week 6 process recording

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

Agency Information: Mentally Fit is a community-based substance abuse counseling center offering individual and group counseling, substance use assessments, and psychoeducation and referral to higher levels of care. The agency practices a harm-reduction and trauma-informed approach. I am completing my internship working with licensed counselors to conduct intake evaluations and engage in individual counseling with supervision.

Client information (confidentiality of course): The client is named M.T., which is a 34 year old male who presented voluntarily for intake on substance abuse. M.T. is a part-time employee and living with his girlfriend and their two children. He uses alcohol since he was 17 years old, and his alcohol use has increased in the past two years. He admits to taking any drugs at present. He tells the doctor that he has some mild anxiety and trouble sleeping, and claims this is because of his alcohol use. No psychiatric history is recorded. He has a partner who was supportive and encouraged him on seeking help.

Session Number : Session 1, Initial Intake

Date: June 15,2026

Presenting Issue (reason for referral): M.T. self-referred as a result of the ability to recognize that his drinking is out of control. He reports taking 6-8 beers every day and has missed work a few times and is strained with his boss. He recently faced divorce threat from the wife recently upon the failure to seek any form of help.

Relevant Information: This is M.T.'s first time getting professional help for substance use. He says he is not sure whether he is "truly an alcoholic" He has never had any other legal problems from drug or alcohol use. Cultural context: M.T. grew up in a family environment that was typical of the heavy drinking of men, which may contribute to his thoughts about his drinking as a problem.

Goal of Session

1. Client Goal: M.T. will list two specific concerns he has with his drinking/alcohol consumption and state one personal reason why he would like to make a change before the end of this intake session (SMART goal: specific, measurable, achievable within one 50-minute session).

2. Your Goal: Your (Intern) Goal: Assessment and engagement — Conduct a substance abuse intake assessment; rapport; explore M.T. readiness for change; formulate initial treatment suggestions.

Dialogue

Please group dialogue together.

Identify (for each section)

1. Theory

2. Tools

3. 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?

Section A: Opening and Engagement

Intern: Good afternoon M.T. I'm an intern here at Mentally Fit. Thank you for visiting. What are your thoughts on being in this place?

M.T.:( Really nervous). I was going to miss coming.

Intern: You have to have guts to go through that door. What made you come on in here?

M.T.: "I was shoved by my wife. But I knew that it was not getting out of hand. [Brief eye contact] I've been drinking a lot recently.

Theory:

Strengths Perspective - understanding help-seeking as a positive attribute.

Tools:

Intake Assessment Form; notepad.

Skills:

Attending - open body posture, warm tone.

Empathy - Normalizing nervousness.

Open-ended question - starting the talk.

MT: was visibly anxious. Changing in his seat, avoidance of the eye contact. Following the validation of nervousness, made brief eye contact, an indication of the affirmation positively received.

His statement that he “almost failed to come” is a reflection of ambivalence whereas his recognition that “thing were not in order” is signaling early preparedness to engagement.

I felt nervous and conscious of not overwhelming him. The priority was on the building of the rapport prior to changing into the formal evaluation.

I could have mentioned confidentiality is limiting earlier to assists him in feeling more secure from the outset.

Section B: Substance Use Evaluation

Intern: I would like to ask you about your drinking to help me understand how to help you. Is that okay?

M.T.: OK. Go ahead

Intern: When did drinking become a concern for you?

M.T.: I began as 17 years old,, just parties. However, the past two years it increased its efforts. Now, I drink daily! Six or eight beers. I've wanted to quit a couple of times. Made it 4 days one time, but work stress got the better of me. [Looks away]

Theory:

Systems Theory - Work Stress and Family context create the conditions for alcohol use.

Tools:

Substance Use Intake Assessment Form.

Skills:

Open and closed questioning - obtaining the clinical history.

Paraphrasing - active listening response.

Encouraging - supporting and reaffirming the disclosure.

MT. grew more forthcoming as the section proceeded. While disclosing a failed quit trials, he looked away, potentially showing shame. The daily utilization of the pattern and the relapse history is an indication of potential physical reliance that warrants medical review.

Request for the permission prior to questioning supported his sense of autonomy and decreased defensiveness.

I was processing the clinical data while making attempts to remain present and empathic, a balance that demands for continuous practice.

When MT. looked away, I resisted the impulse towards instantly re-assure him. Next time, I will be more explicitly recognize non-verbal cues in the moment.

Section C: Exploring Motivation and Goals

Intern: What would your life be like if you didn't drink or drank less?

M.T. [Puts both eyes on one side, as though squinting]: I'd be a better dad. I'm not drunk around my kids but I'm just... not there.

Intern: I'm here for my kids, and that's a very strong motivation to want things to change.

M.T.: Yeah. But my man deserves better. I don't want to lose my family because of beer.

Intern: Your family is definitely your driving force. What is one little thing you could do after today?

M.T.: [Chairs it up; returns to standing position] Back to it. Talking to someone. I believe I should get that.

Theory

Motivational Interviewing (MI) - prompting change talk; examining ambivalence.

Strengths Perspective - Family as inner motivator and protector.

Tools:

Readiness to Change Ruler (verbal).

Skills:

Reflection of meaning - support, family as change factor.

Summarizing - bringing together the key factors.

MT.’s eye is filled while naming his child, the session most emotional great incidences. His posture straightening was a signal of shift from ambivalence to motivation.

He moved from “my partner pushed me” at the start to “I believe I require this” by close meaning preparedness to change with a single session. The best response was to the reflective listening instead of direct questioning (Galvani, 2014).

The moment was found to be moving and had to ensure careful maintenance of professional presence. There was a feeling of genuine hope for the client.

I retrospect; I need to have explicitly affirmed his family-centered motivation, since MI research indicate that it strengthens dedication. I will do so it in the next session (Ivey & Daniels, 2016).

Section D: Closing and Next Steps

Intern: Many thanks for your openness today M.T. I suggest that you are matched with a counselor to receive individual counseling once a week. Is that OK?

M.T.: Yeah. What happens next?

Intern: We'll make an appointment for your first appointment before you leave. Your counselor will create a plan based on your objectives. It is your responsibility to recover.

M.T. (nods): Okay. Thank you. I'm feeling better than I thought.

Theory:

Strengths Perspective - honoring customers right to choose.

Tools:

Referral and scheduling documentation; intake summary form.

Skills:

Summarizing - giving a short review of the session.

Psychoeducation - offering a session roadmap.

Empathic Closing - appreciating the customer’s work (Galvani, 2014).

MT’s smile and expression of the relief is an indication of hopeful close. The question “what happens next?” is a reflection of active investment as opposed to the passive compliance, a positive indicator for ongoing engagement.

Non-verbally, he seemed more replaced than at intake with open posture, long-term eye contact, and brief smile.

I felt quite sense of success, not from fixing anything, but creation of 9 space where MT felt safer to practice honesty.

Next time, I will ensure revisiting the SMART objective at close to ensure evaluation on whether it was achieved. There will also be consultations with the supervisor concerning the possible medical referral due to the daily use pattern.