After a counselor has listened to the intake interview and identified the presenting problem, history of the problem, and background on the client, the next step is to conceptualize the issue and identify the disorder.
In Week 2, you examined a case study and started to become familiar with the biopsychosocial assessment process, including the mental status exam. This week’s assignment will extend the scenario and focus on completing the final part of the biopsychosocial assessment and case conceptualization.
Access Carolyn's Case Study: Session 2 and complete it using the accompanying instructions.
Prior to completing the Biopsychosocial Form: Part 2 section in Carolyn’s Case Study: Session 2, listen carefully to the case in Carolyn’s Case Study: Session 2 in the audio file. You can read the full conversation in Carolyn’s Case Study: Session 2.
Imagine you are a counselor, and you are meeting your client, Carolyn, for session 2. In this session, you spend time getting to understand Carolyn better and getting more details of her life, her thoughts, her beliefs, and her experiences.
Examine the following case study scenario about Carolyn.
Client Interview
Carolyn discusses her fears more in depth, especially those that are happening currently. She states that although she realizes that these are not rational thoughts, it is hard for her to simply talk herself out of them or ignore them. She has such intense feelings of panic and anxiety that she cannot move beyond the feeling. She has continued to work and doesn’t want to stop, but she is becoming concerned that she is so preoccupied with these fears that she will be unable to function at work, or worse, she’ll make a horrible mistake with a patient. You ask whether she has ever made a horrible mistake with a patient in the 15 years that she has been a nurse. She denies any such mistakes, but states that she has never been this distracted and preoccupied before.
You ask Carolyn to provide additional background on the fears that she is experiencing by asking her to tell you more about the move across country and the event in the tunnel when the first anxiety attack happened. She states that she was stressed before the move because she was trying to pack up the house and get things ready for the move. She hadn’t taken time off work, so she was trying to work her shifts, pack, get the kids’ school things together for a smooth transition, and research the housing market, school districts, etc. in the new location. She hadn’t been sleeping well because she was worried that the kids would have a hard time adjusting to their new surroundings and schools. She feared that they were at the age where making friends wasn’t as easy or natural and that they would feel like they didn’t fit in at the new school or community as budding teenagers. She states that she has always been very aware of her children’s growth, development, friendships, accomplishments, and attitudes and has done everything possible to maintain the best environment for growing children to blossom. She doesn’t want her children to ever be resentful of her or her husband for taking them out of their comfortable environment and moving them to a new environment where they wouldn’t fit in.
She says that her husband had actually gone out to the East Coast first to start the job while she stayed behind with the kids, allowing them to finish the semester at school. Her plan was to then fly them to spend a few days with her mother while she finished packing. The moving truck took the major stuff and it went to storage temporarily, and she would drive the family pets and the essentials out in the car. She had everything prepared for the drive and wasn’t afraid of driving the long distance alone. She looked forward to it because it gave her time to be alone with her favorite music or audiobooks, and she would only drive about 8 hours each day, then stop, relax, and start up again. She said that all was well, at first, but then she began to worry about the kids and about the changes facing them. She tried to stop the worrying, but she just kept wondering what these changes would bring. She was deep in thought and suddenly was in traffic, crawling along. It seemed like they were in a tunnel for a long time, and she was getting very tired. She says that she was trying to focus on the music playing in the car but couldn’t keep her mind on that. After about 15 minutes of barely moving, she thought, “What would the kids do without me?” She began imagining her kids growing up in a single-parent home. This thought made her feel extremely sad, and she began to question whether it was a good idea for her to drive alone across the country. Her friends all thought she was really taking on a lot and that she should have had a driving buddy. Then she remembered how the tunnel seemed so dark and the traffic surrounded her. She couldn’t stop the thought that somehow this was dangerous and she might not make it across the country.
You ask about the accident in the tunnel and what she saw. She states that the traffic was just crawling by and all she saw of the accident that stopped traffic had involved 2 cars with some damage but nothing significant. It was just that there was no place to pull off the road in the tunnel, so traffic got backed up.
You ask how the rest of the drive went for that trip, and Carolyn reports that she spent most of the trip on her cell phone talking to her sister-in-law, her mother, her kids, or her husband. She drove faster and put in more hours on the road just to be able to get there. She says that once she arrived and got to the rental where her husband had been staying, she insisted on finding a house and getting everything settled as soon as possible. She says that everything got settled in record time because she worked nonstop to get everything done. She says, “I even got a job almost immediately!”
You ask if she always works this hard and has this much energy, how her sleep is, and if she ever feels exhausted after doing so much. She replies that she actually feels exhausted often, especially over the past 18 months, and even though she feels like she is getting enough rest, she is still exhausted often. She states that she has always worked very hard to make sure everything runs smoothly for everyone and she really doesn’t like to have “loose ends.” She also doesn’t like to have people become inconvenienced because she didn’t complete something.
You ask her a few more questions about previous treatment and substance use. She states that she has never been in counseling, nor has anyone in her family, she doesn’t smoke, and she drinks a glass of wine about 4 times a year. She has never used any type of drugs, barely even prescriptions, and neither has her husband. No one in her family has ever had substance issues, had mental health issues, or been on psychiatric medication. Her mom has a history of thyroid disorders and takes medication for a thyroid problem, and her father had high blood pressure, but that is all.
Finally, you assume she has had a medical exam because she is a nurse, so you confirm that there are no medical issues. She laughs a bit and says, “I’m a nurse who doesn’t actually like going to doctors. No, I haven’t seen a doctor in nearly three years. I don’t actually have a primary care doctor here, and I’ve been here 18 months.”
Biopsychosocial Assessment Form: Part 2
Access the detailed instructions for completing this form by downloading the Biopsychosocial Assessment on the College of Social and Behavioral Sciences (CSBS) Resources website in the Clinical Mental Health Counseling menu.
Use the questions provided in the corresponding sections on pp 9–11 of the Biopsychosocial Assessment as a guide to help you determine the relevant information in Carolyn’s case study.
Use the client information given in the session to complete the sections of the Biopsychosocial Assessment form below. As you complete the sections:
- Refer to DSM-5-T® to support your assessment.
- Include a minimum 125-word case conceptualization that explains the issues, symptoms, and diagnosis framed in a theoretical lens.
- Note if any topics were not addressed; do not leave sections of the form blank.
- Use full sentences and appropriate grammar.
- Ensure your assessment is at least 400 words long.