Client Name: JS

Student Clinician Name: Brittany Webber

1. Evaluation and Assessment

Identify Precipitating Problems/Symptoms

The precipitating problems and symptoms that the client has is difficulty maintaining
sleep, inability to fall asleep and/or stay asleep throughout the night, for most nights out
of the week and not being able to fall asleep despite going to bed at a decent time.
According to the client, this has been occurring for about five months now.

The client states that his sleeping patterns have decreased significantly throughout the
past year, specifically due to the stressors of work and the frequent use of having to be
near his cell phone to communicate with his job. The client says that while he enjoys his
job, it has become much more intensive and the amount of work has increased greatly for
him.

Comprehensive Psychosocial Assessment

The client is a 29 year-old male, of Haitian descent, who currently resides in Florida. The
client lives with his wife of six years. He holds a Bachelors degree in Accounting, and
currently works as an accountant for a high volume company. He has worked for the
company for three years now. The client reports this as a very high-pressure job and it
has been more stressful than normal as of lately. He states that he worked very hard in
college to get to the position in which he has now, so he feels very proud of himself.

The client reports his childhood as normal. He grew up living with an older brother and
younger sister, and both of his parents. He was very close with his siblings, and still
maintains a close relationship with them until this day. There are no reports of any
alcohol or substance abuse in the clients family history.

The client reports that as far back as he could remember, that he has always been a
light sleeper. It always took him a while to fall asleep, and often woke up several times
throughout the night. He recalls having to wake up his parents on a few occasions
because of nightmares he had while sleeping. As the client grew up, he was able to
manage his sleeping patterns by altering the times he went to sleep, which mostly helped
him being able to fall asleep more effectively.

The client describes his relationship with his wife as very loving and warm. He states that
they met in college and began a great friendship before becoming romantically involved.
He states that they have always been on the same page and he states that his wife is an
important source of comfort and help when he needs it. The client did not have any prior
treatment, and states he was hesitant to pursue therapy, but his wife insisted that he
needed help for his difficulty sleeping.
Identify Individual and Relationship Functioning

Most recently, the client has experienced extreme irritability, fatigue, and decreased
energy throughout the day. The client explains that this has interfered with his
functioning at work. He states that it is a struggle to get his work done, and may take him
longer than it usually would. This has been very distressing for him, since he has always
been very good at his job.

The client states that his inability to sleep has led him to be on his cell phone for all hours
of his night, which has interrupted the sleep of his wife. He states that his wife has a
strong opinion about the amount of time the client already uses his phone during the day,
so this has caused a strain on their relationship. The client expresses his frustration that he
is unable to fall asleep or maintain sleep throughout the night, and states that he uses his
cell phone as a way to occupy his time in bed, but it has not been effective. The client
reports that the recent stressors in his job have been the cause of the decline in his
sleeping pattern. The client states that his ability to communicate his feelings and
emotions with his wife has always been strength of his, but as of lately they have both
been frustrated to the point where they do not want to communicate about anything.
Feeling more stress from his job, the client states that he often has mood disturbances
throughout the day. This has had a great impact on his marriage, and the client has had
difficulty dealing with this.

2. Diagnosis & Treatment Planning

Client Assessment & Observational Data

The client is displaying difficulty maintaining sleep, an inability to fall asleep and/or stay
asleep throughout the night, despite adequate opportunity for sleep, and distress in
occupational, behavioral and relational functioning for at least 3 nights per week/present
for at least 3 months.

Utilizing Clinical Judgment

The principal diagnosis for the client is 780.52 (G47.00) Insomnia Disorder, as evidenced
by the DSM-5. The client meets the following criteria in the diagnostic requirement:

A. A predominant complaint of dissatisfaction with sleep quantity or quality, associated
with one (or more) of the following symptoms:
1. Difficulty iniating sleep.
2. Difficulty maintaining sleep, characterized by frequent awakenings or
problems returning to sleep after awakenings.
3. Early-morning awakening with inability to return to sleep.
B. The sleep disturbance causes clinically significant distress or impairment in social,
occupational, educational, academic, behavioral, or other important areas of functioning.
C. The sleep difficulty occurs at least 3 nights per week.
D. The sleep difficulty is present for at least 3 months.
E. The sleep difficulty occurs despite adequate opportunity for sleep.
F. The insomnia is not better explained by and does not occur exclusively during the
course of another sleep-wake disorder
G. The insomnia is not attributable to the physiological effects of a substance
H. Coexisting mental disorders and medical conditions do not adequately explain the
predominant complaint of insomnia.

Principal Diagnosis:
780.52 (G47.00) Insomnia Disorder, Persistent; (V 61.10) Relationship distress with
spouse or intimate partner.

Treatment Plan

The clients long-term goals, as desired treatment outcomes, are to be satisfied with sleep
quantity or quality, particularly reaching reasonable sleep goals. The short-term goals for
the client are to mend relationship issues with his wife, learn how to communicate more
effectively, and manage stressors from his job.

The objectives used to meet these goals:
1) Explore relationship conflicts
2) Learn and use effective communication strategies
3) Learn how to cope and manage stress from job

The interventions recommended to meet these objectives will include: Cognitive
Behavioral Therapy (CBT), Relaxation techniques, and Behavioral Therapy. Cognitive
Behavioral Therapy will be effective for the client to focus on his thoughts and beliefs,
while Behavioral Therapy will focus on the clients behaviors and actions. Relaxation
techniques are recommended to help relieve the symptoms of stress.

The clients strengths consist of great insight into the problems that has been affecting his
functioning, as well as motivation and a positive attitude. The client is in the action stage
of change, aware that a problem exists and that he is willing to modify his behavior. One
of the barriers that the client may face, might be financial stress due to the pressure of the
clients job, primarily because the client is mostly responsible for the household income.
The therapy sessions will take place for once a week, for three months. The sessions will
be predominantly individual, but may progress to couples therapy if necessary.










3. Clinical Practice

Determine & Identify Other Services

Outside services recommended for the client to obtain further information:

211 Palm Beach Treasure Coast

Insomnia Support Groups

Mental Health Association of PBC

Jerome Golden Center for Behavioral Health

Ethical and Legal Issues

The ethical and legal issues pertaining to the clients case are necessary to consider. A
possible complication that may arise may be a dual relationship between the therapist and
the client. Confidentiality is also important for the client, in order for them to be aware of
what rights they have. Ethically and legally, it is vital for the therapist and the client to
discuss suicide, as well as the other risks that may occur in therapy.

Scope of Practice/Parameters and Limitations

As a student in my early stages of becoming a Licensed Mental Health Counselor, there
are several limitations that are important to consider. According to the American
Counseling Association (ACA), counselors must practice within their boundaries. At this
time, I would not feel competent enough to treat the client appropriately, as I am
continuing my education as part of the ethical standards in order to become a Licensed
Mental Health Counselor. In order to fulfill the principle of nonmaleficience for the
client, I would continue my education, and gain more knowledge and competence before
treating the client.