Client information provided
by: Client in session: Mental Exam, Bio-psychosocial Assessment
The Presenting Problems
Tonia is the average “Kingstonian” with an introverted
nature. She is well-organized and is
keen on meeting any goal she has set for herself. However, recently, Tonia has been
experiencing loss of interest or pleasure in daily activities, loss of interest
in realizing the goals she has set for herself.
She has been experiencing irritability and by previous subjective
reports and observations; sadness and emptiness has been reported and
observed. Based on previous medical
report, Tonia has also loss significant weight (7%) and she has loss her
appetite. She expressed that she feels
worthless and is unable to concentrate. She has expressed the need to rid
herself of this low empty feeling as it has become debilitating.
Tonia is a 49 years old Jamaican post graduate
female. Her religion is Christianity and
she attends a church in proximity to her home. She is introverted and prefers
low-keyed activities. Enjoys her family but outside of that, prefers to be
Tonia is the second child from a closely-knit
family. She remarried almost a year ago
and lives with her husband and child from her previous marriage
The client’s brother died three years ago, which at
the time, understandably, caused her some amount of trauma. She explained how her coping skills during
the time of her brother’s death and that she intellectualized by planning the
funeral and taking care of all other arrangements in one week.
Tonia has no history of incarceration, substance abuse or
Mental Health History
Tonia expressed that she believes her “low and empty
mood” started when her brother passed as it was a sudden passing and came as
quite a shock to her, her family and all who knew him. The client has no history of mental illness
or treatment and has never required hospitalization as it relates to any form
of mental illness.
Academic and Intellectual History
Tonia attended a prominent traditional high school in
Kingston, Jamaica and was an average student. She recently attained a Master’s
degree in Business Management.
Tonia reports no developmental issues. She was seldom
ill during her childhood years but had seasonal cold and flu from time to time. She was over-protected, was not a physically
active child and preferred to read instead of playing outdoors. She had no allergies or food sensitivities.
She has no legal history other than past divorce
She has no offender issues in her background.
She denies any neglect, physical or emotional abuse
from any relative or parent.
Substance Abuse History
Tonia has no history of substance abuse and this she
attributes to her strong Christian beliefs and principles.
Personal Assets and
herself as spiritual and stated that she grew up with her family in a home that
believed in God. However, she became a
Christian in her 30s.
She has a high
aptitude for mathematics and used her proficiency to assist children in her
community who are preparing for exams.
She began to realize her effective teaching strategies and passion for
teaching and as a result, she resigned from her job as an accountant and opened
her own after school program at home.
This has however come to a halt after there were several shooting
incidences in her community and parents; even herself, became scared of being
on the street after a certain time in the evening.
business was unforeseen and has placed her in a depressed mood because she had formed
a bond with her students, she like disseminating knowledge and also this had
become her source of income and buffered the stress from the high bills as her
husband earns minimum wage.
Mental Status Exam
Appearance: Age-appropriate, adequate
hygiene but it seems not much thought placed in arranging attire
Posture: Drooped Shoulders
Orientation: Place, time, date, person and
Diminished but not severely
Within normal limits
interest or pleasure: Almost everyday
Disorder: Negative thoughts (Based on
inability to contribute financially to household)
When asked in the interview, Tonia says she has no
thoughts of suicide nor homicide.
Trauma as a result of her brother’s sudden
Loss of Income; she was the major bread
Based on her medical report, Tonia appears
to have loss significant weight. Her
attire is presently corporate and age-appropriate but not arranged with much
care. Her hygiene is adequate. She wears
glasses and her natural hair loose. She
presents as clean but not neat and was punctual for her appointment.
Behaviour Observations During the Interview
Tonia speaks fluently and at a
normal but sometimes slow pace depending on the point she is discussing. She maintains regular eye contact. She sat with her shoulders drooped and sits
with her hands clasp in her lap and at times, folded across her upper body. Her
mood was neutral for most of the interview, and at one occasion, she seemed
very sad. Her affect, for the most part,
was flat away from the moment when she appeared very sad. She was oriented to person, place, time, date
Her thought processes were logical
and content was appropriate. Her body
language and motor movements appeared to be normal but at one time, while her
hands were crossed, and she drooped her shoulders.
Tonia’s insight and judgement were normal
and there was no evidence of impulse control issues. Her concentration was slightly diminished. However, she was able to repeat words in
order without error and interpret common proverbs appropriately. There was no
evidence of delusion, loose associations, flight of ideas or though
blocking. She cooperated throughout the
This is no history nor evidence of
suicidal attempt or ideation but admits that she is anxious about getting a
breakthrough and that she has prayed continuously but it seemed as though “God
did not hear” her prayers.
Tonia’s symptoms of depression have
manifested because she had not completed the healing process since the sudden
passing of her brother, unrealized goals and that her aspirations could not
come to fruition because of the violence in the volatile area where she
lives. Symptoms are not severe so no
medication has been prescribed for her in the past, neither has she ever been
to counselling prior to this session.
She experiences sadness and emptiness everyday and her
coping skills appear to be low. However,
it would be appropriate to rectify her feeling sad and train her to develop
coping skills in the event her surroundings become tense as there might be
times when those situations reoccur.
Tonia has met five (5) of the nine(9) criteria and has
been diagnosed with Major Depressive Disorder (MDD)
The client may benefit from Cognitive
Behaviour Therapy (CBT), Gestalt’s “Empty Chair” Therapy to facilitate closure
for her brother’s sudden death and Relaxation Therapy for those days when she
feels an aura of sadness and emptiness. Individual therapy sessions would also
be most appropriate. No
challenges exist to follow up; transportation is not an issue.
to the above therapy. A very important
part of the session will be to discuss:
relocation from the area she now resides.
for another job until the opportunity arise for her to resume her after school
programme; even if it is not in the same area that she lives.
scriptures that would assist her in coping with the days when her situation
will include her achieving the goal/objective of demonstrating a more relaxed
and less depressed mood. She will also
have increased comfort in leaning on the Word of God through reading the relevant
Activity in Treatment:
This model will assist Tonia to find solutions to
her financial problem and her protection for herself and her family, along with
the comfort that trusting in God will evoke.
The counsellor will discuss with Tonia how emotional
pain is inevitable and that at some point, in the lives of human beings, hurt
and trouble will occur but Jesus assured us that although we will have trouble,
we can be comforted by the thought that “He has overcome the world” (The Holy
Bile: New King James version John 16:33).
Through scriptures, Tonia will be comforted by assuring her that God is
faithful and that He is always looking after her and her family; protecting and
proving for them.
Psalm 91 will also be used to reassure her of His
protection of her and her family’s life.
Deuteronomy 31:8-9. The Lord himself goes before
you and will be with you; he will never leave you nor forsake you. Do not be
afraid; do not be discouraged.”
Tonia will be encouraged to read the Story of Job as an
assignment along practicing Relaxation techniques which will be taught to
her. Upon her next visit, Tonia will be
asked about what she has learned and could be applied to her personal life by
reading the story.
When the scriptures are incorporated in counselling
techniques as a part of the eclectic approach (with informed consent), it could
result in spiritual health; however, ethical approaches have to be considered
such as the counsellor being mindful not to impose his or her beliefs on the
client nor indulge the client with superstitions or counsel with insensitivity.
When scriptures are incorporated in counselling, it forms
a vital part of Cognitive Behaviour Therapy (CBT) as dysfunctional behaviour
usually begins with negative and dysfunctional thoughts. The scripture, therefore, can be used to
dissipate, minimize or stop these debilitating thoughts. As in Tonia’s situation and because of her
Christian beliefs and principles, she could be encouraged to delve deeper in
the Word and align her thoughts in order to find comfort and strengthen her