Critical Reflection – a critical reflection supported by evidence which

Intake Date: August xxx IDENTIFYING/DEMOGRAPHIC DATA: Nia is a 29-year-old, African American female who lives with her partner Cassandra in a townhouse in San Francisco. They have been together for 6 years but have known each other since junior high school. Nia’s extended family lives in Oakland, California. She has a very close relationship with her mother and older sister. CHIEF COMPLAINT/PRESENTING PROBLEM: Cassandra initiated Nia coming to her first intake session due to Nia’s feeling sad, down, and having trouble sleeping. Sometimes she has periods of thinking she is dying with heart palpitations. She gets overwhelmed and starts sweating and feels nauseous. This has brought her to the hospital on two occasions. HISTORY OF PRESENT ILLNESS: Nia reports she has trouble sleeping at night thinking she is losing control of things in her life. She falls asleep then awakens and has trouble going back to sleep. Although this has been ongoing for about a year, now she thinks about her losing control of her life. She has recently gained weight since her life is less active because she does not want to go out. She just finds herself sitting around often daydreaming and not even focused on anything, not even concentrating. Cassandra gets upset that they seemed to have been hibernating much more than they need to since Nia fears losing control when they do go out. PAST PSYCHIATRIC HISTORY: Nia reports she was in therapy for a year with another therapist but was unsure how to work with therapy. The therapist rarely would ask her anything. Sometimes the therapist would sit back and read a magazine and Nia knew she was a bad patient. When Cassandra saw that was not helping Cassandra found a different therapist for her. SUBSTANCE USE HISTORY: Nia denies drug or alcohol use. PAST MEDICAL HISTORY: Nia reports feeling ill often. It is disappointing to her that her illnesses (colds, flus, sometimes pain in her joints) comes on so suddenly it stops her from activity that she was planning on and looking forward towards. She visits her doctor which she has been with for 25 years and he gives her medicine to try and help her illnesses. FAMILY HISTORY INCLUDING MEDICAL AND PSYCHIATRIC: Nia is the youngest of three children (one brother and one sister), both of whom are married and live in the same community. Nia believes she is close with both of her siblings and very close to her mother. Nia works in a library and was recently promoted to a supervisor although there are no other employees in her area. In a collateral consultation with her mother, mom reports Nia has always been different and has isolated a lot. During summer vacations at the lake Nia would prefer hanging around mom or playing by herself rather than join the other kids. Nia believed the kids were not interested in her since her likes were different than theirs. Nia reports never feeling as important as her siblings and believes they look at her differently. CURRENT FAMILY ISSUES AND DYNAMICS: Nia really enjoys her job but is always worried that she will be fired. She concerns herself with thinking she is just not doing enough, even though she recently became employee of the month. She has known Cassandra from junior high school. Finally, about 6 years ago Cassandra expressed her feelings for Nia and they immediately started dating. This comforted Nia because she has never been to social activities like bars and clubs to meet people. Cassandra encouraged Nia to get into therapy so they can expand their social circle. Cassandra wants to become involved in the rock and gem club but Nia refuses. Nia’s hesitation is that she does not know a lot about gemstones and the others will recognize that. Nia reports shopping has been a great relief from the time she was working full time but ends up with a lot of returns since she just does not know how to pick out the correct items. MENTAL STATUS EXAM: Nia presented as casually groomed and appeared her stated age. She was coherent and goal directed. Nia denies suicidal or homicidal ideation. She was dysphoric. Posture was tense. Facial expressions are appropriate to thought content. Motor activity is appropriate. Speech is clear and there are no speech impediments noted. Thoughts are logical and organized. There is no evidence of delusions or hallucinations. Nia was found to be oriented to three spheres. Fund of knowledge is appropriate to educational level. Recent and remote memory appear intact. The intake itself was challenging and the information seemed to be coerced from Nia and not easily presented.

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