evaluate a mental health client through the assessment of the clients health, social and psychiatric histories

The purpose of this journal is to evaluate a mental health client through the assessment of the clients health, social and psychiatric histories. After the patients data is synthesized it will be determined if cognitive behavioral would be effective and appropriate for this client Demographics A 32-year-old single, African American female who is currently employed full time at a local grocery store. she lives alone in a house she rents a room in a basement from her Boss She was raised by her grandmother because her mother died at the age of 26 from a gunshot wound by client father who was her mothers boyfriend. Her mother was trying to take her father for child support and the father was afraid that he might have to be paying child support for a long time that was the reason he killed clients mother with a gun to her head 3 times. The father was jailed for life, client refused to see him, because client was bitter about this, plus client was only 4 months old when this happen. Client does not have any relationship with her father. She has no children or boyfriend, she broke up with her last boyfriend 7 months ago because he was cheating on her. Presenting Problems The client stated I cant live like this anymore, I have no one and I need to get off the drugs but every time I try I get so depress and hopeless complain: Increased depression due to chronic drug abuse. History of Present Illness The client is alert and oriented to person, place, time, and situation. Her clothing and hair was disheveled, unclean, and presented malodorous. She had a guarded despondent presentation and was fidgeting in the chair. AS reported that over the last two weeks she has used around $ 200 of cocaine specifically crack cocaine and occasionally methamphetamine which she smokes. She stated, I have not been able to get much sleep for a few days now because all I want to do is get high because when I dont I become so hopeless and then I buy more drugs. She reported to around four hours of sleep a day. She denies suicidal and homicidal ideation and denies any suicide attempts. She does admit that she has had an increase in her risky behavior. AS reported that she has had to resort to prostitution recently and in the past so that she can support her cocaine addiction. She stated, The client informed me that she has attended outpatient drug rehab three times, but it never works. She did state willing ness to try detox and rehab one more time. Past Psychiatric History AS reports to being admitted to the local emergency department three month ago due to an accidental overdose on heroin, which she claims that she was only trying to get high and accidentally took too much cocaine. She reported that because of the heroin overdose she spent 12 days on the psychiatric unit where she was diagnosed with a substance abuse disorder and depression. On discharge she did not continue with the prescribed aftercare, was not compliant with discharge instructions, and never purchased her prescribed medications. She returned to her neighborhood and continued to do the same risky behaviors that she did pre-overdose. Medical History Per the client she has had only one overdose and that there is no other history to report, but she continues to be diversional when asked specific questions about her past. There was no physical assessment done in the office at this time but her vital signs are as follows: she does admit to smoking crack cocaine before arrival but does not know specifically how long ago she used. Substance Abuse History She stated that she started smoking marijuana daily when she was 16 years-old, her cocaine use didnt start until she was 22 years-old and she has intermittently used methamphetamines and heroin. The client stated, I was using because I just wanted to feel good. She reports that she has only smoked drugs and that she would never do these substances IV because needles scare her. She continues to use cocaine daily. She denies alcohol use. She smokes one pack of cigarettes per day but admitted to smoking more the more she used cocaine. DSM-5 Diagnosis 292.84 (F14.24) Substance/Medication induced Depressive Disorder with Cocaine use disorder Moderate or Severe. The client meets all criteria for this diagnosis. She uses stimulants often in large amounts, large amount of time spent obtaining and using substance, failure to fulfill role obligations, markedly increased amounts of stimulant to achieve intoxication (American Psychiatric Association, 2013). Is cognitive Behavioral Therapy Right for This Client? The cognitive-behavioral model of therapy proposes that clients with substance abuse problems lack the effective coping skills to deal with situations and give into temptation (Marlatt & Donovan, 2008). Cognitive behavioral therapy (CBT) is based on three levels of cognition which includes dysfunctional assumptions, core beliefs, and negative automatic thoughts that cause mental distress (Fenn & Byrne, 2013). CBT is a teaching tool that once learned empowers the client to change their dysfunctional perceptions and to have self-awareness of their thought process reducing mental distress (Fenn & Byrne, 2013). The reward of CBT is that it emphasizes self-discovery in the client and a strong therapeutic relationship with the mental health professional (McLeod, 2015). CBT would be beneficial for this patient because it will help her to conceptualize the why she thinks and empower herself to make positive changes in her life. CBT would he appropriate for this patient, but a comprehensive approach to treatment to increase the clients chance for success (Keane, 2018). Legal and Ethical Implications of Counseling The main ethical and legal problem with counseling this patient is the she reported smoking cocaine before coming into the office, so is she of sound mind enough to give informed consent to treatment? On assessment she was alert and oriented leading to the belief that she was of sound mind. Summary Every client is different, some will be text book but most of them will not be that way. It is important to look at the patient as a whole and treat them with respect and dignity.

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