Nicohwilliam

2

Clinical Interview

This is a self-conducted assessment and evaluation where I will be conducting a self-clinical interview to familiarize myself with the process and what it entails. It will also make it possible to understand how a section of the assessment aligns to offer information relating to a patient and can utilize all this to tailor a treatment protocol.

a) Demographic Background

Name: Mrs. Client

DOB:

Age: 49

Ethnicity: Black

Address:

Sex: Female

Marital Status: Married

Phone:

E-mail:

Name of Interviewer: (self-conducted)

Date of Interview: 03/12/2022

b) Presenting Problem or Reason for Referral

Mrs. Client is a 49-year-old female of sound mind healthy living lifestyle choices and has opted to take the initiative to self-refer for counseling services. The request is accepted as the individual has associated the core reason for admitting to needing assistance due to a troubling case of anxiety alongside insomniac behavior. The client pointed out that these conditions result from the grappling fear due to the onset of the global COVID-19 pandemic. The patient admits to struggling with the pandemic's risks to those prone to the virus.

The fear of being admitted to a medical facility due to contracting the virus again troubles the patient as she believes this will have a traumatic impact on her family. The condition does not seem to have an identified cure further presents itself as a life-threatening medical condition. Thus, the thought of something happening to her has caused the client to experience an extensive and elevated case of fear, especially since she has already undergone the virus before, which shows the presence of trauma resulting from her COVID experience (Silver, 2020). Mrs. Client has been able to communicate efficiently and has stated that the cases of anxiety and insomnia developed since the first case of the global lockdown. Covid has made it difficult to relate with others without thinking of what could happen if she gets infected after the client's prompt; further assessments will help identify a diagnosis and treatment plan.

c) Family Background

Mrs. Client has identified she was from a Christian home in Texas with an upbringing that has allowed her to experience the love and care of both parents. Her parents had steady lines of work which ensured that they were well cared for as the mother was a Registered nurse and the father an offshore welder. However, both parents passed away in 2010 and 2017, respectively, due to lung cancer, which left her and her sister, aged 39, and brother, aged 37, orphans. Nonetheless, they all have stable and sustainable lives thanks to their loving parents, who had been together for 37 years. Her parent’s loving marriage has made it possible for her to find similar happiness in her marriage. The client states this and identifies their union as fruitful and enjoyable, especially since they have three children, a 30-year-old daughter, a 28-year-old son, and a 26-year-old daughter. They also have four beautiful grandchildren, an 8-year-old granddaughter, a 6-year-old granddaughter, a 5-year-old grandson, and a 1-month-old granddaughter.

d) Significant Medical/Counseling History

Mrs. Client states that she contracted the COVID virus three months ago, which caused her a lot of suffering from a persistent cough that tormented her and forced her to experience fatigue, resulting in her developing a high case of anxiety. She also points out that she was scared to sleep because she would not wake up the following day. She stated that she did have cases of immense chest pains that made her feel as if her heart would suddenly halt. She was under antibiotics and a mandatory inhaler as she also did have instances where she found it difficult to breathe. She recovered from the condition. However, this did not heal her mental scars and insomniac habits. According to her statement, she is somewhat scared that she may contract the virus again, and the symptoms may be worse. These thoughts have made her anxiety and insomnia remain persistent. She also does say that she has taken the initiative to see her primary doctor but not seek counseling for these conditions.

e) Substance Use and Abuse

Mrs. Client states that she does not smoke nor has used drugs aside from any medically prescribed medications that she takes. However, she does identify herself as taking a glass of wine occasionally.

f) Educational and Vocational History

Mrs. Client attended school in Texas and was able to excel exceptionally in all subjects. She attained a bachelor's degree in Interdisciplinary Studies and is currently working on her Master's degree in Mental Health Counseling. Regarding her personal experiences, she had listed herself as having owned and operated a childcare facility for thirteen years before deciding that she wanted a career change in 2013-2020. Consequently, she started teaching preschool, special education/inclusion, and second grade. However, she decided to take a break from teaching to homeschool her special needs child during the Covid pandemic lockdown. This move influenced her to strive to obtain her Master's degree in Mental Health Counseling, in which she has only six classes left, then on to practicum.

g) Other Pertinent Information

Mrs. Client did not list any information on this section.

Mental Status Examination

Mrs. Client is a 49-year-old Master's student who has opted to herself to the institution to seek counseling services. She has noted that she is undergoing conditions that can only be resolved by assisting individual counseling and therapy services instead of avoiding the issue.

When first introduced, Mrs. Client did appear to be healthy and was well dressed in a respectable manner, showcasing a high sense of coordination and organization. She also seemed to be an individual who has an eye for fashion and a perfect understanding of dressing. Also, she did not overdo it with her outfit, which had a less is more presentation. In the interview, Mrs. Client was distant at first, indicating that she was finding it difficult to admit that she, too, had faults and weaknesses. However, after sharing with her my personal experiences, she warmed up to the interview, and she was open to seeking assistance. Her corporation was reliable as it made it possible to conduct the assessment with utmost ease.

Mrs. Client’s speech was gentle and soft. However, a slight pitch fluctuation could be identified when she was narrating her past events, and this did also appear to be troubling to her as the thoughts ended up hindering her thought process. Her feelings are content due to her experiences with the COVID-19 pandemic that instilled fear in her mindset. She ended up admitting that her train of thoughts has constantly been rather negative off late, and this is very troubling for her. This was not uncommon, as many people feared losing their lives due to the virus, especially since it was highly probable to be infected more than once (Baker, Peckham & Seixas, 2020).

Mrs. Client’s effect was rather sad and mellow and seemed only to get lower as the interview progressed as she was getting even more in touch with her inner feelings and dark thoughts. When asked to elaborate more on her moods, she identified her attitudes as relatively low and somewhat depressing. She could not get the idea of dying out of her mind even when she could survive her first encounter with the virus, considering that it is claiming millions of lives across the world. Nonetheless, she doesn’t have thoughts about self-harming herself but she identifies that she was undergoing a perceptual problem that was hindering her day-to-day life. She did admit that she had a lot on her mind and was not able to function in a normal and her usual manner and was not sure she could be able to do so if she was not assisted. Thus, her insight and judgement have been identified as cognitive and positive.

The results of Mrs. Client’s cognitive functions proved that she is fully oriented and could register four, even more, items and recall the things in an average of two and a half minutes. She was also able to remember the interviewer's name. Still, She did find it difficult to remember her exam schedule or any event that took place before the virus infected her. So, her long-term memory can be considered as being impaired. On the other hand, she could not maintain a consistent attention span, and it was even worse when she was in a backward position. Still, she showcased a strong abstraction level that was compatible with her knowledge base, proving that she is well educated. This has not changed as her intelligence levels were presented after taking part in the serial subtractions and a bold enumeration of similarities and differences.

References

Baker, M. G., Peckham, T. K., & Seixas, N. S. (2020). Estimating the burden of United States workers exposed to infection or disease: a key factor in containing the risk of COVID-19 infection. PloS one, 15(4), e0232452. https://doi.org/10.1371/journal.pone.0232452

Silver, R. C. (2020). Surviving the trauma of COVID-19. Science, 369(6499), 11-11. https://doi.org/10.1126/science.abd5396