assessing client families practicum

Assignment 1: Practicum – Assessing Client Families
Learning Objectives
Students will:
Assess client families presenting for psychotherapy
Develop genograms for client families presenting for psychotherapy
To prepare:
Select a client family that you have observed or counseled at your
practicum site.
Review pages 137–142 of Wheeler (2014) and the Hernandez Family
Genogram video in this week’s Learning Resources.
Reflect on elements of writing a comprehensive client assessment and
creating a genogram for the client you selected.
The Assignment
Part 1: Comprehensive Client Family Assessment
Create a comprehensive client assessment for your selected client
family that addresses (without violating HIPAA regulations) the
following:
Demographic information
Presenting problem
History or present illness
Past psychiatric history
Medical history

Substance use history
Developmental history
Family psychiatric history
Psychosocial history
History of abuse and/or trauma
Review of systems
Physical assessment
Mental status exam
Differential diagnosis
Case formulation
Treatment plan.

Part 2: Family Genogram

Develop a genogram for the client family you selected. The genogram
should extend back at least three generations (parents, grandparents,
and great grandparents).

SAMPLE
Part 1: Comprehensive Client Family Assessment
ï‚· Demographic information
The M.S family is a biracial family of 3, consisting of the mother and her two-mixed teenage
daughter. The mother is a Caucasian female, 35 and the daughters are mixed black and white, 17

and 16 years of age. However, in this family session, the mother’s younger sister, 33 (the
daughter’s aunt) was also present for the meeting. They recently started their family therapy
sessions as of the beginning of the month.
ï‚· Presenting problem
The family has started family therapy at the request of the two daughters who are extremely
concerned about their mothers continued drug and alcohol habits and her new relationship. In
these sessions they have been accompanied by their aunt (Mother’s younger sister) who also
shares the same concerns as the children. The oldest daughter suggested they seek counseling
after her mother expressed her and her new boyfriend’s desires to have another baby. Both
daughters agree that this is not a good idea for their mother at this time, especially due to the fact
that she continues to use and abuse drugs and alcohol and neither of them are financially stable.
ï‚· History or present illness
M.S. (The mother) currently suffers from drug and alcohol addiction. She has an extensive
history
ï‚· Past psychiatric history
There is no reported psychiatric history with the presenting members of the family to include
M.S. M.S reports that she was supposed to have gone to check herself into a hospital for
evaluation but changed her mind. She enrolled in a rehab center where she was diagnosed with
Cannabis abuse, unspecified.

ï‚· Medical history
No noted medical history for the daughters, however MS has a medical diagnosis of Essential
Hypertension, Reflux Esophagitis, and Obesity
ï‚· Substance use history

M.S.’s daughter’s and sister all deny any history or present substance use. M.S admits to a
history and present use of substances to include: Cocaine, Methamphetamine, speed and
Marijuana. She reports that at this time she only smokes marijuana and denies current use of any
of the other drugs. However, M. S’s daughters’ believe that she is doing more than just the
marijuana.
ï‚· Developmental history
Both daughters report to be progressing well in school with passing grades. The oldest has made
the principles list throughout high school and accredits her success to the fact that “I study a lot
and stay after school with study groups to block out my thoughts of what’s going on at home and
to avoid having to go straight home.” The sister reports graduating from high school and
enrolling in college with a major in early childhood development of which she recently
graduated from and is now teaching at an Elementary school in town. M.S. reports that she
dropped out of school in the 9 th grade and never went back to obtain a GED. She has no other
schooling at this time but reports that she never attending any special-Ed classes or had any
developmental issues. M.S reports, “I just didn’t like going to school, it interfered with all my
fun.”
ï‚· Family psychiatric history
M.S and her sister report that their mother was diagnosed with Major depression after separating
from their father and was later diagnosed with Bipolar disorder and was medicated with
Depakote and Lithium. M.S also reports that her brother (29) was also diagnosed with bipolar
disorder and that the last time before they lost contact he was living in California and had been
admitted to an inpatient psychiatric hospital after coming off his medications. M.S reports that
she has no spoken to her brother in about 3 years and is not sure of his whereabouts at this time.

ï‚· Psychosocial history
All members of the family appear to be alert and oriented. In no acute distress. M.S presents
calm and cooperative at this time. She is quietly listening to the concerns of her daughters and
sister, and visibly emotional as a response to their tearful emotions. However, she presents
without any delusional thinking at this time. Her thoughts are logical, goal oriented and
congruent with the current situation, but she lacks insight and judgement on the problem at hand
as she feels that there should not be an issue with her wanting to have a new baby and start a
family with her new boyfriend and she believes that she does not have an addiction problem and
states “I do drugs only when I want to, not because I have to.” She denies having any delusional
thoughts or thoughts of suicide and does not exhibit any signs or behaviors that would be
indicative of auditory or visual hallucinations. M.S speaks fluent English, but sometimes
struggles to find the right word to express what she is trying to say. She expresses her reason for
wanting to have another baby due to the fact that she “wants to enjoy being pregnant being with
the father of her child and actually being together to raise the baby”. MS feels that since she had
to raise her other two children by herself with the help of other friends and relatives, that she was
deprived of the opportunity to have a real family.

ï‚· History of abuse and/or trauma
M.S. has an extensive history of drug and alcohol abuse. Both daughters and sister deny any drug
or alcohol usage at this time. There are no reports of abuse noted. The daughter’s voice that they
only feel “lonely, unloved and neglected” due to their mothers overwhelming addiction to drugs
and her lack of parenting and or spending time with them.
ï‚· Review of systems

All systems noted to be without normal limits for all family members at this time.
ï‚· Physical assessment
The family appears to be well nourished, well developed, dressed appropriately,
cooperative, and no signs of physical distress noted. However, M.S was wearing an oversized
jacket that was zipped all the way up that she refused to take off. Their hygiene looks to be good
and they appear well kempt. M.S however has yellowish brown stained teeth and is missing 3
teeth noted to the upper right side of her mouth. The daughters appear appropriately dressed and
well cared for as they report their aunt helps them a lot of times to get new clothes and things
when their mother can’t afford it. The two daughters appear to be very close to one another and
“were all each other has and we just want our mother to love us like we love her enough to put
the drugs down for good.” The aunt agrees with the girls and states “My sister used to be my
everything, the one I looked up to when my mother was going through her problems until she got
in the streets and for a while I felt like I had nobody.” The sister reports however that she
recently married her boyfriend from college and is happy at home.
ï‚· Mental status exam
The family appears to be mentally stable at this time. All members are alert and oriented to
names, place, time and current situation. All are fluent in English and seem to have logical
thought processing that is able to comprehend what is currently being asked of them as evidence
of them answering all question appropriately. The mood in the room at this time is sad and
depressing as all are expressing their feelings of hurt, worry and pain. Affects are appropriately
changing with moods and tones fluctuate throughout the session. All members are average height
and seem to have average intellectual functioning. They appear to be independent with all ADLs
and have a mindset that is able to care appropriately for themselves.

ï‚· Differential diagnosis
Sever Unknown Substance Use Disorder 304.90 [F19.20]
Moderate Cocaine use disorder 304.20 [F14.20]
Mild Methamphetamine use Disorder 305.70 [F5.10]
Unspecified Alcohol-Related Disorder 291.9 [F10.99]

ï‚· Case formulation
The M.S family is a family of 3 consisting of two teenage girls 17 and 16 and their mother M.S.
(35). M.S has a long history of drug and alcohol abuse since she was a teenager including the use
of cocaine, Methamphetamine, speed, marijuana and alcohol. M.S reportedly dropped out of
school in the 9 th grade and never went back to obtain a GED. M.S got pregnant with the oldest
girl when she was 18 by a man she didn’t know, and the two girls have different fathers. As of
today, M.S has not been able to locate and or identify her first child’s father. However, she
knows the father of her second child but has not seen him in years and he have no contact with
the second child. Both men were guys she used to have sexual relations with for drugs and
money. In the initial interview M.S. reports that as a child she practically raised herself alone
with her younger sister and younger brother as her mother was in and out of psych hospitals after
her father and mother divorced due to her father’s infidelity and cheating with her mother’s best
friend. She reports that her mother began drinking heavily and suffered from major depression
and that her symptoms worsened after the separation. She reports that her mother was also
diagnosed with bipolar and took medication, occasionally causing her symptoms to exacerbate,
resulting in her being admitted to the hospital. M.S reports that she can remember stealing from
convenient stores just to get food and new clothes to wear for her and her sister and brother at

around the age of 13, and then she reports that she got with some friends who introduced her to
drugs and alcohol around age 14 or 15 and she has been doing them ever since. She enrolled in a
rehab program in February of 2012 and was clean for about two years when she relapsed in 2016
after starting to date a man who sold drugs. To make matters worse, M.S recently verbalized her
desire to want to have another baby by the current boyfriend which has brought major concern to
both of her daughters and her sister. The daughters are concerned that this idea is being
influenced by the boyfriend and at this time M.S is still using drugs and sometimes unable to
fully care for herself without assistance from her sister. The daughters report that their mother
has fortunately been able to hold a job cleaning at a hotel and part time at McDonalds when she
goes, which they report is rarely. The daughters report that they have to ask their aunt for money
for food at times and are worried that if their mother is selected for a random drug screen she
will lose both jobs and the little income she has.

ï‚· Treatment plan
The plan will consist of the family attending 12 family therapy sessions, once a week.
M.S will be enrolled in another 13-week drug and alcohol program (outpatient) that she will be
required to attend twice weekly to help her with her addiction.
M.S will identify behaviors displayed that the daughters verbalized as concerning and come up
with alternative measures.
The family will begin to recognize M.S for utilizing positive coping skills other than those
involving drug in order to reinforce these behaviors.
At home the family will focus on verbalizing and showing love to one another as there is a lack.
M.S will delay the idea of wanting to have another baby until she has stabilized and been clean
for at least a year and is able to care for herself without using.

Part 2: M.S. Family Genogram

Please I don’t have the Genogram, Prepare one please.

References

American Psychiatric Association, & American Psychiatric Publishing. (2013). Desk
reference to the diagnostic criteria from DSM-5. Washington, DC: American
Psychiatric Publishing.

 

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