Assessing Client Family Progress 2
Presenting problem
“I want help to get off alcohol”
Past psychiatric history
1- Major Depressive disorder
2- Alcohol use disorder; severe
Medical history
Degenerative joint disease
Substance use history
Alcohol Abuse: First use at age 18, last drink 2 days ago, drinks 6 to 8 (16 OZ) beers, and 5th of vodka per day.
Treatment modality used and efficacy of approach
Client will be started on new antidepressant and be reevaluated in 4 weeks. Client was encouraged to start an alcohol detox program to control his dependence. In addition to a 12 weeks family group therapy. The treatment used is a combination of group/individual therapy along with medication management. It was proven to work with previous client.
Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
We encounter a fair progress with new treatment regimen. No side effect noted to new prescribed medications. Presence of anxiety noted with no signs and symptoms of acute substance withdrawal. Client compliant and responding to treatment. The treatment regimen was set for seven days with a continuum therapy of 3 months. Client was started on a regimen including: Daily multi vitamins, Folic Acid, Thiamine, Magnesium Oxide; In addition, Vistaril 50 mg TID for tremors and anxiety, trazodone 50mg at night to help sleep, Zoloft 50mg Daily to help with the depressive state. Group and family therapy also schedule in a daily basis. Client is currently on target with treatment regimen and will be able to continue with the next step.
Modification(s) of the treatment plan that were made based on progress/lack of progress
Clinical impressions regarding diagnosis and/or symptoms
Based on client response to treatment, no modification was necessary now. Client is well on target and will continue with scheduled therapy. The support provided by the family serve as an encouragement to remain focus on the treatment plan, therefore positive signs of improvement regarding diagnosis and symptoms.
Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
Client reports the desire to quick drinking to save his family from falling apart. He stated that he need help to stop abusing alcohol and “at this point I am willing to do anything”. Denies Suicidal ideations but feels really depressed. Client states he takes his meds every other day, that Latuda does not work. Client currently live in a home with his wife and son. Client reported being self-employed, and enjoys what he does for living due to the flexibility. His job has been affected lately due to excessive drinking and inability to wake up on time in the morning for work. Client reports depression, anxiety, he is calm, cooperative, polite, pleasant with organized thoughts.
Safety issues
Risk for alcohol withdrawal. Client should be carefully monitored if placed in a detox program where alcohol consumption will be denied. Risk for delirium tremens and alcohol induced seizure.
Clinical emergencies/actions taken
Client will be placed in a close unit with no access to alcohol, therefore putting him at risk for withdrawal. Monitor client for withdrawal symptoms, action will be taken as needed.
Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
Daily multi vitamins
Folic Acid 1mg Daily
Thiamine 100 mg Daily
Magnesium Oxide 400 mg Daily
Vistaril 50 mg TID for tremors and anxiety
Trazodone 50mg at night to help sleep
Zoloft 50mg Daily to help with the depressive state.
Ibuprofen 600mg TID for pain
Treatment compliance/lack of compliance
Client previous non-compliance aggravated his condition. He is presently adhering to present treatment. Tolerating prescribed treatment well.
Clinical consultations
A family therapist was brought on board to help address issue with primary family. Patient voiced the interest to return to the home that he owns with his wife after completion of his treatment. Therapy was initiated to involve the spouse and son in this effort.
Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
Rapid advances in microelectronics have made portable communication, data, image, sound storage, and transmission devices affordable and readily; hence, making consultation from one provider to the other much easier. Telehealth is currently used in mental health for a variety of professional services via telephone and other electronic for a continuum of care from one provider to the other (Abeles & Koocher,2011). For instance, before labelling a client with a mental health disorder, it is important to carefully assess. An example will be on a client that we had at clinical, he presented with signs and symptoms of ADHD, and to properly diagnose him and get him started on medication, he was referred to a psychologist. The result of his consultation was send directly to the office where we could download into his file. They are also instance were the therapist was called via telephone or on a screen to intervene in a situation.
Therapist’s recommendations, including whether the client agreed to the recommendations
Referrals made/reasons for making referrals
Therapist recommended that client put his name on the waiting list to get help with the detox program. Client agreed to this referral due to readiness to quick this lifestyle and get his life with family back on track. It gets easier when client is in accordance to be referred for further therapy that will bring change in the situation.
Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
Termination of therapy or counseling is a crucial point when a decision need to be made between the clinician-client relationship. Termination initiated by the practitioner can take place for a variety of genuine reasons, whereas when a patient terminates with the therapist or counselor, the process most often not require the practitioner to do anything further but to document the termination followed by the reasons of the termination (Wheeler, 2014). Most of the time Insurance company will pay for many sessions between the provider and the client; in the situation where more sessions are needed to achieve a better result, it becomes difficult to obtain additional payment leading to a termination. In that case the provider will figure out a better way to terminate the relationship to benefit the client.
Issues related to consent and/or informed consent for treatment
The fulfillment of consent and/or informed consent may vary depending upon the client and the treatment to be provided; however, informed consent generally requires some conditions to be establish. The client must first all be capable to consent; by doing this, the counselor or provider must make sure that the client has been adequately informed of the treatment processes and procedures, the potential risks and benefits of treatments; all followed by a free and without influence expressed and signed the consent; which in turn will be appropriately documented prior of starting the intended treatment or procedure. Sometimes, we are faced with a different category of client; client due to age or mental status that are legally incapable of giving informed consent. Arrangement are then made to obtain informed consent from a legally authorized person, if it does exist and are legally permissible (Abeles & Koocher, 2011). In this present situation, client was ready, and he consented with every step taking towards his functional state.
Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
Maternal family history of mental Illness and Alcohol Abuse. No history of child abuse
Part 2: Privileged Note
Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment.
· The privileged note should include items that you would not typically include in a note as part of the clinical record.
Clinicians should only include in the clinical record those items of which they are assured and that have implications for treatment. In the event where the client discloses a past crimes and sensitive information that may be potentially embarrassing or damaging, the provider could then create a privilege note for future references (Fontes, 2012).
Explain why the items you included in the privileged note would not be included in the client’s progress note.
It is more like a reference to self on how to approach the treatment plan differently if needed. A go to document. Whereas, the progress note provides an ongoing record of a patient’s illness and treatment. Physicians, nurses, consultants, and therapists record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. It is important that each note be clearly written, the date and time recorded, and the note signed (Chunchu, Mauksch, Charles, Ross, & Pauwels, 2012).
· Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.