How to Make a Process Recording of the First Session with a Client

Agency Information: Mental health agency 

Client information (confidentiality of course): A fourteen-year-old, Xxxx, female with a mental problem 

Session Number: First session with the client 

Date: 

Presenting Issue: Xxxxx’s family are not living together. She and her younger siblings are living with their Uncle. Her mother left them due to drugs and mental health problems. The mother lives a mile away with a boyfriend, and she does not visit them. Her father is in prison after he was arrested for selling illegal drugs. Xxxx has been hospitalized two different times for having suicidal ideation. After a DNA test from the department f family and children service, she realized that the man she knew to be her biological father was not. As a result, she had a break down at school. A mental health agency personnel (me) met with Xxxxx to discuss what was to be in her best interest and talk about her being safe and not wanting to commit suicide or harm herself again. 

Relevant Information 

Goal of Session 

Client Goal: get help from her emotional distress. 

Your Goal: help the client atop her suicidal thoughts. 

Dialogue 

Please group dialogue. 

Identity (for each section) 

Theory 

Practice Model 

Techniques and 

Skills 

Analysis/assessment of dialogue 

What was going on?  What were the patient's reactions to your feedback?  How did the client respond verbally (quality of voice, tone, or responded better to closed or open-ended questions?) How did the client respond non-verbally (how did you know they were listening? were they distracted? Did they welcome your feedback?) 

Personal reactions and self-reflection to the interaction 

What were you thinking?  How do you feel the session went?  What could you have done better?  What will you do differently/the same next time? 

Me: At times, people may feel that life is not worth living. Please may you tell me how you are feeling about your life? 

Client: I don't feel that I am living a worthwhile life. 

Me: Do you think or have you ever thought of trying to take your own life or even harming yourself? 

Client: Yes. I have been feeling of taking my life. 

Me: When did you start experiencing these feelings and thoughts? 

Client: After I realized that the man I thought to be my biological father was not my father. 

The patient seems to be so depressed, and she does not see any worth of being alive. 

Her reaction to the question portrayed that she saw suicide as the only option for her situation. 

I thought that the patient needed urgent attention. During this session, I feel that the session went on well, and it is clear that the patient requires urgent attention to help her cope with her difficult situation. 

Me: Have you ever been in a situation in which you started to act on your suicidal thoughts or self-harm, but you stopped before doing it? For instance, you held a bottle of pills in your hands that you want to take but eventually stopped, or you went on a ledge to jump, but then you stopped? 

Client: Yes 

Me: were you alone or you were with other people when you did this? 

Client: I was alone in the house. 

Me: What happened just before you did this, and what happened after? How did you feel after the incident? 

Client: I felt that I disappointed myself for not completing what I had started. 

Me: How do you feel about your future? 

Client: My future to me is like darkness. I cannot figure it out. 

The client was very keen on the questions I asked her and was not distracted by anything. Her reactions indicated that she needed help. Besides, considering her non-verbal cues, her response seems honest, indicating how much she needed help from the mental health agency. 

The client can express her thoughts on harming her-self through committing suicide, and she has been engaged in attempting suicide. 

I think the client the client was truthful with her answers. I needed to ask her more about how she always acts whenever she thinks of suicide to help understand how to change her reaction towards suicidal thoughts to prevent future suicidal attempts. 

Me: Are you currently under the influence of alcohol or any other drugs? 

Client: I am not. I do not take either of them. 

Me: Have you been avoiding other people or friends? If so, what could be the reason? 

Client: I have been avoiding my mother most of the time, even though she does not come to visit us. That is because I think that she is the cause of my problems. 

Me: Would you still want to die if your situation changes. 

Client: There would be no reason to think of dying if my problems will no longer exist. 

Assessing the client's response, it is clear that the client is at a very high risk of committing suicide. However, if her problems are changed instantly, she will have no problem with suicide or any other self-harm. It is also clear that the client is highly depressed, and she needs more counselling and anti-depression therapy. 

The session went on well, and the client seems to be interested in her wellbeing. However, I would have inquired more about her family history to establish a predisposing to suicide that may be proven through a blood test.