Seems to have a hard time communicating with father, father is loud and angry, client is more open when father is not around, siblings were supportive following accident, however for the last 5 weeks they have been unsupportive. Only child living a home. He has a friend that comes over 2 -3 times per week. Use of Recreational Time: He used to enjoy seeing seeing school friends and playing video games, but now reports having no energy for much else. Complains of lacking energy to see people. Psychiatric/Mental Health Status and Intra-personal View:
He reports “I might as well be dead, I can’t do anything now and never will” Self destructive behavior, eluding to loss of hope/giving up Spirituality/Role of Religion: unknown Diagnostic Impression AXIS I: Substance abuse related disorders. Mood disorder. Adjustment disorder. Possible Eating disorder Description: pain med abuse and testing positive via urinalysis for THC, opioids, & meth. Mood swings – one moment he is excited and talkative & in a few hours or next day he will complain of not having any energy or interests.
He felt that the accident was the end of any opportunity for a professional career, feeling hopeless, lack of enthusiasm for getting healthy. (Possible weight loss) AXIS II: N/A Description: N/A AXIS III: Leg injury-compound fracture left leg above knee 10 months ago *Referred by primary care doctor AXIS IV: Primary support group, educational problems.
Problems related to social environment, other psychosocial and environmental problems AXIS V: GAF: 47 Crisis management and intervention strategies: drug use – address it, talk about it; suggest rehabilitation for drug use suicidal ideation- address issue with client Treatment Plan: A. Description of theoretical models used: 1. Short term goals: i. Relief of symptoms of depression ii. Restore relationships with previous friends iii. Find at least one new activates that evoke positive feelings iv. Develop no self harm contract v. David will report no suicidal ideation for 4 consecutive weeks vi. Learn coping skills to work on adjust and adapt to injury vii.
Learn to identify maladaptive, negative thoughts and how to replce them with more positive adaptive thoughts which will be measured by demonstrating these skills during therapy sessions and by homework assignments for 4 consecutive weeks 2. Long term goals: i. Explore education options ii. Explore consistent individual therapy iii. Substance abuse Recovery, Group therapy iv. Improve sense of self and confidence v. Stable support system vi. Reduce symptons of depression B. Model of individual therapy: (motivational interviewing, group therapy, fam therapy, etc) Individual therapy twice a week for 4 weeks the once a week for 6 weeks until symptoms have approved pending other requirements and or limitations.