Learning Objectives: Students Will Assess Clients' Presentat ✓ Solved

Learning Objectives Students will: Assess clients presentin

Learning Objectives Students will: Assess clients presenting for psychotherapy Develop genograms for clients presenting for psychotherapy To prepare: Select a client you have observed or counseled at your practicum site. The Assignment Part 1: Comprehensive Client Family Assessment With this client in mind, address the following in a Comprehensive Client Assessment (without violating HIPAA regulations): Demographic information Presenting problem History or present illness Past psychiatric history Medical history Substance use history Developmental history Family psychiatric history Psychosocial history History of abuse/trauma Review of systems Physical assessment Mental status exam Differential diagnosis Case formulation Treatment plan Part 2: Family Genogram Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).

Paper For Above Instructions

Introduction

This paper provides a de-identified comprehensive client family assessment and a three-generation genogram summary for "Client A," a composite, anonymized case created to illustrate assessment procedures while protecting confidentiality (HIPAA-compliant). The assessment synthesizes standard clinical evaluation domains and offers a case formulation and treatment plan grounded in evidence-based practice (American Psychiatric Association, 2013; McGoldrick, Gerson, & Petry, 2008).

Demographic Information

Client A is a 34-year-old cisgender female, married, employed full-time as a school administrator, living in a suburban household with spouse and one school-aged child. She identifies as Caucasian and reports a college education. Insurance: private. These demographics contextualize risk and resilience factors relevant to treatment planning (Kaplan & Sadock, 2014).

Presenting Problem

Client A presents with 10 months of increasing anxiety, difficulty sleeping, intrusive worry about work performance and family safety, and episodic low mood. She reports functional impairment at work and increased conflict with spouse. She seeks psychotherapy for anxiety management and relationship support.

History of Present Illness

Symptoms began after a promotion and concurrent caregiving stress for an aging parent. Worry is generalized, with occasional panic-like episodes triggered by high-stakes meetings. Sleep onset insomnia and early morning awakening are reported. Symptoms have waxed and waned and intensified over the past three months despite brief attempts at self-help (Beck, 2011).

Past Psychiatric History

Client A reports a remote episode of major depressive symptoms in her mid-20s treated with brief counseling for 6 months; no psychiatric hospitalizations, no prior medication except a short SSRI trial two years ago for situational anxiety (discontinued by client). No history of suicidal attempts; passive ideation noted historically but not current (APA, 2013).

Medical History

Generally healthy: controlled hypothyroidism on levothyroxine, BMI within overweight range, no chronic pain conditions. Primary care follow-up occurs annually. No current medications besides thyroid hormone. Medical contributors to mood and anxiety will be monitored (Groth-Marnat, 2009).

Substance Use History

Client A reports moderate alcohol use (3–4 drinks per week) and no illicit substance use. No history of substance use disorder. Use does not appear to drive current symptoms but will be monitored as part of safety and treatment planning (NIDA, 2020).

Developmental History

Raised in a two-parent household with stable early development. Milestones achieved appropriately. Reports early family emphasis on achievement and high parental expectations. No childhood medical complications noted. School performance generally strong; social relationships described as adequate but conflict-avoidant tendencies emerged in adolescence.

Family Psychiatric History

Notable family history: maternal grandmother had recurrent depression; father had alcohol use disorder in remission; maternal uncle diagnosed with bipolar disorder. No known schizophrenia or psychotic disorders in direct lineage. Family psychiatric history suggests increased vulnerability to mood and substance-related disorders (McGoldrick et al., 2008).

Psychosocial History

Client A reports strong vocational identity but high career-related stress. Marriage generally supportive though recently strained. Social network includes a few close friends; limited extended family involvement due to geographic distance. Financial stressors are moderate but manageable.

History of Abuse/Trauma

Client A discloses a single history of adolescent emotional neglect and one episode of non-contact sexual harassment at age 22 while in college; no physical abuse and no current safety concerns. Trauma-informed approaches are recommended (SAMHSA, 2014).

Review of Systems and Physical Assessment

Review of systems reveals sleep disturbance, occasional headaches, palpitations with anxiety episodes, and fatigue. Physical exam by PCP within past year was unremarkable except for controlled hypothyroidism. Labs including TSH are within expected range on medication. Medical etiologies for mood/anxiety have been screened and largely ruled out (WHO, 2013).

Mental Status Exam

• Appearance: well-groomed, appropriate attire.
• Behavior: cooperative, mildly restless.
• Speech: normal rate and volume.
• Mood/Affect: anxious mood, constricted affect but reactive.
• Thought process: linear and goal-directed.
• Thought content: no current suicidal or homicidal ideation; occasional worry themes; no delusions.
• Cognition: alert and oriented x3; intact memory and concentration with mild difficulty sustaining attention during anxiety peaks.
• Insight/Judgment: fair insight into symptoms and good judgment regarding safety.

Differential Diagnosis

Primary considerations include Generalized Anxiety Disorder (GAD) and Major Depressive Disorder, recurrent, mild to moderate (DSM-5 criteria), with comorbid adjustment difficulties related to caregiver stress (APA, 2013). Rule-outs: substance-induced mood disorder, thyroid-related mood changes (medical workup stable), and bipolar spectrum given family history—screening for hypomanic symptoms is recommended (Kaplan & Sadock, 2014).

Case Formulation

Client A's symptoms are best understood through a biopsychosocial formulation: genetic/familial vulnerability to mood/anxiety disorders, environmental stressors (promotion, caregiving), and learned cognitive patterns emphasizing perfectionism and responsibility. Trauma history and family dynamics (high expectations, limited emotional expressiveness) maintain worry and avoidance patterns, contributing to impaired sleep and relational strain (Beck, 2011; McGoldrick et al., 2008).

Treatment Plan

Short-term goals (0–3 months): reduce acute anxiety symptoms by 40%, establish sleep hygiene, and develop stress-management skills. Interventions: cognitive-behavioral therapy (CBT) targeting worry and cognitive distortions (Beck, 2011); brief behavioral activation for low-mood symptoms. Weekly 50-minute sessions with progress monitoring. Safety plan and crisis resources reviewed (NIMH, 2019).

Long-term goals (3–12 months): consolidate relapse prevention, address interpersonal patterns through either couples therapy or interpersonal therapy as indicated, and explore family-of-origin issues using genogram-informed family work (McGoldrick et al., 2008). Consider psychiatric consultation for SSRI trial if insufficient response after 8–12 weeks of psychotherapy (NICE, 2019).

Additional components: integrate trauma-informed care strategies (SAMHSA, 2014), monitor medical contributors with PCP, and include brief interventions for sleep (CBT-I techniques). Regular outcome measurement using validated scales (GAD-7, PHQ-9) will guide treatment adjustments (WHO mhGAP; NICE guidelines).

Part 2: Family Genogram (Three Generations) — Narrative and Structural Summary

A visual genogram is recommended; below is a structured, text-based depiction intended to be converted into a standard genogram diagram (use of symbols for gender, marriage, divorce, and psychiatric diagnoses per McGoldrick et al., 2008).

• Generation 1 (Great-grandparents): Paternal great-grandparents—no known psychiatric diagnoses; maternal great-grandparents—maternal grandmother later developed recurrent depressive episodes in midlife.
• Generation 2 (Grandparents): Paternal grandparents—stable marriage, father described as stoic; Maternal grandparents—maternal grandfather deceased (cardiac), maternal grandmother with recurrent depression treated intermittently.
• Generation 3 (Parents): Father—history of alcohol misuse in early adulthood, now in remission; Mother—anxiety traits, high expectations, no formal psychiatric treatment. Parents married; family system described as emotionally reserved.
• Generation 4 (Client and Siblings): Client A—current GAD/depressive features; Siblings—one younger brother, no known psychiatric diagnosis.

Genogram highlights: multigenerational mood vulnerability (maternal line), substance use in paternal generation, and family interaction patterns emphasizing achievement and emotional restraint—factors included in the case formulation and therapeutic targets (McGoldrick et al., 2008).

Conclusion

This comprehensive assessment integrates biopsychosocial data, a structured mental status exam, differential diagnosis, formulation, and an actionable treatment plan while maintaining HIPAA-compliant de-identification. The three-generation genogram informs intergenerational patterns relevant to treatment. Recommended next steps: obtain baseline standardized measures, initiate weekly CBT with trauma-informed adaptations, coordinate with PCP for medical monitoring, and consider psychiatric consultation if symptoms persist (APA, 2013; Beck, 2011; SAMHSA, 2014).

References

• American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: APA.
• Beck, J. S. (2011). Cognitive Behavior Therapy: Basics and Beyond (2nd ed.). Guilford Press.
• Kaplan, H. I., & Sadock, B. J., & Ruiz, P. (2014). Kaplan & Sadock's Synopsis of Psychiatry (11th ed.). Wolters Kluwer.
• McGoldrick, M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and Intervention (3rd ed.). W. W. Norton & Company.
• Groth-Marnat, G. (2009). Handbook of Psychological Assessment (5th ed.). Wiley.
• Substance Abuse and Mental Health Services Administration (SAMHSA). (2014). SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach. U.S. Department of Health and Human Services.
• National Institute for Health and Care Excellence (NICE). (2019). Depression in adults: recognition and management. NICE Guideline.
• World Health Organization. (2013). mhGAP Intervention Guide for mental, neurological and substance use disorders in non-specialized health settings.
• National Institute of Mental Health (NIMH). (2019). Generalized Anxiety Disorder: When Worry Gets Out of Control. NIMH Publications.
• National Institute on Drug Abuse (NIDA). (2020). Comorbidity: Substance Use Disorders and Other Mental Illnesses. NIDA Factsheet.