History of Presenting Case

History of Presenting Case.

Running Head: WEEK TWO JOURNAL ENTRY

 

 

 

 

 

 

 

 

 

Assignment 2: Practicum Week 2 Journal Entry

 

NURS 6650 Psychotherapy with Groups and Families

Walden University

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Group Therapy Progress Note

 

 

 

 

Client: ___John M_______________________________________________ Date:9/18/2018 ___________

Group name:_____________N/A___________________________________ Minutes:_______45_ Group session # __N/A____ Meeting attended is #:_1_____ for this client.

Number present in group ___2__ of _____ 2scheduled Start time:_1130_______ End time: ___1215_____

 

Assessment of client

· Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn

· Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive

❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________

· Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________

· Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other:_______________

· Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused

❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other:__________________

· Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt

· Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic

· Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able

· Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse

· Other observations/evaluations:________________________________________________________ In-session procedures:

· __________Introduction_________________________________________________________________

· ___

· History of Present Problem____________________________________________________________________________

· _Assessment______________________________________________________________________________

· Formulated Plan _______________________________________________________________________________

· __________ _____________________________________________________________________ Homework: Daily Recording of Sobriety

1. 2. Focus on present and future, not the past Commit to 12 steps Meetings

3.

 

Other Comments:

Brochure provided for AA meetings in the area of city of Phoenix

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

 

 

Leandre

Signatures Date

 

American Psychological Association | Division 12 http://www.div12.org/ 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

History of Presenting Case

 

The family consisted of 40 -year-old John M, and his wife Mary M., who is 32 years old, and they have no children. The clients were seen in a mental crisis center. Initially, Mr. John had been voluntarily admitted to the unit due passive suicidal thoughts, depression, and alcohol dependence. Mr. John had been recently fired from his job due to showing at work drunk. Couple therapy was recommended to speed up his recovery and maintain sobriety.

In the session, Mr. John self-reported mood as depressed, and he acknowledged his drinking problem disrupting his life, and he was prepared to fully participate in the recovery for the sake of his well-being and his marriage. On the hand, his wife Mary, appeared anxious, and frustrated. She blamed the husband for all the misery of the family. She was much worried about their future as the husband had lost his job. However, she was willing to support him in recovery.

Psychiatric History: Mr. John has battling depression for six years, and his PCP prescribed antidepressant (Zoloft) last year but he abruptly stopped taking them as he felt that the medication was affecting his sexuality. He did not follow up with his PCP. He self-medicates with alcohol. His wife reported history of anxiety and occasional panic attacks, she was taking fluoxetine 40mg daily. The medication was prescribed by PCP.

Psychiatric Hospitalization: It was the first time for Mr. John to hospitalized in mental facility.

His wife reported no history of psychiatric hospitalization.

Medical History: They both denied any medical history

Psychosocial History: They both said they smoked marijuana occasionally. The wife works as cashier in a local gas station. They live in a one- bedroom apartment.

Differential Diagnosis:

Major Depression Disorder F 32

Mr. John presented with depressed mood and reported history of loss of interest in pleasurable activities, sleep disturbance and suicidal thoughts lasting more than 2 weeks. In addition, to meet the diagnostic criteria the symptoms had caused clinically significant distress or impairment in social, occupational, or other important areas of functioning( American Psychiatric Association, 2013)

Alcohol Use disorder AUD

To be diagnosed with an AUD, individuals must meet certain diagnostic criteria. Some of these criteria include problems controlling intake of alcohol, continued use of alcohol despite problems resulting from drinking, development of a tolerance ( Grant& Saha, 2015).

Generalized Anxiety Disorder: Ms. Mary exhibited some of the signs of generalized anxiety. Diagnostic criteria symptoms include excessive anxiety and worry as well as restlessness, fatigue, irritability, tension, and sleep problems (Watson& Greenberg, 2017)

Ethical and Ethical Implications of Counselling the Couple

  Family members often experience resentment about past substance abuse and fear and distrust about the possible return of substance abuse in the future (O’ Farrell& Fals-Stewart, 2013)In the case of John and Mary, there is a higher probability that there will be uncertainty and distrust during the recovery. It may be unethical to tell directly his wife that her anxiety and blame towards her husband may demoralize him and impede the recovery. However, it may be beneficial as feelings experienced by the substance abuser and the family often lead to an atmosphere of tension and unhappiness in couple and family relationships( O’Farrell & Fals-Stewart, 2013).

 

References

American Psychiatric Association. (2013). Major Depressive Disorder. Retrieved from https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_MajorDepressiveDisorder.pdf

Frisch, N. C., & Frisch, L. E. (2011). Psychiatric mental health nursing (4th ed.). Clifton Park, NY: Delmar Pub.

Grant, B., & Saha, T. (2015). Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III. Jama Psychiatry, 72(8). Retrieved from https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2300494

Nichols, M. (2013). The Essentials of Family Therapy (6th ed.). United States: Pearson Education.

O’Farrell, T. J., & Fals-Stewart, W. (2013). Behavioral Couples Therapy for Alcoholism and Other Drug Abuse. Alcoholism Treatment Quarterly, 26(1-2), 195-219. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3215582/

Watson, J. C., & Greenberg, L. S. (2017). Emotion-focused therapy formulation of generalized anxiety disorder. American Psychology Association, 54(4), 17-40. Retrieved from https://eds-b-ebscohost-com.ezp.waldenulibrary.org/eds/pdfviewer/pdfviewer?vid=9&sid=0ff11f46-f73e-4f63-8578-ad65a99c45c2%40pdc-v-sessmgr05

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