Part 1: Intake
Eliza, who is aged 18, is a Caucasian female, a freshman student in college. She pursued Engineering and mentioned that her family lived in a small town that was roughly 2 hours away from school. She went out to seek counseling when she was caught using drugs in a non-alcoholic school. Under the influence of alcohol, her friends were intoxicated and she was left out. This was because she did not understand why she drank alcohol, but because her friends were drinking. In addition to that, she underwent some symptoms, which included anxiety, stress, and low self-esteem.
Eliza goes ahead to deny that she had no mental health issue, neither did she have any form of abuse both in the present and in the past. Although she hints at some teasing in high school, she refuses to talk more about it. She claims to have good relationships even though sometimes she feels like they take advantage of her, which refuses to communicate with them. Family wise, she is an only child and terms her mother as controlling and her father as a good guy. She also describes her parent’s relationship as strained since they both complained to her about each other making her feel like the middle-man in the house.
In the self-rated level 1, cross-cutting measure, Eliza responded by saying that it was rare for her to have little interest or pleasure in doing things, to not feel close to other people, not know who she was as well as having sleep problems that affected her overall quality of sleep. She opposed the feeling of depression, irritated, sleeping less than usual, doing risky things than usual, feeling nervous, being frightened, having unexplainable aches, having thoughts of hurting herself, hearing things other people could not hear, feeling that someone could hear your thoughts, memory problems, unpleasant urges, detachment, identity problems, drinking problems as well as taking medicine without precautions. In addition to that, she stated that for several days in the past two weeks, she had been avoiding situations that made her nervous.
Part 2: Biopsychosocial Assessment
Regarding the psychosocial assessment, Eliza, a 49-year-old, preferred herself. She is said to have a typical relationship with her husband and father of her two adult kids, who were against her treatment at first that she had mood swings that would eventually end. Therefore, the main treatment she sought was of dealing with depression and feelings of desolation. The report states that the patient lacked contention in her job and lack of appetite. She also had suicidal thoughts claiming that life was not worth living. The patient stressed the relationship she had with the husband, and despite the couple falling out of love with one another, they clanged to one another as a form of routine.
The patient agrees to be under the use of substances where she explains that she would use alcohol at night because she lacked sleep, estimating it to 2-3 years a night. It was confirmed that she had no past or current addiction. In addition to that, no mental health history or hospitalization regarding mental concern was reported. In addition to that, there was no history of previous trauma or abusive cases. Regarding his social relationship, it involved interchanging with his children in family gatherings. It is reported the client’s sister similarly battled with depression for over 10 years.
Due to her negative point of view of life, exhaustion worth, both physically and mentally, surged since she believed that something went wrong whenever things seemed to be working out. The patient had no involvement in spiritual matters and was not involved in any homicide. Since she lacked contentment in her job, it brought about mood swings, severe depression, lack of appetite, and also referring solitude. According to DSM-5, the patient was diagnosed with major depressive disorder. This diagnosis was made based on the symptoms showed by the patient. When all these factors of mood swings, solitude preference, lack of appetite, and suicidal thoughts, it pointed to a major depressive disorder that brought to light factors that included death thoughts, depressed moods, and fatigue.
The self-care plan was included in the initial goals of treatment. It involved references for a physician to help the client tackle these symptoms and eliminate symptoms that might have been taken for granted. In addition to that, they help with coming up with plans from treatment and the development of plans for safety to counter the suicidal danger. They also satisfy the client’s willingness to attend counseling. Depending on the seriousness of Eliza’s diagnosis, it was to be determined whether she would be admitted to the hospital or if her case was to be referred to another specialist. For this to be accomplished, a screen-test was to be made an inquiry consisting of two questions regarding depression symptoms offered by the nurse influencing BECK DEPRESSION INVENTORY. BDI has dimmed the most satisfactory tool for evaluating depression.
Part 3: Treatment Planning
One of the most important aspects of the process of DSM-5 assessment is that of the use of instruments for free assessments. Level 2 assessment for adults includes anxiety, repetitive thoughts, behaviors, somatic symptoms, anger, sleep disturbance, depression, and substance use. It is important to be very careful in the initial screening since the outcome will be very slow. In this kind of screening, several other assessments can be useful inclusive of disorders in substance use. Another important aspect to look out for is the client-traumatic experience or rather exposure. It can be completed by the life event’s scale that is an instrument for screening trauma quickly.
When giving feedback to the clients, be positive from the beginning since it is easier for one to perceive weaknesses in comparison to strengths. It is important to start with simple results as one progresses to more complex ones. In addition to that, when giving feedback, one should be careful about the language they use. It is also important to involve the client in giving feedback whereby you ask them whether or not they have questions to ask for clarification or even maybe out of curiosity. When delivering difficult feedback, one should first start by saying something unexpected so that they can gauge whether or not their client can take the news. When concluding feedback, one should end it on a positive note to give the client morale.
After delivering the client’s findings, one should stop and support affective reactions by the client as they happen. Some of the feedback given may be hard to comprehend and maybe more difficult if stated to them by a stranger. It is also important for a professional to know that they should not argue with the client on test findings since the session’s main aim in which feedback is being given is so that clarity can be gained and an agreement is reached. It is also important for specialties to know that they owe honesty to the clients and should, therefore not omit findings based on them being embarrassing to discuss.
Part 4: Referrals
It is very common to come upon people who need psychological counseling, generally, and hence referrals to help professionals are made. Not many clients will genuinely want to seek help and therefore, professionals ought to be compassionate and careful while making referrals. The first step in initiating a referral in the mental health sector is having at least qualified patient-specific professionals (Harvey, 2008). The second step in the referral is the discussion on why the client needs a referral. To have a successful referral, the professional should vindicate and bear with the patient’s feelings. The specialist should make the patient understand that they have normal feelings and that there was nothing crazy about them.
When making a referral one should normalize or rather de-stigmatize the referral. The use of words such as therapists, psychiatrists, or even mental health may be dimmed as an insult to their self-esteem and the patient’s integrity. Instead, words like holistic or multi-disciplinary approach regarding the connection between the mind and body as they are words acceptable in the culture today. It is also important that the professional of mental health be humanized. Anxiety and fear of the unknown diminish more patients have an idea of who exactly they are referred to. It is important to assure the patients of the professional’s personality and the human personality to create an understanding and create comfortability between the two.
In medicine, there will come a time when, regardless of how hard one tries, they would manage to identify how to help a patient (PatientPop, 2018). If ever a doctor should find himself in such a situation, they should refer the patient to another specialist. Another case in which a case should be referred to is when the patient’s doctor wants another specialist involved, as is said, ‘two heads are better than one.’ Moreover, it is human nature for some people not to see eye to eye. The same case can apply to a doctor and patient if they try working things through in vain, the doctor may decide to refer the patient to another doctor.