Template The first section is for introducing the client. Ple ✓ Solved

Template The first section is for introducing the client. Please include the following information: Agency Information Dayton, Ohio 45410 Medical is committed to assisting adults with substance use disorder regain their dignity and respect. The agency uses medicated assisted treatment and mental health disorder services.

SW intern informed client she is a mandated reporter and anything she shares with me about harm to herself or another must be reported to my field instructor and field liaison. Ask client for permission for individual session, informed client the session would be recorded for a school assignment. Client agreed and signed a release of information.

Client information (confidentiality of course): The client is an 18-year-old white female, who has a learning disability and substance use disorder and mental illness. She is a high school senior and attends public school. Client has diagnoses of substance use disorder and bipolar disorder. She was recently in the program at Marathon where she began stable with medication, remained sober for 38 days, and graduated two weeks ago. Client lives in a group home and is unhappy living there.

Client reported, “they pick on me.” Client has threatened to harm herself in the past and spent a week on the psych ward at a local hospital. This client hangs out with older friends drinking and doing drugs. She misses curfew and has to sleep on the porch. She reported that is why she came back, because she could not stop drinking and was going to be put out.

Session Number #2 Date 4/19/2021 Presenting Issue (reason for referral): Client is a walk-in. She was recently discharged from the program after successfully completing. Client returned to treatment program due to relapse. Client relapsed on alcohol and cocaine.

Relevant Information: Client has been in the program before. She has a history of attention-seeking behavior. Client reported she wants to attend her graduation from high school and go to prom next month. Client lives in a group home.

Goal of Session:

1. Client Goal: To learn coping skills to avoid relapse. Client will learn two coping skills by 4/30/21. Client will begin attending AA meetings 2x a week and have a paper signed for attendance at every meeting.
2. Your Goal: To teach client relapse prevention skills by 4/30/21 and review her signed meeting slip every two days for compliance and review skills for comprehension by 4/25/21.

Dialogue: Please group dialogue together. Identify (for each section): Theory, Practice Model, Techniques, and Skills Analysis/assessment of dialogue. What was going on? What were the patient's reactions to your feedback? How did the client respond verbally (quality of voice, tone, did the respond better to closed or open-ended questions?) How did the client respond non-verbally (how did you know they were listening? were they distracted? Did they welcome your feedback?) Personal reactions and self-reflection to the interaction: What were you thinking? How do you feel the session went? What could you have done better? What will you do differently/the same next time?

Intern: Hello, R. You’re back, so soon, what happened? Why are you back?

Client: I tried to drink alcohol again. I was drinking by myself this time. I had a friend buy it for me. They had the cocaine. So, I snorted some. It was fun at first, but I got sick this time.

Intern: I remember some of the things we talked about the last time you were here. You told me, when you drink, you don’t remember what you do. What did we call that?

Client: Black out, I know.

Intern: Tell me, what was going on before you started drinking?

Client: I got mad at the lady who runs the house. I want to go somewhere else besides the group.

Intern: Let me see if I understand. You started drinking because you were mad at the lady who runs the group home. And you want to go somewhere else? Hum? Where would you go?

Theory: Client lacks relapse prevention skills. Practice Model: Motivational Interviewing. Technique/Skills: Open-ended questions, express empathy, reflective listening, summarize, affirming, open-ended questions.

Client's demeanor was relaxed, with a friendly, playful tone. Client began to fidget in her seat, shifting her weight. Client hunched her shoulders while she explained drinking and using cocaine. Client nodded her head with recognition of having a blackout. Client’s voice became more intense and raised. She shifted her weight and started swinging her foot. Client has good eye contact, nodding her head in agreement with what I am saying. Client looked away with no response. The client was relaxed because she is familiar with the agency and staff.

This intern was thinking she was afraid because she blacked out early this time. I was thinking she feels safe and knows she will get help here. I feel this part of the session went well. I have not asked about her mental health medication. I think the client is desperate.

Process Recording - Cavanagh (Advanced Year) 2019.

Paper For Above Instructions

The client, an 18-year-old white female, faces significant challenges due to a learning disability, substance use disorder, and mental illness, notably bipolar disorder. Her recent journey has been marked by struggles against addiction and the desire for stability and acceptance in her life. The agency serving her in Dayton, Ohio, focuses on assisting adults with addiction disorders, and this particular client has shown both resilience and vulnerability throughout her treatment.

During her initial session, the intern emphasized the importance of establishing trust while adhering to the mandated reporter protocols, indicating the seriousness of the environment. Understanding the potential need for reporting self-harm or harm to others creates a safety net for the client. This initial meet helped lay the foundation for an open dialogue, highlighting the intern's commitment to care while ensuring confidentiality as much as possible within the constraints of legal obligations.

The client's recent discharge from the treatment program after a successful period in recovery was a highlight, but also a point of concern as she relapsed shortly after returning home. Recovering from substance use disorders often entails coping mechanisms, and it is apparent that this client had not fully developed those skills, leading to her relapse into alcohol and cocaine use. Engaging in motivational interviewing, the intern aimed to promote the development of these skills while validating her experiences.

The dialogue captured during session two was revealing. The client’s admission of feeling driven to drink due to frustrations with her living situation painted a clear picture of her circumstances. These external pressures exacerbate her internal struggles, often leading her back to substances as a coping mechanism. The reference to her previous experience of “blacking out” indicates both awareness of the potential risks involved in drinking but also highlights the lack of effective coping strategies. Thus, the session focused on guiding her toward recognizing triggers and developing healthier responses.

Utilizing open-ended questions allowed for a deeper exploration of the client's thoughts and feelings. At times, the client engaged more actively during discussions that prompted her to reflect on past decisions. This engagement showcases motivational interviewing’s effectiveness in enhancing client self-efficacy. The intern noted the client’s emotional reactions, including fidgeting and intensifying body language, as indicators of distress but also engagement. These distractions reveal the client's inner conflicts, which need addressing to facilitate recovery.

Additionally, the intern's reflections highlight the necessity of understanding the client holistically. While the immediate focus was on substance use reignition, there is an underlying theme of needing stability. The relational dynamics within the group home pose additional difficulties, as the client feels ostracized from her peers, affecting her mental health, and potentially steering her back to substance use for solace.

Setting clear goals was imperative in guiding this client's treatment journey. By structuring the objectives around learning two coping strategies and ensuring consistent attendance at AA meetings, the intern has created a framework that fosters accountability. Recognizing her desire to attend high school graduation and prom indicates her aspirations are not extinguished; therefore, the goals should align with fostering these dreams that may act as motivation to remain sober.

As the intern reflects on the session, there arises an opportunity for growth in her practice. Noting the necessity to inquire about the client’s mental health medications would have been a pertinent factor in understanding her overall stability. Consistently integrating that aspect during sessions could lead to better-informed discussions around medication adherence and its role in relapse prevention.

The intern's feelings during the session indicated a mix of empathy and concern for the client’s well-being. A careful balance must be maintained between providing support and challenging the client to explore uncomfortable feelings related to her substance use. Moving forward, the intern aims to create a space where the client can freely express herself while also revisiting coping strategies to manage her environment and emotions without resorting to substances.

In conclusion, clients battling substance use disorders present unique challenges that require a tailored approach. Understanding the intricate relationship between their mental health, environmental influences, and individual aspirations will be critical in facilitating lasting change. As treatment progresses, reinforcing the development of coping skills, enhancing self-efficacy, and supporting the client’s aspirations will be essential in guiding this young woman toward a healthier, substance-free life.

References

• Substance Abuse and Mental Health Services Administration. (2020). Behavioral health treatment services locator.
• American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
• White, W. L. (2012). Recovery: The New Standard of Care. Alcoholism Treatment Quarterly.
• Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.).
• Becker, K. D., & Michalak, J. (2020). Substance use and co-occurring disorders: A comprehensive guide for counselors.
• Drake, R. E., Mueser, K. T., & Brunette, M. F. (2017). A manual for the Integrated Treatment of Co-occurring Substance Use and Mental Disorders.
• Harris, E. W., & Kearns, J. M. (2019). Essentials of recovery-oriented mental health services.
• National Institute on Drug Abuse. (2020). Principles of drug addiction treatment: A research-based guide.
• Galanter, M., & Kleber, H. D. (2015). The American Psychiatric Publishing textbook of substance use disorder treatment.
• Savic, M., & Best, D. (2016). The role of personal factors in recovery from substance use disorders: A review of research and practice.