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Clinical Case Presentation Template Social Work

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Clinical Diagnostic Social Work Case Presentation

Transcript: Clinical Diagnostic Social Work Case Presentation Date 1 Ebony L. Welch Western New Mexico University Reason for Referral and Presenting Problem Presenting Problem Client: Cindy Woods Cindy presents with a history of suicidal and homicidal ideations, self-injurious behaviors, auditory hallucinations, delusions, disorganized thoughts, and substance use disorder. Per her medical records, she stated that "there are worms under her skin and people in the television who want to watch me die." She also states that voices are telling her to kill herself and others. Cindy was jailed and taken to the hospitals, emergency department, then transferred to an in-patient psychiatric facility for 30 days. Cindy was referred for individual psychotherapy, following the 30 days in-patient psychiatric hospitalization. Description of Client Client's History 54 year old Caucasian female 20+ years of Chronic Homelessness 2 Children (33y/o Jane & 35y/o John) Estranged from both children/ No support system Divorced from ex-husband Currently on Social Security Disability (SSDI) $800/m Methamphetamine and Cocaine dependency Disorganized thoughts/speech Cognitive functioning: low during psychosis Moderate cognitive functioning w/out psychosis Appearance: Appropriate. Although clothes are ill fitted Mood: Anxious Brief Pertinent Life History Brief Life History Cindy's family has a history of Severe mental illness (Schizophrenia) Childhood neglect and maltreatment Alcohol and substance abuse Cindy reports being homeless for more than 20 years after her home caught fire. She has stayed in temporary shelters and on the street. The client also reports intimate partner violence by her ex-husband for the extent of their marriage. The client reports extensive suicidal ideations and attempts due to hopelessness, isolation, and lack of resources. The client reports extensive legal history, with several arrest. Past Psychiatric History Past Psychiatric History The client has an extensive history of in-patient psychiatric hospitalization. She reports three in-patient psychiatric hospitalizations lasting 30 days or more, with the most recent admissions being May 2019 and early Jan 2020. In Jan, the client presented with self-injurious behaviors, auditory hallucinations, delusions, disorganized thoughts/speech. Per her medical records, Cindy stated that she harms herself "when it is necessary." On the Jan occasion, per her chart, when asked about her religious/spiritual beliefs she stated "I like to burn bibles." She also stated that "the worms under her skin multiply" when she takes her medication. Upon discharge in Feb 2020, the client followed up with Mental Health Mental Retardation (MHMR) Services, Risk Assessment Care Team (RACT), and MHMR respite for housing. Upon discharge she expressed that she wanted to continue to get well, so that she could get her social security card, state ID, and birth certificate to get an apartment. She also expressed getting healthy to reconnect with her two children. Past Medical History Chronic Obstructive Pulmonary Disease (COPD) Hypothyroidism Noncompliance with medication Clinical Impression of Concerns and Strengths Clinical Impression Axis I: 95.70 (F25.0) Schizoaffective Disorder, Bipolar Type; 304.40 (F15.20) Amphetamine-Type substance, Severe 304.20 (F15.20) Stimulant Use Disorder, Severe: Cocaine Axis II: None Axis III: COPD & Hypothyrodism Axis IV: Chronic homelessness, economic problems, no social support Axis V: Will assess The client's dual diagnosis of substance abuse and psychotic symptoms have gravely contributed to chronic homelessness, poor social support, and impairment in social skills. Strengths: Independent living Sense of humor Willingness to participate with treatment Clinical Impressions of Concerns and Strengths Clinical Impression Cont. Mental health disorders that can be ruled out Schizoaffective disorder depressive type Schizophrenia Delusional disorder The client best meets the criteria for schizoaffective disorder bipolar type rather than the other disorders. Further, Cindy may have a genetic predisposition of psychotic mental illnesses from her father. According to the American Psychiatric Association (2013) individuals who are most at risk for schizoaffective disorders are first degree relatives of those who have schizophrenia, schizoaffective disorders, and bipolar. Treatment Planning Treatment Intervention Approach: Cognitive Behavioral Therapy (CBT) Referrals MHMR Psychiatrist Substance Abuse Treatment program Narcotics Anonymous Workforce solutions (for life skills) Support Group for Severe mental illnesses Treatment Plan Cont. Treatment Plan Cont. Empirical evidence has linked Substance Use with psychotic disorders, specifically those on the schizophrenia spectrum (Nesvag et al., 2015). It is believed that mental health disorders such as schizoaffective have an influential affects on substance usage. Also, combination treatments such as antipsychotic, mood stabilizers, and

Clinical Social Work

Transcript: Tools Utilized • Mental Health facilities • Private Practice • Schools • Government • Hospitals • Clinics/Agencies Interveiw with Pam Cont. • Social Security • Medical Insurance • 401K/403B • Pension • Disability • Vaction/Sick Leave • Develop Therapy plans and goals for each client. • Assist Clients with finding and accessing agencies (food, housing, etc.) • Work with insurance companies to get the best rates for clients. What do you like best about your career and what do you like least? How will I succeed? Will this career support my desired lifestyle? Describe your career (hours, Working conditions, Good & Bad features) Interview with Pam Washington (per year) 25%: $31,790 Median: $50,820 75%: $71,140 Opportunities for Growth I choose this career because I love helping people overcome difficult obstacles in their lives and help them find ways to better their well-being. In the next 10 years, the growth for Social Workers will grow by 19% for all branches of Social Work. "What I like best is working with people. I have a passion for doing that. What I like least is working with insurance companies and working with agencies and meeting with them. Agency is a pretty heavy load." Clinical Social Work Paige Batton What are some requirements of your career? (edu/training, degrees, certs, personal/physical) Yes, this career will definetly support my desired lifestyle. Message to Underclassmen • High School Diploma • Bachelor's Degree • Master's Degree in Social Work • Two years or 3,000 hours of post-master experience to become licensed. • Pass the state board exam for licensing. My message to all the underclassmen for the next years of their high school career is to start thinking about your future as soon as possible. Don't wait until the last minute when you have to give someone an answer. Have a rough draft of what you want to do even if you think you are going to change the plan at least you will have something to work off of. • Your Knowledge Basis • The documents and papers you use • Agencies • Computers Salary Benefits Why did I choose this Career? Interview with Pam Cont. "You will be better off with a Master's Degree in Social Work. I have a MSW with 37 years of experience. You will need to do 36 hours of Continuing Education Courses every 2 years. You can go to workshops too. Every 6 years, you need to go to suicide workshops. As for personal requirements, just stay on top of your own proccessing and stress levels. Physical excerise is a great idea also.'' •Graduate High School •Go to BC for 4 years to get a BA in Psychology •Go to EWU to go in to the School of Social Work program and get a MSW Professional Responsiblities Employment Outlook • Social Workers in general can advance to working as a program manager or assistance director. • Experienced Social Workers can teach or consult with others. •Some SW go into private practice. Growth in knowledge base. Education "In agencies, you usually will start around 8 or 9 in the morning and end the day around 4 or 5 in the evening. Working in Private Practice, there are flexible hours, no weekend work if you choose. One bad thing about Private Practice is that if there is a crisis, they are usually restricted to going to an agency rather than you. Also, you can work in a variety of different places if not private practice, but if you are then you can work at home if you wish". Locations for Jobs

Clinical Diagnostic Social Work Case Presentation

Transcript: Clinical Diagnostic Social Work Case Presentation SWK 620: Advanced Psychosocial Approach to SWK Practice Lisa Chumney Western New Mexico University Clinical Diagnostic Social Work Case Presentation-seeking a case consultation for client that has been court mandated to the substance abuse intensive outpatient treatment program 1. Reason for referral / Presenting problem Problem-Substance Abuse/Mandated to Recovery Program for Probation REASON FOR REFERRAL Addiction to methamphetamine Seeking services for addiction recovery and to return to a normal life. Must complete program or will return to jail. Clients chief complaint: Either complete substance about program or return to jail. Client states "I know my triggers are loneliness, boredom, and a big one is when I get angry." Goals: To maintain sobriety "I don't want to use anymore" DESCRIPTION OF CLIENT CLIENT 2. Description of the Client: Age-28 White unmarried male On probation No income/unemployed Living in homeless shelter No significant others client states "I have burnt all of my bridges" One adult female child No support system other than shelter residents, staff and staff of the program Level of Functioning This Social Worker observes on the first meeting with client: Client's physical appearance is clean, healthy and appears rested. Complexion is clear of blemishes. Primary language is English. Harmful to self from addiction. No harm to others. Behavior is respectful, hyper and engaged. Client appears receptive to guidance and instructions. Emotional presentation is determined and confident (APA, 2021). Social Worker is able to follow client's thinking although speech of the client is very rapid. Client states to writer that "My sleeping and eating are good" Orientation/cognition/memory accurate to place and time of day and recollections. (The Mental Status Examination, 2012)) LIFE HISTORY LIFE HISTORY 3. BRIEF PERTINENT LIFE HISTORY Mother left him when he was eight. Maternal grandmother took over his care. Graduated high school. Started using drugs and alcohol at age fifteen. "I fell in love with a minor the day after I turned eighteen. I was arrested for statutory rape and spent 10 years in jail for it." Client is interested in acting. Started using drugs and alcohol at age fifteen. Client has not experienced abuse. Was on probation and sent back to jail for possession of methamphetamine. 4. Past History of the Presenting Problem or Psychiatric/Medical PAST HISTORY Began snorting methamphetamine at fifteen years old. Social worker asked if he has used intravenously and he states "I have never used that way". No medical history. No hospitalizations. Client states that methamphetamine affects him differently than everyone else. "It calms me down. It quiets my mind". Client is hyper and self-medicates with methamphetamine. Client has had no previous treatments for drug or alcohol abuse. 5. Clinical Impressions of Concerns and Strengths Client speaks honesty regarding being an addict, homeless, and on probation. Isolation Social worker observes client is concerned about ability to stay in active recovery due to his inability to fight his triggers. Interpersonal family concerns Client states, "this is hard and I am scared." IMPRESSIONS CONCERNS Impressions of the client's concerns: Client is concerned about his triggers of feeling lonely, being bored, and getting angry. • "Thus, people with Napoleon complex often compensate for their short stature by displaying negative behaviors in various areas of their lives" (Exploring your mind, 2019). Client exhibits traits of having Napoleonic syndrome for self-disclosed issues with anger. The client is if short stature based on national height statistics for the U.S. (World Population Review, 2021). Client exhibits risk-taking behavior through drug use, unprotected sex, self-diagnosing, disobeying rules, disregard of future consequences and lack of self-control. F15.20 Methamphetamine- SEVERE F10.20 Alcohol Use Disorder- SEVERE F90.2 Attention Deficit Hyperactivity Disorder, Combined Presentation STRENGTHS STRENGTHS TO DRAW UPON CLIENT IS: ARTICULATE BRIGHT GOOD INTERPERSONAL SKILLS POLITE PLEASANT ANALYTICAL RESPECTFUL ENJOYS READING 6. Treatment Planning Client will attend Cognitive Behavioral Therapy (McHugh, Hearon, and Otto, 2010) in the intensive outpatient substance abuse program: Length of treatment: 4 days a week 8 hours a day for 3 months. 4 days a week 4 hours a day for 3 months. After care for 3 months: 2 days a week 4 hours for 1 month 2 days a week 2 hours for 1 month 1 day a week for 1 hour for 1 month 5 outside meetings documented for 9 months during treatment program Client will begin working in Big Book of Alcoholics Anonymous on Step 1 of recovery. Client will share Step 1 package with group withing 2 weeks of beginning program. Client will set Goals according to S.M.A.R.T. – specific, measurable, attainable, realistic and timely standards SHORT TERM GOALS: Client enjoys exercises. Daily 9.

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