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Brian Mann

CNS 771
Final Exam Case

(1) After you talk with Peggy about the purpose of counseling, share your personal
disclosure statement, and discuss the informed consent form that Peggy signs, you
conduct an intake which includes a biopsychosocial assessment. Write up the results of
that assessment using the case study example as a guideline to follow: Biopsychosocial
assessment example. You will need to add information that is not included in the case
study in order to complete the write-up. You may create this material, making it as
realistic as possible.
Identifying Information: Peggy is 65 year old, married, Caucasian female, referred by husband,
reluctantly seeking treatment to deal with recent onset of insomnia, forgetfulness, social
withdrawal and anxiety.
Present Psychiatric Illness/Symptoms: Client reports forgetfulness, insomnia (every night),
anxiety, social withdrawal, lack of purpose in life, suicide ideation, reduced energy level and
change in disposition.
Past History of Treatment: None
Mental Health Medications: Ambien for insomnia
Medical Concerns: Recent weight loss, reduced energy level undiagnosed.
Current Medications: Client reports taking over the counter aspirin for daily pain relief.
Dependency/Addiction History: None; Occasional alcohol use.
Family History of Psychiatric/Addiction Illness: None
Spirituality: Client was raised in a religious home (Christian), but has not regularly attended
services for twenty years. Client identifies as a Christian. No active involvement in church
community.
Personal History: Client is older of two daughters, raised in mid-west in farming community.
Parents married for 52 years, both now deceased. Father worked at feed store, and mother was
school teacher. Sister died 5 years ago at age 56 of lung cancer. Client has two children Roger jr,
and Claire. Roger jr. lives in San Francisco is software designer and is unmarried. Claire lives in
Seattle, is married 17 years and is a stay at home mother of two girls Joan (12) and Judy (15).

Education: Client is college educated with masters degree in education. Places high value on
education. Husband and both children also have advanced degrees.
Work history: 35 years as public elementary school teacher. Received accolades as top teacher
in district several times; recently retired; strong feelings that the education system has devolved
in recent years via budget cuts, reduction in resources and mandate on new teaching methods.
Legal History: Client has no history of legal involvement and no pending action.
Marital/Relationships: Client is married 40 years to husband Roger, reportedly happily
married. No reports of abusive relationships.
Mental Status: Client appears professionally dressed, neatly groomed and cooperative. She is
calm and there is no evidence of tremors, tics or muscle spasms. She is soft spoken and her mood
is depressed. She is oriented to time, place and person. Her thoughts flow logically however she
has repeated herself several times. No evidence of hallucinations or delusions. Client has strong
sense of frustrated self-determination.
Summary Impression: Client appears to be grieving loss of career, which supported her sense
of purpose. Adjustment to new stage of life may be overwhelming her, causing many of the
symptoms being expressed.
Short-Term Goals:

Develop meaning and sense of purpose.


Build coping skills for adjusting to new life phase.
No known medical conditions, however, client is overdue for physical. Refer for
appointment to screen for Alzheimers.

(2) Write a case conceptualization of Peggy (approximately 300 words). What do you think
the primary issue is?
Peggys symptoms seem to stem from her adjustment to retired life. She was a long time
teacher who now lacks a sense of purpose and meaning within her life, which in turn may be
effecting her disposition and energy level. These changes have come to impact her social life and
her sleep habits, and ability to concentrate. Concern over these changes may be fueling her
anxiety about the changes she has seen in herself since retiring. Her recent auto accident has
damaged her confidence to travel independently, which in turn forces her to stay home alone,
ruminating over her concerns, fueling this cycle.
At the root of her adjustment difficulties is her ineffective grieving over the loss of her career.
She likely assigned great meaning to her role as a school teacher, and the contributions she made

to her students development. She had a long career with achievements she was proud of, and
had daily interaction with fellow staff members who were a large part of her social world. Now
that shes retired, the client finds herself in a place that seems foreign to her; one without these
social interactions and sources of satisfaction. She has not yet found healthy replacements for her
lost sense of purpose and social life in this new stage of her life.
Having a routine, a mission, social interaction, and reasons to get up in the morning are
essential. Exploring with Peggy the losses she incurred as she left her teaching career could
identify some of the things she is struggling with most. Coping strategies then could be
deployed.
(3) Write a treatment plan for Peggy, following the guide in your textbook (page 129). Use
your text describing the DSM-5 to make a diagnosis, if warranted.
Primary Issue/Problem Statement:
Depression due to changes associated with recent retirement. These changes have led to her
withdrawing socially, having fear of driving, insomnia, mild/moderate suicidality and depression.
Goal statement and expected date of achievement:
1.)
2.)
3.)
4.)
5.)
6.)

Develop safety plan for thoughts of suicidality (Session 1).


Refer to psychiatrist to discuss pharmacological support options and screen for
Alzheimers. (Session 1).
Explore thoughts and fears about new free time. Identify top concerns and reframe as
opportunities for new activities. (Session 2)
Develop wish list of activities that are meaningful.(session 3)
Develop strategy for self-sufficient mobility. (Session 4)
Develop plan for involvement in group activities from wish list. (Session 5)

Treatment modality: Client will meet weekly with a Licensed Professional Counselor (LPC).
The treatment modality that will be used is Cognitive Behavioral Therapy (CBT) with elements
of transcendental therapy. The onset of clients symptoms coincide with her recent retirement.
These thoughts and behaviors will be explored for development of effective coping strategies.
Clinical Impression or diagnosis: (F32.9) Unspecified Depressive Disorder
Name and credentials: Treatment plan provided by Brian Mann, Graduate Student -Clinical
Mental Health Intern. October 12, 2014

(4) During the session, you will conduct a suicide assessment. You do not need to write a
script of the assessment. Instead, use the SLAP model (p. 215) to guide you as you
make up what you think Peggy would reveal in the session. There are no right or

wrong answers, and you may use bullet points. Then determine Peggys level of risk.
Provide a rationale for that risk. Based on the level of risk, what would your next steps
be?
Specific: Client does not have a specific plan. Indicates lack of motivation to continue living
rather than need to end life.
Lethality: Client is uncertain how she would carry out suicide. She joked that she would have to
get her husband to take her out to the barn to shoot her.
Availability of Method: Old hunting rifle in house, she is unsure of whether they even own
bullets.
Proximity of helping resources: Husband is present and attentive to situation, but client is home
alone during week days during work hours.
Level of risk: Low to moderate. Client is currently overwhelmed and not thinking clearly. Has
indicated suicide as a solution but lacks specific plan. With gun in house, there is an available
method. Husband is in close proximity and active in caring for client when not at work. During
work hours, client is left home alone, with no one to monitor her.
Next Steps: Safety plan to be developed. Husband will be asked to eliminate clients access to
gun. Client will be asked to share suicidal thoughts with husband, if or when they occur.
Husband is to call client several times during work hours to check in on her emotional state.
Suicide hotline information and mobile crisis contact information to be provided to client and
husband.