Biopsychosocial Assessment
For this assignment, complete all components of the Biopsychosocial Assessment found in the Case Study Treatment Plan for the client you picked. When details from the case are vague or missing, you are free to elaborate in the specific area. You will also complete the following specific sections of the Case Study Treatment Plan for the unit 4 assignment: Client Name: Describe any cultural norms specific to the chosen client (for example, sexual orientation, religion, or race). •Cultural background. Describe the importance of family, social networks, and community systems in the treatment of mental and emotional disorders related to issues of human sexuality. •Family background. •Social and community systems. Describe the client’s behavior, including any developmental crises, disability, psychopathology, and situational and environmental factors that affect both normal and abnormal sexual behavior. •Personal background. •Medical background. •Substance abuse background. •Emotional/psychiatric background. Identify ethical and legal considerations relevant to the client’s identified sexual issues. •Ethical/Legal Issues Relevant to Sexual Issue: Identify other professionals that you anticipate will be involved in the care for this client as the treatment continues. Explain how you will arrange for communication with them and what you are likely to communicate to each of them. Identify the kind of information you will need from each source. •Consultations or referrals needed. Describe strategies for working with client to address their identified issue. •Strategies to address identified issues. Apply relevant human sexuality research findings support the identified strategies. •Sexuality research to support strategies. In addition, place an “NA” in the following sections that are not required for the Unit 4 assignment: •DSM-5 diagnosis. •Differential diagnosis. •Ethical and legal considerations of diagnosis. •Short-term goals •Long-term goals. •Strategies to promote optimal sexual functioning. •Evidence-based treatment interventions. •Relevant research to support diagnosis and treatment plan.
TRANSCRIPT- CASE STUDY
PLEASE SELECT ONE OF THESES CASES
Case Study Treatment Plan Introduction For your course project, you will develop a treatment plan for one case study subject that you select from three possible candidates. These potential clients are ethnically diverse and are struggling with psychological disorders related to issues of human sexuality. During the course of this project you will: •Evaluate client information. •Identify the theory/model that is most appropriate to the situation. •Describe the cultural norms specific to your client/s’ identified population. •Discuss the legal and ethical considerations relevant to the sexual issue/s identified. •Review the impact of diversity issues on various disorders and their treatments. •Develop a suggested treatment plan for the client, which includes the completion of a Biopsychosocial Assessment. This project will utilize this Case Study Treatment Plan template. You will complete the sections of the treatment plan designated for each assignment, and then create a PDF copy of the work that you will submit for a grade. When you are ready for the next assignment, you will open the treatment plan and continue your work; your earlier assignments will be saved in the treatment plan. This gives you the opportunity to build your treatment plan in stages, allowing you to go back and refine your earlier work using feedback from your instructor and additional resources you may have found before submitting the completed treatment plan as your final project assignment in Unit 9. Client 1 Case Client is a 37 year old male who has presented for counseling due to the recent issue of finding out that his wife was unfaithful. Reports he is having difficulty in several domains of his life and wants help figuring out what to do. Client has been working at the same job for the past 16 years. He is an engineer at a local firm. Client reports that he is satisfied with his job. Client has a bachelor’s degree in mechanical engineering. Client reports that he is financially secure and is not worried about financial issues at this time in his life. Client reports holding Christian faith. He states that he attends church with his wife at least 2 times per month and that is important to them to raise their daughter and son with these values. Client reports a daughter who is 8 and a son who is 6. Client states that he has few friends and little time for extra-curricular activities. States that he does enjoy fishing, hunting, and gun collecting but that none of these activities seem very enticing over the past several weeks. Client does report having two very close friends that he has maintained since childhood. He states that these friendships have been helpful for him in the past several weeks after he discovered an email between his wife and a man from her work but both friends are telling him he should get out of the relationship because of what his wife did. Client reports that his drinking has increased over the past couple weeks and that he is utilizing alcohol as a way to cope with the current problem. He states that he is drinking 2 to 3 vodka and tonics nightly and that this amount is unusual but it is one of the ways that he is able to sleep and not have to think about what she did. Before finding out about this incident, client reports drinking one to two drinks a week. Client reports no prior problems with alcohol but he does report binge drinking with fraternity buddies while in college. Reports this stopped soon after he accepted a full-time engineering position. Client reports no current or past drug use. Does report trying marijuana while in college but stating he didn’t like it. Client is a non-smoker. Client reports no other general medical concerns. Client and wife have owned their home for the past 10 years and are satisfied with their living conditions. Reports that his parents live nearby and consist of both his mother and father. States he has not told his parents yet because he knows they will be vary mad at his wife. Also reports that he has a sister who he is close to but she lives in Georgia. States he did tell his sister because she left her husband after he cheated on her. States that his parents are still married and have always appeared to be happy. States that he does not have significant issues with his immediate family from when he was a child. Client states that two weeks ago while looking through some emails he found an email between ‘some guy’ and his wife. States that he immediately knew that the emails were inappropriate because they discussed intimate issues between his wife and ‘that guy’. States that he confronted his wife that evening and his wife denied any such an issue until client produced the emails. States that since that time him and his wife have been arguing non-stop. Reports he cannot believe whether or not the information she is telling him is true and is worried that the relationship between his wife and ‘that guy’ is significant. States that he recognizes that his relationship with his wife has been distant over the past few year but sites issues of work stress as the cause. States over the past two weeks that he is having headaches, that he feels sick to his stomach, that he is crying, that he cannot concentrate, that he is having nightmares and visions of his wife having sex with ‘that guy’. Reports that he cannot get thoughts of his wife and ‘that guy’ out of his head. State that this is distracting him at work and at home. States that he had a consultation with his pastor but it was not helpful and no matter how much he prays, he still feels horrible and does not understand why God would allow something so cruel to happen to him. Client 2 Case Client is a 54 year old male. Client reports that he is attending counseling today because his wife made him. States that she is tired of catching him with pornographic materials on his phone and on the computer. Client reports a long history of porn watching beginning in childhood. States that he thinks his family dynamic was ‘fine and that there weren’t any problems when I was growing up’. Does report that his mom and dad were distant and very conservative. Reports they treated him like a child even after he became an adult. States he had many rules he had to follow as a young boy so when he was tired of following the rule he just hid what he was doing from them. States his mom used to say that it was her job to make sure he turned out right and he always felt like it was his job ‘to make sure she didn’t find out what I was up to’. States that he has two younger brothers and his relationship with them has always been fine. States that he attends ball games with them and sometimes watches Monday night football at the bar with them. States him and his brothers still have dinner with his parents every Sunday. Client reports he has been married to his current wife for 25 years. Reports that the relationship has had ‘ups and downs’ over this time but that it is generally ‘allright’. States that it is currently ‘down’ because of her knowledge about the pornography use. States that he and his wife have owned their home for 20 years. Client states that he has worked as a journeyman tool maker for the past 33 years and a satisfied with his job. Reports military service for ‘four years and then out’ completing when he was 23. Client states that he makes enough money but always could use more. Client reports that he was recently diagnosed with high blood pressure and has started taking medication for this. Client is a smoker and reports currently smoking about half a pack a day. States that he has smoked half a pack a day for the past 10 years and does not think he will ever quit. Client reports no other medical conditions at this time. Client states he has never had any mental problems but he does report that he and his wife went to counseling about a year ago for three or four sessions. States that he really ‘didn’t appreciate having to spend his money that way because the counselor wasn’t all that helpful’. States that the therapist said that it was all his problem and he needed to change. Client report a long history of alcohol use that began when he was 13. Currently, he states that he is drinking 3 to 4 times a week and he drinks rum and cokes. States that he drinks 2 to 3 of these each evening. Reports having received a DUI when he was 23 and attending a weekend program but no other treatment for alcohol use. States that he does not believe his drinking is a problem. Report several hobbies including boating, snowmobiling, fly fishing, and amateur photography. States that he enjoys these hobbies and they help keep him busy when he’s not at work. Reports two grown children who are happy and on their own. Reports that his daughter who is 24 lives in California and his son who is 23 lives in Nevada. States he talks with them by phone once every few weeks. Reports intermittent use of marijuana throughout his life time that also begin around age 13. States that he used heavily throughout his 20’s and 30’s but now only uses occasionally. Client states that he will smoke one joint one to two times per month. Client reported he has never been in trouble because of drugs. Client reports no other drugs of abuse. Client reports that he is Presbyterian and attends church on holidays but that his wife goes more often and is involved in church activities. Report that his first experience with porn occurred when his father gave him a Playboy magazine to look at. States his dad told him that he could learn about sex if he looked at these pictures and read the articles. Client states that he was supposed to ask his dad after reading the magazine if there were any additional questions. Report he learned about masturbation by reading an article. Client reports since that time his pornography use increases and decreases but has always been present. He states that he was able to look at pictures from magazines for several years but when the internet ‘boomed’ porn became more and more of an issue. Reports that over the past 10 years he will spend one to two hours a day looking at sites on the internet. He also reports utilizing chats. Reports getting ‘in trouble’ once at work after they found porn on his computer. States that now he is more careful and only uses his phone and the home computer. States he is bothered by how much time his porn watching consumes and sometimes wishes he could do a better job breaking away from it. States that he spends considerable time thinking about sexual acts and knows that women look at him the same way he looks at them. Reports several other sexual acts over the past two decades. These include sex with strangers, internet hook-ups, and sex for pay. States that he does not know why ‘those urges’ come-and-go and reports his wife is unaware of these additional issues. Reports he does not think porn watching is a problem but also reports that he is open to discuss this issue if you think it is a problem. States he is worried because he is having so much trouble getting and maintain an erection and that this is the problem he wants fixed. Reports “I just wanna have and keep an erection during sex”. States he has been having difficult having erections for the past year and that his porn watching has increased due to the trouble having erections. States that he wishes his wife could be a little more understandable that he is not able to have sex with her without the pornography. Client 3 Case Client is a 22 year old female. She states she has come to counseling because she wants to do a better job knowing herself and be brave enough to let others know her too. Client reports that she came out as bisexual several months ago and has had mixed reactions to this announcement. She states that she has told a few friends and some of them have disowned her. She also states that she has not told her parents or her best friend because she is worried that the same thing might happen (being disowned). She reports being conflicted about her sexuality for the past 4 or 5 years and states that she has known that she was different for a long time. She reports that she did not do anything about this in high school and ignored how she felt because she was worried about what others would say. She states now that she is in college and on her own that she feels it is safer to be able to explore her sexuality. She reports three relationships with men and two relationships with women but the relationships with women were a secret. She states that the last woman broke up with her because the client insisted on secrecy. Client reports a stable family environment growing up in a two-parent home. She reports that her mother was very controlling and tried to make her do ‘all sorts of things’ while she was growing up. She states she mostly complied because she did not want to get into trouble. She reports that her dad was somewhat dismissive and allowed her mom to ‘control the house’. She states that she received good grades throughout high school and was basically ‘a stellar child’. She reports that she played basketball and tennis and was interested in sports her junior and senior year. She reports one older brother and one younger sister and strong relationships with both siblings. She reports that she has lived away from home for the past three years with the first year on campus and the last two years living in a house with friends. She has been part of a sorority since her freshman year and feels very connected to the women who also are part of the sorority. She is worried that if they find out about her secret, they might kick her out of the sorority. Client states that she is studying environmental sciences and is happy with this choice. Client reports little income and is primarily supported by her parents. She states she works part-time on campus in the dean’s office and she likes this job, but she knows she needs to find something different that is more in her field of study. She reports no drug use, but she does reports some alcohol use. She states she primarily drinks when she is at parties with her sorority sisters. She reports no past or current legal problems. She reports no medical problems. She states that she has grown up Catholic, but she is currently not practicing. She states that she believes there is a God but she does not know how to reconcile this belief with her thoughts and feelings about herself. She states that her faith only makes her feel guilt. She states that she is worried that she is bisexual and that she is never going to ‘pick a side’. Her gay and lesbian friends are always joking around with her because she just ‘falls in the middle’. She reports this is her only real problem of concern. Her grades are As and Bs and she is on track to graduate in the fall. Biopsychosocial Assessment Form Cultural Background Name: Age: Gender: •Male •Female Race: Ethnicity: Religious Issues: Sexual Orientation: Relevant Cultural Norms: Other Relevant Cultural Norms: Current Symptoms Reason for Visit Listed as DSM-5 Symptoms: Family Background Family of Origin Issues: Family Environment in Childhood/Adolescence: Marital/Partnership History: Children Issues/Concerns: Social/Community Background Connections to Community Support (Church, AA Group): Support Network: Hobbies or Volunteer Activities: Personal Background Developmental History: Disability: Educational: Military: History of Trauma: Employment Status: Legal Status: Financial Status: Other Circumstances, Such as Transportation, Housing, et cetera: Medical Background Medical History: Use of Medication: Current Medications: Substance Use Background Substance Use Background: Mental Health Background Previous Psychological Issues (Depression, Anxiety, et cetera): Previous Counseling, Hospitalizations: Family Fistory of Mental/Psychological Issues: Ethical/Legal Background Ethical/Legal Background: Consultations/Referrals Needed Consultations/Referrals Needed: Strategies to Address Presenting Problems 1: 2: Sexuality Research to Support Strategies 1: 2: Treatment Plan Instruments/Screens to Facilitate Diagnosis Instruments and Screens: DSM-5 Diagnosis DSM-5 Diagnosis: Differential Diagnosis Differential Diagnosis: Ethical/Legal Consideration of the Diagnosis Ethical/Legal Consideration of the Diagnosis: Short-Term Goals to Address the Diagnosis Short-Term Goals to Address the Diagnosis: Long-Term Goals to Address the Diagnosis Long-Term Goals to Address the Diagnosis: Strategies to Promote Optimal Sexual Functioning 1: 2: 3: Evidence-Based Treatment Interventions to Support Strategies 1: 2: 3: Relevant Research to Support Diagnosis and Treatment Interventions Include six citations formatted according to current APA style and formatting guidelines: Credits Subject Matter Expert:Rob Eubanks, PhD, LMFTInteractive Design:Estelle Domingos, Tara SchillerInteractive Developers:Peter Hentges, Justin LeeInstructional Design:Marisa JohnsonProject Manager:Alan CampbellImage Credits:©iStockphoto/NickS, ©iStockphoto/ericsphotography, ©iStockphoto/ProArtWork, ©iStockphoto/jcarillet Licensed