The Case Study of Shamiel

The Case Study of StephanieAssessment in Counseling

Client DescriptionStephanie21 year old African-American femaleOne childSophomore at community collegeJob / family related issuesReceived counseling with Region III

Purpose of AssessmentIntake AssessmentBackground informationThinking about withdrawing from college Depressed about home / social lifeBeck Depression Inventory (BDI-II)Level of DepressionThe Substance Abuse Subtle Screening Inventory (SASSI-3)Alcohol / drug abuse or misuse

Assessment Procedures and ProtocolIntake AssessmentInitial meeting with clientBackground informationBeck Depression Inventory (BDI-II)Conducted during 2nd session with client21 item self report instrument4pt scale ranging from 0-3 for each itemThe Substance Abuse Subtle Screening Inventory (SASSI-3)26 Frequency questions, 67 true / false questions, 10 scales: 2 for questionnaire and 8 for true / false

Medical / Development HistoryNo serious medical issues were reportedDiagnosed with depression last yearCurrently on low dosage medicationReports to Region IIISpeaks with a counselor concerning her academic, career, and family support system

Familial Psychiatric HistoryThe client reported no history of her family members having psychiatric issues. The client did report issues of alcohol and drug use from previous family members.

School / Academic HistoryProblems begin occurring during high schoolMood Changes / Anger issues aggressed after graduating hsFelt abandoned emotionally by her momCurrently enrolled in junior collegeAverage studentFear of withdrawing from collegeTorn between changing majors and continuing with college educationDesires to have a better life plan for herself and her childConsidered the idea of joining the military

Home Behavior / SocialFamily of Origin (mom, step-dad, two brothers, and a son)Oldest siblingDistant relationship with momAcademicCurrently attending community collegeSocial lifeDating sons fatherOccasion fights and argumentsEmploymentCurrently working at fast food restaurant

Assessments Used and Appropriate InterpretationsIntake AssessmentLack of support system at home / career choiceEmotional stress and depressionBeck Depression Inventory (BDI-II)Minimal 0-13, Mild 14-19, moderate 20-28, and severe 29-63Test-retest reliabilityIncreased content validityThe Substance Abuse Subtle Screening Inventory (SASSI-3)

Summary of FindingsIntake AssessmentLack of support system at home / schoolEmotional stress and depression from the strained relationship with her mom and step-dadBeck Depression Inventory (BDI-II)Mild level of depression; score of 16The Substance Abuse Subtle Screening Inventory (SASSI-3)Low Probability on FVA, FVOD, SYM, OAT, SAT, DEF, SAM, FAM, and COR

DSM Diagnosis Axis I Clinical DisordersDiagnosed with depressionAxis II Personality Disorders / MRNo Diagnosis (V71.09)Axis III General Medical ConditionsNone reportedAxis IV Psychosocial / Environmental ProblemsFeels as if her mom sides with her step-dad, no supportive system within her family structure, relationship problems with boyfriend, at a cross road with career / college choiceAxis V Global Assessment of Functioning61-70

Treatment Plan and RecommendationsTreatment PlanMonitor level of depressionContinue counseling sessions with appointed counselorContinue medication RecommendationsEncourage the client to continue her education and seek out a career advisor concerning her career choice. Seek counseling with her mom in order to build a support system with her and her step-dad.

References

Beck, A.T. (1996). Beck Depression Inventory II (BDI-II) American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.Miller, G.A. (1988, 1997). The Substance Abuse Subtle Screening Inventory (SASSI) Manual, Second Edition. Springville, IN: The SASSI Institute.Whiston, S. C. (2009). Principles and Applications of Assessment in Counseling, Third Edition. Cengage Learning.