4 pages due by 24 hours

PRE-ENGAGEMENT COMMENTS

Indicate any activities that have occurred before meeting with client(s) such as collateral contacts, telephone call with the client, etc.

Medical Social Worker received an SBIRT order for a 47 year old male. No collateral contact prior to our encounter

NARRATIVE

Record what has transpired between you and your client(s). This should not be a total verbatim report, but a description of observations and the interactions, both verbal and non-verbal. Dialogue should be recorded selectively and when pertinent.

I knocked on the patient’s room door for a verbal response to enter as the patient was sleeping at the moment. Social work team met with the patient for an SBIRT request using the AUDIT intervention process. The patient’s first language is Spanish, therefore I was able to translate the AUDIT questions. Patient did not appear to feel remorseful or ashamed of his alcohol use. However, patient was open to the intervention and verbalized an understanding of how abusing alcohol can impact his everyday functioning. Patient stated “I was sober for 15 months prior to last Sunday.” Patient reported he began drinking alcohol again this week after finding out bad news about a project he was working on in his home county El Salvador. Patient stated “I felt devastated because I was working hard to send money to build a house”. The bad news triggered drinking alcohol to help him cope. He acknowledged that drinking alcohol contributed to the fall that led to his hospitalization. I provided the patient reflective listening and discussed goals about taking responsibility for his alcohol use and behavioral changes related to drinking. Patient did understand the negative consequences of drinking alcohol by nodding his head several times. Patient stated “I will not drink again and my goal is to remain sober from alcohol for one year” We discussed goals around utilizing his family or friends for support when he feels the urge to drink alcohol. Patient reported he has friends and family to lean on for help. In addition, he is in contact with his son from El Salvador every day. At the end of the conversation, patient accepted a list of outpatient substance abuse counseling in his community.

IMPRESSIONS

Describe and discuss your feelings and reactions.

I felt compassionate about his loss and emotional reliance on alcohol to cope. I did my best to understand his life stressors and mental effects of alcoholism. I felt the powerlessness about his situation because of his efforts about building a better life for his family. In some ways, I related to him since my most of family live in another country. In itself, it’s difficult to admit the power of alcohol and unmanageable consumption. I felt his acknowledgement about alcohol abuse was important to accepting ownership connected with his actions.

By “getting into the client’s shoes”, discuss how you think the client(s) may have experienced both the interview/meeting and your interventions.

I think, the patient felt comfortable talking about his alcohol abuse. During the intervention, tuning into his responses highlighted his vulnerability and honesty. In general, hospital settings are intimidating due to the fact that it’s related to death.

Provide your impressions and/or thinking about the client(s) and your reflections on you interventions in the interview/meeting.

Sometimes we only see the outside part of people and possibly forget the things going on inside. I think, that thought alone is interesting.

PLAN/NEXT STEPS

Patient expressed his motivation to stop drinking and schedule an appointment with Alcoholics Anonymous outpatient rehab.

QUESTIONS/ISSUES

Indicate questions or specific issues emerging from this interview/meeting that you would like to discuss in supervision.

Does SBIRT make an impression during brief interventions?