Assessing Clients Families
In psychotherapy, it is necessary to assess a client’s family background. In this assessment, the psychotherapist determines the client’s family in terms of medical history, family relationships and ties, and the social life of the client’s family. Assessing a client’s family history helps the psychotherapist to understand the client well. The therapist can use this information to draw meaningful conclusions about the client and to understand the client’s source of illness. Through the assessment of a client’s history, the therapists may advise the patient appropriately and treat the patient in a better manner since they understand a patient’s background history. This paper will present an assessment of a client’s family background. The client will be named as Client A for confidentiality purposes. The paper will conclude by drawing the client’s family’s genogram. Client family assessment is essential to the psychological evaluation and treatment of a client.
Part 1: Client Assessment
Demographic Information: Client A comes from a small family. The great grandparents of the client who are both dead had four children who are all gone by now. The client’s grandparents are also gone, and they had three children with one of them being gone. The client’s father and his mother only have two children, a boy, and a girl. The client’s mother has no family history since she was brought up under foster care. The client is male. He has one wife and one concubine with only one child with his wife. The existing family members of the client are his uncle, who is married and has two children, his parents, his sister, his wife, his child, and his concubine. The total number of people sharing blood ties to the client is ten people.
Presenting Problem: Client A has been reported having signs and symptoms that are consistent with Bipolar disorder. These Symptoms are feeling extraordinarily excited and sometimes sad for an extended period, lack of sleep, being restless and impulsive, high-speed speech, being overconfident, and indulging in risky behaviors. These signs are consistent with a mania, which could also translate to Bipolar disorder (Watson, 2020). The client also indicated that sometimes he experiences extreme feelings of sadness and hopelessness to the point that he contemplates committing suicide. He came for therapy to achieve psychological healing for the sake of his son.
History of Present Illness: Client A indicates that he has been having issues with his wife for more than six years now. His wife claims that he is impulsive with a don’t care attitude. Many years down the line, he often lacks sleep and night, making him go out jogging in the middle of the night. This behavior has caused him trouble with his wife. He says that he cannot control his hyperactivity, and most of the time, he is repulsive and engages in risky behavior, putting his life and his family at risk. His grandfather posse’s similar characteristics, and he strongly thinks that he might have inherited those character traits from his grandfather. For five years, client A has noticed his character of hyperactivity increasing to uncontrollable levels.
Past Psychiatric History: The client has no previous psychiatric history. He has not been to a psychologist before this first time.
Medical History: The patient’s medical history has a few instances of notable health hazards. The patient was once diagnosed with obesity. He claims that he started doing exercises and going to the gym to lose weight. He also once contracted severe pneumonia, which he recorded from in a few days. Besides those two cases, the client has not had any critical illness. In his family background, there are several cases of chronic diseases like diabetes, which has affected three people already from his family. There are also cases of high blood pressure and a stroke. His great grandfather died of cancer, but no one else in the family lineage has been diagnosed with cancer. His grandfather as well suffered from obesity. Obesity a condition that can be linked to bipolar disease (Bledsoe, 2010); this increases the chances that the client has bipolar disorder.
Substance Use History: Client A was once a drug addict. He indicates that he started using substances while he was in college. He used light elements, but later, he used cocaine. He records that when he could control his cocaine use, his family took him to a rehab center for one year, where he got clean. Since then, he has not abused any drugs. He currently doesn’t smoke or take alcohol. In his family history, there is no known case of substance abuse. The one time he abused substances could have increased his chances of contracting the bipolar disease (Bledsoe, 2010).
Developmental History: The client did not have any developmental challenges as he was growing up. He says that his parents used to describe his childhood as a healthy one. He was, however, a very active and bright kid. At some points, he was hyperactive, but he did not bother his parents much. There have not been any major developmental cases among children in his family background. There could be a possibility that hyperactivity was an early symptom of bipolar I (Daniel, 2017).
Family Psychiatric History: He, however, indicates that his grandfather used to have psychiatric visits regularly. He was too young to understand why, but he remembers that his grandfather visited the psychiatrist periodically. There is no other mental record in his family that he is aware of. His father, his mother, and his sister have also not visited a psychiatrist.
Psychosocial History: Client A has exhibited psychosocial disorders. He showed high qualities of excessive excitement and enthusiasm. The patient is most of the time in high spirits, which is above the normal levels. A few times, the client is gloomy, and he completely shuts himself out of society. These psychosocial characteristics are similar to bipolar disorder characteristics.
History of abuse or trauma: The client has no previous history of injury or trauma. The client has reported having a happy and healthy childhood. The client did not even undergo abuse or any traumatic events even during his adulthood. The client’s family as well has not had any major traumatic events affecting them.
Review of Systems: There was no notable problem in the client’s body systems. The client was put through several checkups, but no problem was observed within the patient’s body. The lack of any issues in the patient system rules out the possibility of other diseases in the patient’s body.
Physical Assessment: The client physically appeared to be extremely excited and happy. He was restless, and in the course of the session with him, he kept fidgeting on his seat. The client’s speech was a little bit faster than usual. These physical characteristics are similar to those of a bipolar patient, especially on the pace of the client’s statement (Watson, 2020).
Mental Status Exam: The mental status exam for the patient showed that the patient was unstable. The patient was unsettled mentally and not able to settle for a long time. The patient shows showed symptoms of having excess energy levels and hyperactivity.
Differential Diagnosis: The patient can be diagnosed with bipolar. The symptoms exhibited by the patient are mostly similar to those of bipolar one. The patient has shown many signs of manic episodes like sleeplessness, overexcitement, and excessive energy levels, racing thoughts. The patient is most likely to be suffering from Bipolar 1. Other tests performed on the patient have ruled out the possibilities of the patient having other illnesses. It can be therefore concluded that the client is suffering from bipolar 1.
Case Formulation: The case formulation for the client indicates that the patient is suffering from bipolar one disorder. The patient has exhibited manic characteristics like over excitement, lack of sleep, running thoughts, fast speech pace, and being over-energized. These symptoms indicate that the patient has the bipolar one disorder. The cause of the disease is from inheritance. In the patient’s records, he suggests that his grandfather had similar characteristics as his. He also noted that his grandfather visited a psychiatrist regularly. This shows that the patients, the condition comes from inheritance. The patient is at an advanced stage of the disorder. Early symptoms were first noticed when the patient was a child through the patient’s hyperactivities. The patient is now at the superior level of the disease. The patient needs serious attention.
Treatment Plan: Client A requires going through a medication plan. Bipolar disease is a lifelong disease that will require the client to be under medication throughout. The patient should be put under different kinds of drugs. The first type of drugs that the client needs to be put through is the mood stabilizers. They will help the patient to have average moods that are not so high and not so low. Anti-convulsions are part of the medication that is used for mood stabilization. The client will also require to be put under antidepressants (Marcia, 2020). These medications will help the client to reduce his level of stress. Finally, the client will require a prescription to slow down his energy levels and hyperactivity. These medications offered to the client are applicable for a long time. Their purpose is not to heal the patient, but instead, they are supposed to stabilize the patient and to make him cope well in the environment.
Client’s Family Genogram
The patient, in addition to medication, should also undergo different kinds of therapy. The first recommended therapy is cognitive-behavioral therapy. Scholars under this kind of treatment argue that manic sessions are caused by being too positive (Geddes and Miklowitz, 2013). Through this therapy, the patient will learn how to control his thoughts as advised by the therapist. The client should also undergo family therapy. Family therapy is dome to the patient and the patient’s family members (Geddes and Miklowitz, 2013). This therapy helps a client and his caregivers to learn how to associate with each other and have a mutual understanding. Family therapy focuses on interpersonal relationships with the client and problem-solving strategies. This therapy is vital for the welfare of the client. Finally, the patient needs to go through group psychoeducation. This therapy has proven useful to bipolar patients after a long period. This therapy equips the patient with more knowledge on how to handle situations.
Clients Family Genogram
Bipolar
| 35 |
| 29 |
| 3111 |
| 4 |
Conclusion
Assessing family relationships is essential in determining the health conditions of a patient. Some health problems experienced by people can trace back to their family histories. Through evaluating the family background of a patient, the caregivers may gain more relevant information about a client. The information on the family background can help a doctor to determine risk factors for a client. It is, therefore, necessary to assess the family background for a client.
This paper assesses the background of a patient A. The patient suffers from symptoms that are similar to bipolar 1. These symptoms are like hyperactivity, running thoughts, lack of sleep, overconfidence, and extremely high and low moments. After assessing the family background of the patient, it occurs that the patient’s family history has a case of bipolar 1. The client has high-risk factors for bipolar one due to family history. The paper even draws the client’s genogram. The article indicates the process and importance of assessing a client’s family history.
References
Bledsoe, A. (2010, Feb 12). Conditions linked to bipolar disorder. [Blog post] Retrieved from https://www.everydayhealth.com/hs/bipolar-depression/bipolar-disorder-comorbid-conditions/
Daniel, K. (2017, Jan 04). Bipolar Disorder in Children: Is that possible. [Blog post] Retrieved from https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/expert-answers/bipolar-disorder-in-children/faq-20058227
Geddes, R & Miklowitz, J. (2013, May 11). Treatment of bipolar disorder [Blog post] Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3876031/
Marcia, P. (2020, March 4). Treating bipolar disorder. [Blog post] Retrieved from https://www.verywellmind.com/treating-bipolar-disorder-3576129
Watson, K. (2020, Feb 13). Could it be a bipolar disorder? Signs to look for [Blog post] Retrieved from https://www.healthline.com/health/could-it-be-bipolar-signs-to-look-for