Running Head: EVALUATION OF CLIENT SITUATION

EvaluationofClientSituation
AlyssaDannhausen
June12,2016
WayneStateUniversity
SW4997
DY7028

EvaluationofClientSituation

Abstract
Everyclientthatwecomeincontactwithisdifferent.Theclientsneedsmaybedifferent
thananyothersandtheirpersonlifemayaffecttheirneeds.Afteraclienthasbeeninvolvedina
seriousaccidenttheirlivesareturnedupsidedown.Asasocialworker,wehavetodecidewhat
theclientsimmediateconcerns/issuesare,howweneedtoaddressthem,andwhatinterventions
willhavethebestoutcome.Basedoffofrecentstudiesinterventionscanbeselectedand
formattedtotheclientsneeds,aslongasweareabidingbyourethicalstandards.

EvaluationofClientSituation

BioPsychoSocialAssessment
ReasonforReferral
Mr.EricSmith*wasreferredforaninitialevaluationduetoarecentautoaccident,
resultinginsevereinjuries.Mr.SmithhasdisplayedpossiblePosttraumaticstressdisorderthat
coincideswithdepressionsandanxiety.Mr.Smithsinterdisciplinaryteamhasatreatmentplan
inplaceandwillberevised.
IdentifyingInformation
Mr.EricSmith*isatwentytwoyearoldAfricanAmericanmale.HelivesinDetroit,
Michigan,byhimself.Ericwasinvolvedinanautomobileaccidentthatlefthimwithseven

EvaluationofClientSituation
fractureswithinhisspine,cervicalandlumbarpain,traumaticarhropathyofthehipsandlegs,
anddepression.
Strengths
Ericfirstwasinasemicheerfulmoodandwasveryrespectful.Erichadnoproblem
interactingwithothersanddisplayedageappropriatelanguageandskills.Ericwaswillingto
discusshisconcernsandproblemswiththeexaminer,howeverhedidshowsomenervousness.
Ericunderstoodthathewouldhavetodiscussuncomfortabletopics,suchashisfamilylife,but
displayedsomereluctancetothetopic.Erichasshowngreatcommunicationskillsbutstartsto
displayalookofannoyance.
Needs/Concerns
Ericcommunicatedwiththeexaminerthathehasdifficultytakingcareofhimselfat
home,whichincludesdressing,bathing,eating,etc.Erichasalsoexpressedhisconcernofhis
finicalsituationduetonotworkingandnowbeingunabletoseekemployment.Duringthe
discussion,Ericdisplayedalotofaggressionandbecomingveryirritable.AtonepointEric
explainedthathefeltthatnoonewaswillingtohelphimandlistentohisconcerns.The
examinerexplainedthathistreatmentwillbetakenseriouslyandallinvolvedwillexpressgreat
interestinhiscare.ItwasalsoexplainedtoMr.Smiththathiscarewillbeaslowprocess,dueto
hisextensiveinjuries,towhichEricdisplayedgreatirritabilitytowards.
Eric,afterbeingreluctanttodisclose,admittedtobeingviolenttowardsothers,especially
hismother.Erichasbecomeverballyaggressivetowardsothersinhislifeandadmitsthatthisis
becomingworseaftertheaccident.AfterdiscussingtheaggressionwithEric,itseemsasthough
hismaturitylevelisnotfunctioningathischorologicalage.

EvaluationofClientSituation
PresentPsychiatricIllnessandSymptoms
Erichasbeendisplayingsymptomsdepression,PTSD,andanxiety,asofrecently.There
hasbeennoconfirmeddiagnosisbyaprofessional,howevertheclienthasbeentrackinghis
symptomsanditisrecommendedbyhisPM&RdoctorthataPsychologistevaluatehim.
Ericisalsoexpressingextremeaggression,irritability,andmoodswingsthatwerenot
previouslypresent.ManyofthesesymptomscoincidewiththepossibledepressionandPTSD,
howeveritisbecomeworseastimegoesby.
PastHistoryofTreatment
Erichasneverbeeninvolvedinpsychologicalcounseling.
MentalHealthMedications
EricsPM&RdoctorhasprescribedaverylowdoseofZolofttohelpdecreasehis
depressionandanxiety.Erichadrecentlystatedthathedidnotfeelanydifferentaftertaking
Zoloftfortwodaysanddecidedhedidnotwanttotakeitanymore,regardlessoftheinformation
giventohimonthedosage,timeframethatZoloftisexpectedtowork,dangersofstopping
depressionmedication,etc.
MedicalConcerns
Therearemanymedicalconcernsthatwerecausedbytheautomobileaccident.Eric
sufferedsevenmajorfracturestohisentirespine.Hesufferedbruisedrips,andstrainedneck.
Erichasbeenforcedtouseawalkertostabilizehisbalancewhenheisupandwalking,however
hasrecentlyhadtouseawheelchair.SincetheaccidentEricisloosingalotofmuscletoneand
strength,duetothepainwalking,standing,andmovingcauses.

EvaluationofClientSituation
Ericisalsoshowingsignsofbecomingdependentonhisnarcotics.EverytimeErics
PM&RdoctorwritesanarcoticprescriptionEricwillcallthenextdaytocomplainthatitisnot
strongenough.EricsPM&Rdoctorhasexpressedthatthenarcoticsarenotmeanttocompletely
takethepainaway.
CurrentMedications
Ericisonmultiplemedicationsthatareconstantlychangingduetonorelief.Currently
EricisbeingprescribedOxycodone,Nalfon,Cyclobenzaprine,Colacen,Zoloft,andFlexural
patches.
DependencyandAddictionHistory
Ericssubstanceuseoccurredearlyoninhisadolescence.AroundtheageofthirteenEric
beganusingalcoholandtobacco.ItwaseasilyobtainableinhisneighborhoodandEricusedit
themostfromtheagesofthirteenseventeen.Whileusingalcohol,Ericwoulddrinktwotimesa
day,typically.Ericstobaccousehasbeenongoingsincetheageofthirteen,andstillcurrently
smokesthreefourcigarettesaday.AttheageoffifteenEricbeganusingcannabisandisstill
continuingtodoso.Ericwillsmokemarijuanathreetimesaday,onanaverageday.
FamilyHistoryofPsychiatric/AddictionIllness
Ericsmotherhasahistorydocumenteddepression;hisfathershistoryisunknown.
Ericsmotheralsohasahistoryofanxietyandmajormoodswings.
EricsfatherisanalcoholicandhasbeenforaslongasEriccanremember.Hisfather
wasincarceratedduetodrugsandthathascontinued.
PersonalHistory

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Ericlivedwithhismotherformostofhislife,ashisfatherabandonedhimearlyon.His
motherleftapproximatelytwoyearsagoandasallowedErictoliveinherSection8home.
Ericsrelationshipwithhismotherishostileanddisplaysangerwhendiscussingher.Ericalso
hasdiscussedthathisfatherrandomlywillcallhimandEricbecomeveryupsetwhendiscussing
hisfatherandhisfathersactions.NeitherofEricsparentsispresentandsupportiveinhislife.
Erichasa2yearolddaughterwithhisFiancandhasaveryunstablerelationshipwithher.
ReceivingtreatmentisastruggleforEricduetohislowfamilysupport.Hiscase
managementcompanyprovidesEricwithtransportationtoandfromhismedicalappointments,
whichisarelieftoEric.However,Ericstatedthathisfriendshavestoppedcomingaroundto
helpEricwhenheneedsit.
Community
Ericreportedlylivesinaveryunsafeneighborhood,aswellashisfiancandtheirchild.
Ericwarinvolvedinhischurchbutsincetheaccidenthisparticipationwasdeclined.WhenEric
wasinschool,heparticipatedinbasketballandwhenspeakingaboutbasketballhisfacelitup.
DuetoEricsinjuriesheisnowunabletoplaybasketballwithhisfriends.
EmotionalHistory
Erichasahistoryofdisplayingangertowardsothers.Erichashadangermanagement
issuesasayoungchild,especiallytowardshisfathersabandonment.Ericadmitstobecome
extremelyirritableandirrationalattimes.Ericstatesthathisangercanbejustverbalhoweverhe
hasatendencytobecomephysicalwithothers.ItisnotedthatErichasacriminalhistoryof
domesticviolencewithhismother.
EducationHistoryandSchoolBehavior

EvaluationofClientSituation
Ericseducationhistoryendsatthesophomorelevelofhighschool.Ericstatedthathe
didnotfeeltheneedtocontinuehishighschooleducationatthetime,andgoesbackandforth
ontheideaofreturning.Ericsmainfocuswasmakingmoneyandschoolwasintheway.Erics
gradeswerenotwheretheyshouldhavebeenandEricadmittedtonottryinghardinschool.Eric
wenttoapublicschoolinWayneCountyandtheschoolwasextremelyunderstaffedanddidnot
haveadequateresources.Ericgotalongwithothersinhisschool.
WorkHistory
Ericsworkhistoryisveryunstableandisunabletokeepasteadyjob.Hesaysalotof
hisjobincomehasbeenunderthetableandstrugglestokeephisjobs.

LegalHistory
Erichaspreviouslybeenincarceratedfordomesticviolenceagainsthismother.The
domesticviolenceincludingaweaponandhespenttwoyearsinjailandhasthreeyears
probation.
Martial/Relationship
Ericisnotmarriedbuthasbeenenragedtohisfiancfortwoyears.Therelationshipis
extremelyunstableandtoxic.Erichasstatedthathisrelationshipcauseshimalotofstressand
angerthathetendstodisplace.
SpiritualHistory
EricstatedthatheisaChristianandregularlyattendschurch.

EvaluationofClientSituation
ShortTermGoals
Erichasthreeshorttermgoalsthathewouldliketoobtain.Healingfromhisaccidentis
hismostimportantgoal.ToobtainthisgoalEricmustcontinuetoregularlyseehisdoctor(s)and
beginphysicaltherapytogainstrengthandmuscleback.Ericsnextgoalistoattendavisitwith
aPsychiatristtobeevaluatedfordepression,PTSD,andanxiety.ToobtainthisgoalEricneeds
toscheduleandshowuptohispsychologicalevaluation.ThelastshorttermgoalEricwouldlike
tocompleteistotreathisdepression,anxiety,PTSD,andangerissues.ToensureEricobtains
thatgoalhewillhavetoregularlyvisitthePsychiatristandfollowhistreatmentplan,whichmay
includeprescriptions.
CurrentServices
Ericiscurrentlyreceivingcasemanagement(CM)servicesbecauseofhisaccident.
AlongwithhisCMservices,Ericisreceivingtransportationtoandfromhismotorvehicle
accidentrelatedappointments,householdreplacementservicestohelpwithhisdailychores,and
inhomecare.
Overview/Summary
Erichasbeeninaseriousaccidentthatleveltemporarilyimpairedandinpain.Erichas
beenexperiencingPTSDanddepressionthatiscausinghimtolashoutonothersandevenif
thoseothersarehelpinghim.Erichasshownthatheisfearfulofgettingapsychological
evaluationbecausehedoesntfeellikethemedicationswillnotanything.
Ericisalsodisplayingsignsofbecomingdependentonhisnarcoticsandthiscouldalso
befactorinhismoodswingsandirritability.SeekinganevaluationfromaPsychiatristwillgive

EvaluationofClientSituation
EricagoodinsightastowhatcanpotentiallyhelphimrecoverfromthePTSDanddepression
thattheaccidenthaslefthimwith.
ConsensusandAgreements
EricagreesthatheneedstoseekhelpwithhisPTSDbutisafraid.Heagreestotryingto
obtainhisgoalsanddowhatwehaveagreeduponwithhisshorttermgoals.
DSMIVDiagnosis
AxisI:DepressionPTSD;AxisII:N/A;AxisIII:PanicattacksPTSD;AxisIV:Low
familysupport,lackoffiancs;AxisV:60GAF
Recommendations
MyrecommendationsforEricarethatheneedstoseeaPsychiatristtotreathisPTSD.
MostofEricsemotionalandbehavioralproblemsarestemmingfromthePTSDhehasfromhis
accident.AlsoIbelieveEricneedstodiscusspossibledependencyonnarcoticsandeducationon
howtopreventthisfromhappeningafteramajorinjury.
AnotherrecommendationisfamilycounselingforEric,hismother,andisfianc.Each
memberneedstopartakeinthistherapytoensurethatEricspastishealingandwillallowhim
tomoveforward.
Ericalsoneedstoreceiveindividualizedtherapytoensurethatheisrecoveryandcoping
withhisfearsandtohelphimfollowthroughwithhisgoals.
Intervention
EricSmithunderstandsandagreesthatalotofhisproblems,asidefromthephysical
injuries,arestemmingfromthePTSDthathehasfromhisaccident.Hehasshownagreatdeal
ofunderstandingonwhyalotofhissymptomsarerelatedtohisPTSD,howeverheshowsalot

EvaluationofClientSituation
ofconcernandconfusion.Ericdoesntlikethefactthatthereispotentialformoredepression
medicationtobeprescribed.EricfeelsliketheZolofthewasprescribeddidnothelporalleviate
anyofhissymptomsbeforeanddoesntfeellikeheshouldgiveanewmedicationatry.
DuringtheconversationEricexpressedthathewantstounderstandandlearnwherehis
angerandaggressioniscomingfromandwouldliketoworkonthoseissues.Ericshowedalot
ofeagernesstofixthisissuethathehas.Erichassuggestedthathecandiscussanger
managementwithhispsychologist.HealsorecognizesthattreatinghisdepressionandPTSD
couldpotentiallyhelpwithhisangerandirritability.
EricsPTSDisamajorissuethatneedstobeaddressed.Thesuggestedinterventionwas
involvedinastudyconductedbyMeganKearns,KerryRessler,DougZatzikc,andBarbara
OlasovRothbaum,in2012.Thisinterventionincludesmultipleinterventionideas,whichinclude
pharmacotherapy,cognitivebehavioraltherapy(CBT),andmotivationalinterviewing.Thisstudy
wasperformedinaninpatienttreatmentcenteranditgreatlyreducedthePTSDsymptoms
(Kearns,etal,2012).Amajorcontributortothereducedsymptomsisthepharmaceuticaldrug,
Propranolol.Propranololallowsthereductionofneuralreactivityintheamygdala,whichinturn
reducesthetraumaticstressreactionsthatoccur(Kearns,etal,2012).Thisinterventionwouldbe
beneficialbecausetheclientisseverelysufferingfromPTSDsymptoms.Accordingtothestudy
manyparticipantscontinuedtohavereducedsymptomstwomonthsafterthetesting(Kearns,et
al,2012).
Ericsuffersgreatlyfromdepression,whichcancoincidewiththePTSD,howeveritis
alsostemmingfromhispersonallifeproblemsandfinances.AccordingtothearticleStepped
earlypsychologicalinterventionforposttraumaticstressdisorder,otheranxietydisorders,and

EvaluationofClientSituation
depressionfollowingseriousinjury,30%ofpatientsdevelopapsychiatricdisorderaftera
serioustrauma/injury(ODonnell,etal,2012).Theinterventionsuggested,asitwasabove,isa
CBTintervention.Howevertheinterventionneedstobeflexible,aseachpatientscaseis
different.InEricscase,hesuffersfromPTSD,whichalsoincludesanxiety,stress,and
depression.HoweverEricsdepressionisalsofromhispersonallifestressors.Notonlywith
CBT,whichcanbedoneinwithhispsychiatrist,helpwiththePTSDdepression,butitcanalso
helpwithhispersonallifeissues.ThesuggestedCBTinterventionincludesaflexibletreatment
thatusesstructuredhomeworkactivities(ODonnell,etal,2012).Theresultsofthisstudy
showedthatthosewhoreceivedCBTshowedagreatimprovementintheirdepression.Eric
wouldbenefitfromgreatlyfromCBTinterventions,inmorewaythanone.
Ericisfailingtorecognizehisdependencyonhisnarcoticsatthistime.Whenthetopicis
broughtup,Ericgetsveryagitatedandupset.Refusaltodiscussthetopichasbecomethenorm
forEric.DiscussingandgettingErictounderstandthatthereisaproblemhascreatedtrustissues
inthepastandtheclientcontinuestobeindenial.Thepresenceofdepressionoranxiety
disordersmaycontributetoincreasedriskofsubstanceusedisordersamonglongtermopioid
users(Ling,etal,2011).Erichassuspectedanxiety,depression,PTSD,aswellassymptomsof
beingdependentonhisnarcotics.Therearecurrentlyothermedicationsthatclientscantaketo
helppreventionfurtheraddiction.Methadoneandbuprenorphinearetwomedicationsthathelp
clientsmaintainabstinencefromtheopioidsandhelptorecuedaddictionrelatedbehaviors
(Ling,etal,2011).EnsuringthatEricisnotbecomingaddicted,orfurtheringtheaddiction,isa
veryimportantinterventionstep.
EthicalDilemma

EvaluationofClientSituation
Asasocialworkerourmainconcernisprovidingourclientswithqualityand
knowledgeablecare.Sometimestherecomesatimewherewehavetomakeadecisionbasedon
ourmoralandethicalcodesputinplacebytheNationAssociationofSocialWorkers(NASW).
TheCodeofEthicsisacodethatisenforcedbytheNASWthatguidessocialworkersintheir
practice.
Ericsfamilyissmall,unsupportive,anddysfunctional.OneofthevaluesintheCodeof
Ethicsistorecognizetheimportanceofhumanrelationships(NASW,2008).Duringthe
interventionprocess,alotoftimesfamiliesareaskedtobeinvolvedforloveandsupport.The
supportthatfamilycanprovidetheclientwithisunlikesupportasocialworkercan,inmany
cases.InEricscasehedoesnothavefamilytohelpsupporthimthroughtheprocess.The
importanceofhumanrelationshipvaluestatesthatitisimportantforthesocialworkerto
strengthenrelationshipsamongpeopleinapurposefulefforttopromote,restore,maintain,and
enhancethewellbeingofindividuals(NASW,2008).Iknowthatstrengtheningthe
relationshipbetweenEricandhismother,aswellashisfianc,wouldenhancehiswellbeing,
howeverEricdoesnotseeitthatway.Ihadtomakethedecisiontonolongerpushforhimto
joincounselingwithhismotherbecausehewouldgetvisiblyupsetandangry.Thegoalisto
controlEricsangryandheisclearlynotreadytodealwithhisrelationshipwithhismotherjust
yet.
Theory
WorkingwithEricallowedme,asasocialworker,togaingreatinsighttotheecological
perspective,particularlypersoninenvironment.Eachpersonisaffectedbytheirsystemsintheir
environment,whichincludesfamilyandfriends,work,school,religion,politics,etc.(Krist

EvaluationofClientSituation
Ashman,Hull,2015).WhenlookingatEricssystems,therearenotmanyconnections.Eric
doesnthavemanytransactions,whichthewaywecommunicationandinteractwithouts,within
hisfamilyandfriends(KristAshman,Hull,2015).Ericsfamilysupportislowandthereiszero
tononetransactionsoccurring.Ericsfriendsarenotactiveinhislifeandbecomeanegative
factor.Theinterface,whichiswheninteractionbetweentheclientandtheirenvironment
happens,iswhatfamilytherapywouldbenefit(KristAshman,Hull,2015).Theproblemwithin
Ericsfamilyisnosupportorcommunication,whichistheinterfacethatneedstobeworkedout.
AnotherproblemisEricsnewdisability,whichiscausinghimtoadaptintoanew
environmentandlifestyle(KristAshman,Hull,2015).Ericspreviouslylifestyle,onewherehe
wasabletocareforhimself,isnoneexistent.ItisimportantthatEricisabletoadaptandcopeto
hisnewlifestyleandifthereareanyinterfacesthatoccur,theyareaddressedimmediately.

Reference
Kearns,M.C.,Ressler,K.J.,Zatzick,D.andRothbaum,B.O.(2012),EARLY
INTERVENTIONSFORPTSD:AREVIEW.Depress.Anxiety,29:833842.
doi:10.1002/da.21997

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KristAshman,K.,&Hull,G.(2015).PracticeSkillsforWorkingwithIndividuals.In
UnderstandingGeneralistPractice(7thed.,pp.6162).CengageLearning.
NationalAssociationofSocialWorkers,CodeofEthics.(2008).Retrievedfrom
http://www.socialworkers.org/pubs/code/code.asp
O'Donnell,M.L.,Lau,W.,Tipping,S.,Holmes,A.C.N.,Ellen,S.,Judson,R.,Varker,T.,
Elliot,P.,Bryant,R.A.,Creamer,M.C.andForbes,D.(2012),Steppedearly
psychologicalinterventionforposttraumaticstressdisorder,otheranxietydisorders,and
depressionfollowingseriousinjury.J.Traum.Stress,25:125133.
doi:10.1002/jts.21677
LING,W.,MOONEY,L.andHILLHOUSE,M.(2011),Prescriptionopioidabuse,painand
addiction:Clinicalissuesandimplications.DrugandAlcoholReview,30:300305.
doi:10.1111/j.14653362.2010.00271.x