole is raising her two children on a salary of $800 per month and an infrequent child-support check of $200 per month. She has no telephone or car and must travel by public transportation to work and the day-care center. Traveling from her apartment to work, including dropping her children at the day-care center, requires her to take six buses each way every day. Nicole must get up at 4:30 a.m. in order to get her children to day care and herself to work by 8:30 a.m. She gets home at 7:30 at night, despite the fact that she finishes her work day at 4:30 in the afternoon. As a case manager at the housing unit, you meet Nicole during a home visit. Nicole expresses a desire to obtain counseling to assist her with her life skills and family-of-origin issues that have made it difficult for her to function well at work. You agree to see her for counseling once a week for 2 hours. One hour will be used to assist Nicole with life skills such as parenting and home maintenance skills. The second hour will be utilized for counseling.

Progress Note from Your First Session with Nicole: As a child, Nicole lived in New Orleans with her parents and older sister, Marcia. Nicole’s parents remained married until she was a teenager. Nicole’s father sexually abused her from the time she was 8 years old through her mid-teens. He forced her to have sexual intercourse with him approximately three times a week. Several of her father’s friends were allowed to sexually abuse her as well. Nicole’s mother was physically, verbally, and mentally abusive, often striking her, calling her names, reading her private journals out loud to other family members, and watching her in the bathroom. On one occasion, Nicole’s mother struck her across the face with a belt buckle, leaving a permanent scar above her upper lip. On another occasion, Nicole’s mother took a poem that Nicole had written and submitted it to a magazine under her own name. Her mother claimed a prize but never acknowledged the fact that it was Nicole’s poem. Her older sister was also physically and verbally abusive to her. Nicole left home when she was 18 years old and married the father of her two children. She referred to this as “getting married to escape hell,” stressing the fact that although she couldn’t stop the “torture” of her family situation, she could leave it behind by getting married. She stated that she left the marriage because her husband was a very “passive” person, and she didn’t want to turn into someone like her mother. Before her marriage, she fell in love with a man named Douglas with whom she now has an estranged relationship. Nicole and Douglas were never sexually involved even though they have been intimately involved on and off for about 8 years. Nicole stated that sex makes her feel “dirty, ashamed, and sick to her stomach.” She hasn’t spoken with or seen Douglas for about 6 months, as he will not return her calls. 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.” Although Nicole is not involved at the present time in an intimate relationship, she does find support at her job with coworkers and has one close friend, Vickie, in whom she can confide. 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 first 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 is needed. She also has a very good sense of humor that she displayed throughout the interview.

**What diagnoses are you considering at this time?

**What will be your primary area(s) of exploration at the next session?

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 coworker 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 happened 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 incident 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’s touching her the other day.

Nicole pauses for several moments and then sighs deeply. “I think it’s related to all that ‘childhood 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? Why can’t you play with us?” Nicole states that her children’s comments made her feel like a “terrible mother.”

When you ask her about her goals for the future.

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.

**What are some of Nicole’s strengths?

**Are you concerned about the potential for Nicole to commit suicide? If so, how would you assess the potential for danger in her situation?

**What resources might be available to assist Nicole?

**What would be your preliminary diagnosis for Nicole?

**What cultural and psychosocial factors may be impacting this diagnosis?

Description: Description: UOPX_Sig_Hor_Black_Large College of Social Sciences Master of Science in Counseling

Biopsychosocial Assessment

NAME(S):

DATE OF BIRTH:

PRIMARY LANGUAGE:

REFERRED BY:

INTAKE DATE:

EVALUATED BY:

DESCRIPTION OF CLIENT(S):

Write what you observe about the client—age, sex, ethnicity, appearance, behaviors, and impressions.

PRESENTING PROBLEM:

Describe the problem as the client has presented it, including perspective, function impairment, and symptoms.

HISTORY OF PROBLEM:

Describe the course of the problem and specific onset and symptoms.

MENTAL STATUS:

Activity:

Mood and Affect:

Thought Process, Content, and Perception:

Cognition, Insight, and Judgment:

Suicidal and Homicidal Assessment

If a more thorough suicide/homicide evaluation is conducted, it may be documented in a separate section.

SOCIAL HISTORY:

Describe the client’s present living situation:

Family:

School:

Health:

Occupational/Work:

Spiritual/Religious:

Legal:

Social History (include history of abuse/trauma):

HEALTH & WELLNESS HISTORY:

Substance use (including alcohol, drugs, tobacco and caffeine intake):

Sleep habits:

Exercise habits:

Eating habits and appetite:

PREVIOUS THERAPY / PSYCHIATRIC SERVICES:

Have you ever been in counseling before? No Yes, Inpatient Outpatient Day Treatment

Name of Provider Clinic Year Diagnosis / Problem

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Have you ever seen a Psychiatrist before? No Yes, Inpatient Outpatient Day Treatment

Name of MD: _______________________________________ Clinic: _____________________________

Was any of your previous therapy related to substance abuse? No Yes

Have you ever had serious thoughts of suicide or homicide? No Yes

Have you ever made a suicide / homicide attempt? No Yes Explain: ____________________________

_____________________________________________________________________________________

Do you presently feel suicidal or homicidal? No Yes Explain: __________________________________

FAMILY RELATIONSHIP HISTORY:

Describe the client’s current and historical family status and relationships, including during childhood/adolescence.

STRENGTHS:

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

CHALLENGES

Describe aspects’ of the client’s life circumstance that may impede progress/change, such as homelessness, major psychiatric disorder, financial hardship, etc.

DIAGNOSIS:

Using the information gathered thus far, make a diagnosis using DSM 5.

DISCUSSION/CLINICAL FORMULATION:

Provide your rationale for the provided diagnosis. Describe the appropriate theory to consider using with this client. Note the basics of this theory and how it might apply to this client.

_________________________________________________ __________________

Student/Counselor in Training Date

_________________________________________________ __________________

Supervisor Date

 
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