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Constant 1

Abigail Constant
Bio-Psycho-Social Assessment
February 18, 2014
Introduction
Casey Nelson (pseudonym) is a 21 year old, single, Caucasian female. She is currently studying
psychology at Western Michigan University. In addition to attending school, she works as a
nanny five days a week. She lives in a house with four other college age females. She is currently
going through a break up with her boyfriend of three years. She has very little support from her
friends and roommates and is suffering from anxiety and mild depression. Her grades have
started to decline as a result of this anxiety and depression.
Family of Origin History
Caseys mother, Elaine (pseudonym), was 40 years old when Casey was born. Her father, Walter
(pseudonym), was 46. They were married at the time of Caseys birth. At the time of Caseys
birth, Elaine and Walter already had one child together named Courtney. Courtney was four
years old when Casey was born. Both of their pregnancies were planned. Walter has five
children from two previous marriages. Mark (pseudonym) is Walters first born; he is currently
49 years old and lives in Georgia with his wife and two children. Mark is an electrical engineer.
Anne (pseudonym) is 45 years old living with her husband in South Carolina. Anne is a
journalist. Marie (pseudonym) is 39 years old living in Georgia with her husband and three
children. Marie is a homemaker. James (pseudonym) is 32 years old and lives in California with
his girlfriend. James is high school teacher. Tyler (pseudonym) is 30 years old living in Alaska.
He is in the military. It is unknown if the pregnancies of Walters children from his previous
marriages were planned. Casey has a positive relationship with all of her half-siblings.
Walter and Elaine divorced in 2011 due to irreconcilable differences. They had an amicable
divorce and continue to have a friendly relationship. Elaine is currently 61 years old; Walter is
67 years old. Casey grew up in a happy, supportive household. Her family was very united and
close. Her family did not celebrate many holidays because they had no religious affiliation.
Christmas was spent with the immediate family. The holiday included gift giving, a large
breakfast, movie watching as a family, and a festive dinner. Casey expressed that the only other
celebrations were birthdays which were celebrated with a dinner chosen by the person with the
birthday. Walter and Elaine both have doctorate degrees in orthodontics. Courtney has a
bachelors degree in communications and public relations. Walter, Elaine, and Courtney are all
in good physical health. Elaine has a history of depression however Casey did not know how this
depression had been treated.
Casey has not experienced a death of a close family member. Elaines estranged brother passed
away in 2012. Due to Elaines relationship with her brother, Caseys family did not acknowledge
or dwell on his passing.
Developmental History
Casey had very little knowledge about her developmental history. Elaine had a normal pregnancy
length. Casey had no knowledge of any possible problems that might have occurred during the

Constant 2
pregnancy. Elaine had a C-section when giving birth. It is unknown if Casey was breast or bottle
fed or if she had any feeding issues. Prior to walking, she was at an above average weight which
was resolved when she increased her mobility as a toddler. Casey was never told that she had any
developmental delays. To her knowledge, she had a very average and normal development.
Health History
At birth, Casey was very healthy. As a toddler, she suffered from chronic ear infections. She
stated that she almost needed surgery on her ear tubes but fortunately, the infections began to
lessen. At age seven, she broke her wrist when she fell off her bike. In her adolescent years, she
frequently suffered from sinus infections and strep throat. Consequently, she had her tonsils
removed. Casey had surgery on her upper jaw to fix an orthodontic problem. At age fifteen, she
had mononucleosis for five weeks. As an adult, she had her wisdom teeth removed. Casey has
always been slim and has maintained a healthy weight and figure. Her family has a history of
heart disease, diabetes, dementia, and depression. She had her first menses at age fourteen. She
has used birth control pills since age sixteen and is currently using Loestrin 24 Fe. She is also
prescribed a low dose of Ativan for her anxiety and Cymbalta for her depression. She has no
allergies to medications.
Relationship/Sexual History
As a child, Casey had a lot of friends. She was very close with two girls who were also her
neighbors. They were close friends through high school but have since lost touch. Casey
expressed that she struggled with making friends in high school and that she only had a few close
friends. As a college student, she joined a sorority at Western Michigan University and has made
many friends and enjoys the socialization that she has experienced. Her friendships typically last
for a long period of time and only come to an end as a result of physical separation (i.e. going
away to college, moving away from home, etc.) Casey is heterosexual and began dating at age
sixteen. She had her first sexual experience when she began her first relationship at age sixteen.
She stated that she has no problems with her sexuality but did not feel comfortable discussing
intimate details. Recently, she had been in a serious relationship for three years. Her boyfriend,
Chris (pseudonym), broke up with her a month ago. She has started dating other people but is not
currently in a sexual relationship. Since she became sexually active at age sixteen, she has been
on birth control. Casey stated that she and her previous boyfriend did not use any other forms of
protection but feels that protection with a new partner would be necessary. She has no history of
sexually transmitted diseases.
Family of Creation History
Casey has only been in one long term committed relationship. As mentioned above, this
relationship with Chris recently ended. She has never been married. She does not have any
children and has never been pregnant. Casey and Chris had been dating for three years. She
stated that she was not surprised when he broke up with her because their relationship had been
breaking down for several months. She explained that Chris enlisted in the army which caused a
significant amount of stress on their relationship. Prior to his enlistment, she was very satisfied
with their relationship however, their lives started to go in different directions, causing the

Constant 3
breakup. She has never experienced any form of abuse in her relationships. Casey expressed that
she does want to get married and start a family in the future when she finds to right person.
Mental Health History
Casey explained that in her adolescent years especially, she struggled with her mental health. At
age seventeen she attempted suicide by over dosing on Xanax. She stated that she had a lot of
anxiety due to her lack of strong friendships while going through high school as well as the
pressure she felt to make good grades. She clarified that she had never taken Xanax before the
attempted suicide and does not have any history of substance abuse. Caseys mother found her in
time to get her to the hospital where she received treatment and psychiatric care. She was
diagnosed with anxiety and depression, which were treated with medication. Although she did
not like the medication because of the way it made her feel, she admitted that it significantly
helped her to move past the worst of her anxiety and depression. Casey was able to wean off of
her medications after using it for one and a half years when she started college. However, she
began seeing her psychiatrist again when she moved into her sorority house. Upon her move into
the house, she felt an increase in anxiety simply because of the living situation that she was
exposed to. With the help of the anti-anxiety and antidepressant medications, she was once again
able to stabilize and voiced that she is doing and feeling much better about her mental health.
Casey does not have any history of legal problems, financial problems, or immigration issues.
She explained that she is generally happy with her life despite her battle with anxiety and her
recent breakup.
Prioritizing the Problems

Suffering from anxiety and depression as a result of her recent break up


Lack of communication with friends and family
Declining grades and participation in school

Translating Problems into Needs

Suffering from anxiety and depression as a result of her recent break up Needs
counseling to determine severity and if medication is needed
Lack of support from friends and family Needs resources to improve communication
skills
Declining grades and participation in school Needs contact to Western Michigan
University Academic Resource Center and services provided by the school

Evaluating Levels of Intervention

Micro

Pros
Depression and Trains client to
anxiety; lack of identify problems and
communication to come up with
with friends and realistic solutions;

Cons
Deals with the
here-and-now
symptoms, may
not be best if

Strengths
Client is
willing to put
in work to
improve her

Constant 4

Mezzo

family
Problem
Solving
Therapy
Declining
grades
Supplemental
Instruction and
Seminars

deals with everyday


problems; can also
help with
communication skills
SI provides client with
extra instruction for
individual classes;
seminars provide
training to improve
studying and time
management skills

symptoms
continue

Not individual
assistance,
client has to
rely on herself
to improve
work ethic

situation;
Client is
willing to
seek help;
Client wants
to improve
her
relationships;
Client wants
to improve
her grades

Macro

Developing Goals, Objectives, and Tasks


I.

II.

III.

Goal #1 Clients goal is to reduces her symptoms of depression


a. Objective #1 Meet with a psychologist who can conduct Problem-Solving
Therapy
i. Task #1 Using the list of psychologists provided to client, the client will
call different offices tomorrow to schedule an appointment
ii. Task #2 Client will schedule an appointment and will call me tomorrow
to let me know when her appointment is and to discuss her next steps.
b. Objective #2 Begin Problem-Solving Therapy
i. Task #1 Once therapy begins, client will set up a schedule with the
psychologist and will attend all sessions
ii. Task #2 Client will report progress to both psychologist and to me in
order to keep track of the clients progress.
Goal #2 Clients goal is to improve her relationship with her family, particularly her
mother and sister
a. Objective #1 Make plans with her mother in order to spend time together
i. Task #1 After scheduling appointment with psychologist, client will call
her mother tomorrow and set up time to have lunch together. When client
calls to report her appointment time, she will also report when she will be
meeting with her mother.
ii. Task #2 Client will find a place to have lunch with her mother.
b. Objective #2 Make plans with her sister in order to spend time together
i. Task #1 Client will also contact her sister to ask if she would like to see
a movie together. She will report to me if they make plans and we will
discuss further steps.
ii. Task #2 Dependent on clients sister; if they decide to see a movie,
client will find a movie for them to see. If they do not decide to see a
movie, client will discuss other ways to open the lines of communication
with her sister.
Goal #3 Clients goal is to improve her grades

Constant 5
a. Objective #1 Meet with professors to determine if client can make up missing
assignments
i. Task #1 Starting on Monday morning, the client will meet with her
professors after classes to discuss the possibility of making up assignments
and extra credit. At the end of the week, the client will call me to report
how the meetings went and to create a schedule for completing
assignments.
ii. Task #2 Client and I will work together to create a schedule to complete
any make up assignments, extra credit opportunities, and current
assignments. Client will follow the schedule and report to me weekly to
discuss progress.
b. Objective #2 Utilize resources offered by the Academic Resource Center
i. Task #1 Client will go to Academic Resource Center on campus on
Wednesday to find a schedule of seminars. During next appointment, the
client and I will discuss which seminars would be best to attend.
Task #2 Client will attend the seminars that we determine to be necessary. During our
appointment following the seminar, we will discuss how the client can use the information in
order to improve her