1. Running Head: CLINICAL CASE PRESENTATION 1
Bio-Psycho-Social-Spiritual Assessment:
Clinical Case Presentation
Shelby L. Simpson
Loma Linda University

2. CLINICAL CASEPRESENTATION 2
Identifying Information
K is a client referred from a psychiatrist at a local inpatient facility. K is a 26-year-old
married Caucasian female with two young children. Client lives with her husband and two male
children, ages 2 ½ and 1 ½, in a two-bedroom apartment in Hemet, CA. Client is of a middle
class socioeconomic status, is a high school graduate, currently is unemployed and states she has
sporadically gone to church in the past but identifies herself as non-practicing Catholic.
Presenting Problem
Reasonfor Referral
K was referred to the author (social work clinician) from a psychiatrist, Dr. W.,
approximately six years ago. She was referred because it was recognized that she needed a
multidisciplinary team to help manage her care and the social worker and Dr. W. worked
collaboratively for several years.
Initial Complaints and Symptomatology
Client reports that currently she is more stable than in the past, however, she still has
occasional auditory or visual hallucinations. She reports the most recent visual hallucination (per
report “a couple of months ago”) occurred while driving somewhere with her mother-in-law and
she saw an Indian appear in the middle of the road, per the client report it took several moments
to determine the man was not really there. She further states that she will have hallucinations
(both visual and auditory) sometimes when she is “really stressed or anxious” and that these
hallucinations most often come in the form of voices calling her name, people at the windows or
inaudible talking.
Client also reports problems of insomnia due to spells of paranoia where she will hear
people in the hall or living room of the house or at the windows. She further reports that she will

3. CLINICAL CASEPRESENTATION 3
hear things all evening and constantly need to get up to check and make sure that no one is
actually there. She states that she often complains of these noises to her husband who tells her to
“not worry about it” and “go back to sleep.” She also states that she has a “rocky” and “love-hate
relationship” with her husband. Client reports that she will say “terrible things” and “be mean” to
her husband and immediately feel better and later feels guilty.
Per K’s report these problems have been ongoing for the duration of her time in treatment
(six years). The client reports better taking care of herself and maintaining her insulin, less
frequent fights with husband and less frequent visual or auditory hallucinations but still endorses
feelings of hopelessness and mild symptoms of depression. She reports that she often has been
told that “God only gives what you can handle. But I can’t handle this, this is too much.” The
client further states that she often does not understand why her husband has stayed with her and
that she does not have a true support network and is for the most part isolated.
Assessment
Client Presentation and Interview Behavior
Client appears casually dressed, well-groomed and is cooperative throughout the
interview. She is calm as she speaks and her speech is soft and at times quiet. Client’s affect is
congruent throughout most of the interview although there are brief moments of incongruence
(i.e. laughing while rhetorically asking why her husband has not yet left her or when she talks
about how she has thrown things and physically hit him but feels remorseful). Further the client
is tearful throughout most of the interview and presents with depressed mood. Client is oriented
to time, place and person and thoughts flow logically and appear organized.
Bio-Psycho-Social-Spiritual History

4. CLINICAL CASEPRESENTATION 4
Medical information. Client reports that she was diagnosed as a diabetic at the age of 18
and has a lot of problems resulting in this diagnosis. When she was first diagnosed she spent a
month in the hospital on insulin and had seizures. She states she has kidney problems and has
previously had kidney infections and blood in her kidneys. She reports that she has peripheral
neuropathy, diabetic retinopathy and that she has a poor immune system, “when I get sick I can’t
just get a cold I get pneumonia.” She reports that she was in and out of the hospital when she was
pregnant with her second child and that she was in the hospital for most of the pregnancy. She
also reports that he was born four months premature and that caused a lot of problems because
she has two children with serious medical conditions.
Medications. She reports that she has been on numerous medications in the past that
have not worked for her. Client stated that she was on Desipramine but that it caused her to have
increased hallucination. She stated that Desorelle made her really dizzy to the point where she
could not stand and could only remain in bed. Per the client report Lithium and Tegretol made
her very sick, Prozac “didn’t work,” and she has been on Wellbutrin, Haloperidol and Triavil
previously. Client mentioned that she was Epogen briefly but that she experienced high levels of
depression and hopelessness as a side effect. She reports that she used to take Benadryl as a sleep
aid and currently has been on Klonopin for approximately four years. Per the client report she
states that she likes Kolopin the best because it does not make her drowsy, she still feels relaxed
and present while taking the medication. She reports that she previously abused her medication
and would take more than the recommended dosages or would take “a pill or two and drink
alcohol.”
Drug and alcohol use. Client states that she was never “addicted to drugs” and only
experimented when she was younger. She reports that she has tried alcohol, marijuana, cocaine

5. CLINICAL CASEPRESENTATION 5
and speed. Per the client report she only tried these drugs if readily available and her peers told
her “come on and try it” and did not seek out or purchase drugs on her own.
Hospitalizations. Client reports that she has been hospitalization in an inpatient setting a
total of six times and that these six were all during a yearlong period. She reported that her
shortest hospitalization was one week and her longest was three and a half weeks. She reports
that she always knew when she was going to be hospitalized because it was voluntary and a
referral from her therapist or psychiatrist. She states that she was “not in control at all” and
“screaming at people and aggressive,” she stated that she had a short fuse and would often “be
mean and call people terrible names.” She reported that she was able to see the signs of when she
would go to inpatient because she would start to lose control, say bad things or throw things at
people, had crying spells where she could not stop crying, was not interested in doing anything
or going out, could not get out of bed and had a lack of motivation and would even purge on
occasion.
She reported one specific instance where she was in the psychiatric hospital for two
weeks, discharged and re-admitted the following day. She reported that her last hospitalization
was approximately four and a half years ago and that she participated in the intensive outpatient
program for six weeks after her discharge as a form of follow-up care. She reported that she
would go back to the hospital once a week and participate in the inpatient groups which made
her feel “really uncomfortable and relieve the experience.” She reports that she has previously
attended anxiety groups (once or twice), taken walks and hired a baby-sitter to have time for
herself.
Family of origin and childhood history. Client was born and raised in Pittsburgh, PA
and came from a lower socio-economic status. Client is the oldest sibling in a set of four siblings,

6. CLINICAL CASEPRESENTATION 6
one boy and three girls. She reports that she did not get along well with her siblings while
growing up, “we fought all the time” and that her parents did not seem to understand the severity
of her sadness and depression. She stated that her mom “nagged all the time” and had a mentality
that “her way was always right not matter what your way was.” She reported that her family was
not wealthy and that her father was always sick and because of his illness did not really work.
She stated that her family “didn’t think I could do things on my own” and when she was 18 and
moved to California they moved there two months after her.
Client stated that her father was authoritative when she was younger and would yell and
scream at the patient. Per the report, she stated that her father was a Vietnam veteran and would
frequently have flashbacks and problems related to his military service. She reported that her
parents still live a mile away from her in Hemet, CA and that she sees them occasionally. She
states that one of her sisters is married and recently moved to Oceanside and they will talk
intermittently.
Traumas. When she was sixteen her father told her that he would smoke Marijuana and
when he would smoke it would make him horny. She also recalled one incident where her father
had just come out of the shower and told her that he was horny and asked the client what she
would to about it, the client stated she told him “Dad that is incestuous” and his response was
“we could have oral sex.” She reported that she never told anyone about this situation and that
nothing like this had ever happened before or since the incident. She also mentioned that it was
odd to her because he never brought anything like that up again and “pretended like it never
happened.”
School and work history. Client states that when in high school she was in a “tough
crowd” and that she would often get into trouble in school. She states that she remembers times

7. CLINICAL CASEPRESENTATION 7
where she was really happy, per report after eleventh grade and times where she was very sad
and depressed, per report from the ninth or eleventh grade. She reports that she was often truant
in school and remembers never being caught due to how large her high school was. Client
reports that she began to work while in the twelfth grade and often would miss classes in order to
work. She reports that she “took all the easy” and “basic science, math, English classes” and
graduated high school with a 3.2 GPA. Client states that she worked often in the early years of
her marriage but due to health concerns and a recommendation from her primary physician she
decided to stop working. Per the clients report she would develop kidney problems from standing
long hours at work and that would lead to other medical problems. When she was working she
worked as a pharmacy technician in Hemet but it was stressful to her.
Significant and/or broken relationships. Client reports that she has been married since
she was 19, she further states that she has a strained and difficult relationship with her husband
where he often ignores when she is angry or says mean things. She also states that she has a
broken relationship with her siblings and rarely speaks to them or sees them.
Social supports available. The client reports that her family is close by but that they still
are not that close and the relationship is strained. She further stated that she has few friends and
often does not go out or see them. Client also reports a difficult relationship with her husband
where “I sometimes love him and I sometimes don’t.” She does not mention any close
friendships or any relationships of significance to her and states that she often does not go out or
do things that are social in nature.
Religious orientation. Client stated that she was raised Catholic but is currently non-
practicing although she has gone to church sporadically. She reported that when she was younger
the family would go on and off to church and that they would not always stay throughout the

8. CLINICAL CASEPRESENTATION 8
service. She reported that she had her two sons baptized but did not identify a strong spiritual or
religious connection. She also reported having feelings that “God gypped me” in regard to the
difficult situations with her children, strained relationship with husband and family and her own
poor health.
Relevant ethical issues. During the beginning of the interview the client was informed about
confidentiality and given informed consent regarding the purposes and later use of the filmed
interview. However, confidentiality may need to be broken to report the emotional-sexual abuse
the client suffered since there are still children living in the house with her father, to determine if
this is an area of concern I would need to know the actual ages of her siblings to determine if
they are minors or not. Further, it would be wise to discuss this area of concern with my
supervisor in supervision to determine other potential ethical issues.
Other areas of ethical concern such as conflict of interest do not seem to apply to this
case. The client will need to be informed about potential termination however; it does not seem
to be an issue that is yielding high importance at this time because the client is still in need of
services to improve functioning and quality of life. In regard to self-determination the client is
free to make her own choices and has done so in the past in regard to her therapy with scheduling
appointments via telephone conference, or spacing appointments out farther or having multiple
appointments during the week when she has determined necessary. Finally, I do not see any
multicultural issues that could become a barrier with this client and I do not anticipate any
boundary issues at this time.
Relevant legal issues. As mentioned in the previous section it would be important to discover
the ages of the sibling(s) that are still in the house with the client’s father and to determine via
supervision if it is a reportable issue. The client has also mentioned that there have been times

9. CLINICAL CASEPRESENTATION 9
when she has been physical to her husband both hitting and throwing things at him, I would seek
counsel on this issue as well from my supervisor to determine in this is a reportable domestic
violence issue. Potentially, there is the concern of whether or not this physical abuse has
occurred in front of the young children and if so that is a legally reportable issue as well.
The client has also mentioned that she has had suicidal ideation previously and that she
even considered overdosing but has the fear of following through with her plan. It would be
important to explore if these are current feelings that she is having and help her to not only
address these feelings but to determine triggers and ultimately to cope with her suicidal ideation.
She also reported that there have been times in the past where she would forgo taking insulin
because she knew her limits, it would be important to discover if this is still common practice for
her and when the last time this occurred was.
Finally, the client reported that she slapped her 1½ year old toddler on the leg to get him
to stop having a tantrum, which may be reportable despite no marks being left on the child.
Further, the client expressed feelings of wanting to “shake the tantrum” out of her son on
multiple occasions. It would be important to discuss this with a supervisor and further with the
client to determine if this is a reportable abuse issue as well.
Involvement with other agencies and client systems. Client reported that she currently is
seeking supportive services and counseling for her youngest child who is becoming increasingly
aggressive and violent. So there may be involvement with these agencies, also, there are
potentially other supportive agencies that are helping her children with their medical illnesses. If
abuse is determined to be reportable then there will be involvement with Child Protective
Services.
Case Integration

10. CLINICAL CASEPRESENTATION 10
Because of K’s dysfunctional family life and the lack of attachment she had with her
parents as a young child she has problems with becoming intimate and close with her husband.
These issues have also extended into her psychological functioning and she finds it difficult to
attach to her youngest and per her report, more difficult child. Socially, she has become unable to
form attachments with her peers and lacks a support system or friendships. Spiritually, she finds
it difficult to connect with God and often feels like he gave her a poor hand and too much to deal
with. This goes back to the attachment theory in that she was unable to attach with her parents in
infancy and youth and sought to detach from them not only while in school but also as soon as
she could move she did so (at age 18).
In regard to her medical conditions she has worsening problems because she chooses to
not take better care for herself and she believes that she can sense when her blood sugar levels
are lower or higher than normal which leads to her self-testing on an infrequent basis. It can be
considered that she may not have taken proper medical care of herself while she was pregnant
and therefore, this could be a contributing factor to her children’s medical illnesses and delays.
Further, the client does not see any areas of strength in her life and overall has a sense of
hopelessness, and empowerment is influenced by the environment. This means that a person is
not only shaped by their heredity but also by their environment and the client has been shaped
negatively by her environment in that she feels as though she is medically disadvantaged and this
discourages her from creating meaningful friendships or relationships with her family or
husband. She further feels that she cannot do the same things as others because she is often sick
and since she suffers depression, feels like staying in and not going out on a frequent basis.
Overall, all the issues the family is facing overlap into multiple areas of her life and therefore,
they are all interrelated.

11. CLINICAL CASEPRESENTATION 11
I am concerned about her suicidal ideation and the tendency she had to both self-medicate
in the past as well as her previous attempts to self-harm by taking more than recommended
dosages or taking pills and drinking alcohol. I am concerned about her lack of social supports
and the minimal relationships she has, which is also a reason for her to introvert and avoid or not
go out with others. I am also concerned greatly with the thoughts she is having about her
youngest child and that she mentioned she had thought about “shaking the tantrum” out of him
on multiple occasions out of frustration.
These previously mentioned problems are both concerning and need to be addressed with
manageable goals to improve the client’s condition. In order to discuss any potential ethical
concerns or issues I will seek consult from my supervisor in supervision as well as contact the
NASW ethics hotline or review the NASW Code of Ethics. I do not foresee any issues of
countertransference but if any should arise I will bring them to my supervisor’s attention and
discuss in supervision.
Theoretical Formulation
Attachment theory. Attachment theory focused on the relationships and bonds between people
and specifically focuses on the bond between a parent and child in early life and how this
attachment impacts a child in later life. This theory was developed by John Bowlby and is
focused on separation anxiety and potential stress that children experience when separated from
their parents. Bowlby defined attachment as, “an emotional bond between another person”
(Bretherton, 1992). Because K was unable to form a secure attachment she is not only unattached
to her parents but also fears that her husband is not attached to her. She suffers from an
anxious/ambivalent attachment where she both passively and actively shows hostility to her
parents. She has an anxious attachment in regard to her husband and worries that he does not

12. CLINICAL CASEPRESENTATION 12
really want to be with her often asking herself and therapist why he stays with her when she is so
mean to him.
Erikson’s stages. K is 26 and she should be in the young adulthood stage of life, Intimacy and
Solidarity VS Isolation, which extends from age 18 to 35. During this stage of life a young adult
will seek companions and love, dating is normative and the young adult is seeking to marry and
create a family. If this stage is successful the virtue is love and intimacy on a deeper level,
however if this stage is not successfully completed then the young adult will be isolated and
distances themselves from others (Sokol, 2009). The client has married and has started a family
but she admits that she finds it difficult to be intimate and form an attachment with her husband
and her children, which means she is not successful in achieving the virtue of this stage. Further,
she isolated herself and has minimal friendships or relationships with others.
Proposed Treatment Plan
Goals. K will learn three new coping skills to reduce her paranoia and feelings of hopelessness
and depression. She will further report the use of one or more of these skills for each incident of
paranoia, hopelessness or depression for five consecutive weeks as recorded in her feelings
journal. K will report a decrease in symptoms of anxiety or paranoia without cause. K will be
encouraged to describe her feelings using positive self-statements rather than negative and will
discuss her feelings and any differences she recognizes when using positives to help maintain a
positive self-image and decrease feelings of hopelessness or suicidal ideation. K will report an
increase in hours of sleep by sleeping seven or more hours per night for five out of seven nights
during the week. K will improve her health by taking medications as ordered by physician and
report compliance, symptoms or side effects to physician and therapist.

13. CLINICAL CASEPRESENTATION 13
Interventions. K will maintain and take notes in a feelings journal for a five-week period and
will bring the journal to sessions for further exploration and discussion. K will participate in
family therapy sessions to promote communication of the client’s feelings of depression and
hopelessness. K will become involved in a social activity such as volunteer work or a support
group. K will work to learn coping skills to help with suicidal ideation, hallucinations and
emotion regulation. K will enroll in a parenting skills class to better manage her feelings of
frustration and anger with her children.

14. CLINICAL CASEPRESENTATION 14
Bibliography
Bretherton, I. (1992). The Origins of Attachment Theory: Joh Bowlby and Mary Ainsworth.
Developmental Psychology,759-775.
Hepworth, D. H., Rooney, R.,Dewberry-Rooney, G., Strom-Gottfried, & Larsen, J. A. (2010). Direct
social work practice: Theory and skills (9th ed.). Belmont, CA: Wadsworth. C
Sokol, J. T. (2009). Identity Development Throughout the Lifetime: An Examination of Eriksonian
Theory. Graduate Journal of Counseling Psychology.