Micro Counseling Services LLC

Biopsychosocial Report

Date of report: 09/12/2023
Name of client: Merkel, Beth

Source of referral: Recommended by Family Doctor
Source of information: Client.

Report Completed By:

Reason for referral: Client is seeking to reduce stress by working on her relationship with her ex-husband and eradicate alcohol as her coping mechanism.

Background Information

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Client demographics:

Beth is a divorced white female, age 35. She currently lives at home with her 4- and 12-year-old children, Arthur, and Barry respectively. Arthur suffers from Autism and requires more attention from her mother. Both of her sons have lived in the home with Ms Beth since she was divorced 2 years ago. Ms. Beth reports that she is currently struggling financially and has had to move to her mother’s house due to the financial burden after being divorced.

Behavioral observations:

Ms. Beth arrived on time for the appointment, and she had brought her younger kid with her, Arthur. Her appearance was a bit stressed and was wearing a messy dress. She appeared to not be aware of her surroundings as her focus was mostly on Arthur. Ms. Beth gave out detailed answers to questions about her history and current situation. However, her voice tone sounded a bit distraught.

Problem description:

Mr. Gump stated that he has been feeling “very sad” since the passing of his wife, Jenny, two years ago. He stated that he has begun to have dreams almost every night about his wife and about several others in his life who have passed away. In addition to his wife, Mr. Gump shared that he has lost his mother, and he lost a friend in the war who died in his arms in battle. He said he found talking to people to be helpful so he decided to try counseling. He denies problems with eating or sleeping with the exception of the nightly dreams, which he describes as not unpleasant, but he usually awakes feeling sad and missing those he has lost.

Multi-system review

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Biological:

Mr. Gump reports that he has always been “a little slow” but that his Momma told him “Stupid is as stupid does” so he did not ever feel he was “stupid”. As a child he wore braces on his legs, but eventually his legs were strengthened, and in fact he found he could run very fast. He also reports that he has excellent eye hand coordination and was a ping pong champion during his military service. He denies history of substance abuse or behavioral health problems, and has had access to appropriate medical care. He reports his lifestyle is healthy and includes regular exercise and good nutrition for himself and his son.

Psychological:

Mr. Gump appears to be able to accept most things, even those that have been troubling to him, in a generally positive way. He says he values honesty and loyalty and cares deeply for the people in his life. He speaks in a very matter-of-fact manner about the events of his life, without strong emotional affect.

Other than describing himself as “a little slow” Mr. Gump denies any history of psychological/behavioral health problems. His self esteem appears to be appropriate.

He denies suicidal ideation or history of suicidal thoughts. He states he is not aware of any history of psychological problems in his family.

Family:

Mr. Gump was raised by his mother. His father was not involved in his life and he did not, in fact, know his father. Mr. Gump was an only child. As a child he became good friends with a girl in his class, Jenny, and although he described their relationship as primarily platonic for most of their lives, one sexual encounter resulted in Jenny becoming pregnant with his son. He stated he was not made aware of his son’s existence until the child was three or four years old. He reports that Jenny was diagnosed with a terminal illness and contacted him because she needed him to take care of the child. He subsequently married Jenny and cared for her until her death two years ago. He is now a full time stay at home parent. He has no other children. No family history of mental health issues or other significant health issues noted.

Religious/spiritual:

Mr. Gump did not describe himself as particularly religious but did state that he believed in God.

Social/environmental/vocational:

Mr. Gump was raised in Georgia in a small community. When he became an adult he enlisted in the military and served overseas until his honorable discharge. He spent one year, as he described it, “running”, he ran across the United States, along with a growing number of followers. His closest friends were his friend Bubba, whom he met at boot camp, who was killed in combat, his friend and business partner “Lieutenant Dan”, and until her passing, his wife and childhood friend, Jenny. Lieutenant Dan lives in another state but they communicate regularly. He reports that he gets along well with his neighbors and with the other parents of children at his son’s school.

Mr. Gump reports that he has had a wide range of experiences throughout his career in the military and later in business, which includes world travel and meeting dignitaries and famous people. His success in business has allowed him to live comfortably and he does not currently work outside the home, although he does volunteer work in his community.

History of Trauma

Mr. Gump reports he experienced exposure to trauma during his military service including losing friends in combat. He denies history of physical, emotional, or sexual abuse in childhood.

Assessment:

Overall Mr. Gump appears to be a healthy, well adjusted adult male. Although he describes himself as “slow” he appears to be functioning at an appropriate level and able to care for himself and his son very well. He appears to be experiencing normal grief symptoms related to his wife’s death, and these do not appear to be so severe that he is unable to function. He does not appear to be clinically depressed, even though he describes himself as “sad”, he denies suicidal ideation or any of the more severe symptoms of major depression. His strengths include a strong relationship with his son, financial stability, good physical health, and an overall positive outlook on his life. He does have one close friend he speaks to regularly.

Plan:

Mr. Gump has agreed to individual therapy on a weekly basis for six weeks initially.

Treatment goals will include decrease in the frequency and severity of feelings of sadness and tearfulness and improved enjoyment of everyday activities as he progresses through stages of grief.

He may benefit from attending a grief support group and/or a single parent support group or other means to strengthen his social support network