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Using the information provided, create Part One of Biopsychosocial…
Using the information provided, create Part One of Biopsychosocial History for Eliza (Topic 2) This includes identifying stage of change and initial diagnosis. On what do you base your justification for services upon this part of the assessment?
Your client, Eliza, is a Caucasian female with average height and slender build. The client is currently a freshman in college and she is majoring in engineering. The client’s family resides in a small town approximately two hours away. Her family is high-achieving with both of her older brothers having successful careers in engineering, just like their father. Eliza has ‘mostly B’s’ in her classes but reports a lot of struggles in maintaining her GPA. The client states her coursework is very demanding, and she attends tutorials in the engineering department at least twice per week between classes. She considers her family a support system but is not in daily contact and doesn’t get to go home very often.
At the onset of the session in late January, the client came to your office in the university counseling center because of being caught in a campus dorm with alcohol (it is an alcohol-free campus, and the client is underage). She presented as visibly distraught as evidenced by the initial refusal to sit down and pacing in front of your desk for several minutes before finally sitting down in the chair across from your desk. Eliza was dressed in jeans, tennis shoes, a t-shirt, and zip hoodie. She appeared somewhat disheveled as evidenced by hair that was uncombed and wrinkled clothes. She struggled to make any eye contact during most of the initial session and rubbed her arms and upper legs often when talking. She said she was ‘very tired’ and admitted to sleeping less than five hours per night ‘most days’ and ‘catching up on sleep on Saturdays and Sundays until noon.’ Concerning the incident, the client stated “the RAs were called because my friends were being too loud in my dorm. When they arrived, they saw us with alcohol, and we got in trouble.” The client stated that her friends in the dorm were intoxicated but she was not, adding, “I was just buzzed” and adding that she was drinking “because they were” and “it’s just something to do.” Eliza appears to minimize the severity of the allegations. Eliza further rationalizes drinking to unwind from her stressful course load as an engineering major, and because parties are “a way to mingle and forget about things since her closest friends and family live over two hours away.”
The client identified school as a life stressor, adding “things came easy to me in high school, I just figured it would be the same in college”. The client says she was not prepared to deal with things NOT coming easy to her in college, and voices resentment over having to attend tutorials every week to stay caught up with the material. She reports immense pressure to do well in her major since she comes from a family of engineers.
Eliza also disclosed in the initial assessment that in addition to the difficulty in increased study requirements in her second semester, she has struggled with making friends, stating, “a lot of my friends from high school have either gone to college somewhere else or are doing other things,” although she denied feeling lonely. When asked about a support system, the client denies having close friends at school, and could not identify anyone on campus that she fully trusts to talk to about her problems. She says she goes to a lot of parties and that is where she mingles with people the most, and usually does not engage with people in her classes beyond the classroom “because she feels embarrassed about going to tutorials.”
Eliza became very emotional and agitated when asked about substance use. She denied having a drug or alcohol problem, adding that she tried marijuana once in high school but “I didn’t like how it made me feel” and had not taken it since. The client stated that she was introduced to alcohol in HS when “friends asked me to drink it with them.” The client stated that “I sometimes drink on the weekends with friends,” denying drinking in excess or ever suffering symptoms of being hungover. When asked for more details about the parties she attends, the client replied again about going to parties on weekends and has been doing so since the first week of classes in late August. Although she denies drinking in excess, she admits to mixing drinks such as several beers chased with shots of liquor and engaging in drinking games that require drinking amounts of alcohol very quickly. The client also reports there have been “a couple of times where she’s pretty sure she took some pills” while under the influence but could not remember what kind or how much. The client says she goes to parties ‘most weekends’ during long semesters, and usually drinks at home when visiting with friends who go to other colleges. When asked to expand on how many beers and shots on average per party, she finally admitted drinking at least 5-6 beers and 3-4 shots of liquor ‘on average’ per party. Although client denies experiencing hangover, she did say she has a hard time waking up the next day after a party, and usually isn’t able to eat until much later in the day following a night of drinking. When asked specifically to detail how much and how often she drinks, the client had to stop and think several times, made some notes and tallies on a sheet of paper, and seemed surprised by the amount once she shared the information. She frequently paused to stop as she counted and appeared confused. The client is going to 2-3 parties ‘most weekends’ and admits drinking in her dorm at least twice per week. The client says she didn’t drink that much at the beginning of the semester, usually a beer or two at parties, but now drinks much more and goes to more parties. She says she drinks 5-6 beers and does 3-4 shots at parties; she also admits to sneaking wine into her dorm and drinking ‘a glass or two’ at night to help her fall asleep. In terms of other addictive behaviors, the client stated that she occasionally plays a Massive Multiplayer Online game. When asked how often the client played, the client stated “one or two times a week” for approximately “three to five hours” at a time. The client denied gambling or pornography issues. The client says she is most likely to spend time gaming after tutorials for her classes, where she feels a lot of pressure to do very well, and gaming helps her unwind and forget about the stress of school.
Eliza denies hospitalizations, but says she has history of cutting in high school due to pressure from her family to achieve high grades and get scholarships. She said she used to cut with a razor blade she kept hid under her mattress. She said she wore long sleeves to hide it from her parents, friends, and teachers. She said the cutting started near the end of her junior year and became more frequent in her senior year, as often as three times per week. The client said cutting helped her relieve pressure. As you discuss the incident further with Eliza, she interrupts and states she is cutting again due to the “overwhelming stress” of everything going on but denies suicidal ideation. She voluntarily raises her sleeves where you observe several cuts on her left wrist and arm. Some of the cuts are superficial while others look deeper. The area around the cuts is very red and inflamed. Eliza discloses cutting 2-3 times per day every day for the last week.
She also said her brothers talked about drinking a lot in college to unwind from stressful days in class. She also says her mother has a very controlling attitude, and this caused a lot of stress in their home. She said her mother drinks wine every night to unwind before bed but has never seen her mother intoxicated. The client denied any current or past abuse, although stating in passing that she did experience some level of teasing in HS, although the client denied discussing specifics. Eliza denies legal history at this time, but says her RA reported the drinking incident to campus police. She hasn’t heard anything from them since the incident was reported.
The client stated that she had quality relationships, but added that she felt as though she was, at times, being taken advantage of. When asked for details, the client stated that her friends oftentimes pressure her to complete their homework, as well as often push her to “party in my dorm.” When asked if the client had ever talked with her ‘friends’ about said issues, the client stated that she had not, adding, “it’s not that big of a deal.” Eliza also implies struggle with not being able to go home very often, and her close friends from high school went to college elsewhere, so they are not as close. The client’s support system is completely different at this time in college compared to what she had at home in high school. During the assessment, Eliza was asked to share more information on what she meant by ‘things not coming as easy in college as they did in high school.’ She was teary-eyed and very emotional talking about her grades. She said she achieved good grades in high school, and all A’s during her senior year, “without having to study too much.” She said she never had to attend extra study sessions or tutoring, and she is embarrassed about having to go to tutorials as a freshman in college. The client said, “it was always expected that she would attend the university and pursue a degree in engineering like her brothers and father” and she “never really felt like she had a choice.’ She says she does find the engineering field interesting but stresses out a lot over difficulty of classes. She said her second semester is “even harder than the first” and really worries about maintaining her GPA as she continues in college.
Eliza also elaborated on her family during assessment. She stated that she was the youngest of three children in her family, describing her mother as “kind of controlling” and her father as “a good guy.” She has two older brothers. Neither are married yet and have successful careers as engineers. The client went on to state that her mother required her to call approximately once a week “or else she gets worried,” adding that during high school her mother “was always asking where I was going or what I was doing.” Eliza stated that her parents seemed to have a strained relationship at times, stating, “when I call, I talk to my mom first, and then she hands the phone off to my dad, and he goes into another room to talk with me.” The client also stated that the two frequently complain to the client about the current status of their marriage. In the conversation, the client also acknowledged sometimes feeling as though she were “the middleman” when living at home. The client says she “rarely” hears from her brothers while she is at school, but they visit in person when she can go home. She identified her religious preference as agnostic. The client also stated that her parents are Irish Catholic, even though “they mostly only go to church on Christmas and Easter.”
Discuss the following questions about Eliza.
What’s the Identifying Information?
What’s the Presenting Problem?
Are there any Life Stressors?
Is there Substance Use?
Any Addictions?
Are there any Medical/Mental Health Hx/Hospitalizations/Abuse/Trauma?
Does she have Social Relationships:
Are there any Strengths:
Legal History/Educational History?
Family Information?
Spiritual?
Suicidal/Homicidal?
Has she had a Mental Status Exam (MSE):
