Biopsychosocial Assessment

Identifying Information: Daniel Jiang, is a 55 year-old Chinese American, married with

two grown children. He’s financially stable and is presenting with concerns relating to
depression and anxiety.
Present Psychiatric Illness/Symptoms: Client reports changes to his physical
functioning, chronic fatigue, and finds it difficult to get out of bed. Client has had little
motivation for work, has been worrying about his health, has very little appetite, and he
has lost ten pounds. Client has also had a panic attack episode.
Past Hx Of Treatment: Client was taken to the nearest hospital for panic symptoms.
After a thorough check-up, the doctor suggested professional mental health help for
what he was experiencing. Client has never been to counseling but made an
appointment with a counselor
Mental Health Medications: No history of medication use and not current use.
Medical Concerns: Daniel is chronically fatigued and worried about his health. His
appetite has dropped and he thought he was having a heart attack when he was having
a panic attack. Client is concerned about physical and psychological symptoms and
says “I am not myself."
Current Medications: Client is not currently taking any medications
Dependency/Addiction History: Client reports that he does not drink or do drugs.
Family History of Psychiatric/Addiction Illness: Client reports his father died of a heart
attack at age 65 and his mother died of cancer when he was 25 years old. No reports of
any psychiatric/addiction from any family members.
Spirituality: Client reports that he goes to the Methodist church in town, but that he
hasn't attended for the past 6 months. He states that spirituality is important to him, but
that God has not answered his prayers for help.
Personal History: Client has one married sister, who has two teenagers. He reports that
she lives in North Carolina and they see each other twice a year. His mother and father
have passed away, but client does not report any ill relationships with parents. Client
stated that he has a few "good friends," but that he hasn't had the energy to do anything
with them during the past 6 months. Client is married with grown children, but his wife is
concerned about his lack of interest in activities they used to enjoy together. Client has
no criminal record but received a speeding ticket two months ago.

Education: Client has not disclosed educational history.

Work History: Client has not disclosed his line of work but worked at the same company
for 30 years. Client says he used to enjoy going to work, but now he has no motivation
and is concerned that the quality of his work is suffering as a result.
Legal History: Client recently received a speeding ticket but is the first one he has ever
received. No other legal history is known.
Marital/Relationships: Client is married and seems to have a positive relationship with
wife, although his wife is concerned by his lack of interest in activities he used to enjoy.
Mental Status: Client appeared anxious and sad at initial counseling session. He had
trouble sitting still, and he did not make eye contact with the counselor. Daniel stated "I
know that I am not crazy, but something is going on. I am not myself." He went on to
talk about the past six months, concluding, "I feel worthless and don't think that I can go
on living this way." Client presents with concerns of sadness and anxiety but is oriented
to time and place.
Summary Impression: Daniel Jiang, is a 55 year-old Chinese American who is married
and is seeking treatment for symptoms related to depression and anxiety. Client is
struggling with motivation and panic symptoms.
Short-term Goals:

1. Develop treatment plan related to clients depression and anxiety

2. Develop safety plan in case thoughts of worthlessness and not being able to go
on living the way he is.
3. Develop self-care plan
4. Possibly assist client in finding support groups

Case Conceptualization
Daniel Jiang is a 55-year-old Chinese American who is married and has two grown
children that live out of state. Daniel has not had a history of mental illness and no
previous complaints of depression or anxiety up until more recently. The client has
reported changes to his physical functioning, chronic fatigue, and has found it difficult to
get out of bed. The client has had little motivation for work and is concerned that the
quality of his work is suffering as a result. He has been worrying about his health, has
had very little appetite, and has lost ten pounds. The client reports that he spends a lot
of time alone and his wife is concerned with his lack of interest in activities he used to
enjoy. The client has had a panic episode where he reported breathing rapidly,
sweating, and feeling as though his heart was about to explode. Those symptoms had
him worried enough to be sent to the hospital. The doctors were unable to find anything
wrong with his heart and suggested the client see a mental health professional in order
to address the physical and psychological symptoms he’s experiencing. The client has
never been to counseling until now and is presenting with concerns related to
depression and anxiety, which are the primary issues.
Treatment Plan
The client is currently exhibiting symptoms related to depression and anxiety, including
a recent panic attack episode that resulted in the client going to the hospital. The goal
for the client is to develop a treatment plan related to the client's depression and anxiety
symptoms. Those goals include (1) develop a safety plan in case thoughts of
worthlessness and not being able to go on living the way he is, (2) develop a self-care
plan (3) create coping techniques for clients to use during anxiety attacks, (4) explore
client starting medication to manage anxiety and depression, and (5) possibly assist
client in finding support groups.

SLAP Model
● Specificity: The client has mentioned that he feels worthless and doesn't think
that he can go on living this way. The client did mention that he has not made
any plans for suicide but that he does have a gun that he keeps locked up in the
house. Although he does not have plans to commit suicide, the client did say that
if he were to think of a plan, the gun would be the likely option for means of
suicide. He tends to spend quite a bit of time alone and would have the time and
place to make it happen if he chose to.
● Lethality: Having a gun is a fairly lethal means for suicide if the client were to
decide to go through with creating a plan. A gun can cause serious harm and
depending on where the client shot himself, it could be extremely lethal.
● Access to means: The client has easy access to the gun if that were to be his
chosen method for suicide. He knows the lock combination and could access it at
any point.
● Proximity of social support: He does live with his wife, which would be the closest
means of support for the client. Although his children live out of town. He does
speak with them regularly. Also, even though he has been isolated more than he
used to, he does have friends he can rely on if he were to reach out to them.
I would consider the client to be a moderate-low risk for suicide. The client has not
brought up suicide specifically but has said things that point to hopelessness,
worthlessness and mentioned how he feels he cannot continue to live the way he
currently is. The client has not made a specific plan but does have the means to carry
out suicide if he chose to. He has easy access to a gun, however, the client does have
a decent support system and people to rely on. I would go ahead and create a safety
plan with the client and I would like the client to agree to move the gun out of the house,
or have his wife change the lock to prevent him from having access to the gun. I would
reiterate the importance of a support system and provide additional resources for the
client to rely on.