1. Clinical Assessment
By: Raelle Plante

2. Demographic and Presenting Problem
Belle French (Pseudonym)
34 years old
Caucasian
French Immigrant
Married, Stay at home mother of a five month old daughter
Referred by the Parenting Program
What is the presenting problem?
*Anxiety/fearful *Hopelessness
*Intrusive thoughts *Isolation
*Unable to turn her mind off *Going through the motions
*Unable to sleep *Tearful

3. Biopsychosocial Assessment
Physical History
Early physical and developmental history is unknown.
G1P1
Early Prenatal Care
Spontaneous Vaginal Delivery at 38.2 Weeks
Breastfeeding Successfully
Psychological and Cognitive History
There are no obvious signs of cognitive impairment. However, it is unknown.
Previous psychological history is unknown. However, she reported now that she knows more (about mental health) she has always been an anxious person and fearful of bad things happening.
She is currently seeing a psychologist.

4. Biopsychosocial Assessment Continued
Socio-cultural contexts and environmental issues:
Moved to U.S. with husband due to his employment 3 years ago
Slight language barrier
Neither have friends or family near by
She video calls her family often and reports intense homesickness.
Husband is supportive.
Unable to share this time in her life with family.
She watches youtube videos that depict french scenery,

5. Strengths Resources and Vulnerabilities
Motivated to get better and do the work
Determined to be a good mother
Supportive husband
Physically healthy
RESOURCES
Socioeconomic Status
Access to Care
Technology
Support Group
VULNERABILITIES
Lack of access to family
Homesick
Acculturation

6. Cognitive Profile
Relevant Background Information: Family in France, Birth of first child, History of anxiety,
Core Beliefs: I am not good enough. The world is not safe. People may or may not be safe.
Conditional Beliefs: If I have bad or scary thoughts about my child then I am a bad mother.
Rules: I must never tell anyone my scary thoughts. I should not be left alone with my baby.
Compensatory Strategies: I continue to go through the motions and keep busy, so the scary thoughts won’t creep in.
Automatic Thoughts: My baby deserves a better mom than me. I am a terrible mom. I will never have joy in my life again.
Emotional Consequences: Sad, anxious, fearful
Behavioral Consequences: Afraid to go to bed, afraid to express her thoughts, unable to sleep, avoids being alone with baby

7. Antecedents: An intrusive thought occurs
Behavioral Profile
Antecedents: An intrusive thought occurs
Behavior: Tries not to think about and then can’t stop thinking about it
Consequence: Intense feelings of fear, anxiety, and guilt
Strength: Strong- it happens daily
Strength:
outlining the targeted problem (be specific), the baseline strength of the problem, antecedents and consequences. When describing behaviors do so in objective, observable, measurable terms and underscore the “strength” of the behavior.

8. Diagnostic Assessment and Treatment Plan
DSM-IV-TR
Axis I: Obsessive Compulsive Disorder
Axis II No known
Axis III Recent childbirth
Axis IV Problems related to the social environment
Axis V GAF score 50
Strength:
outlining the targeted problem (be specific), the baseline strength of the problem, antecedents and consequences. When describing behaviors do so in objective, observable, measurable terms and underscore the “strength” of the behavior.

9. Diagnostic Assessment and Treatment Plan
DSM 5 Diagnosis and ICD-10:
Obsessive Compulsive Disorder (ICD 10- F42) with comorbid Major Depressive Disorder with moderate anxious distress in partial remission (ICD 10- F32.4)

10. Problem: Intrusive thoughts
Treatment Plan
Problem: Intrusive thoughts
Goal 1: To reduce anxiety regarding thoughts
Objective 1: Will read information about exposure therapy and educational materials about intrusive thoughts.
Objective 2: The client will use breathing and meditation strategies to reduce anxiety and increase relaxation.
Objective 3: The client will experience and evaluate the intrusive thoughts at each session.

11. Treatment Plan Continued
Goal 2: To reduce depression resulting from intrusive thoughts
Objective 1: The client will identify and challenge cognitive distortions.
Objective 2: The client will participate in a postpartum adjustment support group.
Objective 3: The client will record a thought journal and assess automatic thoughts and reactions each week

12. Engagement Issues and Reflection
How did you facilitate the therapeutic alliance?
Reflect on your use of self.
What obstacles, if any, did you face in establishing a therapeutic alliance?
Overall, in your work with this client how do you feel that you did through the entire process?
What worked? What did not work? What would you do differently?

13. Question!
Perinatal mood disorders have been well documented. Unfortunately, the DSM 5 does not live up to the expectations of many who anticipated a bigger change regarding these disorders. Is it ethical to make a diagnosis (we know diagnoses can follow a person through life) that isn’t quite right?
For example...