Assessing Client Family Progress.

Posted: November 22nd, 2022

Assessing Client Family Progress.


Part 1: Progress Note: 16
Treatment Modality Used and Efficacy of Approach
The parents demonstrated efforts in supporting their children and began attending the parenting education classes that were to run for three months. They have also began practicing some of the good parenting skills taught in the sessions which are evident by the expression of affection and love and development of good relationship between them and the children.Assessing Client Family Progress. They are also trying to change their supervisory behaviors characterized by leaving the children alone in the house. However, they are struggling with the addiction even though they demonstrate commitment towards the detoxification program.


Minimal modifications were done to the treatment plan since the patients were cooperative. The social worker encouraged them to remain resilient and focused in order to achieve the treatment goals.
Clinical Impressions
The clients have increased cravings for methamphetamines and hence were unable to conduct the daily activities without the drug. They had increased anxiety which increased with the lack of drug use, poor parenting, lacking track of time, poor judgment, depression is evident in the mood, pressured speech, limited insight, and worrying.
Psychosocial Information
F.P.’s electrician job is affected by drug abuse. The family is not committed to religious activities. C.P. began abusing alcohol and drugs at the age of 13 following sexual molestation. It helps her forget the terrifying incident. They attend parties and socialize with their neighbors.Assessing Client Family Progress.
Safety Issues
Safety issues associated with this case include locking the children in the house without supervision which could result in accidents. They could harm each other or start a fire or engage in other risky activities (Conrod, 2016). Leaving the children wandering on the streets could attract kidnapping or accidents. There is a lack of adequate supervision of children even when available physically due to drug abuse. Children could be exposed to drug abuse in the house as the parents often carry them home.
Clinical Emergencies
Alcohol withdrawal associated with rum fits and shakes can occur from relative reduction in alcohol consumption and are manifested through the upset of the GI system, anxiety and tremulousness. Delirium tremens are characterized by alteration of mental status which can cause the collapse of the cardiovascular system. More so, hallucinations with autonomic hyperactivity are a common clinical emergency affecting at least 25% of patients withdrawing from substance abuse (Simpson, Wilson & Nordstrom, 2016). Seizures are also likely to take place during the third stage of withdrawal which is reported to occur in 3% to 10% of the clients (Simpson, Wilson & Nordstrom, 2016). These emergencies could have adverse impact including death and therefore, the treatment plan includes Benzodiazepines medications that can manage these manifestations and prevent their negative outcomes. In case of an emergency, these drugs will be administered in small frequent doses.
The patients were under no prescribed or unprescribed medications other than methamphetamines, a stimulant to the central nervous system.Assessing Client Family Progress.
Treatment compliance
The patients were compliant with the treatment plan and demonstrated commitment and motivation to get better. They attended the rehabilitation and parental programs as indicated by the plan. They also reported their progress to the social worker and have managed to develop children supervisory programs. They have also collaborated with various experts recommended to assist in coping, management of risks and substance abuse avoidance.
Clinical Consultations
Clinical consultations for these patients involve the clinical pharmacists, special psychiatrists and addiction medicine-certified physicians. These help in identifying the root cause of the clients’ problems, the diagnostic approaches, interventions and treatment options as well as prevention of relapses (Brown et al, 2015). Moreover, they will answer questions related to addiction and advice the patients’ on how to effectively cope and avoid the drugs as well as advice on parenting skills. The clinical consultations were often conducted through phone calls.Assessing Client Family Progress.
Collaboration with other Professionals
For effective management of the family’s problems, interporfessional collaboration between pharmacists, social workers, psychiatrists and physicians is necessitated. The social worker ensures that the parents adhere to the treatment plan provided and oversee the guardians and the parent’s responsibilities towards the children. The family psychiatrists provide psychotherapeutic therapy to the parents and children as well as the guardians (Simpson-Adkins & Anna, 2018). Pharmacists avail drugs to the patients in the event of clinical emergencies while the physicians provides diagnosis and treatment alternative. Psychotherapists also promote successful rehabilitation for addiction and detoxification programs and parenting classes.
Therapist’s Recommendations
The therapist recommended consistency and compliance to the treatment plan. This involved attendance of good parenting classes and engagement in detoxification programs without fail. He also recommended engagement in cognitive behavioral therapy to facilitate change in parenting behaviors and improvement of addiction management outcomes. In addition, he recommended the development of good parent children relationship through engagement in mutual activities such as playing with them and eating together.
Referrals made/reasons for making referrals
Patients were referred to professional psychiatrist for a mental examination test. This sought to identify the mental damage caused by the abuse of drug and substances. On the other hand, referrals to the drug rehabilitation center were done. The patients were enrolled in a drug and alcohol detoxification program to facilitate recovery from addiction. a refer to the parenting education classes was also done to train the parents on the best parenting skills to improve their supervisory and abilities t care for their children.
Termination of the treatment plan was conducted before the scheduled date. The clients reported that the insurance company had withdrawn their payment due to inconsistence payment of the premiums. This is because; the two parents were no longer working and F.P. was the only breadwinner and could not manage. The family was currently experiencing a financial crisis and therefore sought to have the session terminated 14 days before the actual date. However, the patients had recovered fully and positive progress in parenting was evident. Consequently, the drug cravings were eliminated and they were able to comfortably go on with their daily activities.
Informed Consent, Child Abuse and Therapists Exercise of Clinical Judgment
Informed consent is important in the assessment, treatment, diagnosis and, counselling among other aspects of healthcare. It involves granting full knowledge regarding the treatment plan to clients. In this case, the patients were informed of their addiction and parenting problems. They were also informed of the approaches to amend the situation beginning with taking up the children and the importance of detoxification and parenting programs. They were also informed of child abuse and its effects and the legal measures that could be taken in the event of continued neglect (Syyder&Merrit, 2016). The therapist was also given a right to judgment since drug addicts are often considered unfit to make informed decisions regarding their wellbeing and treatment.Assessing Client Family Progress.
Part 2: Privileged Note
Privilege psychotherapy notes were important in analyzing and documenting the conversation content during the therapy sessions. In this case it was designed to provide the outline of the basic information regarding the sessions attended. The items that were not included in a note as part of the clinical record included the results of the clinical tests conducted on the patients, treatment modalities and frequency, the start and end of counselling sessions, monitoring and prescription of medication and diagnostic summary. Consequently, the progress notes summary to date, prognosis, symptoms, treatment plans and functional status summaries were also excluded in the privilege psychotherapy note.Assessing Client Family Progress.
These items are excluded to prevent them from leading to the psychotherapy notes being defined as progress notes. The progress notes typically contain the excluded items. They provide information that is separate from the rest of the individual’s medical record. The information contained in the privileged note is protected by the Health Insurance Portability and Accountability Act of 1996 which prevents it from being included in the client family’s progress note because they contain sensitive information. The preceptor uses privileged notes to document the client’s information during the therapy sessions. The type of information included on the note by the preceptor include the hypothesis for the psychiatrist’s diagnosis, feelings and thoughts about the patients situation, observations made during the session, and the uniqueness of the client’s situation. Even though the preceptor’s privileged notes do not contain a formal format, they document the conversation held during the therapy and they help in analyzing the clients problems and devising an appropriate and effective treatment plan.Assessing Client Family Progress.

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