Client Termination Summary Practicum

Client Termination Summary Practicum

Assignment 1: Practicum – Client Termination Summary- WK1064N
Learning Objectives
Students will:
• Develop client termination summaries
To prepare:
• For guidance on writing a Client Termination Summary, review pages 693–712 of the Wheeler text in this week’s Learning Resources.
• Identify a client who may be ready to complete therapy.
The Assignment
With the client you selected in mind, address the following in a client termination summary (without violating HIPAA regulations): SEE ATTACHED CLIENT INFORMATION- USE THIS FOR THE ASSIGNMENT BELOW
• Identifying information of client (i.e., hypothetical name, age, etc.Client Termination Summary Practicum )
• Date initially contacted therapist, date therapy began, duration of therapy, and date therapy will end
• Total number of sessions, including number of missed sessions

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• Termination planned or unplanned
• Presenting problem
• Major psychosocial issues
• Types of services rendered (i.e., individual, couple/family therapy, group therapy, etc.)
• Overview of treatment process
• Goal status (goals met, partially met, unmet)
• Treatment limitations (if any)
• Remaining difficulties and/or concerns
• Recommendations
• Follow-up plan (if indicated)
• Instructions for future contact
• Signatures

Practicum for Psychiatric Disorders linked to Trauma

Post-traumatic stress disorder (PTSD) is a response to an extreme trauma which is likely to cause persistent distress to people and it involves incidents like natural or man-made disasters, combat, serious accidents, witnessing the violent death of others, being the victim of torture, terrorism, rape, or other crimes. These symptoms are associated with events that would be distinctly stressful to virtually anyone. The individual may experience the trauma alone or in the presence of others. The characteristic symptoms include re-experiencing the traumatic event, a sustained high level of anxiety or arousal, or a general numbing of responsiveness. Disturbing recollections or nightmares of the event are common. Such patients resort into behaviors like anger and aggressive behavior, and relationship problems to overcome their ill feelings in the past.Client Termination Summary Practicum .  There is therefore significant interference with social, occupational, and other areas of functioning.

The purpose of this practicum assignment is counseling of client with disorder related to trauma and the necessary therapeutic approaches that were used with the expected outcomes. The legal and ethical implication will also be explained.

Client History and Background Information of a Disorder Related to Trauma.

Kathy is 64 years -old white female who had past traumatic sexual experience from her father at the age of 9 years. Patient also reported of being brutally raised by her grandmother after leaving her father’s foster care at a young age of 10 years. The patient verbalized of her deceased son at the age of 22years and who she dearly loved. The patient had a total of four children, Patient still have the ashes of crimination her deceased son in her and wanted the son to be buried with her. Patient son's ashes secured in the room with the patient. The client becomes financially unstable after suffering from stroke and making her inability to perform daily functions by self. The client has weakness on both of the lower extremities. Life became stressful leading her to depressive moods swings mixed with fears of the past. The patient reports of occasional night nightmares of past experiences and depressed due to inability to walk and perform both IADLs and ADLs as a result of disease process of stroke. The client has to end up admitted to the nursing home after hospitalization of severe anxiety and depressive and psychotic features.Client Termination Summary Practicum . The client believed that her son is in heaven and just that she does not have any physical contact with him.

Pertinent history or Medical information including Medications.

Kathy was previously diagnosed with depression and anxiety and had previous psychiatric hospitalizations. Socially, the client is divorced and had currently three children excluding the deceased son.  Smokes cigarettes daily and former drinker of alcohol. The client reports of drinking coffee daily about three to 4 cups a day and is Christian who loves to go to church every Sunday.

The Client has history of hypertension, hyperlipidemia, depression with psychotic features, anxiety with sleep disturbance and insomnia related post-traumatic stress disorder (PTSD). The current psychiatric medications are as follows:

  • Clonazepam 0.5mg at bedtime for anxiety
  • Depakote 100mg at bedtime for mood stabilization
  • Zoloft 200mg daily for Depression with mood swings
  • Trazodone 100mg at bedtime Insomnia related to PTSD and anxiety
  • Abilify 2mg daily for psychosis

Kathy has been undergoing psychiatric treatment for post-traumatic stress disorder (PTSD) exhibited by the low mood with mood swings, anxiety and depression. The PTSD treatment involved cognitive behavioral therapy (CBT) that entails weekly group and also used exposure therapy in the past sessions (Wheeler, 2014)Client Termination Summary Practicum.

 Justification of the Client Diagnosis Using the DSM-5

Kathy is suffering from low mood and with mood swings, anxiety and depression that resulted from PTSD. The PTSD was caused by traumatic experience by her father at a young age and brutal childhood care by her grandmother as evidenced by fears, nightmares, and sleep disturbance. The loss of the client son, inability to perform daily functions due to stroke render the client to become financially unstable with inability to work and raised her children and depending on the family for help who eventually abandon her. In that respect, the client feels worthless with her lifestyle changes that is mostly dependent on people for support and therefore attributing to depressive mood mixed with agitation and anxiety. Post-traumatic stress disorder (PTSD) symptoms can be so debilitating and distressing that they cause anxiety, depression and changes in mood. That is seen in the present case, since the traumatic incidence and abandonment by family members has caused Kathy to detach herself from activities in the nursing home of which the client used to partake when at home.Client Termination Summary Practicum (American Psychiatric Association, 2013).

Therapeutic Approach Used 

Cognitive behavior therapy (CBT) would be effective in addressing the client’s diagnosis of Insomnia related PTSD, Depressive and anxiety disorders.  That is because it focuses on targeting the relationship between behavior, feelings and thoughts, while targeting the current problem event as it changes patterns of feelings, thoughts and behaviors that led to the symptoms. This means that using CBT would change how the client associates objective reminders of the past traumatic incident and bearing in mind that the past experiences and recurrent depressive symptoms are negative distortions of the mind that can lead to healthy functioning (Nixon, Sterk, Pearce & Weber, 2017). For instance, the client was counseled and made to understand that although the she was the victim of sexual trauma and childhood brutality and with disability without family support, it does not imply that her life does not have much value and she should contemplate on it very day leading to unhealthy behavior outcomes of mood swings, fear, social isolation and worthlessness. Instead, the client is taught to consider those issues as life events and should find ways of making the best of her life by engaging in enjoyable activities that keep her busy. The client was taught to participate in activities, avoid thinking of the past and substitute loneliness with self-activities like puzzling, watching interesting channels on the television and having supportive therapy (Wheeler, 2014)Client Termination Summary Practicum .

The client also talked about having exposure therapy before and more emphasize was made on its importance. It is imperative to understand that exposure therapy is a psychological treatment that was established to assist people to challenge their fears. When individuals experience dreadful events, they tend to evade them.  Although this avoidance might help lessen feelings of fear in some way, it can eventually make the situation of the fear worse than before   In this respect, client was also encouraged to use the exposure therapy to help disrupt the pattern of avoidance and fear.Client Termination Summary Practicum . In this form of therapy, a safe environment is created to expose the patient to those things in this case talking about such incident if appropriate of which they fear and try develop the best coping mechanism to avoid such past traumatic memories.  The exposure to the feared objects, activities or situations in a safe environment helps reduce fear and decrease avoidance (Goodson, Lefkowitz, Helstrom & Gawrysiak, 2013)

 

 

Expected Outcomes Based on the Therapeutic Approach.

The expected outcome is that the client would stop associating the experience of the traumatic incidences and abandonment by her family with existing beliefs of about herself and others and thinking about enjoyable moments of live. This would enable the patient to stop seeing herself as a worthless individual who is of no value to her family. Instead, the client would consider the traumatic past incidence as an abnormal event whose possibility of occurring again would be neglected in the mind and think about self-actualization (Becker, 2015)Client Termination Summary Practicum .  The client view being of the abandonment by her family should be observed as certain life situations that can happened to any individual and not recognizing herself as worthless by the use of cognitive behavior therapy. That means that her belief would change from associating her bad experiences with having made mistakes, to simply accepting that these experiences are peculiarities in people’s lives (Wheeler, 2014).

The client should focus of doing things she likes most especially reading the bible before going to bed. The client continues to have supportive care and the use of CBT to prevent any negative distortions that can affect her behavior and to always think positive of self.Client Termination Summary Practicum.

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Legal and/or Ethical Implications Related to Counseling the Client.

Counseling this client has an inherent ethical implication since it involves the client’s rights to confidentiality of information and trust.  The past events of traumatic sexual experience by the client’s father was of paramount importance and should be handled carefully as the client does not was to involve the family into any past experiences coupled with sad memories.  It is therefore essential to ensure the client that all shared information will be private and confidential as determined by health care professionals.  It is also worthwhile to seek the consent of the client if it is appropriate to talk to her children and involve them in any supportive therapy for the client financially or the past incidents.   If the client fails to involve her children, then the patient’s mood could still remain down thus failing to eliminate her justification for resolving and issue at hand. On the other hand, if the trust and confidentially is breached by talking to the family to find out the exact cause of the incident, then a cautious measure needed to get the necessary information of the client past when talking to the family (Gunn & Taylor, 2014)Client Termination Summary Practicum . In this respect, the ethical concern is whether the therapist should respect the client’s request that her family should not be informed about her traumatic incidents or violating the trust and confidentiality by involving the children to save her life to come out with an appropriate plan of care ( Wheeler, 2014)

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Becker, C. J. (2015). Integrating Art Into Group Treatment for Adults With Post-Traumatic Stress Disorder From Childhood Sexual Abuse: A Pilot Study. Art Therapy: Journal Of The American Art Therapy Association, 32(4), 190-196. doi:10.1080/07421656.2015.1091643

Goodson, J. T., Lefkowitz, C. M., Helstrom, A. W., & Gawrysiak, M. J. (2013). Outcomes of prolonged exposure therapy for veterans with posttraumatic stress disorder. Journal Of Traumatic Stress, 26(4), 419-425. doi:10.1002/jts.21830

Gunn, J. & Taylor, P. (2014). Forensic psychiatry: clinical, legal and ethical issues (2nd ed.). Boca Raton, FL: CRC Press.

Nixon, R. V., Sterk, J., Pearce, A., & Weber, N. (2017). A randomized trial of cognitive behavior therapy and cognitive therapy for children with posttraumatic stress disorder following single-incident trauma: Predictors and outcome at 1-year follow-up. Psychological Trauma: Theory, Research, Practice & Policy, 9(4), 471-478. doi:10.1037/tra0000190

Petiprin, A. (2016). Hildegard Peplau Theory. Retrieved on 14th June 2018 from http://www.nursing-theory.org/theories-and-models/peplau-theory-of-interpersonal-relations.php

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

The client who was counseled during my practicum in week four at the stated nursing home above was 51year-old white female with diagnosis of bipolar disorder and depressive disorder.  The patient was concern about her inability to sleep at night due to her medications. She stated that “I have a lot on my mind” and was asked about her problem. The client went on to say that her son lost his job due to her girl friend who created a problem at his work place and did not know how he would care for himself and his little baby of 1 year-old.Client Termination Summary Practicum . She also talked about her past history leading her to physical disability and making her have recurrent headaches and depression. She experienced depression and challenges in movement, her appetite dismissed and she experienced crying spells throughout the day.  The patient was complaining about multiple problems in terms of her medications like the Prozac 40 mg a day making her more anxious and the Trazodone not working and making her not to sleep well.

Past Medical and Psychiatric History

  • Bipolar disorder in partial remission
  • Depression
  • Age related physical disability
  • Spastic hemiplegia
  • Osteoarthritis
  • Gastroesophageal reflux disease (GERD)Client Termination Summary Practicum

Current Psychiatric Medications

  1. Fluoxetine (Prozac) 40mg PO daily
  2. Latuda (Lurasidone) 80mg PO at bedtime
  3. Trazodone 50mg PO at bedtime
  4. Gabapentin (Neurontin) 300mg PO three times a day

From her past medical history, it was noted that the client had experienced a concussion that resulted in her losing consciousness at 19 years of age from a motor bike accident with her husband. The patient reported that her husband wanted to kill her that time and cause that accident to happen.  For many years the client had been experiencing mood swings, and was a social drinker especially in the teenage years. Following the poor response, she had with antidepressants, diagnosis for a depressive disorder was probable.Client Termination Summary Practicum . The patient diagnosis of spastic hemiplegia with physical disability caused her to be having depressive mood swings as the client thought there is nothing else to do to become a healthy human being in future and decided to avoid group activities.

According Diagnostic and Statistical Manual of Mental Disorder (DSM-5), the patient’s condition depicts the diagnosis of Bipolar-1 with disorder with episodes of depression and mixed manic features as it is associated with another medical condition (Goldstein, Liu, Schaffer, Sala & Blanco, 2013). The patient is experiencing more depressive episodes than manic episodes.  The patient has rapid cycling of more than four depression and mania episodes in a year.Client Termination Summary Practicum .

Cognitive behavioral therapy (CBT) is the most effective therapeutic approach for the client. The goal of the therapy is to help the patient gain a new outlook on her situation by challenging all the possible negative distortions and thoughts and teaching the patient how to control them (Wheeler, 2014). As a result the patient is expected to handle her disability and family issues to relieve the depressive episodes and follow the appropriate support to be provided for optimum health.  According to Mcakay (2016), the cognitive behavior therapy requires both parties contribution to achieve results. The first step is to determine what is bothering the patient. Secondly. an examination is done to her thoughts, emotions, and behaviors. In the event, negative thoughts are spotted and the therapist helps in changing the client’s reaction to these thoughts.Client Termination Summary Practicum . Most important, is the ease in the patient accepting the condition and will to monitor her mood in the process of cognitive restructuring. The client was therefore counseled to remove all the negative distortions from her mind that will affect her behavior. Advised to have a conversation with the son and the family and how best to face the challenges of life. The client was made aware not to become discouraged if one technique seems not to be working and decide on the alternative. The client is encouraged to always think positive and try to avoid any negative ideas or thoughts that will bother her. Encouraged to participate in activities. Supportive therapy will also be available in terms of having family support and in house physical therapy to achieve the maximum self of independence (Wheeler, 2014)Client Termination Summary Practicum.

When counseling the client there are various legal and ethical implications guiding the therapist. The law requires that although any 18 years old and above individual has the right in decision making, for bipolar patients in a case where the condition can endanger the patient the court gives room for legal guardianship (McKay, 2016). Ethically, the patient has the right to treatment but before this, the therapist should ensure that the patient is well informed of her condition and the possible outcomes of the treatment. Unless a legal guardian has been appointed for the patient, the information about the patient is confidential and should remain only between the therapist and the client (Bourin, 2018)Client Termination Summary Practicum.

In conclusion, Bipolar disorder is a mental condition associated with a shift in one's moods. Common symptoms include moods elevation known as mania. Consequently, the condition can be diagnosed following depression episodes. During the depressive, one easily one experiences deep sadness, energy loss and the lack of interest in various activities.  DSM-5 has been used to diagnose the condition creating room for better treatment using cognitive behavior therapy guided by the possible ethical and legal implications. DSM-5 is an effective tool for carrying out a patient diagnosis to give the therapist a clear approach to the treatment process of the patient. Some prescribed drugs for the condition have a tendency of worsening the patient’s condition instead of improving it hence the need of administering cognitive behavior therapy is the best mode of controlling the client’s bipolar disorder since it involves both the therapist and patient contribution. Moreover, the therapeutic approach is often guided by the ethical and legal guidelines (Wheeler, 2014)Client Termination Summary Practicum. It is therefore imperative to provide the necessary support for the client and encouraged in activity participation to occupy the mind with joy.

References

Bourin, M. (2018). Treating the Cognitive Impairment in Bipolar Patients. Bipolar Disorder: Open Access04(01). doi: 10.4172/2472-1077.1000119

Goldstein, B., Liu, S., Schaffer, A., Sala, R., & Blanco, C. (2013). Obesity and the three-year longitudinal course of bipolar disorder. Bipolar Disorders15(3), 284-293. doi: 10.1111/bdi.12035

McKay, D. (2016). “You Mean CBT Addresses Emotions, Too?” Strategies for a Core Reason for Seeking Treatment“You Mean CBT Addresses Emotions, Too?” Strategies for a Core Reason for Seeking Treatment. Psyccritiques6161(2424). doi: 10.1037/a0040330

Petiprin, A. (2016). Hildegard Peplau Theory. Retrieved on 14th June 2018 from http://www.nursing-theory.org/theories-and-models/peplau-theory-of-interpersonal-relations.php

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: a how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.Client Termination Summary Practicum.