PCN-485.R.Client File 2-3-14 2 PDF

Preview

Summary

Advanced addiction counselor notes/Addiction Counseling Competencies: The Knowledge, Skills, and ... clinical reports, clinical progress notes, discharge summaries, and other client-related...

Description

PCN-485 Client File Directions: The forms contained in this document will be completed throughout the course. Use the "Case Study: Matthew" document to complete the forms. Some items within the forms have been completed for you. 1. Presenting Problem 2. Risk Assessment 3. 4. 5. 6.

Assignment Addendum: Screening and Assessment Strategies Assessment for Motivation for Treatment Substance Use Screening Potential Treatment Recommendations

7. Biopsychosocial Assessment 8. Case Management Progress Note 9. Individual Treatment Plan 10. Assignment Addendum: Reassessing the Treatment Plan 11. Multidisciplinary Treatment Team 12. Continuing Care Services Form 13. Relapse Prevention Plan 14. Discharge Summary 15. Assignment Addendum: Understanding Major Classifications of Mental Illness

© 2014. Grand Canyon University. All Rights Reserved.

Presenting Problem Directions: Using the case study of Matthew, document Matthew's presenting problem using the template below. Each response should be 50 to 100 words. Client's perception of the problem: From the client’s perception of the problem, he believes that drinking and abusing prescription painkillers help him forget about the things that happen in the war and it keeps him calm. However, since he has been off of his medication for almost two weeks, he has been trying to manage his PTSD and depression by using more prescribed painkillers than are normal and drinking on a regular basis. Case manager's perception of the problem: It believes that Matthew has been experiencing PTSD symptoms from being in the war and getting injured. Nevertheless, causing Matthew to drink and abuse prescription painkillers in order to numb his pain. He has been experiencing flashbacks, nightmares about the incident and at the most unexpected times, Matthew’s thought process has shift from a normal event back to the time of the ambush. Therefore, the counselor believe that this is deeper than depression. His PTSD goes into fear of rejection and grief. Current Symptoms: The client consistently tries to avoid thoughts and images related to injuries and deaths of others due to being hit by an improvised explosive device during war. In spite of this, the client’s current symptoms are drinking/possible abuse of OxyContin, abdomen pain from military service injury, anxiety, and depression. However, the counselor also believe that he is going through PTSD, fear of rejection and grief as well. Client's reason for seeking treatment: The client has identified many different reasons for seeking treatment. However, the client states that “he just wants his life and his family back and that he’s so sick of the war in his head.” Also, he has been experiencing flashbacks, nightmares about the incident and at the most unexpected times, Matthew’s thought process has shift from a normal event back to the time of the ambush.

© 2014. Grand Canyon University. All Rights Reserved.

Client: Matthew Smith Date: July 11, 2021

Risk Assessment To be completed by the case manager: Consider each of the questions below and indicate how closely they describe the client’s current lifestyle. Mark the number that best describes the client’s current level of functioning. 1

2

3

4

5

Strongly Disagree

Disagree

Neither Agree or Disagree

Agree

Strongly Agree

1. Are there emotional, behavioral or cognitive problems due to a substance abuse issue? 1

2

3

x

4

5

2. Have they been depressed or down for nearly every day for the past 2 weeks? 1

2

3

x

4

5

3. In the past month, did they think that they would be better off dead or wish they were dead? 1 x 2 3 4 5 4. Have they ever experienced or witnessed or had to deal with an extremely traumatic event that included actual or threatened death or serious injury to them or someone else? 1

2

3

4

x

5

5. Do they feel like they need help for their emotional or substance use issues? 1

2

3

4

x

5

6. Have they ever given into an aggressive urge or impulse that has led to negative consequences? 1 2 3 x 4 5

© 2014. Grand Canyon University. All Rights Reserved.

7. Are there times in which they suddenly feel anxious or uneasy that they feel scared, unsteady or like they would faint? 1

2

3

4

x

5

8. Do they feel guilty about drinking or drug use? 1

2

x

3

4

5

9. When their emotions are out of control, do they turn to alcohol or drugs? 1

2

3

4

x

5

10. In your opinion, is this client at risk to harm themselves or others? 1

2

3

x

4

5

Total score: 41 Scoring: Total up the points, highest possible score is 50. 36-50=At risk and further assessment is needed. 25-35=Moderately risk-potential referral for services. 15-24=Are at low risk and referral services may/may not be needed. 0-15=Does not appear to pose any risk to self. *Note: If a client scores a 4 or 5 on Question 10, report this to your supervisor.

© 2014. Grand Canyon University. All Rights Reserved.

Assignment Addendum: Screening and Assessment Strategies Directions: Use the information from the case study of Matthew to answer the following questions. Your answer should be 250-500 words. Include a minimum of one scholarly reference to support your response. What screening and assessment strategies would you use with Matthew? Explain why you chose these strategies. As the counselor look over Mattew’s chart. The counselor can see that the screening and assessment strategies that the counselor would use in this case is The Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS). This tool consists of a combined screening component (TAPS-1) followed by a brief assessment (TAPS-2) for those who screen positive (McNeely, Wu, Subramaniam, Sharma, Cathers, & Svikis, 2016). These tools can be used by the patient (self-administered) online or administered as an interview by a health professional. Upon completion, the tool will automatically generate a risk level for each substance class. Implications of the score, along with suggested clinician actions and additional resources, will be provided. The TAPS tool starts with questions about the frequency of use of tobacco, alcohol, and other substances in the past 12 months (McNeely, Wu, Subramaniam, Sharma, Cathers, & Svikis, 2016). Endorsement of any substance use during the initial screening phase (TAPS-1) prompts few additional questions regarding use-related behaviors through a brief assessment (TAPS-2) (McNeely, Wu, Subramaniam, Sharma, Cathers, & Svikis, 2016). Scores on these questions generate a risk level per substance endorsed, based on a range of possible scores per substance. The counselor also chose the NIDA Quick Screening tool. This screening tool is a validated instrument designed to assist providers in screening adults for substance use (National Institutes of Health, 2009). The screen simply inquires whether a participant has used drugs (mood-altering, illegal, or prescription for nonmedical reasons), alcohol, or tobacco products within the past year and how often these substances have been used (National Institutes of Health, 2009). The NIDA website also provides guidelines for brief intervention and/or treatment referral for patients who may have or be at risk of developing a substance use disorder.

© 2014. Grand Canyon University. All Rights Reserved.

Reference McNeely J, Wu L, Subramaniam G, Sharma G, Cathers LA, Svikis D, et al. Performance of the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) Tool for Substance Use Screening in Primary Care Patients. Ann Intern Med. 2016;165:690-699. doi: 10.7326/M16-0317 National Institutes of Health. (2009). NIDA Launches Drug Use Screening Tools for Physicians. Retrieved from: https://www.nih.gov/news-events/news-releases/nida-launches-drug-use screening-tools-physicians

© 2014. Grand Canyon University. All Rights Reserved.

Client: Matthew Smith Date: July 18, 2021

Assessment for Motivation for Treatment Consider each of the questions below and indicate how closely they describe the client's thoughts and feelings. Mark the number that best describes your response. The statements below are from the client's point of view. 1

2

3

4

5

Strongly Disagree

Disagree

Neither Agree or Disagree

Agree

Strongly Agree

1. I wish I had more ideas on how to solve this problem. 1

X

2

3

4

5

2. I feel that my substance use is a very serious problem in my life. 1

2

3

X

4

5

3. I don’t like myself because of my substance use. 1 2 3 X

4

5

4. Lately, I feel if I don’t change, my life will keep getting worse. 1

2

3

X

4

5

2

3

X

4

5

3

4

5

3

4

X

5

3

4

X

5

5. I feel bad about my use. 1 6. I know I’ve hurt a lot of people. 1

2

X

7. I’ve got to change my ways. 1

2

8. Maybe this place will be able to help me. 1

2

9. Using has caused problems for me and my family. © 2014. Grand Canyon University. All Rights Reserved.

1

2

3

X

4

5

10. I sometimes worry that I’m out of control with my use. 1

2

X

3

4

5

Total score:38

Scoring: Total up the points, highest possible score is 50. 36-50=Motivated for change 25-35=Moderately ready for change 15-24=Considering change 0-15=Hasn’t recognized that change is necessary

© 2014. Grand Canyon University. All Rights Reserved.

Client: Matthew Smith Date: July 18, 2021

Substance Use Screening Instructions: Mark either yes or no for each question to indicate your answer. Use the information provided in the case study of Matthew to answer these questions. 1. Have you used drugs other than those required for medical reasons?

X Yes

No

2. Have you abused prescription drugs?

X Yes

No

3. Is it difficult for you to limit your drinking or drug use in certain situations?

X Yes

No

4. Do you have difficulty getting through the week without using?

X Yes

No

Yes

X No

X Yes

No

Yes

X No

X Yes

No

9. Have you done something illegal to obtain the drug or alcohol?

Yes

X No

10. Have you experienced withdrawal when you don’t use?

Yes

X No

5. Do you find it difficult to stop using when you want to? 6. Have you had “blackouts” or “flashbacks” as a result of use? 7. Have you ever neglected your family or friends because of use? 8. Have you been arrested while under the influence?

To score: If the client says “yes” to 6 or more questions there is the potential for a substance abuse problem.

© 2014. Grand Canyon University. All Rights Reserved.

Client: Matthew Smith Date: July 18, 2021

Potential Treatment Recommendations Directions: As a result of the Assessment for Client’s Motivation for Treatment and the Substance Abuse Screening Form, please list the potential treatment recommendations. An example has been provided for you. Treatment Recommendation 1 (Example): It is recommended that the client receive 1:1 individual counseling to address his concerns of war-time activity, with a possible diagnosis of Post-Traumatic Stress Disorder. Responsible Party or Referral Contact (Example): State of Indiana Veteran’s Affairs Association, 99 Jameson Parkway, Indianapolis, IN, 46652, 555-555-5555. Contact person is Dr. Chandra, ext. 123, email: [email protected] Treatment Recommendation 2: It is recommended that the client receive outpatient treatment to address his drinking/possible abuse of OxyContin, with is due to suppressing feelings. This can be done at the Recovery Place INC in Savannah, Ga. It is also recommended that the client goes through group therapy and family therapy at this outpatient treatment facility. Responsible Party or Referral Contact: Recovery Place INC. 835 E. 65th St. Savannah, GA 31405, (912) 355-1440 Treatment Recommendation 3:

It is recommended that the client receive cognitive behavioral

therapy (CBT), cognitive processing therapy (CPT), cognitive therapy (CT), and prolonged exposure therapy (PE) from Hope Counseling in Savannah, ga to address the Pt. mental and emotional health, anxiety, depression, relationship issues and life challenges. Responsible Party or Referral Contact: HOPE COUNSELING, 37 West Fairmont Ave, #201 Savannah, GA 31406, Contact person is Bonnie’s Phone: (912) 661-2801, Bonnie’s Email: [email protected] OR Andrea’s Phone: (912) 507-2483, Andrea’s Email: [email protected]

Cotia Wallace Case Manager Signature

July 17, 2021 Date

© 2014. Grand Canyon University. All Rights Reserved.

Biopsychosocial Assessment Directions: Complete the Biopsychosocial Assessment below using the case study of Matthew. Some items have already been completed for you. 1. Client Information Client’s Name: Matthew Smith

D.O.B.

Date of Assessment: July 10, 2021 Time Involved: 12PM Primary language: English

10/20/71

Age: 42

Sex: M

Face-to-Face: Yes Method of communication: Verbal 2. Presenting Problem

Description of the client’s perception: From the Pt. perception of the problem, he believes that drinking and abusing prescription painkillers help him forget about the things that happen in the war and it keeps him calm. However, since he has been off of his medication for almost two weeks, he has been trying to manage his PTSD and depression by using more prescribed painkillers than are normal and drinking on a regular basis. Level of distress expressed by client: None mild

moderate

severe

3. Psychological, behavioral information Description and history of presenting problem: The Pt. consistently tries to avoid thoughts and images related to injuries and deaths of others due to being hit by an improvised explosive device during war. In spite of this, the client’s current symptoms are drinking/possible abuse of OxyContin, abdomen pain from military service injury, anxiety, and depression. However, the Pt. is also going through PTSD, fear of rejection and grief as well do to combat. Duration of problem and current episode: Duration of problem and current episode that the Pt. has been experiencing PTSD symptoms from being in the war and getting injured. Nevertheless, causing Matthew to drink and abuse prescription painkillers in order to numb his pain. He has been experiencing flashbacks, nightmares about the incident and at the most unexpected times, the Pt, thought process has shift from a normal event back to the time of the ambush. Therefore, it is believe that this is deeper than depression. His PTSD goes into fear of rejection and grief.

Previous attempts to resolve, including help sought from other sources: The Pt. has met with the case manager he was referred to by the Veteran’s Administration. When the case manager asked the Pt. why he was there and what motivated him to receive treatment, he replied “I just want my life and my family back and he is sick of the war in his head.” The agency’s psychiatrist, Dr. Thomas Charles, met with the Pt. and decided that the Pt. should begin taking an anti-depressant to help him stabilize his mood. The Pt. was prescribed Xanax, an anti-anxiety medication, for the times in which the Pt. experiences a panic attack or feels that he is getting ready to have a flashback or intrusive thought. © 2014. Grand Canyon University. All Rights Reserved.

Potential for injury to self/others: Yes, potential for injury to self/others due to PTSD symptoms from being in the war and getting injured. The effects of PTSD can cause someone to put them in danger or even endanger others including their family members. Suicidal: Client denies suicidal thoughts at this time, however he is at risk for these thoughts. Explain: The Pt. has stated that he was experiencing flashbacks from the war, remembering the blood and men screaming in the night. These flashbacks can trigger suicidal thoughts. He also broke down and started crying to his wife Jasmine and she realized that he was experiencing extreme stress. Self-Mutilating: No Explain: N/A

Violent/Homicidal: Client denies homicidal thoughts at this time" Plan would only be needed to be discussed if the client had a plan to hurt himself or others. Explain: The Pt. has not shown any violent or homicidal to others, however to himself. The Pt, has taking pills and drinking therefore causing harm to himself and his health.

Describe plan, available means, intent, and urgency: I really don’t understand this part History of suicidality: None Describe: N/A History of violent/assaultive behavior: Yes, in Operation Desert Storm Describe: Veteran of Operation Desert Storm. Veterans who served in Operation Desert Shield or Operation Desert Storm were subject to many different factors that could lead to various illnesses, health concerns or disabilities after service. 4. Social History A) Identifying Information: a. Age: 42 b. Race: African American c. Gender: Male d. Height: 6'1" e. Weight: 190 lb f. Description of Client: Matthew is a well-dressed man, wearing blue jeans and a sweater. He appears to look tired, and his eyes are red with bags under them. He is walking with a stooped posture, with a far-away look on his face.

© 2014. Grand Canyon University. All Rights Reserved.

B) Relationships within the family/family origin Where were you raised? Chicago, IL By Whom? Biological Mother  Biological Father  Paternal Grandmother Maternal Grandmother Adoptive Mother Foster Home

Stepmother Stepfather Paternal Grandfather Maternal Grandfather Adoptive Father

Do you have siblings? Brother  Sister  Half-Brother

Half-Sister Stepbrother Stepsister

Discuss significant relationships with any family members: Matthew has a good relationship with his mother. His father passed away 15 years ago from a heart attack. He doesn’t stay in much contact with his brother and sister, primarily because they all live in different states. C) Developmental History Are you aware of having any problems with any of the following as a child? Sitting Up Toilet Training Enuresis Feeding Self Crawling

No No No No No

Dressing Self Frequent Nightmares Standing Walking

No No No No

Did you physically mature around the same time as most peers your age? Yes D) Trauma History a. Have you ever been sexually abused? No Degree/extent: b. Have you ever bee...