In Week 3, you developed a biopsychosocial assessment based on a client in the case study document from Week 1. In this assignment, you will use evid

2

Biopsychosocial Assessment

Student’s name

Institutional affiliation

Course name

Professor’s name

Due date

Biopsychosocial Assessment

Date: [Insert Date Here]

Client Name: Emily Jones

Referral Source: Self (Prompted by Husband)

DOB: [Insert DOB Here]

Demographics:

Emily Jones is a 35-year-old White, married, cisgender, heterosexual female residing with her husband, Jack, and their two children, Pete (8) and Taylor (10). Emily identifies as Christian and has been heavily involved in her church. She is employed part-time as an accountant and holds a master’s degree. The family’s church community is a significant part of their lives. However, Emily’s engagement with the church has recently been a source of familial tension due to conflicting views on mental health treatment.

Presenting Problem and History of Symptoms:

Emily was brought to therapy by her husband, Jack, who has expressed significant concern regarding Emily’s erratic behaviors. Jack threatened to divorce her if she did not seek help, and Emily herself acknowledged attending reluctantly. Over the past few weeks, Emily has shown signs of elevated energy, staying awake for days and displaying behaviors she perceives as highly productive. She describes her current mood as the best she has felt in a long time, during which she has read the Bible cover to cover, completed a substantial work project, and cleaned her house extensively. However, her husband and children report distress over Emily’s recent behavioral changes. Jack describes Emily as irritable and prone to anger, especially if he or the children do not meet her expectations. Emily has missed obligations for her children’s extracurricular activities, and her behavior has impacted her children emotionally, with Pete avoiding her and Taylor reporting discomfort with Emily’s sudden interest in activities typically suited for a younger child.

In addition to her current high-energy episode, Jack mentions that Emily experienced a low mood two weeks prior, during which she struggled to get out of bed and engage in daily self-care. Jack shared that these episodes of fluctuating moods have increased in frequency and intensity over time. Emily’s past also includes a hospitalization at age 15 due to depression, where she engaged in self-harm as a coping mechanism. She continues to experience intermittent suicidal ideation and occasional cutting to alleviate stress. However, she asserts she would not harm herself due to her religious beliefs and commitment to her children.

History of Mental Illness and Previous Mental Health Treatment:

Emily’s mental health struggles date back to adolescence when she was hospitalized for depression at 15. Her self-harming behaviors were noticed by her parents, who initially believed she had attempted suicide. Although Emily denies having had suicidal intentions at that time, she reported using cutting as a way to cope with emotional distress. During her hospitalization, she was prescribed Prozac, which she found ineffective and unhelpful. Emily eventually ceased the medication after leaving for college, feeling her parents’ control over her mental health decisions had lessened. Since then, she has not sought formal mental health treatment. Despite occasional suicidal thoughts and continued self-harming behaviors, Emily is adamant about not seeking psychiatric help, expressing distrust of medical professionals.

Medical and Physical Health History:

Emily has a medical history of hypothyroidism and is on prescribed medication for the condition. No history of other chronic illnesses, major surgeries, or recent traumatic injuries was reported. Jack reported that Emily is resistant to the treatment with health providers despite her depressive symptoms. Her high-energy/sleepless mood states during her manic episodes may exacerbate her thyroid condition, although there have been no reported recent examinations or medication adjustments.

Family History:

Emily describes her childhood as strained. Her family dynamics were sometimes difficult. Emily was raised with one younger sister- the “golden child.” She had a contentious relationship with her parents in that her mother was strict primarily and critical of her. Emily reports she felt unsupported by her father, as he worked a great deal and rarely, if ever, participated in discipline. Her mother, too, being an educator in the same elementary school where Emily was enrolled, had high expectations from her academically and would always show disappointment due to struggles at school. She attributes this struggle during her childhood years-including bullying and her performance at school, the expectations imposed on her by the family, and the lack of emotional support. Recently, she has had disputes with her sister, who advised her to seek mental health care. She rarely sees her.

Social History:

Emily reports a complicated social history, stating that she has struggled to maintain successful friendships. Her distrust and/or fear of abandonment limit dependent connections; hence her past relationships were short-lived. Despite having a few childhood friends, she has struggled to maintain them. Currently, her social world is small; however, she does have acquaintances through her church community and as an accountant. Her distrust toward coworkers and feelings of isolation contribute to her sense of disconnection from others. Her behaviors over the last few months have created tension among her religious community within the church, especially because many clergy have advised against her seeking treatment for her mental health.

Client Strengths and Protective Factors

The positive aspects of Emily’s situation include her education, part-time employment as an accountant, and her work with the church. She has struggled with establishing and maintaining a support system; her current support includes herself, her husband, Jack, and the church, which, at this time, is serving more as a source of stressors. One key protective feature is the concern for her children, as she emphasizes being there for the children. Although religious considerations have been a factor for Emily in resisting the search for formal treatment for her mental health, they provide a foundation of hope and resilience.

Diagnosis: F31.9 Bipolar I Disorder, Unspecified

A probable working diagnosis is F31.9 Bipolar I Disorder, Unspecified. Emily experiences periods of high energy, decreased need for sleep, and excessive productivity, followed by depressive episodes where she avoids basic self-care. Her elevated mood, impulsivity, irritability, and grandiosity during these highs, coupled with her history of depression and self-harm, indicate bipolar traits. These mood swings disrupt family life, reflecting classic characteristics of Bipolar I Disorder (National Institute of Mental Health, 2024).

Treatment Recommendations and Referrals

Recommended treatment could be individual therapy, family counseling, psychoeducation, follow-up with primary care, and community support. It will be useful to initiate Emily with Cognitive Behavioral Therapy for mood fluctuation, interpersonal issues, and self-harming behaviors. Family counseling sessions with Jack should be recommended to address marital stress and family dynamics and improve communication (Gupta & Ganguly, 2020). Psychoeducation can raise Emily and her family’s awareness about the signs of mood disorders and the available treatments, with the aim of reducing the stigma associated with mental health services (Bahrami & Khalifa, 2022). Emily can also discuss her thyroid problem with her primary care doctor because, as for any other patient with hypothyroidism, her condition may be affected by mood and sleep changes. Additionally, the patient should be referred to a faith-based support group consisting only of her religious background to embrace mental health intervention.

Summary

Emily Jones is a 35-year-old White, married, cisgender, heterosexual female and mother of two who was referred for psychotherapy by her husband, Jack. Emily’s symptoms reflect a mood disorder with high mood, hyperactivity, and sleep disturbance, followed by low energy and motivation. Her disease appears to be cyclical due to mood fluctuations that impair daily life, relationships, and parenting. Emily has struggled with depression as an adolescent, self-harm, and familial troubles. Her inability to trust doctors and recent denial of her husband’s concerns about her behavior complicate treatment. Despite these hurdles, Emily’s family, religion, and commitment to her children provide a framework for therapeutic intervention. Emily’s intense activity, lack of sleep, and unpleasant mood may indicate Bipolar I Disorder. Emily’s refusal to take medication or mental treatment may limit her treatment options, requiring family and psychological assistance.

References

Bahrami, R., & Khalifi, T. (2022). The effect of psycho-education on the affiliate stigma in family caregivers of people with bipolar disorder. SAGE Open Nursing, 8, 237796082211321. https://doi.org/10.1177/23779608221132166

Gupta, E., & Ganguly, O. (2020). Effectiveness of family therapy on poor communication and family relationship: an intervention study. National Journal of Professional Social Work, 21(1), 27. https://doi.org/10.51333/njpsw.2020.v21.i1.240

National Institute of Mental Health. (2024). Bipolar Disorder. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/bipolar-disorder

Last Completed Projects