Example Client Report

  Date: 04 Apr 16 Patient Name: John Doe Patient DOB: 12 Jul 78 Admission Date: 28 Mar 16 Presenting Issues Alcohol Use Disorder Level of Engagement Mr Doe has met with me three times this week for approximately two hours in total and has attended every group required of him. Group Participation His presence in Group Therapy is noted as cautious and risk averse. Work Undertaken this Week The Patient has commenced a schedule of work arranged around 12 Step principles and we have processed his understanding of these both conceptually and in their application to his specific narrative in targeted groups. Progress with Work Undertaken He demonstrates a broad understanding of his current situation and has good insight. He will transition into the CBT Group from Monday 11th April. Emerging Themes in Treatment Much of the Patient’s work on powerlessness was underpinned by his denial that he was coping with his addiction and could manage the symptoms of his dependence. Fear of being caught and disciplined by his employer have led to furtive and secretive behavioural patterns accompanied by disproportionate and irrational levels of fear. The additional stress of familial and relationship tensions have also been pivotal in both the narrowing of his using repertoire and the growth in his tolerance and desensitization to his drug of choice. Anticipated Roadblocks/Blindspots We have examined both his need to lie and to create complex situations that supported his continued supply and acquisition of substances and explored how this was in conflict with this value system. Anticipated Treatment/Assignments Mr Doe will benefit from work specifically designed to challenge his illusion of control. Discussions on this subject will be conducted in both individual counselling and group sessions from next week. Mr Doe has also been assigned work to further illuminate cognitive processes that underpin his dependent behaviour and these will also be explored over the coming week. He will specifically be undertaking work on setting and maintaining healthy boundaries. Current Prescribing Mr Doe is currently prescribed eCitalopram 20mg o.n.s. which he tolerates well. Recommendations for Discharge The patient has completed a total of 46 days treatment in total. Upon discharge he is advised to continue with the following aftercare plan: 1. Attend 90 Alcoholics Anonymous 12 Step support groups in the initial 90 days once he has exited treatment; details of which are held by the patient. 2. Attend morning meetings Monday to Friday prior to going to work 3. Undertake weekly individual counseling with his care provider and referral service. 4. Undergo mandatory random urine and breathalyzer testing with Community Drug and Alcohol Services 5. Commit to severing ties with individuals hazardous to his recovery 6. Commit to avoiding places where he may be compelled to drink alcohol or engage in substance use. 7. To seek and locate a 12 Step Sponsor. This should take place within 7 days of exit from treatment. 8. Undertake a program of recovery aligned with 12 Step principles under the guidance of a 12 Step Fellowship Sponsor 9. For Mr. Doe to access regular follow up psychiatric care in the locality he is travelling to. 10. For Mr. Doe to maintain strict compliance with any prescribing and refrain from altering designated prescribing regimen. 11. For Mr. Doe to attend Online Group Therapy sessions as part of his aftercare programme with The Cabin Chiang Mai. 12. For Mr. Doe to abide by boundaries set by his Family 13. For Mr. Doe to maintain contact with The Cabin’s Therapeutic staff. Contact should commence within ONE WEEK of discharge, and continue indefinitely as needed. The patient had agreed to comply with this plan upon exit from treatment. Is an Extension Recommended? Yes The cognitive dissonance that his accelerating dependence has created, has been flagged up as a key source of his stress and anxiety and that has informed alterations in his systems of meaning. Mr Doe would clearly benefit from extended treatment to work on deeper psychological processes that underpin his current substance dependence. Mr Doe describes significant levels of shame across his early childhood development. Current Discharge Date 15 Apr 16   Lee Vallis MBPsS
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