Part 1: Progress Note Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations): Treatment modality used and efficacy of approach Pr

Practicum – Assessing Clients

Psychotherapy Individual: Prac 6640

6/21/2020

Practicum – Assessing Clients

Part 1: Comprehensive Client Family Assessment

Demographic Information

Name: Camila R

DOB: 2/20/1988

Age: 32

Gender: Female

Race: Hispanic American

Facility: REH Crisis Stabilization Program

City: Minneapolis

State: MN

Presenting Problem

Substance abuse, social withdrawal, and excessive worry.

History or Present Illness

Camila is an immigrant from Mexico. She left the country in search for a well-paying job that could cater to her needs and those of her family. However, so far, she has only managed to get minimum-wage jobs, which are not able to sustain both her and her family. Consequently, she has entered a depressive state due to her constant worrying about the future. She uses marijuana and alcohol as coping mechanisms. Shanmugam (2017) notes that this is a common trend among many addicts. Her constant worrying has made her irritable and withdrawn from her friends. Camila feels that she needs to get over her mental problems if she is to keep on working hard for the sake of her family.

Past Psychiatric History

Camila has noted that most of her days are spent worrying about money and where she can find a good job that will meet all her needs adequately. Consequently, she has had to depend on drugs and alcohol for solace. Whenever she is high, she forgets about her issues. However, her substance abuse is getting out of hand because it is affecting her performance at work. She has been irritable, angry, unable to get along with others, had mood swings, and has even had thoughts of suicide. Camila worries that if this trend continues, she will lost the only job she has with no guarantees of getting another one soon.

Medical History

Camila has been taking prescription antidepressant medication. She has been consuming 20 mg of Prozac per day. The medication has made her feel better but has not eradicated her problem.

Substance Use History

Camila has abused alcohol for approximately eight years. She has also taken excessive amounts of marijuana for the past year. She desires to be treated for both her substance abuse and her mental problems.

Developmental History

There is no available history since Camila is an immigrant from Mexico and has only stayed in the country for one year.

Family Psychiatric History

There are no records of Camila’s family psychiatric history.

Psychosocial History

Camila’s problems have made her withdrawn from her friends and family. She rarely interacts with close friends and prefers meeting with strangers whose she feels will not judge her apparent ‘failure in life,’ as she puts it.

History of Abuse/Trauma

Camila was raped on her way home from work this year. This episode triggered her excessive use of marijuana to cope with the feelings of shame. Acierno, Resnick, Flood, and Holmes (2003) assert that many women turn to drugs after being raped to handle the emotional turmoil. She did not report this case to the local authorities or to her family, preferring to suffer alone.

Review of Systems

General: Camila appears to be oriented to her surroundings. She answers queries succinctly and appears to be of sound mind. However, she only weighs 100 lbs. This is quite low for a woman whose height is 5’10. She attributes this to lack of appetite.

Skin, Hair, Nails: All these factors appear normal.

HEENT- Camila states that she does not have a headache. However, due to her poor eating habits, she regularly experiences dizziness and has even had syncope in the past. Her vision and hearing are relatively good.

Cardiovascular: Camila states she has never had any chest pains or heart issues. Her BP is 120/80. She has a regular heartbeat of 90 beats per minute. She has a regular heart rate of 90 beats per minute.

Pulmonary: Despite being a smoker, Camila says she has no breathing or respiratory issues. She has a 98 percent oxygen saturation.

Gastrointestinal: Camila’s bowel movements are regular.

Genitourinary: Camila’s urinary pattern is regular

Neurologic: Camila states that she has never been diagnosed with a neurological problem.

Musculoskeletal– Camila states that she has never been diagnosed with a musculoskeletal problem. However, she has slight back and knee pains.

Hematology: Camila states that she has never been diagnosed with any blood disorders or malignances.

Endocrine: Camila’s endocrine functions are normal.

Physical Assessment

Camila is alert and appears her age. However, she is underweight (100 lbs) for a height of 5’10. As aforementioned, her vitals are normal, that is cardiovascular, pulmonary, neurological, and gastrointestinal, among others.

Mental Status Exam

Camila was very coherent during the exam. She tried to maintain constant eye contact and effectively answered all questions concisely. However, she was moody and appeared distant at times. She was fidgeting all the time and noted it was due to her withdrawal from alcohol. Nonetheless, she was not delusional or paranoid. She was aware of her mental issues, which she stated had adversely affected her relationship with her family and friends. Camila took the Patient Health Questionnaire-9 (PHQ-9) and got a score of 25, which depicts severe depression.

Differential Diagnosis

Camila was diagnosed with severe substance abuse and depression.

Case Formulation

Camila’s mental issues have likely arisen from her inability to cater to the needs of her family. Everyone seems to look up to her and she is overwhelmed with the responsibility bestowed upon her. Additionally, the rape incident made the situation worse.

Treatment Plan

Goal 1

Camila will successfully undergo treatment for drug and alcohol abuse.

Objective

Camila will take all the necessary steps to be admitted into Park Avenue Women’s Center.

Intervention

Camila will be subjected to motivational interviewing. This model takes the form of counselling where the patient is encouraged and pushed to adopt positive behavioral changes. The changes are expected to lower Camila’s addictive habits.

Goal 2

Camila will effectively reduce and manage her social withdrawal, excessive worry, and anxiety

Objective

Camila will adopt effective coping skills through therapy techniques and use of antidepressant medication.

Intervention

Camila will be subjected to cognitive therapy and antidepressants.

Part 2: Family Genogram

Camila’s child is 10 years old

Camila is separated from her daughter’s father

Camila’s extended family lives in Mexico

References

Acierno, R., Resnick, H. S., Flood, A., & Holmes, M. (2003). An acute post-rape intervention to prevent substance use and abuse. Addictive Behaviors, 28(9), 1701-1715.

Shanmugam, P. K. (2017). Alcoholism & Drug Dependence. Journal of Alcoholism & Drug Dependence, 5(4).