Psychotherapy with individual

Student Name:

Part 1: Comprehensive Client Family Assessment

Demographic Information

Name Brenda S.

DOB: 4/20/1985

Age: 35

Gender: Female

Race: African American

Facility: Lin Crisis center

City: Indianapolis

State: Indiana

Presenting Problem

Constant and excessive worrying, substance use and social withdrawal

History of Present Illness

Brenda migrated from the Uganda to the United states with her family many years ago. She left a highly paying to the US with the hope of being gainfully employed in the US. Brenda is anxious and depressed because she been dealing with financial instability and dealing with divorce proceedings. According to Brenda, her Ex-husband her has not been supportive financially as she also has not been able to secure a well-paying job to provide for her needs and support her family. As a result of this, Brenda was diagnosed with depression five years ago. Brenda has been constantly anxious of what the future holds. Brenda smokes Marijuana and drinks alcohol to deal with her anxiety as a coping mechanism. According to American addiction centers (2020), the use of Marijuana and alcohol are common are the young adults.

Past Psychiatric History

Patient was told that her diagnosis is Major depressive disorder. She has been hospitalized 2 different times. She was hospitalized one time in 2015 due to suicidal ideation with a plan to overdose of alcohol. Patient was also hospitalized in 2018 for overwhelming depression and anxiety. She is also been seeking to get admitted to treatment center for her addictions because she feels living with her husband is a trigger to her depression and anxiety as well as her substance abuse. Brenda started from 5omg of Zoloft daily in 2015 which has been gradually increased and she currently on 300mg per day. Brenda stated that she sees her psychiatry every month from medication refill and for her outpatient care.

Medical History

She has previously been diagnosed with hypothyroidism and she takes Levothyroxine 75 mcg daily. She also takes Zoloft 300mg daily for depression which Brenda reported that has been helpful with her symptoms but not has “really eradicated” it.

Substance Use History

The patient has a history of substance abuse; she has been addicted to alcohol since she was 18 years and started using Marijuana approximately about 3 years.

Developmental History

Brenda has no developmental history.

Family Psychiatric History

Brenda explained that she has family history of Bipolar disorder staring from her great grandfather. Her father was also diagnosed with bipolar disorder and he is currently on medications. She also reported that one of her uncles dealt with addiction problem. She denies any family history of mental illness from her maternal side.

Psychosocial History

Brenda lives with her family currently with her daughter which is like a family house. Her brother and his wife also live in the same house. Brenda reported that her addictions and depression has made her withdrawn from friends and this is also affecting the relationship with her daughter. She prefers to stay indoors. She finds it difficult to socialize. She feels she has failed because all her friends are married to supportive husbands with booming careers.

History of Abuse/Trauma

No history of trauma or abuse. Brenda also denies any history of abuse.

Review of Systems

General: Brenda is a well-developed African American female who is cooperative and alert.

Skin, Hair, Nails: they all appear normal

HEENT:  Brenda states that she has no loss of hearing or vision. She does not suffer from nasal congestion, no cases of sneezing, postnasal drainage, or rhinorrhea. The nasal mucosa is moist and pink. The tonsils are not enlarged. She denies headache.

Cardiovascular : Brenda's BP is 128/72. She experiences a regular heartbeat of 86beats per minute

Pulmonary: Brenda denies any respiratory issues. Thorax symmetrical, chest moving with respiration. Normal air entry on auscultation

Gastrointestinal: Non-tender and non-distended with active normal bowel sounds were heard during auscultation.

Musculoskeletal: No discomfort noted, such as joint pain. No limitation in both active and passive movement.

Genital/ Rectal: Denies rectal or genital discharge. 

Neurological: Brenda is an oriented and awake individual. 

Hematology: Brenda denies any hematological process. She denies any diagnosis of hematological problem.

Endocrine: Brenda was diagnosed with hypothyroidism 5 years ago and she takes Levothyroxine 75mcg for that.

Skin: No cases of edema or ecchymosis. The turgor of the skin is normal, and no cases of jaundice or cyanosis are noted.

Physical Assessment

Brenda is alert and appears fit for her age. As mentioned above, no abnormality in any part of her body that was identified during physical examination.

Mental Status Exam

Brenda is coherent during the exam. She is well-groomed, observed good hygiene, and sits upright on the couch. She observes constant eye contact, and no abnormal movement is noted. Her speech is fluent and observes appropriate volume, quantity, latency, and rate. Her effect is euthymic. She reported that she is anxious. She said her anxiety is 6/10. Her thought process is goal-directed, and she understands that she must deal with her addiction and be clean so she can have an healthy relationship with her son but she us depressed because she doesn’t know how to go about it. No cases of homicidal ideation, hallucinations, and delusions are noted. The patient is alert and fully attentive in that she can name the months of the year backward. She experiences 3/3 delayed recall. Knowledge fund fits the educational level. The executive functions are intact, while the judgments made are fair.

Differential Diagnosis

Brenda was diagnosed with Major depressive disorder and substance abuse. According to Paris (2018), depression is a mental illness frequently co-occurring with substance abuse.

Case Formulation

Brenda mental instability possibly arise from her infertility issue and her husband’s attitude towards her. Also, her inability to provide for her immediate needs because of her inability to secure a well-paying job because her parents look up to her as well.

Treatment Plan

Goal 1

Brenda will successfully secure a treatment center to care for her addictions.

Objective

Brenda follow the steps necessary steps require to be admitted to Albany care for her addiction problems.

Intervention

Motivational Interviewing will be adopted to enable Brenda to come to terms with her situation, the consequences of her actions and that she needs help. Motivational interviewing highlights the dissonance between unhealthy behaviors and he person’s values and goals (Wheeler,2014).

Goal 2

Brenda will effectively manage her anxiety, social withdrawal and develop a health relationship with her daughter.

Objective

Brenda will continue to comply with the use of her The use of antidepressant medication and effectively adopt positive coping skill.

Intervention

Cognitive behavioral therapy will be introduced to Brenda as well as antidepressant (Zoloft).

Part 2: Family Genogram

Brenda ‘s daughter is 11 years old

Brenda’s grandfather, and father were diagnosed with Bipolar

Brenda’s uncle was also dealt with substance abuse.

Brenda is separated from her husband and she is dealing with the divorce proceedings

References

American addiction Centre, (2020). Alcohol and drug abuse among young adult. Retrieved from https://americanaddictioncenters.org/rehab-guide/addiction-statistics/young-adults.

Paris, J. (2018). Differential diagnosis of Major depressive disorder. Psychiatric Clinics of North America, 41(4), 575-582.

Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

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