Discharge Summary

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School

Grand Canyon University *

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523

Subject

Arts Humanities

Date

Jan 9, 2024

Type

docx

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5

Uploaded by ChancellorLion3521

1 Discharge Summary and Summary Statement Paola A. Duarte College of Humanities and Social Sciences, Grand Canyon University CNL-610: Clinical Assessment, Diagnosis, and Treatment Dr. Elizabeth Aura October 4, 2023
Discharge Summary and Summary Statement Eliza D is a 19 year old Caucasian female who presented to therapy with concerns of elevated stress levels, anxiety and depression. The client also had concerns of poor sleep. The client’s concerns revolved around school related stress. The initial treatment goals were to help the client learn how to properly cope with elevated stress, anxiety, and depression levels without the use of substances and self-harm. The client’s goals were also to improve her relationships and communication skills with her family, friends, and roommates. Finally, the client was to identify 3 healthy coping mechanisms and practice them regularly when she experienced elevated stress, anxiety and depressive symptoms. Unfortunately, the client does not seem to have met the goals of the treatment plan. Based on information gathered from the last therapy session, Eliza has been involved in two more drinking incidents. This has resulted in Eliza being charged for public intoxication. The client denied her involvement in the incidents and states that she is innocent. The client got very agitated and engaged in poor eye contact. This demonstrates that unfortunately the client continues to struggle with substance use as well as with regulating her mood. The client did not demonstrate the use of healthy coping mechanisms to regulate her emotions. The client’s poor attendance and lack of commitment to the individual therapy sessions and the alcohol classes contributed to the inability to meet the treatment plan’s goals. The client had access to resources to work on her substance use and on her anxiety, depression and high stress levels. However, the client continued to use substances and was charged with public intoxication. The language I would use to communicate the outcome to the client is the following: When you came in for your first therapy session you reported concerns with sleep and elevated stress and anxiety levels. You also reported feeling lonely as your friends and family 2
were back home. Over these past few weeks we have worked on helping you manage your anxiety, stress, and depressive symptoms with the use of coping mechanisms. We have learned that you tend to use substances (alcohol) when you feel stressed as well as engaged in self-harm. One of our goals was to have you decrease your alcohol use as it seems to be impairing your ability to stay focus in class and to complete important assignments. This is our last session and I would like to ensure that we are on the same page. Unfortunately it looks like the treatment goals were not met. With this in mind I would like to have you continue attending therapy sessions and alcohol classes. However, I belive that you would benefit from attending an IOP focused on substance use and co-occurring disorders over the summer. I believe that an IOP will help you manage your substance use and it will help you learn how to properly manage your increased stress and anxiety levels. I would document the final session by stating how termination was discussed and by writing a discharge summary. The discharge summary will include the presenting problem upon admission, current medications, reason for discharge, resources and referrals, and projected prognosis. According to Abramson (2022), it is extremely important to plan the goodbye. Abramson (2022) states that “Ask the patient what they envision for the last session, and determine a plan you both feel comfortable with. For example, you may write a note to one another, exchange a symbolic object that reflects the patient’s work, or decide to hug or shake hands during the last session. In any case, Woodhouse says the exchange should be planned so the patient isn’t surprised.”. Finally, Bray (2021) states that “It’s not uncommon for counselors to see clients who have received a prior diagnosis from another clinician. If the client comes via referral, the counselor may have case notes that include the diagnosis in writing. In other situations, a client might report to the counselor that they were told they have a certain diagnosis. 3
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