SOCW 6520 Week 9 Process Recording

The first section is for introducing the client. Please include the following information:

Agency Information

Dayton, Ohio 45410

Medical is committed to assisting adults with substance use disorder regain their dignity, and respect. The agency uses medicated assisted treatment, and mental health disorder services.

SW intern Informed client she is a mandated reporter and anything she share with me about harm herself or another must be reported to my field instructor and field liaison. Ask client for permission to for individual session, informed client the session would be recorded for a school assignment. Client agreed and signed a release of information.

Client information (confidentiality of course) The client is an 18 year white female, who has a learning disability and substances use disorder and mental illness She is a high senior and attends public school. Client has diagnosis substance use disorder and Bipolar disorder. She was recently in the program at Marathon where she began stable with medication, remain sober for 38 days and graduated two weeks ago. Client lives in a group home and is unhappy living there. Client reported, “they pick on me”. Client has threaten to harm self in the past and spent a week on the psych ward at a local hospital. This client hangs out with older friends drinking and doing drugs. She misses curfew and has to sleep on the porch. She reported that is why she came back, because she could not stop drinking, and was going to be put out.

Session Number #2

Date 4/19/2021

Presenting Issue (reason for referral) Client is a walk-in. She was recently discharged from the program after successfully completing.

Client returned to treatment program due to relapse. Client relapsed on alcohol and cocaine.

Relevant Information Client has been in the program before. She has a history of attention seeking behavior. Client reported she wants to attend her graduation from high school and go to prom next month. Client lives in a group home.

Goal of Session

1. Client Goal- To learn coping skill to avoid relapse. Client will learn two coping skills by 4/30/21. Client will begin attending AA meetings 2x a week and have a paper signed for attendance at every meeting.

2. Your Goal- To teach client relapse prevention skills by 4/30/21, and reviewed his signed meting slip every two days for compliance and review skills by for comprehension 4/25/21.

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Dialogue

Please group dialogue together.

Identify (for each section)

1. Theory

2. Practice Model

3. Techniques and

4. Skills

Analysis/assessment of dialogue

What was going on?  What were the patient's reactions to your feedback?  How did the client respond verbally (quality of voice, tone, did the respond better to closed or open-ended questions?) How did the client respond non-verbally (how did you know they were listening? were they distracted? Did they welcome your feedback?)

Personal reactions and self-reflection to the interaction

What were you thinking?  How do you feel the session went?  What could you have done better?  What will you do differently/the same next time?

Intern, Hello, R. You’re back, so soon what happened? Why are you back?

Client: I tried to drink alcohol again. I was drinking by myself this time. I had a friend to buy it, for me. They had the cocaine. So, I snort some. It was fun at first, but I got sick this time.

Intern: I remember some of the things we talked about the last time you were here. You told me when you drink you don’t remember what you do. What did we call that?

Client: Black out, I know.

Intern: Tell me what was going on before you started drinking?

Client: I go mad, at the lady who runs the house. I want to go somewhere else besides the group.

Intern: Let me see if I understand. You started drinking because you were mad at the lady who runs the group home. And you want to go somewhere else?

Hum? Where would you go?

Theory: Client lacks relapse prevention skills.

Practice Model: Motivational Interviewing.

Technique/ Skills

Open-ended questions.

Express empathy

Open-ended question.

Reflective listening.

Summarize

Affirming

Open-ended question

Client demeanor was relaxed, with a friend tone playful tone.

Client began to fidgeting in her seat. Shifting her weight.

Client hutched her shoulders while she explained drinking and using cocaine.

Client nodded her head with recognition of having a black out.

Client voice became more intense and raised. She shifted her weight and started swinging her foot.

Client has good eye contact, nodding her head in agreeing with what I am saying.

Client looked away with no response.

The client was relaxed because she is familiar with the agency and staff.

This intern was thinking she was afraid because she blackout early this time.

I was thinking she feels safe, and knows she will get help here.

I feel this part of the session went well. I have not ask about her mental health medication.

I think the client is desperate