Assignment 2: Week 3 Practicum Assignment

Objective Assessment:

“My son’s new behavior has taken a toll on me. It is so depressing. Before he never used to do drugs and we used to have an exemplary relationship Assignment 2: Week 3 Practicum Assignment

The client reported that her son’s new behavior that included drug-taking has strained her relationship between her son and her. The client further reported that the son had started taking alcohol and was neglecting his academic work; this was really depressing to the mother. The client also reported that she is experiencing sleeping problems, has stopped eating as before and as a result has lost a lot of weight. The client further reported that she no longer attends social gatherings as before, feelings of hopelessness, and has lost interest in activities she enjoyed before.

Subjective Assessment:

Allergies: none

Past medical history: She was once admitted for meningitis

Suicide Risk Assessment: Low risk of suicide

From the provided health information, the condition of the son has had a big effect on the client. The client is managing the son’s addiction alone and as a result, this has taken a very big toll on her. Consequently, she has become depressed as manifested by the depressive symptoms she reported.

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Assessment

MENTAL STATUS EXAMINATION: The client, xx is a 41-year-old Africa American female whose appearance looks normal for her age. She appears withdrawn throughout the examination but she is oriented to time, person and place as well. Throughout the interview, the client was able to respond to questions actively and reported depressive symptoms. Her thought process is intact and normal as indicated by her capacity to answer all presented questions actively. The client does not have any suicidal ideation and her cognitive functioning appears normal. Assignment 2: Week 3 Practicum Assignment

Diagnosis

Major Depressive Disorder

The symptoms of major depressive disorder for this client are manifested by symptoms such as feeling of sadness and depressed mood every day; loss of appetite, weight loss, withdrawing from social activities, sleep disturbance, lack of interest in activities that were interesting before, as well as, feelings of hopelessness (American Psychiatric Association, 2013). The client also reported being very worried about her son’s condition.

Treatment Plan

• Getting informed consent from the client
• Prescribed medication: The client should start citalopram 20 mg PO qDay and her progress will be reviewed after two weeks. The client will be informed to come back if she experienced bad side effects after taking the medication.
• Future plan: The current does of citalopram 20 mg will be maintained if the depressive mood improves and the client is able to tolerate the medication. However, if the client does not report any improvement and, she experiences significant side effects, it will be important to consider switching the medication.
• Cognitive-behavioral therapy (CBT): The psychotherapy choice for the client is CBT. The client will attend 12 CBT sessions and it is expected that the client will achieve complete symptom remission after completing the CBT sessions. During the CBT, the client will be educated on how she can manage her fears and worries regarding the son. In addition, the client will be educated on how to replace the negative thinking pattern with a more positive thinking pattern, in order to eliminate the negative feelings, thoughts, and mood (David et al, 2018).
• Education: The client will receive education on how to take her medications and the significance of adhering to the prescribed treatment regimen.

Part 2: Privilege Note

The client cooperated well during my contact with her even though she was very worried and paranoid about her son’s condition. I recognized that the client has some bitterness towards the son’s father who he blames for his son’s condition. The client kept saying that had the dad not abandoned them, the son would not have turned into drugs. After being informed of the diagnosis of major depressive disorder, she said that her diagnosis would be a well-kept secret. I informed her about the significance of having family and friend’s support when someone has a mental condition such as major depressive disorder.  However, I respected her privacy and confidentiality. From my observation, if the client properly adheres to the pharmacological and psychotherapy treatment, she is likely to have complete symptom remission (Mark et al, 2016).

The privilege notes normally contained information that was discussed and gathered during interaction with the client and also during the client’s assessment.  Some of the contents included in the privilege note also include my personal perspective on the condition of the client. In addition, the private and confidential information that cannot be recorded in the progress notes is documented in the privilege notes. According to Brattland et al (2018), the diagnosis, prescribed medications, and psychotherapies, as well as the treatment plan are not supported to be included within the privilege notes. Assignment 2: Week 3 Practicum Assignment

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Brattland H, Juni H, Olav B, Binder P & Iversen V. (2018). Learning from clients: A qualitative investigation of psychotherapists’ reactions to negative verbal feedback. Psychotherapy Research. 28(4), 545-559.

David D, Cristea I & Hofmann S. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Front Psychiatry. 9(4).

Mark C, How C & Ping Y. (2016). Major depression in primary care: making the diagnosis. Singapore Med J. 57(11), 591–597.

Assignment_2-_Practicum_____Assessing_Client_Family_Progress_-_Week_3_Practicum

Assignment 2: Week 3 Practicum Assignment