Biopsychosocial Assessment: Part 2

Refer back to the movie you selected and watched or the case study you read during Topic 1. Continue working on the biopsychosocial assessment submitted in Topic 2 and complete Part 2 of the biopsychosoical assessment. Make any suggested changes from your instructor on part 1.While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.You are required to submit this assignment to Turnitin. Refer to the directions in the Student Success Center.APA site the case study


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Psychosocial Assessment
Name: David
Age: 49
Date: 3/28/18
____ Part 1 (Topic 2)
____ Part 2 (Topic 3)
DOB: 3/28/1969
Start Time: 1pm End Time: 3pm
Identifying Information:
Client is a 49 male who has been married for twenty one years and has two grown children. David
has been a metallurgical engineer 20 years but reports that no longer enjoys going to work. Client
reports being irritable, having low energy, feeling blue and reduced appetite.
Presenting Problem:
Client reports being irritable, having low energy, feeling blue and reduced appetite. David also
report trouble sleeping and reduced interest in work/social activities things that he used to enjoy.
Life Stressors:
David reports no specific stressors.
Substance Use/Abuse: Client reports no history of substance abuse. But reports consuming 2-3
beers a night.
Addictions (i.e., gambling, pornography, video gaming)
Client reports no history of substance abuse. Client states when younger he used to drink more
but now drinks two or three beers per night. Client reports drinking more at night because he has
not been sleeping well.
Medical/Mental Health Hx/Hospitalizations:
Client reported no hospitalizations or medications. But states over the last two months he has had
increasing pain in his back and neck.
Client reports no abuse or trauma.
Social Relationships:
Client reports his relationship with his wife as typical.” He reports that they spend little time
together. His oldest son is concerned because his is not himself and thinks he should see a doctor.
Family Information:
Client has two grown children and has been married to his high school sweetheart for twenty on
years. David’s sister Lisa has suffered from depression for a decade and current receives
treatment from both a psychiatrist and a counselor.
Client reports no information regarding his spirituality
Psychosocial Assessment
____ Part 1 (Topic 2)
____ Part 2 (Topic 3)
While client did not specifically talk about suicide. He did state sometimes, he feels like life is
hardly worth living.
Client report no homicidal thoughts.
Initial Diagnosis (DSM):
Initial Treatment Goals:
Psychosocial Assessment
____ Part 1 (Topic 2)
____ Part 2 (Topic 3)
Name: _____________________________________________
Date: __________________
PCN-610 Option 2: Case Study
David is a 49-year-old married man with two adult children. He has been married for 21 years.
He has been employed as a metallurgical engineer in a local steel mill for 20 years. David noted
he use to enjoyment going to work, but now, he states some days he would rather just stay home.
David married his high school sweetheart. He describes their relationship as “typical.” They eat
meals and attend family gatherings together but do little else as a couple. David use to spend his
spare time reading, playing golf, and watching TV. For the last 6 months, David has felt blue and
his appetite has decreased. He stated he doesn’t have any desire to do any of things he use to
enjoy and would rather spend time alone in his bedroom. David complained of irritability and
low energy. Within the last 2 months, David noted he has experienced more physical pain in his
back and neck area. Because he has not been sleeping well, Robert drinks more at night. He
stated that when he was younger, he use to drink more frequently but now he only drinks two or
three beers per night. Sometimes, he feels like life is hardly worth living. Robert has tried to
“snap himself” out of this sour mood, but nothing seems to work. David oldest son stated he is
concerned his father may need to go see a doctor, because his father appears to be acting usual.
David stated that his sister used to have similar problems. He is resistant to going to see a doctor
and believes his mood will eventually improve.
David’s sister Lisa has struggled with depression for over 10 years. She is currently seeing a
psychiatrist and a counselor. In the past, Lisa reported an increase in emotional and physical
fatigue, low mood, increased weight gain, and disrupted sleep. Lisa has a negative outlook and
states that when things are looking up, something always goes terribly wrong.
© 2017. Grand Canyon University. All Rights Reserved.
Thinking Skills
Diagnosis, Case Conceptualization, and
Treatment Planning
Introducing Chapter 1: Reader Highlights and Learning Goals
Individuals who choose careers as mental health professionals—including counselors,
psychotherapists, social workers, counseling and clinical psychologists, psychiatrists, and
those in similar career paths—often enter the counseling field because earlier in their
lives, in their families of origin, in their schools and neighborhoods, and among their
friends and peers, they found themselves in the role of good listener, intelligent analyzer,
or effective problem-solver when those around them encountered life’s difficulties
(Neukrug & Schwitzer, 2006). In other words, many people already are “natural helpers”
when they decide to become professionals (Neukrug & Schwitzer, 2006, p. 5). As natural
helpers for friends and family, they have relied on their intuition, personal opinions, and
natural inclinations as they spontaneously listen, support, analyze, encourage, push, or
make hopeful suggestions.
However, the demands of professional counseling work go beyond the qualities
needed by natural helpers. Compared with the spontaneous nature of natural helping,
professional counseling requires us to rely on purposeful skills and to systematically
guide the counseling relationship through a sequence of organized stages, intentionally
Copyright © 2015 by SAGE Publications, Inc.
The Use of Clinical Thinking Skills
in Counseling and Psychotherapy
The transition from natural helper to professional counselor can be a daunting one. We
become aware that a client’s decision to seek counseling is an important “investment in
time, money, and energy” (Vaughn, 1997, p. 181). We realize that when clients choose
us as professional consultants for their therapeutic “journey,” it takes substantial determination
for them to stay the course with us “when the going gets tough” (Vaughn,
p. 181). We learn that counselors are responsible for helping the individual understand
his or her own view of himself or herself and his or her life, discover new choices,
create a new view of himself or herself, and bring about his or her own changes
(Weinberg, 1996). We recognize that when counseling succeeds, our clients should be
better able to form their own insights and apply the benefits of psychotherapy to new
life situations when they arise (Vaughn, 2007). To accomplish these tasks, we make
aiming to achieve specific client outcome goals (Neukrug & Schwitzer, 2006). That is,
professional counseling requires us to become competent at using clinical thinking
skills “to facilitate [the] provision of mental health treatment” (Seligman, 1996, p. 23).
These skills include diagnosis, case conceptualization, and treatment planning. The
goal of our textbook is to help you understand and become competent at these three
important clinical thinking skills. The text explores each skill in detail. In Chapter 1, we
introduce all of the key concepts and then in Chapters 2, 3, and 4, we discuss them
more fully.
In the current chapter, first we discuss the role that clinical thinking skills play in
counseling and psychotherapy. Next, we define diagnosis, case conceptualization, and
treatment planning. Following our definitions, we relate these skills to caseload management,
explain how they fit into the stages of the professional counseling process, and
summarize. We then will be ready to explore each skill more fully in the separate chapters
that follow.
At the end of this chapter, you should be able to:
• Discuss the role of clinical thinking skills in counseling and psychotherapy as
they are practiced in today’s professional mental health world
• Define diagnosis, case conceptualization, and treatment planning
• Distinguish among these skills and caseload management
• Summarize the stages of the professional counseling relationship and discuss where
diagnosis, case conceptualization, and treatment planning fit into the process
• Be ready to move on to the three specific chapters that follow, dealing in detail
with diagnosis, case conceptualization, and treatment planning
Copyright © 2015 by SAGE Publications, Inc.
Clinical Thinking Skills ? 15
judgments about our clients, decide what goals seem reasonable and feasible, consider
how we will communicate with our clients, and determine how to implement the
change process (Basch, 1980). Further, we must pay attention to what we know about
empirically supported practice, evidence-based practice, and other best practice information
(Wampold, 2001). Basch (1980) referred to all of this as “listening like a
psychotherapist” (p. 3). It means that a lot of decision-making responsibility rests on
our shoulders.
Correspondingly, to accomplish the shift from natural helper—giving advice at the
dinner table or comforting a coworker who is upset—to counseling professional—
meeting in a therapeutic setting with child, adolescent, young adult, adult, couple,
family, or group clients who are in need—a set of tools is required with which to
describe the client’s functioning, gain an understanding of the person’s situation and
needs, identify goals for change, and decide on the most effective interventions for
reaching these goals. This set of tools is summarized in Figure 1.1. Specifically, diagnosis
is a tool for describing client needs, case conceptualization is a tool for understanding
these needs, and treatment planning is a tool for addressing these needs to
bring about change. When employed by counseling professionals, the treatment plan
follows directly from the case conceptualization, which builds on the diagnostic
impressions. All three of these clinical thinking skills are required competencies for
today’s counseling and psychotherapy professionals (Seligman, 1996, 2004).
Defining Diagnosis
In today’s professional counseling world, diagnosis refers to the use of the
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5;
American Psychiatric Association [APA], 2013) to identify and describe the clinically
significant patterns associated with our clients’ distress, impairment, or risk.
Certainly, there are other mental health diagnostic systems besides the DSM-5. The
World Health Organization’s (WHO) International Classification of Diseases, Tenth
Edition (ICD-10) is an important example. Further, some fields of counseling and
psychotherapy maintain their own systems of diagnostic formulation; for instance,
there are psychoanalytic systems for diagnosing client personality structures
Describing the
client’s concerns
Addressing the
client’s concerns
understanding the
client’s concerns
Leads to Leads to
Figure 1.1 Clinical Thinking Skills
Copyright © 2015 by SAGE Publications, Inc.
(McWilliams, 1994, 1999). However, it is the DSM-5 that is the widely accepted,
official nomenclature for making a mental health diagnosis in today’s clinical practice.
It is used throughout the United States and, increasingly, around the world. The
DSM-5 has been translated into more than 14 languages. As mental health professionals
who work with multiple constituencies and colleagues of various disciplines, mastering
the DSM-5 is a professional survival skill for counselors and psychotherapists in all
settings and contexts.
Specifically, the DSM-5 is a classification system that divides client presentations
into mental disorders based on sets of criteria that are made up of observable features.
In other words, diagnoses of mental disorders in the DSM-5 are criterion-referenced.
This categorical approach stems from the traditional scientific/medical method of
organizing, naming, and communicating information in as objective a fashion as possible.
The job of the counselor is to find the best match between what the clinician
observes the client to be experiencing and the various criteria for the different clinically
significant patterns found in the DSM. This type of diagnosis can help us determine
the primary focus of counseling. For example, a focus on a mood problem might
need different counseling responses than a focus on anxiety complaints, and a focus on
an adjustment problem would be addressed differently than a focus on long-term life
problems like personality disorders.
The DSM-5 provides several hundred separate diagnoses. It includes disorders of
infancy, childhood, adolescence, and adulthood; describes both short-term client concerns,
such as adjustment disorders, and longer-standing problems, such as intellectual
disability and personality disorders; covers a wide range of behavior, from substance
abuse to sleep disorders to bereavement; and pays attention to characteristics of
thought, mood, behavior, and physiology. A fully formulated, start-to-finish DSM
diagnosis requires several different types of information, each of which helps the counselor
to describe what the client is experiencing or presenting. The different types of
information include clinical disorders of children and adults and other conditions that
may be a focus of counseling; medical conditions; psychosocial stressors and environmental
problems encountered by the client; and an assessment of a person’s vulnerabilities
and functioning. Further, the criteria—or requirements—for each clinical
diagnosis derived from the DSM-5 has four parts: (1) client behaviors, thoughts, mood,
and physiological symptoms; (2) the frequency and duration of the person’s concerns;
(3) the severity of the distress or life dysfunction the person encounters as a result of
his or her concerns; and (4) the ruling out of other possible conditions that might
account for the person’s needs. As an illustration, the criteria that must be met for a
diagnosis of Generalized Anxiety Disorder include excessive anxiety, worry, and physical
stress (thought, behavior, mood, and physiological features) present at least 6
months (duration) that are interfering with daily functioning (severity) and are not due
to substance use or a medical problem (ruling out differential diagnoses). In addition,
the system has severity specifiers, course specifiers, and subtypes that are used to
describe individual client variations within a diagnosis.
The primary purpose for making a DSM-5 diagnosis is to describe and communicate
with other professionals who are familiar with the system. Having all mental health
Copyright © 2015 by SAGE Publications, Inc.
Clinical Thinking Skills ? 17
professionals using the same diagnostic system is intended to enhance agreement
among clinicians about the client picture they are seeing and should improve the sharing
of information about client presentations and client needs. By itself, a diagnosis does
not reflect any specific theoretical perspective (such as person-centered counseling or
cognitive-behavioral therapy) or indicate any specific mental health field (professional
counseling, psychology, etc.); rather, the DSM-5 diagnoses are theory-neutral and do
not reflect any one orientation. As a result, using DSM-5 categories and descriptions
allows clinicians to describe client needs and communicate with mental health colleagues
across disciplines—and then later apply their own professional viewpoint and
theoretical approach during case conceptualization and treatment planning.
Defining Case Conceptualization
Following diagnosis, which provides a method for describing and communicating
about client presentations, effective treatment in today’s mental health world next
requires that we use case conceptualization to evaluate and make sense of the client’s
needs (Hinkle, 1994; Seligman, 2004). Conceptualization skills provide the counselor
with a rationale and a framework for his or her work with clients—and with today’s
emphasis on briefer counseling approaches, extensive use of integrated and eclectic
psychotherapy models, and greater focus on evidence-based best practices, efficient
case conceptualization has become essential (Budman & Gurman, 1983; Mahalick,
1990; Neukrug, 2001; Wampold, 2001). Specifically, case conceptualization is a tool for
observing, understanding, and conceptually integrating client behaviors, thoughts,
feelings, and physiology from a clinical perspective (Neukrug & Schwitzer, 2006).
Case conceptualization involves three steps (Neukrug & Schwitzer, 2006): First,
the counselor thoroughly evaluates the client’s concerns by observing, assessing,
and measuring his or her behaviors. Second, the clinician organizes these observations,
assessments, and measures to his or her patterns and themes among the
client’s concerns. Third, the therapist select …
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