Background information: John Smith is a Caucasian male in his mid-forties still living with his parents. The patient was admitted at the SBBH for having hallucinations, delusions, and suicidal thoughts. John Smith reported that his hallucinations and delusions kept progressing over the past few weeks. The patient has an ongoing struggle with psychosis and suicidal ideation for a couple of years. John Smith reports that he had his first psychotic breakdown in 2003. The patient was unaware of him receiving therapeutic treatments in the past. Currently, the patient is disabled and his major …show more content…
source of income is social security. John Smith has no legal matters; however, his barrier for treatment is no transportation. John’s strengths consist of family support and motivated for treatment. On the other hand, his weaknesses include: substance abuse, hallucinations, delusions, and psychosis. Patient meets the criteria for 295.90 Schizophrenia. The patient’s symptoms consist of delusions, hallucinations, psychosis, and disorganized speech.
John Smith presented with a flat affect during the interview with the intern student. The patient avoided eye contact as evidenced by staring at the floor. Also, the patient proceeded to be somewhat irritated when asked multiple questions. In addition, the patient has preoccupied thoughts and appeared to be withdrawn.
I explained to the patient that I am an intern student. I would be sitting in on session from time to time.
The patient was cooperative when he was talking and engaging with the intern student.
The therapist and patient have not met in previous interviews or individual sessions. Therapist and intern student gather information about the patient that pertains the issues to that need to be addressed before he is discharged.
The student started with small talk and asked the patient his thoughts and feelings.
The intern student asked, “are you married?” John Smith reported, “No, I am not married. I have been separated for 5 years.”
The student asked, “do you have any kids?” The patient shakes his head no.
The student asked, “have you received any treatments in the past? He said, “not that I am aware of.”
The student asked, “are you living alone?” The patient reported, “no, I am living with my parents, but they are trying to get me into some kind of home.” The intern asked, “what kind of home?” The patient said, “I don’t know. That is the only thing I know.”
I asked, “are you seeing or hearing things that other people are not?” It took him a few minutes to say, “I guess.” I asked, “are you hearing voices or seeing things?” I observed the patient did not want to answer the question. He said, “hearing voices.” I asked, “what are the voices saying?” The patient just nods no.
The student asked him questions from the recreational assessment. Immediately, the patient got irritated when I started asking him questions that pertain to this assessment.
Student asked, “do you do activities with your family, friends, or alone?” the patient said, “alone.”
The student asked, “name 3 words that describe you?” Patient just shrugged his shoulder.
The intern student ended the session by asking him do you have any questions for me? John Smith nods no.
This is the first time I interview John Smith. He presented in a flat affect and had impaired cognitive thoughts. In addition, the patient was withdrawn and avoided eye contact throughout the session.
The patient appeared to be somewhat paranoid during the interview.
I felt like he was not comfortable with me asking him personal questions.
The intern student utilizes a wide range of social work skills include the following: empathy, rapport building, active listening, and Socratic questioning.
The student utilized empathy during the interview.
The student attempted to establish a rapport with the client, but was unable to do so cause of him still being paranoid.
The technique I tried to utilize was being silent for a few minutes. I noticed this did not have an effect on him.
The patient will attend assigned therapies prior to discharge.
The patient will be compliant when taking his medications
everyday.