Biopsychosocial History and Assessment Interview

Summary

In this session, a social worker named Courtney conducts an intake assessment with Jimmy, a military veteran facing difficulty sleeping due to chronic back pain. He reports irritability at work and home, often due to lack of sleep and increased caffeine consumption. Courtney explores Jimmy’s mental health history, including past ADHD symptoms, family dynamics, and parenting challenges. They discuss his relationships, including his close bond with his mother and children, and his struggles with anger management. The session concludes with plans to address Jimmy’s sleep and irritability issues in future appointments, emphasizing the importance of a follow-up to create an effective treatment plan.

Takeaways

• 😀 The client, Sergeant James, prefers to be called 'Jimmy' and is attending a behavioral health assessment for the first time.
• 😀 Jimmy's main concern is difficulty sleeping, which has led to irritability both at work and at home.
• 😀 He reports consistently getting less than four hours of sleep per night, with frequent wake-ups and difficulty falling back asleep.
• 😀 Jimmy attributes his sleep issues to back pain, which started after his last deployment two years ago and has progressively worsened over the last couple of months.
• 😀 He has not seen a doctor for his back pain, partly due to concerns about being held back from future deployments.
• 😀 Jimmy uses over-the-counter pain relievers (ibuprofen) and sleep aids (melatonin, Zzzquil) to manage his symptoms, but they are not very effective for long-lasting relief.
• 😀 His irritability has been noticeable to others, especially at work, where his mood changes have raised concern among his colleagues.
• 😀 He drinks around four to six cups of coffee or energy drinks per day, which may be contributing to his increased irritability.
• 😀 Jimmy has no prior mental health diagnoses or treatment, although he mentions some childhood symptoms that may have been related to ADHD, but they do not significantly affect his work.
• 😀 He reports no history of physical, sexual, or emotional abuse, though he experienced some verbal abuse from his father during childhood, primarily directed at his mother.
• 😀 Jimmy has a supportive relationship with his mother and maintains long-term friendships from his hometown, Wichita Falls, Texas, which offer a source of emotional support.
• 😀 He is a single father with a good relationship with his children, and he strives to provide them with affection and support, learning from the lack of such expressions in his own upbringing.

Q & A

What is the primary reason Sergeant James came in for the assessment?

Sergeant James came in because he has been experiencing difficulty sleeping, which is affecting his mood and irritability at work and home. He also mentioned wanting help managing his stress and anger.

How many hours of sleep does Sergeant James typically get per night?

Sergeant James typically sleeps about 4 hours per night, and this occurs at least four nights a week.

What challenges does Sergeant James face when trying to sleep?

He faces difficulty falling asleep (taking 1 to 3 hours) and wakes up 2-3 times during the night. It also takes him up to 1-2 hours to fall back asleep once he wakes up.

What does Sergeant James attribute his sleep problems to?

He attributes his sleep problems to chronic back pain from an injury sustained during his last deployment, which makes it uncomfortable for him to sleep, especially when lying on his back.

Has Sergeant James sought medical help for his back pain?

No, he has not seen a doctor for his back pain, as he is concerned that medical treatment could interfere with his upcoming deployment.

What medications is Sergeant James using to manage his pain and sleep issues?

Sergeant James uses over-the-counter medications like ibuprofen and Advil for pain relief, as well as sleep aids like melatonin and ZzzQuil to help him fall asleep.

How has Sergeant James' irritability affected his relationships and work?

Sergeant James' irritability has been noticed by others, especially at work, and has led to a slight increase in mood issues. Although he has not had serious altercations, his increased mood swings are concerning to those around him.

What role does caffeine play in Sergeant James' life?

Sergeant James drinks 2-3 cups of coffee in the morning and 2-3 more in the afternoon, along with some energy drinks. He believes the increased caffeine consumption is contributing to his irritability.

What is Sergeant James' history with mental health services?

This is Sergeant James' first time seeking behavioral health support. He briefly saw a counselor as a child due to potential ADHD symptoms, but he never received a formal diagnosis or treatment.

How does Sergeant James describe his relationship with his parents?

Sergeant James has a strained relationship with his father, primarily due to his father's alcohol use and emotional distance. However, he is close to his mother and maintains a supportive relationship with her, especially as an adult.

What parenting challenges does Sergeant James face, and what is he focused on improving?

Sergeant James has identified irritability as a challenge in his parenting. While he is committed to being a good parent and has not been abusive, he acknowledges that his temper has become shorter, especially with his children.

What does Sergeant James hope to achieve through therapy?

Sergeant James hopes to improve his sleep, manage his irritability, and develop strategies to reduce stress. He is also focused on improving his parenting skills and emotional regulation.

Has Sergeant James been in any significant romantic relationships since his divorce?

No, Sergeant James has not had any significant romantic relationships since his divorce. He has dated casually but has focused more on his children and personal responsibilities.