Journal 8
Develop diagnoses for clients receiving psychotherapy*
· Evaluate efficacy of existential-humanistic therapy for clients*
· Analyze legal and ethical implications of counseling clients with psychiatric disorders*
· Analyze clinical supervision experiences*
For Part 1, select a client whom you observed or counseled this week (other than the client used for this week’s Discussion). Then, address the following in your Practicum Journal:
· Describe the client and identify any pertinent history or medical information, including prescribed medications.
· Using the DSM-5, explain and justify your diagnosis for this client.
· Explain whether existential-humanistic therapy would be beneficial with this client. Include expected outcomes based on this therapeutic approach.
· Explain any legal and/or ethical implications related to counseling this client.
· Support your approach with evidence-based literature.
For Part 2, reflect on your clinical supervision experiences. Then, address the following in your Practicum Journal:
· How often are you receiving clinical supervision from your preceptor?
Twice weekly
· What are the sessions like?
I really enjoy the sessions. They are casual in nature. I am usually asking a lot of questions about how I could od handled things correctly or were some of my responses appropriate
· What is the preceptor bringing to your attention?
Keeping the client focused on the topic at hand. Not to let the side conversations take over
· How are you translating these sessions to your clinical practice?
I am taking the suggestions and trying them out at the next session that I meet with a client
PATIENT DATA:
Data:
PT met with patient to complete biopsychosocial assessment. Pt presents as a 43-year-old male, DOC is heroin, pt reports using 8mg Suboxone daily for the past 6 years. Pt also reports misusing his prescription of Adderall for the past year. This is pts first time in treatment. Pt reports that six years ago be had 5 months clean. Pt denies seizures, blackouts, DT’s, and OD’s. Pt reports that there is addiction in his family. Pt reports feelings of depression and anxiety. Pt reports a history of sexual assault at a younger age. Pt denies a family history of mental illness. Pt reports dangerous behavior, including driving under the influence in the past, and working under the influence. Pt reports that he did not feel high while using at work but he did take substances there. Pt plans to return home with wife and two children after discharge. Pt reports that both of his children are hyperactive and his son takes speech classes. Pt is employed as an Amtrack driver. Pt completed 2 semesters at college. No history of arrest.
Assessment:
AD1: Pt reports that his skins feels “creepy crawly.” AD2: Pt reports pre-Diabetes which is managed by Metformin. Pt refused BS check, stating that he does not check his BS but does check A1C routinely. Pt has chronic pain due to a car accident in 2007. Pt denies any other medical issues. AD3: Pt reports a history of SI, specifically having thoughts about not waking up. Pt reports feelings of depression and anxiety. Pt rates depression 10/10 but that it fluctuates during the day. Pt rates anxiety 3-8/10. Wellbutrin ordered to start after detox. AD4: Pt presents in the contemplation stage of change. Pt is not sure what will help him in treatment because this is pts first time. AD5: Pt expressed that he is experiencing increased stress due to detox and the relationship with his wife. Pt reports that he hasn’t had much clean time and that he doesn’t know his triggers. Pt reports that it is difficult to give up using because it gives him energy to complete his daily tasks. AD6: Pt lives with his wife and two children, plans to return there after treatment. Pt denies any AA/NA attendance. Pt reports that he is employed, pt does have an EAP, and they have been contacted. Pt denies any history of arrest.
Plan:
PT will follow up with necessary department regarding pts EAP. Pt will follow up with nursing regarding detox protocol.
PMHNP:
met for the 1st time in evaluation of this 43-year-old white male who has just recently completed his detox. While he is agreeable to coming to my office, the 1st thing he says to me is “today’s not the day for me to talk with you, I am withdrawing really bad, my skin is crawling, my muscles are twitching!” Patient reports that he feels like vomiting and having a diarrhea attack at the same time, he does not want to be evaluated today. He reports a high degree of physical discomfort. He says that he was just restarted on his Wellbutrin at a dose of 300 milligrams daily.
Objective:
Mental status exam reveals a robust casually dressed white male who seems restless irritable and physically ill. He does not want to sit still in my office, he is clearly uncomfortable, not agreeable to an examination at this time, he is somatically preoccupied. He adamantly denies suicidal or homicidal thoughts. He says “it takes everything for me to do simple things like climbing the stairs, I feel worse at night, I am going out of my mind!” That said, he reports being very motivated for this recovery saying “it’s my 1st and only time, I am never going to need to come back here again, I am sure of that!” Unfortunately, he does not allow for the remainder of the detailed psychiatric examination today.
Assessment:
Depressive disorder, unspecified and opioid use disorder and stimulant use disorder
Plan:
patient claims he is still physically withdrawing, his last Suboxone dose was just a day ago, he thinks the taper was too fast, he does not want to be evaluated psychiatrically at this time. Apparently he had been off his Wellbutrin, it was just restarted today at 300 milligrams daily, this could be contributing to his restlessness and even to physical discomfort. It also presents a significant seizure risk. For now I think he should be off the Wellbutrin until he is much more physically stable. Therefore, I will discontinue it from his orders today. When reinstituted it should be restarted very slowly so as to minimize side effects.
Subjective:
Met for the 2nd time with this 43-year-old married white male who was initially seen by me approximately 1 week ago when he presented with physical symptoms including crawling skin, muscle tension, nausea and GI distress, stating that he was still in substance withdrawal, he did not want to speak at that time. Today he is more agreeable. He is demanding regarding his medications however. He says that an outpatient psychiatrist had started him on a combination of Effexor, Wellbutrin, Adderall, and Klonopin couple of years ago. He thinks the Adderall contributed to agitation and ultimately to more substance use. He does admit to prior episodes of depression with anxiety, he says that the Wellbutrin helped his mood and motivation a great deal. He is unsure whether the Effexor had done anything. He says he was given various psychiatric diagnoses in the past including bipolar disorder though upon careful examination he denies history of manic episodes or significant mood fluctuations. He does report having had seasonal affective depression. Currently he is taking immediate release Wellbutrin 75 milligrams daily but he is no longer on the Effexor, he is certainly not taking stimulants or benzodiazepines here. He still reports feeling anxious and depressed at times, felt very anxious yesterday for unknown reasons. He says “I was stressed to the gills about going home again and facing everything” patient describes being here as “being in Disney Land” away from all of his potential stressors. He is married and his wife is supportive of his being here, he has 2 very young children. He is also a borderline diabetic and is being followed by endocrinology. He has had some recurrent headaches, plans to see an outpt neurologist. He apparently underwent some type of recent cardiac workup when a co-worker of his suddenly died of a heart attack, so far patient’s findings have been relatively benign other than the borderline diabetes. Works on tracks at Amtrak, feels unfulfilled.
Objective:
patient is a robust well groomed white male with multiple tattoos, he makes very good eye contact and is socially engaging, his speech is loud at times, he can be demanding though cooperative. He is very sure of himself when it comes to medications, if in fact he orders me at 1st to put him back on exactly the medications he had been taking prior to admission because he has prescriptions for them. I explained to him that we would choose medications in a rational way, and go gently, one at a time to avoid side effects. Patient denies feeling deeply depressed today, he does appear restless and mildly anxious but he says this is better than yesterday. He reports “I woke up today with great zest, I want to make amends to everyone important to me!” Denies racing thoughts, no FOI. His thought process is mostly goal directed. He denies suicidal thoughts hopeless or anhedonia. He has no thoughts of harming others, no psychotic symptoms, his cognition is grossly intact, he does not appear lethargic or over-sedated, he is not tremulous.
Assessment:
Depressive disorder, unspecified and opioid use disorder and stimulant use disorder
Plan:
Patient has not had side effects from being on 75 milligrams daily of Wellbutrin, he says it helped his mood very much in the past, I am it agreeable to increasing his dose to 150 milligrams of the extended release version. I do not think it wise to add Effexor to the Wellbutrin though I am unconvinced that he has a bipolar diathesis, he never had manic episodes or significant mood swings. I explained to patient that given his prior diagnoses he may be at risk of mood lability, he should let us know if his mood changes significantly, he is agreeable. He is also staying on gabapentin 200 milligrams 3 times a day for now. I plan to follow up with him within 1 week to see whether his mood has been stable. We talked about the possibility of adding a mood stabilizer or atypical antipsychotic (such as Abilify) especially given his seasonal component/mood variability, he let me know that he tried Depakote in the past but did not seem to tolerate it. Would need to proceed cautiously given his pre-diabetic status with chronically elevated HbgA1c.
