Psychotherapy with trauma and addictive disorder

The purpose of this journal entry is to evaluate a client and develop an appropriate therapeutic plan of care. The treatment plan will utilize the DSM-5 criteria and evidence-based practice. The legal and ethical implications of counseling a client will also be explored as it applies to the mental health professional.

Demographics

GH is a 39-year-old married, Caucasian female who is employed at a local department store part-time, her husband is an engineer for a local manufacturing company. GH lives in a housing development with her husband and two children aged five years and six months. She speaks clearly and intelligently. She reports that she tries to attend church regularly and considers her faith and the church community as a part of her social support.

Presenting Problems

CC: Increased depressive symptoms. The client states, “I have been so sad since the birth of my youngest child, It scares me I just don’t know what to do”

History of Present Illness

The client presents with an increase in anxiety and depressed mood. The onset was around six months ago. The course of symptoms is constant. The degree of symptoms is moderate but are exacerbated when her child cries. There are no relieving factors. The client’s depressive symptoms include increased lethargy, decreased motivation, and anhedonia. She denies suicidal and homicidal ideation. GH presents to the office in appropriate attire and is well groomed but presents with a flat affect and doesn’t consistently maintain eye contact. She informed me that she enjoys reading and sewing but lately doesn’t have the motivation to do those tasks. The client stated, “I am so drained and often have to force myself to take care of myself and family.” GH has no complaints of insomnia and sleeps 8 hours a day and takes naps throughout the day. She has not been consistent with her therapy appointments and stated, “sometimes I just don’t have it in me to come to my appointments.” The client’s current medications include Vistaril 50 mg PO Q6H PRN for anxiety which was prescribed by her PCP. She takes no other prescribed, over the counter, or herbal medications.

Past Psychiatric History

The client first met with a therapist when she was 15 years of age due to the traumatic sudden death of her father who was murdered. She was diagnosed at this time with anxiety disorder and depression. She was prescribed Paroxetine CR 37.5 mg PO Daily and Lorazepam 1 mg BID PRN for anxiety. The client was seen by a therapist and Psychiatrist until the age of 18 when she decided that she did not want to continue with any further mental health treatment. The client has not had any psychiatric hospitalizations, and no acute psychotic episodes. Around the age of 29 she had an episode of moderate depression for three months and decided at that point to seek help from mental health professionals. She discontinued treatment after her first child was born because she felt that the medication was not needed at this point in her life. This decision was never discussed with her mental health provider his services were discontinued with out notice.

Medical History

The client has only been hospitalized two times for the birth of her two children. She has no known medication allergies. The client’s immunizations are up to date, she refused the influenza vaccination this year. The client’s surgical history is limited to two caesarian sections, both were live births. The client has no medical history other than previously stated and a physical assessment was not preformed during this session.

Substance Abuse History

The client denies using any past or present illicit drugs. She denies alcohol and tobacco use as an adolescent and in adulthood.

Differential Diagnosis

Puerperal Psychosis: The client does not meet the criteria for this diagnosis because she lacks the core features. The core features of puerperal psychosis include rapid onset, profound confusion, delusions, infanticidal tendencies, and often associated with undiagnosed bipolar disorder (Sit, Rothschild, & Wisner, 2006). Puerperal psychosis is more common in clients under the age of 25 and with a family history of mental illness for which this client doesn’t meet the criteria (Sharma, Rai, & Pathak, 2015).

DSM-5 Diagnosis

296.32 (F33.1) Major Depressive Disorder, recurrent, moderate severity, with peripartum onset. The criteria for this diagnosis is requires the client to have five out of the nine symptoms present during a two-week period, at least one symptom of depressed mood, and one of lost interest or pleasure (American Psychiatric Association, 2013). The criteria that qualified the client for this diagnosis is, depressed mood most of the day, diminished pleasure in almost all activities, hypersomnia, fatigue, and daily inability to think (American Psychiatric Association, 2013). GH also has the specifier of peripartum onset because the depression started within two weeks post-partum.

Individualized Plan

Legal and Ethical Implications of Counseling

It is important to be aware of legal and ethical implications of counseling clients. The American Psychological Association (APA) has created a ten-section code of conduct for mental health care providers. Section 3.04 of the code of conduct explains that the mental health provider must take reasonable steps to avoid harm to the client and to minimize foreseeable harm (APA, 2017). The directive given in section 3.04 should always be at the forefront of the care provided to a client. The mental health provider should assure informed consent to therapy has been obtained on every client, because this is a fundamental right that should not be infringed upon (Pope & Vasquez, 2016) The APA has given directive on informed consent in section 10.01 and it is the responsibility of the mental health provider to assure the client is of sound mind.

Reference

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Washington, DC: Author.

Ethical Principles of Psychologists and Code of Conduct. (2017, January 1). Retrieved from http://www.apa.org/ethics/code/index.aspx

Paroxetine - FDA prescribing information, side effects and uses. (2018, February 28). Retrieved from https://www.drugs.com/pro/paroxetine.html

Pope, K. S., & Vasquez, M. J. (2016). Ethics in Psychotherapy and Counseling: A Practical Guide, 5th Edition. John Wiley & Sons.

Sharma, I., Rai, S., & Pathak, A. (2015). Postpartum psychiatric disorders: Early diagnosis and management. Indian Journal of Psychiatry, 57(6), 216. doi:10.4103/0019-5545.161481

Sharma, V., & Sharma, P. (2012). Postpartum Depression: Diagnostic and Treatment Issues. Journal of Obstetrics and Gynecology Canada, 34(5), 436-442. doi:10.1016/s1701-2163(16)35240-9

Sit, D., Rothschild, A. J., & Wisner, K. L. (2006). A Review of Postpartum Psychosis. Journal of Women's Health, 15(4), 352-368. doi:10.1089/jwh.2006.15.352