Refer back to 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. 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 LopesWrite. Refer to the directions in the Student Success Center. This assignment meets the following NASAC Standards: 25) Gather data systematically from the client and other available collateral sources, using screening instruments and other methods that are sensitive to age, culture and gender. At a minimum, data should include: current and historic substance use; health, mental health, and substance-related treatment history; mental status; and current social, environmental, and/or economic constraints on the client's ability to follow-through successfully with an action plan. 28) Determine the client's readiness for treatment/change and the needs of others involved in the current situation. 29) Review the treatment options relevant to the client's needs, characteristics, and goals. 31) Construct with the client and others, as appropriate, an initial action plan based on needs, preferences, and available resources. 32) Based on an initial action plan, take specific steps to initiate an admission or referral, and ensure follow-through. 33) Select and use comprehensive assessment instruments that are sensitive to age, gender and culture, and which address: (a) History of alcohol and other drug use (b) Health, mental health, and substancerelated treatment history (c) History of sexual abuse or other physical, emotional, and verbal abuse, and/or other significant trauma (d) Family issues (e) Work history and career issues (f) Psychological, emotional, and world-view concerns (g) Physical and mental health status (h) Acculturation, assimilation, and cultural identification(s) (i) Education and basic life skills (j) Socio-economic characteristics, lifestyle, and current legal status (k) Use of community resources (l) Behavioral indicators of problems in the domains listed above. 34) Analyze and interpret the data to determine treatment recommendations. 36) Document assessment findings and treatment recommendations. 37) Obtain and interpret all relevant assessment information. 111) Prepare accurate and concise screening, intake, and assessment reports. AttachmentsPCN-610.R.T2-T3BiopsychosocialTemplate.doc Psychosocial Assessment Template ____ Part 1 (Topic 2) ____ Part 2 (Topic 3) Name: ______________________________ Date: _________________ DOB: ________________ Age: ________________________________ Start Time: ____________ End Time: ___________ Identifying Information: David is a self-referred 49-year-old, in a ‘typical’ relationship with wife and two adult children at first resisting treatment with the notion that his mood swings will, in the long run, be better. The treatment being sort, therefore, entails dealing with the feelings of melancholy and depression. Presenting Problem: The client reports that he is not contented with his job, thus not enjoying it, reduced levels of appetite, various instances of feeling ‘down’ and unhappy, the lack of the inclination to do things which he used to formerly, preference for solitude, unsuccessful attempt to get out of the current mood swings, suicidal thoughts “life is hardly worth living." Life Stressors: The client’s life stressor entails his ‘typical’ relationship with his wife. Despite the couple not being in love with each other anymore, they are still clinging to each other based on the standard routine and accommodation. Substance Use: Yes No The client reports using alcohol at night due to a lack of sleep. He claimed that he used to partake in alcohol more regularly during his young years. Now he only drinks an estimated 2-3 beers per night. Addictions (i.e., gambling, pornography, video gaming) The client has no history of addictions. Medical/Mental Health Hx/Hospitalizations: The client reports neither a previous history of mental health nor hospitalizations on the basis of mental concerns in his lifetime. Abuse/Trauma: The client has no previous history of abuse or trauma. Social Relationships: The client’s social relationship mainly entailed family gatherings, where he would have recurring interactions with his children. Family Information: The client reports his sister used to have the same depression problem, which she battled for over ten years. His sister’s emotional and physical exhaustion had escalated in the past, with her having a negative viewpoint claiming that when things seem bright, something immensely wrong happens. He now reports that his sister is seeing a psychiatrist and counselor. Psychosocial Assessment Template ____ Part 1 (Topic 2) ____ Part 2 (Topic 3) Spiritual: The client has no history of spiritual involvement. Suicidal: The client has no history of suicidal attempts or involvement. However, he reports that “life is hardly worth living at times." Homicidal: The client has no history of homicidal attempts or involvement. Assessment: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Initial Diagnosis (DSM): ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Initial Treatment Goals: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ Plan: Psychosocial Assessment Template ____ 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, David 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. David 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. 1. Diagnosis and Treatment Planning Skills Read Chapter 2 in Diagnosis and Treatment Planning Skills. URL: http://gcumedia.com/digital-resources/sage/2014/diagnosis-and-treatment-planningskills_ebook_2e.php 2. Navigating the DSM-5 Read “Navigating the DSM-5.” 3. Standardized Mini-Mental State Examination (SMMSE) Review the Standardized Mini-Mental State Examination (SMMSE), from the British Columbia, Ministry of Health website. URL: http://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/cogimp-smmse.pdf 4. Developing the World Health Organization Disability Assessment Schedule 2.0 Read “Developing the World Health Organization Disability Assessment Schedule 2.0,” by Ustun et al., from the National Center for Biotechnology Information website. URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2971503/ 5. WHO Disability Assessment Schedule 2.0 (WHODAS 2.0) Explore “WHO Disability Assessment Schedule 2.0 (WHODAS 2.0),” from the World Health Organization website. URL: http://www.who.int/classifications/icf/whodasii/en/ 6. An Integral Approach to Counseling Ethics Read "An Integral Approach to Counseling Ethics," by Foster and Black, from Counseling & Values (2007). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=a 9h&AN=24884344&site=ehost-live&scope=site 7. Examining the Content of Mental Health Intake Assessments from a Biopsychosocial Perspective Review “Examining the Content of Mental Health Intake Assessments from a Biopsychosocial Perspective” by Meyer & Melchert, from Journal of Psychotherapy Integration (2011). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=p dh&AN=2011-05097-003&site=ehost-live&scope=site 8. What Should ICD-11 Do That DSM-5 Did Not? Read “What Should ICD-11 Do That DSM-5 Did Not?” by Goldberg, from Australian and New Zealand Journal of Psychiatry (2013). URL: http://journals.sagepub.com.lopes.idm.oclc.org/doi/abs/10.1177/0004867413516169 9. ICD-11 Should Not Repeat the Mistakes Made by DSM-5 Read “ICD-11 Should Not Repeat the Mistakes Made by DSM-5,” by Frances & Nardo, from The British Journal of Psychiatry (2013). URL: http://bjp.rcpsych.org/content/203/1/1.full-text.pdf+html 10. Case Formulation Application Charts Read “Case Formulation Application Charts” by Goldman & Greenberg, from American Psychological Association (2015). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=p syh&AN=2014-25807-009&site=ehost-live&scope=site 11. Ethics in Case Conceptualization and Diagnosis: Incorporating a Medical Model Into the Developmental Counseling Tradition Read “Ethics in Case Conceptualization and Diagnosis: Incorporating a Medical Model into the Developmental Counseling Tradition” by Dougherty, from Counseling & Values (2005). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=p syh&AN=2006-10013-005&site=ehost-live&scope=site 12. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). American Psychiatric Publishing.
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