Psychosocial Assessment Part One
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Grand Canyon University *
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640
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Arts Humanities
Date
Feb 20, 2024
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docx
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Uploaded by ChancellorIceStingray40
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Psychosocial Assessment: Part One
Taylor McLean
Department of Humanities and Social Sciences: Grand Canyon University
PCN-640: Specialization in Professional Counseling Dr. Alice Crawford
December 6, 2023
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Psychosocial Assessment: Part One
Psychosocial Assessment Form:
Client Name
: Kelly Date:
12/6/2023 DOB:
11/14/2012
Age:
11 Start Time:
2:00 pm End Time:
3:00 pm
Identifying Information:
Client, Kelly, is an 11-year-old female who lives with her 32-year-old divorced mom, Dori, who is employed as a receptionist at a local salon. Kelly and Dori live in an apartment located near Dori’s job.
Presenting Problem:
Kelly is currently struggling with fear and panic during her bus ride to and from school as she was sexually assaulted by a peer about 3 months ago. Kelly now wears baggier clothes, withdraws from friends and is falling behind on classwork due to skipping school. Kelly reported
that she feels like it is her fault for what happened to her and for her mom drinking more and feeling sad. Kelly reported that she craves peace and quiet and just wants to be alone. Life Stressors:
Kelly’s mom, Dori, currently earns a low salary and does not receive any financial support from Kelly’s father. This could potentially cause difficulties in meeting basic needs; however, it is noted that Kelly’s mom has been managing to support Kelly and herself without the assistance from Kelly’s dad. Kelly was sexually assaulted on her bus that she takes to school which resulted
in a court session that led to the boy returning to school. She reported feeling “dirty” and that it was her fault. With this, she has also been skipping school which has resulted in her falling behind in classwork. Kelly is also spending more time with her Grandma Iris and cousins as her mom “never gets out of bed.” Kelly reported feeling like this was her fault since her mom’s
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behavior change started to occur after the trial. Most recently, Kelly could not get a hold of her mom and waited hours for her to return home. Kelly reported that her mom had disheveled hair, ripped clothes, smeared makeup and was crying. Kelly reported helping clean her mom up and helped her to bed where she stayed for days and stated that she feels her mom is sad because of what happened to Kelly after school. Substance Use: ☐
Yes
☒
No
Kelly does not currently engage in substance use or abuse. However, there may be a family history of alcoholism as Kelly reported “All she does is drink wine and watch tv” in regard to her
mom. Process Addictions (i.e., gambling, pornography, video gaming)
No process addictions reported at this time. Medical/Mental Health History/Hospitalizations:
No medical or mental health history was disclosed by Kelly or her mom at this time. No hospitalizations were disclosed at this time. Abuse/Trauma:
Kelly’s father left when she was one year old, and he has not been involved in her upbringing. Kelly’s grandfather died in a car accident years ago. Kelly reported that an older boy she had a crush on touched her and forced her to perform “unclean” acts on him after school about 3 months ago. With this, she attended a court session that left her feeling “dirty” and that it was her
fault. The boy has returned to school. Kelly is aware that her mom has been drinking a lot and is feeling sad. Kelly did not know where her mother was recently for an extended period of time in which she came home with ripped clothes, smeared makeup, and crying.
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Social Relationships:
Kelly spends a lot of time with her Grandma Iris and cousins, Jolene, and Shannon during the afternoon or on weekends. Kelly reported that she has recently had a sleepover with a few friends she still knows on social media and her cousins. Since the sexual assault, she has not been attending school and has been withdrawing from her friends.
Family Information:
Kelly lives with her mom, Dori, who is 32 years old. Kelly does not have a relationship with her father, and he has not been involved in her life since the age of one. Kelly’s only male figure was
her grandpa who died a years ago in a car accident, he was described as “loud” and “angry.” Kelly has three uncles that she sees during Christmas and Thanksgiving. Kelly spends most of her time with her Grandma Iris, Dori’s mother, and her cousins Jolene and Shannon. Spiritual:
Kelly states that when she skips school, she will go to her Grandma Iris’ church and help the custodian or sit and draw. No other indication towards spirituality was noted. Suicidal:
Kelly did not report any suicidal ideations, plan, or intent. Homicidal:
Kelly did not report any homicidal ideations, plan, or intent.
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Summary:
Based on the information provided, Kelly has experienced many adversities in her life thus far. She has limited knowledge of her biological father as he left the family when she was one and her mom does not talk about her father to her. This could potentially lead to attachment issues and/or difficulties, along with her not having a consistent and healthy male role model in her life.
Considering the sexual assault she experienced her behaviors, thoughts and feelings are indicative of a trauma response. This has led to changes in how she feels about herself, how she interacts with others and her ability to be present in school. Kelly has also taken on a caregiver role within her relationship with her mom as she had reported that all her mom does is drink wine and watch tv. Kelly has good awareness of when her mom’s behavior started and feels as though it is her fault since the behavior started right after the trial. Kelly being in this caregiver role, she took care of her mom when she returned home after not knowing where she had been for hours. This experience added to Kelly feeling guilty about the sexual assault and a contributor to why her mom is sad. When a child is put into a caregiver role, intentionally or not, it causes them to grow up at a faster rate and takes away from her ability to be a child. The recent
experiences with her mom could also cause strain in their relationship. Despite Kelly’s adversities, she has been managing her experiences to the best of her abilities, this includes going
to her grandma’s church to help the custodian or sit and draw. She has a good support system within her relationships with her Grandma Iris and cousins Jolene and Shannon. Kelly appears to
care deeply about others and takes on the responsibility of others. Diagnosis: F43.10 Posttraumatic stress disorder, without dissociative symptoms
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Kelly’s current feelings and behaviors are fairly typical of posttraumatic stress disorder. Based on the information provided, Kelly has directly experienced a traumatic event as she was sexually assaulted by a peer after school. She experiences struggles with fear and panic during her bus ride which is an indicator of intense psychological distress at the exposure to internal or external cues the symbolize or resemble an aspect of the traumatic event. Kelly has been skipping school since her court date that resulted in the peer returning to school, being an indicator of avoidance of external reminders that arouse distressing memories, thoughts, or feelings about or associated with the traumatic event. She experiences distorted cognitions about the cause or consequences of the traumatic event that lead her to blaming herself. Kelly experiences exaggerated negative beliefs about herself as evidenced by her stating that she feels “dirty.” Prior to the cour session, Kelly had been falling behind in school which could be an indicator of problems with concentration. With this, Kelly has engaged in reckless behavior as she has been skipping school regularly. The disturbance that Kelly has been experiencing has lasted more than one month and has been causing significant distress and impairment in social, occupational, and other critical areas of functioning. Due to the direct exposure to actual or threatened death, serious injury, or sexual violence (criterion A), timing, and meeting all other criteria of PTSD this would rule out both acute stress disorder and adjustment disorder(s). There are some features of major depressive disorder (MDD) present such as withdrawal from friends, wanting to be alone (isolation), and feelings of excessive or inappropriate guilt, however this diagnosis was not offered as there was not enough information provided. It would be encouraged
to monitor the symptoms and behaviors to decide if this would be an appropriate diagnosis.
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Plan: Moving forward, it would be beneficial for a treatment plan to be created to address Kelly’s current symptoms and provide a safe place for her to process thoughts, feelings and emotions surrounding her adverse experiences. The clinician working with Kelly should be high in Rogerian conditions such as empathy, genuineness, caring and unconditional positive regard. Interventions to consider would be Person-Centered therapy, Eye Movement Desensitization and
Reprocessing (EMDR), Attachment-Based Family therapy, and trauma informed therapy. Initially starting off with individual therapy will provide Kelly with the opportunity to process her adverse experiences and manage symptoms. Once she has become comfortable with this and has noticed a decrease in symptoms, family therapy could be considered due to the discord within her family and providing her with a safe space to process how she feels.