For Ann Harris

CASE STUDY TREATMENT PLAN

BIOPSYCHOSOCIAL ASSESSMENT FORM

Cultural Background:

Name:

Unknown

Age:

37

Gender:

male

Race:

The client is caucasian

Ethnicity:

Caucasian American

Religious Issues:

The client report being a christian and attends church with his wife.

Sexual Orientation:

The client reports that he is heterosexual and is attracted to the female gender. H also reports

not having sex with his wife since the issue of infidelity.

Relevant Cultural Norms:

The client believes in the value of family as an important component to ensuring positive

development among individuals and conveyed that looks up to his parents because they have

stayed married for a long period of time. The client has a sister who has a broken marriage

because of the infidelity from her husband.

Other Relevant Cultural Norms:

The client iso the believe that Family involves faithfulness and Christianity is what holds family

together.

Current Symptoms:

Reason for Visit Listed as DSM-5 Symptoms:

The client reports issues of infidelity from his wife when as he presented to counseling. He

reports having difficulty in several domains of his life such as: his lost of appetite, lack of

concentration due to his inability to stop thinking about his wife's unfaithfulness, a sense of

hopelessness due to feeling that his world has been rocked, constant anxiety due to fear that

his wife is still having any affair with the guy and hidding it from him.

The client also reports lack of trust in his wife and fear he may not be able to trust her again.

He reports that he had turned to alcohol as a means of coping with his current situation and is

worried about losing his family. The client further reports that he is having headache, crying,

continuously, having nightmares and vision of his wife having sex with the guy which is

causing him distraction from work. Client appear to feel guilty due to distancing himself from

his wife for the past few years which he blames on work related stress.

Symptoms appeared more consistent with Major Depressive Disorder (F32.0).

The client meets the following criteria

A- five or more of the following symptoms have been present for at least two weeks

1. Depressed mood most of the day or nearly every day (APA, 2013).

2. Tearfulness hopelessness, sad, empty

5. Agitation

7. Guilt

8. lack of concentration

B. The symptoms cause clinically significant distress or impairment in social, occupational, or

other important areas of function such as his inability to function at work and other functions

(APA, 2013).

C. The episode is not attributable to a psychological effects of a substance or to another

medical condition (APA, 2013).

D. The occurrence of the major depressive disorder is not better explained by schizoaffective

disorder, schizophrenia, schizophreniform disorder, delusional disorder or other specified and

unspecified schizophrenia spectrum and other psychotic disorder (APA, 2013).

E. There has never been a main or hypomanic episode (American Psychiatric Association,

2013).

Reference

American Psychiatric Association (2013). Diagnostic And Statistical Manual Of Mental

Disorders DSM-5.

Family Background:

Family of Origin Issues:

Two parents in a stable marital relationship.

Family Environment in Childhood/Adolescence:

The client reports growing up in a stable family with no issue of unfaithfulness from both

parents however, he conveyed that his sister has experienced unfaithfulness that lead to a

divorce. The client appears to have had a stable up bringing with having just few friends.

Infidelity is believed to be one of the most common presenting issue for marriage and family

therapists. It is devastating to marriages and is believed to be one of the most serious issue to

be treated. The causes of unfaithfulness are difficult and different and can take place in a

happy or unhappy marriage. It furthered asserted that it becomes hard or sometimes

impossible for the faith partner to comprehend the reason why his/her partner is engaged in an

extra marital affairs. While most unfaithful in marriages happens as a result of dissatisfaction, it

is believed unfaithfulness also happen as a result of personal dissatisfaction and low self-

esteem it can be as a result of addiction to sex, love and romance ( Glass,1998).

Reference

Glass, S. (1998, August). Shattered vows. Psychology Today, pp. 34ff.

Dissatisfaction, low self-esteem and addiction to sex, love and romance may lead to infidelity

in marriage.

Marital/Partnership History:

Client and his wife has been married for about ten years now however, client reports that in

the pas few years he had distance himself from his wife due to work related stress.

Children Issues/Concerns:

Client is concern about the future of his two children if he were to file for a divorce and is

concern about his finances also.

Social/Community Background:

Connections to Community Support (Church, AA Group):

The client and his family attends a church in the community at least two times a month. The

client support system includes his Pastor, Sister, friends and religious faith.

Support Network:

Client support network includes his family, friends and Church.

Hobbies or Volunteer Activities:

Client enjoys fishing, hunting, and gun collecting.

Personal Background:

Developmental History:

The client appears to have a normal birth and reports no deformity or disability. The client also

reports that he was brought up in a stable home where both parents are happily married.

Disability:

No known Disability

Educational:

The client holds a bachelor degree in mechanical engineering.

Military:

No Military background.

History of Trauma:

No history of trauma.

Employment Status:

The client works as mechanical engineer with a local firm.

Legal Status:

The client is an adult who is a Caucasian American.

Financial Status:

The client reports that he is financially stable.

Other Circumstances, Such as Transportation, Housing, et cetera:

The client reports that he has live in his home for at least10 years.

Medical Background:

Medical History:

No past or present history of any medication problems.

Use of Medication:

The client is not using any medications.

Current Medications:

The client is not on medications.

Substance Use Background:

The client report previous use of alcohol and drugs (Marijuana) while in college but conveyed

that he discontinued the use of marijuana because he did not like it but maintained social

drinking at least one or two drinks a week however, he reported that due to his present crisis,

he currently drinks two to three vodka and tonic nightly which is an unusual amount.

The abuse of alcohol and dependence often come from the use of alcohol as a coping

mechanism from individuals however, using alcohol as a catch-way to balance out emotional

experience or become less present has some real outcomes (Glass, 1998). A coping

technique is believed to be something that helps an individual deal with situation that are

difficult to handle. While all coping techniques provide an individual with a real or apprehended

outcome, some coping techniques have more negative outcomes connected with them and

unfortunately, alcohol is one of those coping techniques that temporarily benefit an individual

however, is overweighted by a long-lasting negative effects on health and relationship, poor

decision-making and increased dependency (Glass, 1998).

Reference

Glass, S. (1998). Shattered Vows. American Association for Marriage and Family Therapy.

Mental Health Background:

Previous Psychological Issues (Depression, Anxiety, et cetera):

No previous psychological issues reported.

Previous Counseling, Hospitalizations:

None reported

Family Fistory of Mental/Psychological Issues:

None reported

Ethical/Legal Background:

Client is a heterosexual caucasian male who is not from a minority group therefore there is

limited multicultural issue. If this client were to be counsel by a therapist from a minority group

as the writer is, there will be a need for such therapist to understand the dominant culture and

not impose upon the client his/her own biases as stated in the ACA code of ethics B.1.a of the

American Counseling Association.

"Counselors maintain awareness and sensitivity regarding cultural meanings of confidentiality

and privacy. Counselors respect differing views toward disclosure of information. Counselors

hold ongoing discussions with client as to how, when and with whom information is to be

shared" (ACA, 2015).

Reference

American Counseling Association (2015). ACA code of Ethics: Alexandria, VA: Author.

Consultations/Referrals Needed:

Client and wife will be referred for counseling to the licensed Marriage Therapist to enable him

resolve current situation with his wife.

Couples who experiences infidelity is refer for counseling with a therapist who help them

understands the purpose of treatment by externalizing the options. After an infidelity has taken

place, couple who want to rebuild their relationship need to resolve any conflict about staying

in the relationship, or work toward separating in a positive manner. Glass stated that one

partner may want to reconcile while the other is still ambivalent or has decided to leave

because most often the injured partner feel angry while on the other hand the involved partner

struggles with feelings of guilt and shame (Glass, 1998).

Reference

Glass, S. (1998). Shattered Vows. American Association for Marriage and Family Therapy.

Strategies to Address Presenting Problems:

1:

Client has been deeply affected by his wife's unfaithfulness and is struggling to maintain his

basic functions and perform task at work. In other for the client to be restore to previous

function the client needs to explore how his wife action has affected his daily functioning both

at home and worker and seek appropriate therapy to resolve the present issue.

Glass (1998) asserted in his article that treatment to recovery of infidelity can be confusing and

hard for couples and the way in which couples recovery or uncouple after an infidelity has

taken place depends on different components that includes each partner's commitment to the

healing process of the relationship, cultural values and norms, and the effect on the children

should they end the relationship.

Reference

Glass, S. (1998). Shattered Vows. American Association for Marriage and Family Therapy.

2:

Client has expressed serious distrust in his wife and struggles to believe her explanation of not

having an affair with the guy anymore and her failure to give him the password to her social

media is further compounding the pain he feels for her unfaithful fulness and his distrust of her.

For both client and his wife to resolve their issue, a platform must be establish for the couple to

have free communication with each other to enable them resolve the current situation and be

transparent with each other.

Glass asserted in his article that establishing safety and addressing painful emotions and

traumatic symptoms are essential in the initial stage as there therapist needs to manage and

stabilize the emotional reaction to the infidelity and obtain a clear understanding of the

situations surrounding the affair (1998). Being able to explain or tell the story of the affair will

allow the couples move toward forgiveness (Glass, 1998).

Reference

Glass, S. (1998). Shattered Vows. American Association for Marriage and Family Therapy.

Sexuality Research to Support Strategies:

1:

Hyde, J. S., & DeLamater, J. D. (2017). Understanding human sexuality (13th ed.). New York,

NY: McGraw-Hill.

Lehmiller, Justin J. (01/01/2017). "Controversial issues in human sexuality research: The state

of the science". European psychologist (1016-9040), 22 (1), p. 1.

Parker, Richard (04/01/2009). "Sexuality, culture and society: shifting paradigms in sexuality

research". Culture, health & sexuality (1369-1058), 11 (3), p. 251.

2:

Mustanski, B. (2011). Ethical and regulatory issues with conducting sexuality research with

LGBT adolescents: A call to action for a scientifically informed approach. Archives of Sexual

Behavior, 40(4), 673-86. doi:http://dx.doi.org.library.capella.edu/10.1007/s10508-011-9745-

Sakaluk, John K. (01/01/2017). "A Methodological Review of Exploratory Factor Analysis in

Sexuality Research: Used Practices, Best Practices, and Data Analysis Resources". The

Journal of sex research (0022-4499), 54 (1), p. 1.

Zou, Z., Song, H., Zhang, Y., & Zhang, X. (2016). Romantic love vs. drug addiction may

inspire a new treatment for addiction. Frontiers in Psychology, 7, 1436.

TREATMENT PLAN

Instruments/Screens to Facilitate Diagnosis

Instruments and Screens:

N/A

DSM-5 Diagnosis

DSM-5 Diagnosis:

N/A

Differential Diagnosis

Differential Diagnosis:

N/A

Ethical/Legal Consideration of the Diagnosis

Ethical/Legal Consideration of the Diagnosis:

N/A

Short-Term Goals to Address the Diagnosis

Short-Term Goals to Address the Diagnosis:

N/A

Long-Term Goals to Address the Diagnosis

Long-Term Goals to Address the Diagnosis:

N/A

Strategies to Promote Optimal Sexual Functioning

1:

N/A

2:

N/A

3:

N/A

Evidence-Based Treatment Interventions to Support Strategies

1:

N/A

2:

N/A

3:

N/A

Treatment Plan Interventions Annotated Bibliography

Based on your diagnostic impression, develop an annotated bibliography of resources describing suggested interventions for the client. You should describe each source in your own words, not simply use the provided abstract. You will utilize a minimum of five current articles from peer-reviewed journals in the counseling or related professions from the Capella Library. Cite and reference the resources using APA 6th edition guidelines. You may utilize your textbook, but it does not count as one of your five scholarly resources. You are also encouraged to utilize more than five resources if they aid in developing a comprehensive treatment plan.

N/A