Bio-psycho-social-spiritual Assessment

Bio-psychosocial-spiritual Assessment

Evaluation

Client Progress

Goal 3

By Leslie Morgan

5/4 Post Test Score

3/24 Baseline Score

3/31 Intervention Initiated

• Goal 3: PM will improve his ability to interact safely at home and in the community, and learn to identify and use community supports in the next 6 months.
• Objective 3.1: PM and his mother will demonstrate learned skills during scheduled family therapy, unsupervised visits/outings, and telephone calls in at least 60% of situations when given the opportunity.
• Intervention: Therapist will facilitate family therapy as prescribed where family roles, rules, and boundaries are explored and challenged where appropriate and therapeutic for client.
• Intervention: Therapist will participate in treatment planning and maintain contact with family, DJJ, and community resources for the purpose of progress reporting, resource solicitation, and discharge planning.

Goal 4

University of Rhode Island Change Assessment HABITS Lab. (n.d.). Retrieved May 07, 2017, from http://habitslab.umbc.edu/urica/

3/24 Baseline

0-13: Minimal

14-19: Mild

20-28: Moderate

29-63: Severe

Clinical Cutoff Score

• Goal 4: PM will form supportive, cooperative, positive, platonic relationships over the next 6 months.
• Objective 4.1: PM will decrease attention seeking and/or antagonistic behaviors in group settings over the next 6 months.
• Intervention: Therapists will acknowledge and redirect client for inappropriate group behaviors whenever client is in a group setting.
• Intervention: Therapists will educate client on and model appropriate behaviors to client in all interactions.

Treatment Plan

3/31 Intervention Initiated

5/4 Post-test Score

3/31 Intervention Initiated

Devereux Behavioral Health

Unlocking Human Potential

Snell, W. E., et al (1995). The clinical anger scale: Preliminary reliability and validity. Journal of Clinical Psychology, 51(2), 215-226.

Goals

Goal 2

• Threats to validity – Self report, poor judgement/insight, incentives (stingers)
• Clinical & Theoretical significance

Goal 1: PM will reduce frequency and intensity of mood related issues that trigger unsafe behaviors towards himself and others over the next 6 months

Goal 2: PM will learn to cope with memories of abuse with less distress while establishing non-sexualized relationships

Goal 3: PM will improve his ability to interact safely at home and in the community, and learn to identify and use community supports in the next 6 months.

Goal 4: PM will form supportive, cooperative, positive, platonic relationships over the next 6 months.

• Goal 2: PM will learn to cope with memories of abuse with less distress while establishing non-sexualized relationships
• Objective 2.1: PM will attend and participate in Trauma therapy group 2x weekly 80% of the time during the entirety of his stay at Devereux.
• Intervention: Therapist will use TF-CBT and DBT skills within group to teach clients psychoeducation, relaxation, mindfulness, distress tolerance, mood regulation, effective problem solving, interpersonal effectiveness, and positive social skills.
• Objective 2.2: PM will complete the Childhood PTSD symptom scale to clarify the potential effects of trauma on mood and behaviors within the next 30 days.
• Intervention: Therapist will administer scale, and then review findings with client to formulate future treatment goals and objectives.

After Care

Client will remain at Devereux for now, and will continue individual therapy, group therapy, and continue with intern support in other areas besides anger management. Discharge planning and step down options had not been discussed as client was not safe enough to function within the larger community at the end of services.

Advocacy

Intern Support - ADL/IDL skills

Ethical Considerations

Male/female dynamics – question 21

Power differentials – adult/youth, staff/patient

Goal 1

Professional & Personal Reflections

Assessment Data

• Goal 1: PM will reduce frequency and intensity of mood related issues that trigger unsafe behaviors towards himself and others over the next 6 months
• Objective 1.1: PM will establish and choose from his list of coping skills to reduce verbal and physical aggression when bullied, in arguments, or startled by loud noises in the next 30 days.
• Intervention: Therapist will teach client feeling words and help client identify coping skills, and triggers over the next 30 days.
• Objective 1.2: PM will learn to use 2 grounding techniques when experiencing aggressive, intrusive, or distorted thoughts over the next 30 days.
• Intervention: Therapist and intern will teach and practice grounding techniques with client to use when he experiences aggressive, intrusive, or distorted thoughts over the next 30 days.
• Objective: 1.3: PM will engage in anger management psychoeducation and anger replacement therapy to learn to manage his physical and verbal aggression in the next three months.
• Intervention: Intern will complete certified anger management and anger replacement therapy modules with client over the next 60 days to educate client on his response to anger stimuli.
• Objective 1.4: PM will report any urges to self-harm as they occur 100% of the time during the entirety of his stay at Devereux.
• Intervention: When client is feeling unsafe and at risk to self-harm, therapist or nurse will complete a Devereux Suicide Risk Assessment evaluate risk level, and develop or reassess client’s safety plan.

Medical

Professional Growth

Substance Use

• Therapist collaboration – skills and limitations in working with client
• Clinical Supervision – group, clinical department, & individual
• Treatment team – weekly and monthly review
• CADS certification

Cannabis

Hospitalization for:

• cannabis use
• 3 attempted over doses
• cutting and SIB

Current medications include:

• Clonidine
• Gabapentin
• Strattera
• Trazodone
• Zoloft
• DC - Zyprexa

Personal Reflection

Legal History

• Practiced CADS skills
• Dalton – familiarity and assumptions
• Positive regard
• Male/female dynamics

• Loitering/prowling x2
• Theft by taking
• Cannabis use
• Domestic violence/aggression
• Entering a motor vehicle w/ intent to commit felony theft

Diagnostic Impression

Client Information

296.42 Bipolar I Disorder, most recent episode manic, without psychotic features, moderate

313.81 Oppositional Defiant Disorder

314.01 Attention-Deficit Hyperactivity Disorder, combined presentation, moderate

318.0 Intellectual Disability

• Client PM
• 16 year old
• White male
• 10th grade
• Heterosexual
• Christian non-practicing
• mandated for treatment

Presenting Problem

Referral Info

• Client was referred by the Whitfield county DJJ and RYDC

• Agency reports:
• cannabis use
• aggressive behaviors
• difficulty in school

Mental Status

• Mother reports:
• Impulsivity/irritability since 3yrs.
• Hx of sexual behaviors
• Aggression towards her
• Difficulty in school
• Client reports:
• Hypervigilance
• exaggerated startle response

• Client presented in jeans, a t-shirt, and tennis shoes moderate hygiene - noticeably foul breath, greasy hair
• Neutral mood AEB a flat affect, neutral tone, appropriate responses
• His rate of speech, intonation, & response were all within normal range and congruent w/ mood.
• Illogical thought processes w/ low insight, poor judgement.
• Memory was good in all three spheres and oriented to person, place, time, and circumstance.
• Preoccupied with his mother.
• No external stimuli despite hx
• Client denied SI or intent, but admitted to hx and to using SIB as coping strategy

Ecomap

Treatment History

• Hospitalizations: Park Ridge Valley, Peachford, Summit Ridge, Stephens Clinic, Highland Rivers, Youth Villages, and GA Hope wrap around services
• Modalities: TF-CBT, CBT, DBT, family therapy, and wrap around services
• Numerous encounters with DFCS due to neglect with several foster/residential placements

Genogram

Family Composition, Environment & Cultural Context

• Mother (disabled, SA)
• Mother’s boyfriend (abuser)
• Father (incarcerated)
• Older sister & brother
• Dalton Ga, Low SES, domestic abuse (victim/witness)

Client Strenghts & Support Systems

• Cooperative, funny, well mannered, helpful
• Mother, PO