Develop diagnoses for clients receiving psychotherapy*

· Analyze legal and ethical implications of counseling clients with psychiatric disorders*

Select a client whom you observed or counseled this week. Then, address the following in your Practicum Journal:

· Describe the client (without violating HIPAA regulations) and identify any pertinent history or medical information, including prescribed medications.

· Using the Diagnostic and Statistical Manual of Mental Health Disorders, 5th edition (DSM-5), explain and justify your diagnosis for this client.

· Explain any legal and/or ethical implications related to counseling this client.

· Support your approach with evidence-based literature.


· Data:

Met with pt to complete biopsychosocial assessment. Pt presents as a 23-year-old male, DOC is cocaine. Pt unsure of the amount that he was using. Pt reports smoking crack 3-4 times per week and marijuana 3-4 times per week. Pt denies any seizures, DT’s, blackouts, or OD’s. Pt reports that he has been extremely bothered by cravings to use in the past month. Pt was at CBH in December 2018. Pt reports that 3 weeks ago he had 2 months clean. Pt reports that his cousin struggles with substance use and mental health issues. Pt denies SI, HI, and SH. Pt reports dangerous behavior, including buying drugs in dangerous areas. Pt reports that he is unemployed and that it is due to substance use. Pt reports that he has no financial income. Pt plans to return to sober living after treatment. Pt does not have any children. Pt reports that he will not be impacts by religion/spirituality during recovery. Pt signed ROI for mom.

· Assessment:

AD1: Pt reports drowsiness, body aches, and difficulty sleeping. Pt rates cravings to use as 3/10. AD2: Pt denies any medical issues. AD3: Pt reports feelings of depression and anxiety. Pt rates depression as 7/10 and anxiety as 5/10. Pt reports a history of anxiety, depression, and bipolar diagnoses but was unsure when he was diagnosed. Pt reports being prescribed Lithium, Strattera, and Prolixin. Pt denies SI, HI, and SH. AD4: Pt presents in the precontemplation stage of change. Pt reported “I guess so” when questioned about if he wants to stop using or not. Pt reports that giving up using is difficult because he just likes to get high. AD5: Pt is unable to identify any triggers for him to use. Pt reports that sleeping is the only thing that helps him stay sober. Pt lacks insight into relapse prevention skills or any coping skills to manage uncomfortable feeling. AD6: Pt report that he was living at a sober living facility and plans to return there after treatment. Pt has a history of AA/NA attendance but nothing recent. Pt reports that he is unemployed. Pt reports that he has a history of arrest but refused to elaborate.

· Plan:

PT will follow up with patient advocate regarding pt legal issues. PT will follow up with patient on 4/22/19 to discuss goals for pts treatment plan.