A Loss of a Family Member and Counseling Report (Assessment)

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Casey is a 21-year-old Hispanic male that presents for counseling without optimism. During the initial interview, he demonstrated some critical symptoms that highlighted the severity of his condition. He was confused about his identity and was constantly burdened by doubts about whether he was a good son. It was evident that he experienced difficulty accepting the loss of his mother and constantly mulled over the circumstances of her death and the ways in which it could have been avoided. He was disturbed by his friends’ lack of empathy and was bitter and angry about the loss of his mother. It is worth noting that he expressed anger against himself and what he considered an undeserved fate. Even though he is still able to function at school, he lacks the drive he had prior to his loss, and he is no longer excited about future prospects. He reports that he has lost all direction in his life. He also reports experiencing difficulty sleeping and eating after his mother’s passing. He constantly wakes up early in the morning, filled with a sense of dread. He does not work out as frequently as he used to and does not feel connected to his friends.

Presenting Problem

Casey presents with complaints of difficulty focusing at school, which is associated with a lack of motivation. Other associated symptoms include the lack of sleep, the loss of appetite, and persistent panic attacks. He describes waking up early every morning feeling like his heart is racing and his chest is heavy. He reports breathing heavily and experiencing an intense feeling of dread. He states that he experiences difficulty connecting with his father and friends, who seem distant and aloof. Casey feels like they are disconnected and incapable of understanding the challenges he faces.

History of Problem

Casey started experiencing the symptoms three weeks prior to the interview after the tragic loss of his mother in a traffic accident. He reports oversleeping on the fateful day and is constantly plagued by feelings of guilt in view of the fact that he did not speak to her and express how much he loved her. The constant rumination over the events of the fateful day led to a lack of focus at school, which resulted in a decline in his grades. He also reports experiencing difficulty sleeping, loss of appetite, and panic attacks. Attempts to reconnect with his father have been unsuccessful, and the lack of empathy from his friends has further compounded the problem.

Mental Status

Activity

The patient is restless during the interview and is constantly shifting his weight on the chair. There are, however, no abnormal movements such as tics, tremors, or lip-smacking noted. In addition, the patient does not demonstrate evidence of psychomotor retardation, such as delayed responses to questions or a paucity of movement.

Mood and Affect

The patient demonstrates anger at himself when recounting the events of the fateful day. This angry mood is a result of his agitation over his friends’ lack of empathy and his father’s lack of understanding. His overall demeanor and facial expressions demonstrate sadness and anger. The patient has a labile affect, given that he experiences exaggerated alterations in emotion that are not necessarily related to external triggers. He feels like he has insufficient control over his emotional responses. There is, however, a congruency of affect in view of the fact that his emotional expressions are in keeping with the content of his thoughts.

Thought Process, Content, and Perception

Casey demonstrates through blocking because he experiences a cessation of thoughts in the middle of a sentence. He typically starts to say something and is unable to recover what he said a few seconds prior. The client demonstrates abnormal thought content in view of the fact that there is evidence of obsessions. He recounts thoughts and images that occur repeatedly and are out of his control. He constantly recounts the morning of the accident and wonders whether delaying his mother would have changed the course of events. There is, however, no evidence of compulsions, overvalued ideas, or suicidal ideation. It is vital to note that the patient does not demonstrate abnormalities of thought perception. As such, there is no evidence of hallucinations, illusions, derealization, or depersonalization.

Cognition, Insight, and Judgment

The patient demonstrates normal cognition in view of the fact that he is oriented in time, place, and person. In addition, his attention and concentration are normal, as is his short-term memory. Casey has insight because he understands that he has a mental health issue that is affecting his ability to accomplish daily activities successfully. It is worth noting that his judgment remains unimpaired, as evidenced by the fact that he makes informed and accurate decisions.

Suicidal and Homicidal Assessment

Casey does not report experiencing suicidal thoughts or ideation since losing his mother in a tragic traffic accident.

Social History

Family

Casey is an only child who had a close relationship with his mother. He is, however, no as close to his father, who has shown little interest in his wellbeing since the tragic accident.

School

He attends college but has recently experienced challenges that have resulted in poor grades. He also reports that his motivation to attend class has declined.

Health

There are no reported health issues or chronic illnesses such as diabetes, asthma, or hypertension.

Occupational/Work

Casey is a student and is yet to get formally employed.

Spiritual/Religious

There is no reported religious or spiritual history in this case.

Legal

Casey has never been arrested and has no documented legal infractions.

Social History

Casey grew up as a single child in a household with a father and a mother. He developed an intimate relationship with his mother, who recently lost her life in a tragic road accident. He has friends, and even though he loves his father, their relationship is cold. There is no history of childhood abuse or trauma.

Health & Wellness History

Substance use

Casey experimented with marijuana while in high school and has consumed a limited amount of alcohol.

Sleep habits

Casey reports experiencing difficulties getting adequate sleep during the night. In addition, he often wakes up early, filled with dread.

Exercise habits

Casey’s exercise routine has been negatively impacted by the loss of his mother. He seldom exercises as frequently as he used to before the accident.

Eating habits and appetite

Casey’s appetite has declined significantly since he lost his mother three weeks prior to the interview.

Previous Therapy / Psychiatric Services

Have you ever been in counseling before?

  • __ No
  • __ Yes,
  • __ Inpatient
  • __ Outpatient
  • __ Day Treatment

Name of Provider Clinic Year Diagnosis / Problem

________________________________________________________________________

Have you ever seen a Psychiatrist before? __ No __ Yes, __ Inpatient __ Outpatient __ Day Treatment

Name of MD: _______________________________________ Clinic: _____________________________

Was any of your previous therapy related to substance abuse? __ No __ Yes

Have you ever had serious thoughts of suicide or homicide? __ No __ Yes

Have you ever made a suicide / homicide attempt? __ No __ Yes Explain: ____________________________

________________________________________________________________________

Do you presently feel suicidal or homicidal? __ No __ Yes Explain: __________________________________

Family Relationship History

Casey was extremely close to his mother from an early age. He reports that everything he did in life was because of her. He was, however, not as close to his father, who has not shown empathy since the incident. Despite their fragile relationship, Casey states that he loves him.

Strengths

There are specific assets that will facilitate progress and change in Casey’s case. He has demonstrated the capacity for self-discipline given the fact that he previously maintained a rigorous exercise regimen and has stayed away from drugs and alcohol. In addition, he is intelligent, as demonstrated by high grades prior to his mother’s demise in a tragic road accident. Finally, Casey is willing to utilize resources and has demonstrated the willingness to regain his confidence and purpose in life.

Challenges

The Main challenge likely to impede Casey’s progress is his strained relationship with his father. Given that he has no siblings, Casey’s need for family is likely to be unfulfilled if the relationship is not mended.

Diagnosis

F33.0 Mild, recurrent, Major Depressive Disorder.

F41.0 Panic disorder.

Discussion/Clinical Formulation

Casey is suffering from major depressive disorder because he meets the DSM 5 criteria. Or instance, he experiences a depressed mood for most of the day and has demonstrated a significant decline in interest in pleasurable activities. There is a history of insomnia on most days, and he is constantly plagued with feelings of inappropriate guilt over the loss of his mother. The patient also feels fatigued and has experienced these feelings for more than two weeks. The depression is recurrent because, in addition to meeting the basic criteria, he experiences unreasonable feelings of self-reproach and excessive guilt in addition to losing his self-confidence. The diagnosis of panic disorder was arrived at because Casey experienced palpitations and instances of shortened breath. In addition, he experienced chest discomfort that was associated with an overwhelming feeling of fear. It is worth noting that the disturbance is not attributed to another mental disorder or the psychological impacts of substances such as drugs or alcohol.

The cognitive theory of depression is the most appropriate theory to use with this client. It proposes that depression is the result of maladaptive and illogical cognitions that are presented in the form of distorted judgment and thoughts. The theory further posits that depressive cognitions are the result of an individual’s lack of experiences that would foster the development of effective coping skills (Kanel, 2019). The difference in thinking among individuals affected by depression is believed to the primary cause of their illness. For instance, depressed individuals often view themselves and the future with a pessimistic attitude (Kanel, 2019). This leads to the inevitable misrepresentation of facts as they blame themselves for misfortunes that occur. Casey blames himself for his mother’s death because he believes that if he had woken up early and stopped her from leaving the house in time, she would probably still be alive. The cognitive theory can be applied to Casey’s case by instituting elements of cognitive-behavioral therapy (CBT) to facilitate recovery. CBT will facilitate the identification of life factors contributing to depression, and it will help Casey address distorted perceptions and patterns of thinking that aggravate the illness.

_________________________________________________

__________________

Student/Counselor in Training

Date

_________________________________________________

__________________

Supervisor___________________

Date_______________________

Resource Packet

Web Sources

Torres, F. (2020). What Is Depression? American Psychiatric Association.

World Health Organization. (2020). Depression.

Support Groups

Sane. www.sane.org.uk

Togetherall. togetherall.com

Books

McIntosh, D. (2019). This is depression: A comprehensive, compassionate guide for anyone who wants to understand depression. Page Two Books, Incorporated.

Burns, D. D. (2020). Feeling great: The revolutionary new treatment for depression and anxiety. PESI Publishing & Media.

Exercises

  • Deep breathing exercises
  • Meditation
  • Yoga

Reference

Kanel, K. (2019). A guide to crisis intervention (6th ed.). MindTap.

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