prcticum
Recreate it for me.
- Assess clients presenting for psychotherapy
- Develop genograms for clients presenting for psychotherapy
To prepare:
- Select a client whom you have observed or counseled at your practicum site.
- Review pages 137–142 of the Wheeler text and the Hernandez Family Genogram video in this week’s Learning Resources. Reflect on elements of writing a Comprehensive Client Assessment and creating a genogram for the client you selected.
The Assignment
Part 1: Comprehensive Client Family Assessment
With this client in mind, address the following in a Comprehensive ClientAssessment (without violating HIPAA regulations):
- Demographic information
- Presenting problem
- History or present illness
- Past psychiatric history
- Medical history
- Substance use history
- Developmental history
- Family psychiatric history
- Psychosocial history
- History of abuse/trauma
- Review of systems
- Physical assessment
- Mental status exam
- Differential diagnosis
- Case formulation
- Treatment plan
Part 2: Family Genogram
Prepare a genogram for the client you selected. The genogram should extend back by at least three generations (great grandparents, grandparents, and parents).
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Practicum – Assessing Clients
Walden University
Psychotherapy Individual: Prac 6640
6/21/2020
Practicum – Assessing Clients
Part 1: Comprehensive Client Family Assessment
Demographic Information
Name: Camila R
DOB: 2/20/1988
Age: 32
Gender: Female
Race: Hispanic American
Facility: REH Crisis Stabilization Program
City: Minneapolis
State: MN
Presenting Problem
Substance abuse, social withdrawal, and excessive worry.
History or Present Illness
Camila is an immigrant from Mexico. She left the country in search for a well-paying job that could cater to her needs and those of her family. However, so far, she has only managed to get minimum-wage jobs, which are not able to sustain both her and her family. Consequently, she has entered a depressive state due to her constant worrying about the future. She uses marijuana and alcohol as coping mechanisms. Shanmugam (2017) notes that this is a common trend among many addicts. Her constant worrying has made her irritable and withdrawn from her friends. Camila feels that she needs to get over her mental problems if she is to keep on working hard for the sake of her family.
Past Psychiatric History
Camila has noted that most of her days are spent worrying about money and where she can find a good job that will meet all her needs adequately. Consequently, she has had to depend on drugs and alcohol for solace. Whenever she is high, she forgets about her issues. However, her substance abuse is getting out of hand because it is affecting her performance at work. She has been irritable, angry, unable to get along with others, had mood swings, and has even had thoughts of suicide. Camila worries that if this trend continues, she will lost the only job she has with no guarantees of getting another one soon.
Medical History
Camila has been taking prescription antidepressant medication. She has been consuming 20 mg of Prozac per day. The medication has made her feel better but has not eradicated her problem.
Substance Use History
Camila has abused alcohol for approximately eight years. She has also taken excessive amounts of marijuana for the past year. She desires to be treated for both her substance abuse and her mental problems.
There is no available history since Camila is an immigrant from Mexico and has only stayed in the country for one year.
Family Psychiatric History
There are no records of Camila’s family psychiatric history.
Psychosocial History
Camila’s problems have made her withdrawn from her friends and family. She rarely interacts with close friends and prefers meeting with strangers whose she feels will not judge her apparent ‘failure in life,’ as she puts it.
History of Abuse/Trauma
Camila was raped on her way home from work this year. This episode triggered her excessive use of marijuana to cope with the feelings of shame. Acierno, Resnick, Flood, and Holmes (2003) assert that many women turn to drugs after being raped to handle the emotional turmoil. She did not report this case to the local authorities or to her family, preferring to suffer alone.
Review of Systems
General: Camila appears to be oriented to her surroundings. She answers queries succinctly and appears to be of sound mind. However, she only weighs 100 lbs. This is quite low for a woman whose height is 5’10. She attributes this to lack of appetite.
Skin, Hair, Nails: All these factors appear normal.
HEENT
– Camila states that she does not have a headache. However, due to her poor eating habits, she regularly experiences dizziness and has even had syncope in the past. Her vision and hearing are relatively good.
Cardiovascular
: Camila states she has never had any chest pains or heart issues. Her BP is 120/80. She has a regular heartbeat of 90 beats per minute. She has a regular heart rate of 90 beats per minute.
Pulmonary
: Despite being a smoker, Camila says she has no breathing or respiratory issues. She has a 98 percent oxygen saturation.
Gastrointestinal
: Camila’s bowel movements are regular.
Genitourinary
: Camila’s urinary pattern is regular
Neurologic
: Camila states that she has never been diagnosed with a neurological problem.
Musculoskeletal
– Camila states that she has never been diagnosed with a musculoskeletal problem. However, she has slight back and knee pains.
Hematology
: Camila states that she has never been diagnosed with any blood disorders or malignances.
Endocrine
: Camila’s endocrine functions are normal.
Physical Assessment
Camila is alert and appears her age. However, she is underweight (100 lbs) for a height of 5’10. As aforementioned, her vitals are normal, that is cardiovascular, pulmonary, neurological, and gastrointestinal, among others.
Mental Status Exam
Camila was very coherent during the exam. She tried to maintain constant eye contact and effectively answered all questions concisely. However, she was moody and appeared distant at times. She was fidgeting all the time and noted it was due to her withdrawal from alcohol. Nonetheless, she was not delusional or paranoid. She was aware of her mental issues, which she stated had adversely affected her relationship with her family and friends. Camila took the Patient Health Questionnaire-9 (PHQ-9) and got a score of 25, which depicts severe depression.
Differential Diagnosis
Camila was diagnosed with severe substance abuse and depression.
Case Formulation
Camila’s mental issues have likely arisen from her inability to cater to the needs of her family. Everyone seems to look up to her and she is overwhelmed with the responsibility bestowed upon her. Additionally, the rape incident made the situation worse.
Treatment Plan
Goal 1
Camila will successfully undergo treatment for drug and alcohol abuse.
Objective
Camila will take all the necessary steps to be admitted into Park Avenue Women’s Center.
Intervention
Camila will be subjected to motivational interviewing. This model takes the form of counselling where the patient is encouraged and pushed to adopt positive behavioral changes. The changes are expected to lower Camila’s addictive habits.
Goal 2
Camila will effectively reduce and manage her social withdrawal, excessive worry, and anxiety
Objective
Camila will adopt effective coping skills through therapy techniques and use of antidepressant medication.
Intervention
Camila will be subjected to cognitive therapy and antidepressants.
Part 2: Family Genogram
Camila’s child is 10 years old
Camila is separated from her daughter’s father
Camila’s extended family lives in Mexico
References
Acierno, R., Resnick, H. S., Flood, A., & Holmes, M. (2003). An acute post-rape intervention to prevent substance use and abuse. Addictive Behaviors, 28(9), 1701-1715.
Shanmugam, P. K. (2017). Alcoholism & Drug Dependence. Journal of Alcoholism & Drug Dependence, 5(4).
Practicum Experience Time Log and Journal Template
Student Name:
Practicum Placement Agency’s Name:
Preceptor’s Name:
Preceptor’s Telephone:
Preceptor’s E-mail Address:
(Continued next page)
Journal Entries
· Include references immediately following the content.
· Use APA style for your journal entry and references.
© 2012 Laureate Education Inc.
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