Scenario
The client is a 16-year-old male who speaks English and resides with his biological parents and older brother in downtown Phoenix area. The client admits he has been taking drugs and alcohol since he was 11 years old. Client reveals he uses marijuana, beer, and vodka several times a week. He also indulges in opioids few times a month with his first reported use of fentanyl and Percocet being at age 14. Client identified his older brother and school friends as close contacts who offer the drugs. He presents no indication of psychiatric history and denies having depressive and suicidal thoughts. He was placed on probation over a year ago and has been sent to juvenile jail for underage drug possession and use. Past interventions have yielded minimal improvements because the client does not admit to having substance abuse issues. Throughout most of the counseling session, the client remains compliant with questions. He insists that he indulges in drugs due to boredom and “can stop when he wants.”
Goals
Guide the patient in understanding his substance abuse issues.
Help client in recognizing the consequences of substance abuse and establish prevention as a major treatment focus.
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Address client’s denial of trauma after sister’s death.
Clarify and provide the process necessary for the client and his parents to build a successful relationship.
Understand why client relapses to drug abuse after probation and juvenile detention.
Reduce underage binge drinking with peers and older adults.
Provide cognitive behavioral therapy and family therapy.
Identify prevention mechanisms that addressing the issues of social pressures and develop ability to resist such influences.
Subjective
Client states, “I will just stop, this time. I don’t want to come back here.” He indicates that therapy sessions have been ineffective in alleviating his use of drugs. He is unable to give reason to his increased drug and alcohol use over the last three months. Yet, he admits that his marijuana, Percocet, fentanyl, and MMJuse have increased. Client indicates that he has used heroin twice but he disliked it. He has used cocaine on “several” occasions. He states, “I won’t have a record I am a minor” and further underestimates the extent of his probation because he intends to do THC once he is discharged. He indicates his brother and older friends provide easy access to drugs. He denies having depressive and suicidal thoughts after his sister’s death.
Objective
Client is generally dismissive and guarded when asked about the death of his sister. He is aware of his issues and indicates that he has a “problem with drugs and drinking.” Substance-abusing and unsupportive parents are among the reasons for the large gaps in substance use disorders (SUDs) and treatment for youth (Grant et al. 2017). Compliance with treatment options has been poor because client has previously denied having any substance use disorders. He is unable to maintain sobriety since multiple drug tests came back positive despite being on probation. Client believes he is safer than his friends who do more drugs. A review of systems indicates that client is healthy. His height is 5’9, weight is 140 pounds, heart rate is 88, blood pressure is 120/72, respirations 16 while Oxygen intake is normal at 99% on room air.
Assessment
Client needs support in dealing with treatment and taking responsibility for his condition. Research from SAMHSA (2020) suggests that parents should show disapproval of underage drinking and drug misuse. Over 80% of individuals aged between 10 and 18 indicate that their parents influenced their drug misuse habits (SAMHSA, 2020). Client admits having conflicts with his parents but does find it as an issue. He admits spending consecutive days “high,” which indicates diagnosis of SUD. Applying the DSM-5 criteria reveals client is struggling with using and recovering from substance use leading to continuous relapse. Client is agitated once his sister’s death is addressed which rules in PTSD. Increased substance abuse within the past three months confirms that the client has resulted in drugs and alcohol as a coping mechanism after his sister’s death. Facial expressions and boredom reveal depressed mood. Client presents no signs of hallucinations and delusions. Cognitive functioning is age-appropriate and no developmental disorders are noted. Client eventually acknowledges he has SUD at the end of the session.
Plan
Grant et al. (2017) suggests that adolescents respond to treatment based on their setting. Psychotherapy fields have identified the need to move from research, which matches adolescents with SUDs, to research which adapts and readapts treatment programs based on the individual’s needs (Grant et al., 2017). Client requires parental guidance in reorienting his life. The applicable psychotherapy treatment modality is functional family therapy. The client will attend weekly family therapy with his brother and parents. Evidence suggests his brother largely influences his relapse to drugs. Therefore, modifying the 90-day treatment plan with motivational enhancement therapy can alleviate drug misuse concerns between both brothers (Stoner, 2016). Therapists can help them identify helpful activities in which they can participate to reduce idle time (Stoner, 2016). Client will be referred to Dr. Martel for psychiatric evaluation to identify any trauma issues. The psychiatrist will thereafter begin cognitive therapy to help the client in coping with his sister’s death. Additionally, the client will only use medication prescribed directly by the nurse psychotherapist. He will undergo a biweekly evaluation process to determine adherence to treatment.
Part 2
Privileged psychotherapy note:
The client’s unwillingness to change poses a significant challenge to the intervention process. Initial impressions indicate that he is not worried about the consequences of indulging in drug misuse because he is a minor. Client denies that his sister’s death has led to depression and suicidal thoughts. Once his sister is mentioned, the facial expressions indicate the client is unable to cope with her loss. Client spends a lot of time with his brother and older friends. Signs of trauma show prevailing PTSD, which could result in suicide. Client thinks that he can stop using the drugs at will despite having increased use after his sister’s death. Substance-abusing parents show deficiencies in parenting and handling children with drug problems. Information provided shows alcoholism is a common problem within the family. Both maternal and paternal grandfathers have succumbed to alcohol-related conditions. Parental negligence is contributing to poor commitment to treatment. Samples from urine drug screening indicate that the client has not been sober. Improvement is occurring. “I was doing too much.”
Diagnoses: The following diagnoses are based on currently available information and are subject to change as additional information is collected.
Alcohol Abuse, (Active)
Depressive Disorder, recurrent, moderate (Active)
PTSD, (Active)
Long-term goal: Assist client in recognizing, accepting and coping with depressive feelings.
The information included in this note could not be included in the client’s progress note because it contains private information from family counseling sessions. Notably, progress notes are written immediately after a session. Keeping two kinds of notes ensures that therapists are protected by section 45 CFR 164.524 (Corley, 2013). It provides supervisors access to all records on client sessions but excludes psychotherapy notes (Corley, 2013). Therapists can feel free to detail additional information on the client’s state. For instance, past family records indicate that alcoholism caused grandparents’ deaths. However, this information is based on therapist’s observations and cannot be included in the progress notes (Spector, 2014). A privileged note is important for the treatment plan because the therapist can include hypothesis, observations, thoughts, and feelings towards the patient’s condition (Spector, 2014). As the therapist learns more about the client, they can consult their psychotherapy notes to determine an effective treatment plan (Corley, 2013). Additionally, clients may request that some of the information revealed remain confidential (Corley, 2013). At a minimum, therapists must consult clients on the information they feel should be concealed.
References
Corley, S. (2013). Protection for Psychotherapy Notes under the HIPAA Privacy Rule: As Private as a Hospital Gown. Health Matrix: The Journal of Law-Medicine , 22(18), 489-499. https://scholarlycommons.law.case.edu/healthmatrix/vol22/iss2/8/
Grant, S., Agniel, D., Almirall, D., Hunter, S., McCaffrey, D., & Pedersen, E. (2017). Developing adaptive interventions for adolescent substance use treatment settings: protocol of an observational, mixed-methods project. Addiction Science & Clinical Practice , 12(35), 1-9. https://doi.org/10.1186/s13722-017-0099-4
Spector, H. (2014, October 2). Progress note or Psychotherapy note: Are you sure you know the difference? Simple Practice . https://www.simplepractice.com/blog/progress-note-or-psychotherapy-note-are-you-sure-you-know-the-difference/
Stoner, S. (2016). Treating Youth Substance Use: Evidence Based Practices & Their Clinical Significance. University of Washington , 1-4. http://adai.uw.edu/pubs/pdf/2016youth substusebrief.pdf
SAMHSA. (2020). Talking to Kids About Alcohol and Other Drugs: 5 Conversation Goals , 1-2. https://www.samhsa.gov/underage-drinking/parent-resources/five-conversation-goals
