Intake Report 1

Client Name: J Doe

Interviewed by: Sinthia Rahman at Pepperdine Clinic
Identifying Information and Referral Source
J Doe is a 28-year-old Caucasian male who identifies as straight, is a devout Christian,
and currently works as a teen counselor. He is now living in Southern California with his mother
and father while working; he does not have any siblings. J Doe reached out for therapy because
his family and friends noticed a dramatic shift in his mood from very motivated to down in the
dumps. Although urged to come to therapy by those around him, J Doe is just as eager to work
on himself since he recognizes the changes too.

Presenting Problems
The client reports a depressed mood, loss of interest in usual activities, decreased energy,
trouble sleeping when he wanted to, increased appetite, and unintentional weight gain over the
past three weeks. As for emotional impacts, he stated that he felt more sad, hopeless, and
worthless during this period. When asked about how his life was before those three weeks, J Doe
mentioned 4-5 days before those three depressing weeks, during which he suddenly felt more
active, felt a decreased need for sleep, and had racing thoughts. These symptoms persisted for
most of the day, every day of that 4-5 day period. When asked more about those days of
heightened activity, the client stated that they didn't feel like any problems arose and were more
concerned about the sudden shift from that to the three weeks of depressed mood. Before the 4-5
day period, the client has never had such a sudden shift in energy and mood in his life.
During the three weeks, J Doe has started having problems at work, issues with his social
relationships, and has no been spending time with his family and friends like he usually does.
Impairs in functioning during the 3-week depressive phase include significant problems with
work performance, strain on the client's relationships with others, and decreased interactions with
friends and family. During the 4–5-day active phase, the client mentioned that the reduced need
for sleep and racing thoughts, in particular, caused some impairment in work. J Doe explained
that people around him mentioned him talking faster, more than usual, and showing more
energy. His coworkers also expressed concern after noticing the sudden mood changes. When
asked about anything he’s done to alleviate these problems, J Doe stated that he hadn’t tried
anything yet and was hoping therapy with address the issues. Usually, the client plays sports to
alleviate stress, and the last time he did so was during the 4-5 days of increased activity. The
client could not pinpoint any possible precipitating events and reported that the sudden changes
seemed to come out of nowhere.

Personal History
J Doe’s highest level of education completed is a Bachelor of Arts, and during college his
performance was average. He self-described as not exceling but getting a mixture of As and Cs;
the client recalled not enjoying school but knowing it was important to complete. Throughout
college J Doe didn’t develop close relationships with professors and only asked questions when
needed, in addition to gaining knowledge from them. As for peer relationships, the client kept a
small circle of friends, and keeps in touch with them to this day. When asked about the nature of
those friendships, J Doe affirmed that he considers them a part of his support system. Upon
graduating from college in Northern California, the client worked at a teen treatment center for
three years, where he became a team lead before moving to a different part of the state. Neither
he nor his family have ever served in the military.
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The client’s family includes his mother and father in addition to himself. He was born
and raised in Redlands, California, before moving to San Francisco at age eighteen for college.
Growing up J doe was always shy and quiet; he enjoyed have relationships but preferred a small
group of close friends. Although he and his current friends do not live in the same area, the client
expressed happiness and fulfillment in current friendships. J Doe’s mother is a stay-at-home
mom, and his dad is a therapist. The client shared that his father’s occupation sparked his own
interest in psychology. When asked about family values, he expressed an importance of Christian
values and a strong sense of family. J Doe and his family also keep each other accountable,
collaborate on decisions and at the end of the day “have each other’s backs.” To spend time
together, the client and his family have dinner most nights of the week, go out on Saturdays for
fun and go to church on Sundays.
J Doe identifies as straight and is currently single; his last relationship ended while he
was in Northern California. Upon reflecting on that relationship, the client mentioned that he and
his ex-girlfriend were good at listening to each other and supportive. However, some challenges
included stubbornness over certain things, which eventually led to the break-up. When asked
about recent significant life events, J Doe mentioned the end of his two-year relationship,
moving to a new area and starting a new job. (Note: All of these events occurred more than 3
months ago). In terms of accomplishments and resilience, he expressed pride in earing a
counseling position in the mental health field. In the past the client has felt uncertain if those
occupations are a good fit for him or if he is capable of succeeding in counseling roles, however
he points out that he was confident and proud before the onset of symptoms.

Medical History and Medication/Substance Use

The client reported no medical conditions or medication use, and they have not spoken
with a physician to discuss symptom causes. J Doe stated that he occasionally partakes in casual
alcohol consumption on weekends but tries to keep it to a minimum. He reported that his mother
was diagnosed with depression and is currently on medication for it.

Ethnic/Cultural/Religious-Spiritual Identity
Cultural identity: J Doe was born and raised in Redlands, California, and at age 18, he
moved to San Francisco for college. Years later, he returned to Southern California and has been
there since working in various mental health occupations. The client’s racial identity is
Caucasian/White, and he is a devout Pentecostal Christian who goes to church on Sundays with
his family. As Sue and Sue (2015) emphasized, it is essential to keep in mind the tripartite
development of personal identity, which will significantly aid in understanding the different
identities that make up the client's life experience. Knowledge of these various identities and
their interactions will help build rapport and aid treatment recommendations.
Cultural factors impacting coping skills and help-seeking: The client has utilized his
strong faith in God and connection with Christianity to bring faith into his past problems and
persevere. He strongly believes his religion will help him through struggles, consistent with
discussions by Richards and Bergin (2014), yet also stated that it is important to reach out when
things become severe. The client expressed concern over the current depressed mood, which was
more painful than past struggles and is one reason he reached out for support. As for his family, J
Doe’s parents are part of those around him who noticed changes in his mood and encouraged
him to go to therapy. When asked about views towards mental health in Christianity, the client
reported that there isn’t stigma around getting therapeutic help and that the religious community
 Intake Report 3

is supportive, which differs from what is mentioned in Richards and Bergin (2014) and could be
attributed to different experiences in the religion. Being culturally competent and aware of the
values within Christianity is crucial in therapy; however, it is vital not to make assumptions or
generalizations and instead use that information to guide conversations and explore the client's
agreements or disagreements with their culture (Sue and Sue, 2015). The only cultural barrier J
Doe perceives is the stigma around men reaching out for emotional support. He expressed
concern over how men were not expected to need additional help with their mental health and
were supposed to persevere without help merely because of the stereotypes around their gender.
Cultural factors that may impact clinical management or the therapeutic
relationship: A potential barrier to the therapeutic alliance is misunderstandings over
Christianity since the client is Christian and the therapist is not. The clinician should not burden
the client with educating them regarding those religious differences; instead, it is essential to
gather further knowledge by exploring research and even talking with those in the Pentecostal
Christian community (Dobbins 2014). Considering that religion is important to J Doe, it is
crucial that the clinician educates themself on the values in Christianity and utilizes spiritual
resources throughout therapy (Richards and Bergin 2014) to strengthen the therapeutic alliance
and ensure that the client is understood and aids in treatment. As mentioned in Richards and
Bergin (2014) most Pentecostals find themselves feeling guilty or questioning their connection to
God when faced with mental health problems, so it would be important to gently explore that
with the client, even if they’ve mentioned their parents being supportive of therapy.

Behavioral Observations/Mental Status Evaluation

As the intake interview was conducted via zoom, some information may be lacking,
while supplemental information was collected in other areas. The client wore a clean shirt and a
cap, appearing well-groomed. The room he was calling from appeared slightly messy, and his
demeanor seemed low energy or tired. J Doe spoke firmly with many pauses as he appeared to be
thinking deeply about the questions, especially those about his religion and previous
relationships. Response to questions were appropriate and moderate in terms of the amount of
information shared. The client would occasionally make eye contact, yet did not do so during
most of the interview, and preferred to look to the side. Throughout the intake, J Doe would shift
in his chair and sometimes rest his head on his hand. The client’s affect matched the depressed
mood he described as well as the content of his words. He presented self-awareness and
openness to the changes that those around him have noticed. J Doe was cooperative throughout
the interview and seemed hopeful that therapy would help with his issues. There were no
displays of hallucinations, delusions, or other psychotic symptoms.

Diagnostic Impression
F31.81, bipolar II disorder, current episode depressed, mild severity
Diagnostic Process
Substantiation:
The diagnosis of bipolar II disorder was determined for J Doe based on the reported and
observed symptoms of both a depressive and hypomanic phase. He meets all criteria for the
major depressive episode, hypomanic episode, and bipolar II disorder itself.
Hypomanic episode: Criterion A: Distinct period of abnormal and persistent
elevated/expansive/irritable mood as well as an abnormal and persistent increase in
activity/energy, persisting most of the day nearly every day for at least four consecutive
 Intake Report 4

days. J Doe experience a period of abnormal and persistent elevated mood with increased energy
for 4-5 days. Criterion B: During this period, three or more symptoms persisted with a
noticeable change from usual behavior and at a significant degree. The client reported a
decreased need for sleep, was more talkative than expected, and had racing thoughts. Criterion
C: Period is associated with a change in functioning that is uncharacteristic of the
individual. J Doe mentioned being more active than usual. Criterion D: The disturbance in
mood and the change in functioning are observable to others. The client's friends and family
noticed the increased energy, and his coworkers noted changes in functioning at work.
Major depressive episode: Criterion A: 5 or more symptoms have been present
during the same two-week period and represent a change from previous functioning. At
least one symptom is depressed mood or loss of interest/pleasure. During the past three
weeks, J Doe has been experiencing a depressed mood most of the day, loss of interest in most
activities, trouble sleeping, loss of energy, increased appetite, and unintentional weight gain
nearly every day. He reported that these symptoms all present a change from functioning before
the hypomanic episode. Criterion B: The symptoms cause clinically significant distress or
impairment in functioning. The client reported having serious problems with work productivity
and maintaining positive relationships with family and friends. He also stated that emotional
distress such as sadness, hopelessness, and worthlessness have impaired regular functioning.
Bipolar II disorder: Criterion A: Criteria have been met for at least one hypomanic
and at least one major depressive episode. As detailed above, J Doe has met the criteria for
one hypomanic and one major depressive episode. Criterion D: The symptoms of depression
(or the unpredictability caused by frequent alternation between periods of depression and
hypomania) cause clinically significant distress in functioning. The client reported that
symptoms from the past three weeks have resulted in substantial emotional distress and
negatively impacted social and occupational settings.
Differentiation:
Major depressive disorder: The client experienced a period of increased activity prior to
the major depressive episode. Those symptoms met the criteria for a hypomanic episode and thus
did not fit Criterion E of major depressive disorder.
Hypomanic episode: Criterion E: The episode was not severe enough to caused
marked impairment or necessitate hospitalization. While there has been some impairment in J
Doe’s communication in relationships and work setting, they have not caused significant
problems or resulted in hospitalization. Criterion F: The episode isn’t attributable to the
physiological effects of a substance. The client does not use medications or partake in drug
abuse, and while he does casually consume alcohol on weekends, the symptoms persisted before
and after consumption.
Major depressive episode: Criterion C: The episode is not attributable to the
physiological effects of a substance or other medical condition. The client does not use
medications or partake in drug abuse, and while he does casually consume alcohol on weekends,
the symptoms persisted before and after consumption.
Bipolar II disorder: Criterion B: There has never been a manic episode. J Doe has not
previously experienced the symptoms of a manic episode. Criterion C: The occurrence of the
hypomanic and major depressive episodes are not better explained by schizoaffective
disorder, schizophrenia, schizophreniform disorder, delusional disorder, or other specified
or unspecified schizophrenia spectrum and other psychotic disorder. The client has not
experienced delusions, hallucinations, or any other psychotic symptoms, so schizoaffective
 Intake Report 5

disorder, delusional disorder, and other psychotic disorders cannot be linked to the symptoms.
While he was more talkative during the hypomanic episode, the symptoms were not severe to the
point of disorganized speech, so this excludes schizophrenia, schizophreniform disorder and
unspecified schizophrenia spectrum.

Treatment Recommendations
1. Establish rapport and strengthen the therapeutic relationship with the client (Reichenberg
& Seligman, 2016).
2. Assess for suicide or self-harm since suicide risk is high in bipolar II disorder. No
medication recommendations will be made until this has been completed (American
Psychiatric Association, 2015).
3. Assess for comorbidity with an anxiety disorder since it is also common with bipolar II
disorder, and relevant symptoms were not discussed during the intake. (American
Psychiatric Association, 2015).
4. The client’s concerns are regarding depressive symptoms, so the treatment will be catered
to address the major depressive episode. As mentioned earlier, many of those symptoms
include impairment in daily activities such as sleep, work, and social relationships;
therefore Interpersonal and Social Rhythm Therapy (IPSRT) is the suggested treatment
for J Doe. (Reichenberg & Seligman, 2016)
5. A weekly combination of psychoeducation, supportive therapy, and family therapy will
be most effective in addition to IPSRT. (Reichenberg & Seligman, 2016).
a. Incorporate spiritual beliefs and habits as self-regulation and coping mechanisms.
b. Learn to regulate emotions, become less emotionally reactive, and use various
techniques like breathing exercises, distraction, and self-soothing.
c. Learn to keep track of behaviors that may provide temporary relief but have a
rebound effect or may cause harm in the long term.
d. Sessions with the family every 2 or 3 weeks to help them be more aware of the
disorder, empathize with the client during episodes and improve the family bond.
References
American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders.
(5th ed.).

Dobbins, R. D. (2014). Psychotherapy with Pentecostal Protestants. In P. S. Richards & A. E.

Bergin (Eds.), Handbook of psychotherapy and religious diversity (p. 155–178). American
Psychological Association. https://doi.org/10.1037/14371-007

Reichenberg, L. W., & Seligman, L. (2016). Selecting effective treatments : A comprehensive,

systematic guide to treating mental disorders. ProQuest Ebook Central https://ebookcentral-
proquest-com.lib.pepperdine.edu

Richards, P. S., & Bergin, A. E. (2014). Handbook of psychotherapy and religious diversity (2nd
ed.). American Psychological Association. https://doi-
org.lib.pepperdine.edu/10.1037/14371-000

Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th ed.).
John Wiley & Sons. https://pepperdine.on.worldcat.org/oclc/910009543