SOW 5306: Social Work Practice II: Intervention Approaches / Practice
A. Demographic Information
Content should include: client’s name, age, gender identification, relationship status, ethnicity / racial background, occupation, place and length of employment (and/or listing of educational and/or unemployment / military / retired status, etc.), and age and gender identification of any children.
B. Chief Complaint(s) / Presenting Problem(s)
Content should include client’s complaint / presenting problem in their own words.
C. Goal(s)
Content should include what client wants to get out of their therapy.
D. Symptomatology
Content should include what has been the client’s reaction(s) to the problem(s) that bring(s) them to therapy.
E. Crisis/Safety
Content should answer if client in is crisis. If so, describe the type and severity and your plan to address these needs.
F. History
Content should include length of symptoms, any similar symptoms in the past, and any attempts to decrease symptoms and their results.
G. Mental Status
Content should include client’s cognitive, psychological, and emotional functioning.
H. Assessment
Content should include your overall impression/summary of the client). Content can include: (a) how client is dealing with the presenting problem; (b) client’s overall mood, cognition, emotional status, suicidal ideation; (c) other stressors in client’s life and how they affect client’s presenting problem; and (d) support system.
I. Provisional Diagnosis
Content should include a provisional diagnosis, based on your assessment what might be
diagnosis(es).
J. Treatment Plan (format your treatment plan as follows)
· Order of problems to address first
· Issues of safety
· Any issue that requires reporting
· Any non-lethal or non-reporting crisis
· The problem(s) generating the greatest symptoms
K. Treatment Intervention(s) (list each treatment goal and planned actions, as follows:)
Goal 1: insert content here
Goal 2: insert content here
Etc…
SOAP Note
S: content should include how the client describe their problem(s).
O: content should include what you observed about this client.
A: content should include your impression about/of this client.
P: content should include your plan with this client
Case Study Assignment Example
Opening Note
A. Demographic Information
Mary Smith is a Caucasian woman who 54 years old. She has been married for 30 years to John Smith; they have no children. She works in the public library.
B. Chief Complaint(s) / Presenting Problem(s)
Mary presents with multiple concerns related to an unfulfilling marriage, potential loss of employment, and concerns over her husband’s gambling.
C. Goal(s)
Mary would like to first focus on concerns related to her husband’s gambling. Mary states that her husband told her last week that he is approximately $45,000 in debt. Mary is also worried about her job security.
D. Symptomatology
Content should include what has been the client’s reaction(s) to the problem(s) that bring(s) them to therapy.
E. Crisis/Safety
While her situation is difficult, Mary does not appear to be in crisis currently. She denied any thoughts or feelings related to self-harm. She denied any history of self-harm. There are no reporting responsibilities present. She seems to have an active and extended support system.
F. History
Content should include length of symptoms, any similar symptoms in the past, and any attempts to decrease symptoms and their results.
G. Mental Status
Content should include client’s cognitive, psychological, and emotional functioning.
H. Assessment
Mary is devoted to her husband and family but is clearly struggling with their financial difficulties. She complains about increased anxiety, decreased sleep, and some disruption in concentration. She notes a change in mood as she is “worried all the time” and finds herself crying when she feels hopeless. Mary does not describe herself as a person who worries a lot. Her acute symptoms seem particular to her husband disclosing the extent of his debts. She states her appetite is stable and has not experienced any recent gain or loss of weight. She is oriented to person, place, and time. Thinking is linear and her memory appears good. Affect matches content.
She states her performance at work is affected by her personal worries, but there is no current disciplinary action against her. She denies any suicidal or homicidal ideations or actions in the past or present. She states a social use of alcohol. She apparently has a strong support system which includes a large extended family and strong ties to her church community. She states her husband is generally supportive, they are effective parents, but has been less available due to his own worries. He has been avoiding her.
I. Provisional Diagnosis
In considering Mary’s case, I am aware that her greatest stressor is stated as related to her husband’s gambling. Mary relates her changes in mood and concentration as directly related to worrying about their finances. Her predominant mood is described as anxiety, but Mary also complains about crying and feeling hopeless. She has been experiencing problematic symptoms for one week, thus ruling out a chronic problem.
Given this information I am leaning toward a provisional diagnosis of 309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood. Due to the short duration of Mary’s symptoms and her statement that she is not typically a “worrier” I am ruling out Generalized Anxiety Disorder (GAD). Symptomatically she does meet some of the diagnostic criteria for this disorder namely, difficulty concentrating and disrupted sleep. However, GAD is ruled out as she does not meet enough symptoms, or for the required six-month minimum duration.
Mary states she cries often, feels hopeless at times, that her concentration is disrupted, and she has some difficulty sleeping. I am ruling out Major Depression, Single Episode as Mary’s symptoms are not inclusive, severe, or long enough in duration to meet this diagnosis. Mary would need to show five of the required symptoms for a minimum of two weeks. Therefore, given this clinical presentation my provisional multiaxial diagnosis is as follows:
· 309.28 Adjustment Disorder with Mixed Anxiety and Depressed Mood
· No medical conditions stated
· Economic Problems
J. Treatment Plan
· Decrease client’s anxiety.
· Increase sleep and concentration.
· Provide referrals for financial resources and education.
· Improve communication and marital relationship with her husband.
K. Treatment Intervention(s)
Goal 1. Decrease client’s anxiety.
· Use solution focused brief therapy to focus on client’s strengths, skills, and abilities in handling past crises.
· Reinforce client’s coping skills.
· Use CBT to provide psychoeducation on the connection between thoughts, feelings, and behaviors.
· Establish a Thought Record to identify distorted, irrational thoughts and reframe and identify more accurate, adaptive replacement thoughts.
· Schedule self-care.
· Bibliotherapy: “Mind Over Mood” by David Burns.
Goal 2: Increase sleep and concentration.
· Refer to MD for assessment of sleep problem and possible short-term sleep medication.
· Teach client diaphragmatic breathing to decrease anxiety and help as a sleep aid.
Goal 3: Provide referrals for resources/education.
· Refer client to Consumer Credit Counseling for low cost financial education budgeting and financial planning services.
Goal 4: Improve communication and marital relationship with her husband.
· Refer client for couple’s counseling
· Provide client with information from the Office of Problem Gambling as a resource.
SOAP Note
S: Mary complains of increasing anxiety, decreased sleep and concentration problems and that she “is worried all the time.
O: CL describes husband’s gambling is creating significant debt. She was somewhat tearful and labile in session. She appears tired with dark circles under her eyes and shaky hands. She has a neat appearance.
A: CL is clearly in distress, primarily anxiety and hopelessness related to the stresses in her relationship with her husband.
P: Support. Provide psychoeducation on sleep hygiene and problem gambling. Provide CBT and solution focused therapy. Follow-up with CL in one week.
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