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Assignment 2: Practicum – Week 2 Journal Entry

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Learning Objectives

Students will:

  • Apply documentation skills to examine family therapy sessions *
  • Develop diagnoses for clients receiving family psychotherapy *
  • Analyze legal and ethical implications of counseling clients with psychiatric disorders

*

  1. * The Assignment related to this Learning Objective is introduced this week and submitted in Week 3.
  2. Select two clients you observed or counseled this week during a family therapy session. Note:
  3. The two clients you select must have attended the same family session.
  4. Then, address in your Practicum Journal the following:
  5. Using the Group Therapy Progress Note in this week’s Learning Resources, document the family

session.

6   Describe (without violating HIPAA regulations) each client, and identify any pertinent history or medical

information, including prescribed medications.

7 Using the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5), explain

and justify your diagnosis for each client.

Explain any legal and/or ethical implications related to counseling each client.

Support your approach with evidence-based literature

Running Head: WEEK TWO JOURNAL ENTRY

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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  • Participation level: ❑ Active/eager ❑ Variable   ❑ Only responsive   ❑ Minimal   ❑ Withdrawn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
  2.  

                                                                                                                                                               

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).

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