Biopsychosocial Assessment and Treatment Planning

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Identifying Information

The client is an 18-year-old Hispanic female of average height from Los Angeles. She is in 12^th grade and stays in a house with her bio-mother, stepfather, two brothers, and two sisters. She is seeking treatment to deal with symptoms precipitated by an exercise in theater class.

Summary Impression

This 18-year-old female displays depression as indicated by symptoms of anxiety, sadness, difficulty sleeping well, distraction, social isolation, etc. The onset of symptoms of heavy breathing and incoherent speech in theater class seems to stem from social isolation and disinterest in hobbies shown on the latency stage. The client was a victim of sexual abuse and past exposure to domestic violence, which may have implications for her present mood status.

Client History/Information

Medical History

The client wears glasses, is up-to-date on her vaccinations, and reports no medical issues. She is generally healthy, except for episodes of weight/appetite change.

Mental Health History

The client has no history of psychiatric hospitalizations, suicidal/homicidal ideations or self-harm. However, she was exposed to trauma related to domestic violence and sexual abuse at age six, and as a result, she spent a year in foster care.

Developmental History

All developmental milestones were attained at the expected time. However, in middle school, the client began isolating herself from peers and family members. She also had no interests or hobbies at this stage. In high school, she began experiencing anxiety attacks when stressed. She prefers to communicate in English/Spanish.

Family History

There is a substance (alcohol) abuse history in the family. The mother’s alcohol problem seems to be related to domestic violence and the father’s deportation. She stays with her four siblings, bio-mother, and stepfather.

Education

The client is currently in 12th grade at the Magnet School in LA. She is able to follow directions and her grades are good. Thus, she requires no referral for academic or vocational needs. She has no history of behavioral problems at school. She started her education at Russel school before joining Charles Drew School for her middle school. She volunteers at the school library and hopes to pursue a medical profession.

Presenting Problem

The client presents with repetitive prior episodes of heavy breathing and impaired speech whenever performing in a theater class. She further reports recurrent symptoms (seven times a week) of anxiety, sadness, insomnia, and distraction/loss of focus as well as the inability to communicate feelings, poor social skills, and isolating herself from family and friends. She has been withdrawn since age 7-11 years. However, her symptoms grew worse from age 12 onwards with anxiety attack exacerbations related to stress.

Problem List/Strengths

The strengths that can be identified in the client include she is a good listener, a helper, makes eye contact, and displays friendly/approachable demeanor. She is also independent, well groomed, a high performer, and can differentiate between right and wrong. She describes her mother/family as her support system. She expresses excitement and willingness to cooperate with the therapist.

The problems/issues that are the target for therapy from the case include:

Problems with socializing with family and friends;
Difficulty sleeping well due to anxiety;
Lack of hobbies or interests;
Anxiety attacks when stressed;
Lack of expected activity level for a female of her age;
Excessive fears and worries over the past;
Inability to express personal feelings.

Lumping of Problem Factors

Lumping entails combining separate items on the problem list into a single problem (Lambert, 2013). For the client, lumping would produce the following integrated problems for therapy.

Anxiety attacks and inability to focus;
Maladaptive socializing behavior, excessive fears over the past, and dysfunctional self expression related to sexual abuse history and domestic violence exposure;
Lack of expected activity level and involvement in hobbies and interests;
Insomnia and lack of focus from anxiety.

Splitting of Problem Factors

Conditioned anxiety to stressful social situations (social skills);
Recurrent anxiety attacks due to sexual abuse/domestic violence history (trauma);
Lack to focus/distraction (stress);
Maladaptive socializing behavior;
Lack of close friendships/relationships;
Difficulty sleeping well due to stress;
Maladaptive social functioning characterized by lack of hobbies or interests.

Target Problem

This 18-year-old female displays depression/anxiety indicated by symptoms such as worry/fears over her past, insomnia, conditioned anxiety to stressful situations (theater performance), lack of friendships, maladaptive social expression, etc. Therefore, the target problem includes:

Conditioned anxiety to stressful social situations

Goal Statement

The client will acquire social skills and engage in social interactions by speaking to three times a week and taking part in extracurricular activities to improve self-esteem. The client will identify triggers for her anxiety and use coping strategies to reduce anxiety.

Objectives/Steps to Goal Achievement

Speak clearly and concisely to a peer audience three times a week;
Establish friendships with two age mates;
Spend three hours exercising with friends weekly;
Increase understanding of anxiety feelings through exposure to five triggers – theater performances;
Learn to verbalize her feelings without developing anxious feelings/attacks;
Identify three ways to cope with anxiety, worrying, and fear;
Utilize meditation and relaxation techniques in all social interactions.

Treatment Plan

The client’s symptoms fit the criteria for social anxiety disorder, which manifests as fear and anxiety attacks in stressful social environments (Kroenke, 2012). She can benefit from CBT combined with relaxation methods to her manage recent anxiety attacks manifested as impaired speech and heavy breathing during theater classes. Cognitive appraisals of the trigger factors and evaluation of client reactions to stressful social situations will help identify maladaptive behavior.

According to Kroenke (2012), the cognitive appraisals should involve a fear hierarchy and progressive exposures to anxiety triggers or obsessions. The sessions will also involve asking informational questions to understand the severity of the problem and use of emphatic listening to monitor her response to the intervention and progress (Jongsma, Peterson, McInnis, & Berghuis, 2014). During this process, individual therapy offered two times a week is considered adequate.

Further, the anxiety symptoms will be addressed through relaxation therapy. Progressive muscle relaxation (PMR) technique and diaphragmatic breathing (DB) exercises will allow the client to manage physiological arousals during stressful situations. PMR helps reduce tension building up in the muscles, while DB can control insomnia, anxious feelings, and heavy breathing (Gillies, Taylor, Gray, O’Brien, & D’Abrew, 2012). The client will also receive a psycho-educational therapy to develop abilities vital for healthy social interactions. The focus will be on communication, decision-making, peer relationships, and self-management (Gillies et al., 2012). The client will learn new social skills by listening to others and through training on self-assertiveness and expression of positive/unpleasant feelings.

In addition, administering Beck’s Depression Inventory will be necessary to identify depressive symptoms in the client (de Arellano et al., 2014). The client’s anxiety may a direct result of domestic violence exposure and childhood sexual abuse. Her anxiety and impaired social functioning may be a manifestation of benign depression. Therefore, measuring baseline depressive symptoms may be useful in developing a comprehensive treatment for a full recovery. Because of the client’s withdrawn nature, referral to peer support group or class may be beneficial. This approach will allow the client to learn a hobby or develop new interests, overcome her shyness, and learn to develop positive peer relationships.

The client’s anxiety manifests in social situations – theater class. Peer support systems will allow the client to interact socially with friends and reduce her fears/worries. She will also learn to participate in social performances, develop critical social skills for effective relationships, and balance between solitude and social interactions (Jensen, 2014). Providing the client with educational materials on anxious feelings and triggers will help develop a deeper understanding of social phobia.

Further, cognitive restructuring through self-talk will be used to question the client’s past anxiety-causing factors, i.e., domestic violence and childhood sexual abuse. In this way, the trigger factors will be replaced with more positive thought patterns. Pharmacotherapy for anxiety will also be considered to lower her recurrent anxious feelings and create effective coping skills.

Evaluation Plan

The evaluation of the client’s progress will occur at the end of the first month of therapy followed by a re-evaluation after two months. The evaluation will measure the severity and frequency of the symptoms – anxiety attacks, insomnia, fears, and worries – as well as the coping skills acquired. Effective social skills, assertiveness, understanding of the trigger factors, peer relationships, and relaxation during stressful situations will indicate progress.

References

de Arellano, M., Lyman, D., Jobe-Shields, L., Lisa, P., Dougherty, R., Daniels, A.,…Delphin-Rittmon, M. (2014). Trauma-focused cognitive behavioral therapy: Assessing the evidence. Psychiatric services, 65(5), 591-602. Web.

Gillies, D., Taylor, F., Gray, C., O’Brien, L., & D’Abrew, N. (2012). Psychological therapies for the treatment of post-traumatic stress disorder in children and adolescents. Cochrane Database of Systematic Reviews, 12(1), 154-162. Web.

Jensen, T., Holt, T., Ormhaug, S., Egeland, K., Granly, L., Hoaas, L.,…Wentzel-Larsen, T. (2014). A randomized effectiveness study comparing trauma-focused cognitive behavioral therapy with therapy as usual for youth. Journal of Clinical Child & Adolescent Psychology, 43(3), 356-369. Web.

Jongsma, A., Peterson, L., McInnis, W., & Berghuis, D. (2014). The adolescent psychotherapy progress: Notes planner. New York, NY: John Wiley & Sons.

Kroenke, K. (2012). The importance of detecting anxiety in primary care. Journal of Primary Health Care, 4(1), 4-16. Web.

Lambert, M. (2013). Bergin and Garfield’s handbook of psychotherapy and behavior change. New York, NY: John Wiley & Sons.

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