CB: Patient with increase anxiety, depression and sexual abuse trauma
The patient is 21-year-old female college student with present history of anxiety, depression and past hx of sexual abuse. She did experience trauma in the context of sexual abuse during first year of college. Patient states she trying to get better by focusing on finishing college. “I have bought new laptop, organizer to plan all my assignments and also applied for job at FedEx”. Patient states her depression is better but still feels very anxious. Patient cannot get over how Mom broke the trust she had on her by revealing her sexual assault trauma to family members and relatives. Patient states she is presently not in good relationship with mom and her anxiety gets worse whenever she meets mom. Mom has hx of alcohol abuse and would do things for her children just for personal gains. Patient states mom revealed to her kid sister as well as her cousin about her sexual assault. Patient states she presently suffers from this lack of trust and as a result it affects her perception of Mom good dead and her emotions and also increases her level of anxiety to the extent she cannot stand before a stranger. On one occasion, mom and her cousin visited her in school (Washington DC) on her 20th birthday, and mom felt her presence was not recognized as all attention was more on her cousin. Mom got upset and called security to escort this patient out of the hotel room. Patient states she is currently at home with mom and siblings due to the closure of school relating to covid-19 pandemic. Patient states mom continue to refer to her sexual abuse incident which increases her level of anxiety and depression. “Mom broke my trust by revealing this assault to my little sister and my cousin which I feel it is intentional just to make me sad”.
During this session, patient appears to be calm initially then later became tearful as she continues to express how heartbroken she has been knowing that mom is internationally revealing this assault invent to hurt her and makes her anxious.
Patients continue to hold this grudge against mom, believes mom does not meal well for her and she continue to have difficulty developing understanding with mom.
· Assess clients presenting for psychotherapy
· Develop genograms for clients presenting for psychotherapy
· 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.
Part 1: Comprehensive Client Family Assessment
With this client in mind, address the following in a Comprehensive Client Assessment (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).