Discrimination Case Interview Jose Fernando
IDENTIFYING INFORMATION (Age/Gender/Race):
Jose Fernando is a 34 years old Hispanic male with a history of depression, substance abuse and domestic violence, was admitted to Gila regional medical center for overdose of drug after assaulting his ex-wife physically. During the time of the interview the client stated that his ex-wife was saying some provocative words and this made him reacted badly by beating her up and he never wanted to but he could not resist the urge, and how she keeps on comparing him with other guys by telling him to act responsible in providing for the family. Client said he felt remorse for his actions when he saw that his ex-wife was on the floor not moving he thought he has killed her, so taking his own life was the …show more content…
next option.
This is not the first time the clients as attempted to commit suicide, he has been provided with some medications and counselling services but as never participate actively in performing the requested tasks. The client is working in a fast food joint in Silver City and sharing an apartment with his sister who is also divorced.
PAYOR: Medicare
PRESENT PSYCHIATRIC ILLNESS/SYMPTOMS (Including current and past psycho-social stressors
The present psychiatric illness of the client is depression due to the past and current psychosocial stressors such as traumatic encounter, poverty, discrimination, alcoholism, tobacco intake and family related obligations.
BASIC NEEDS & CONCERNS (Include transportation & housing concerns):
Some of the basic need of the client is the provision of a support group for substance abuse patient, housing and good job to support himself and family. Addicted to alcohol prevent the client from performing his duties properly were most of his wages are spent on drinks, also working in a low paying job due to his criminal record.
PAST HX OF OUTPATIENT TX/COUNSELING (Including psychiatric admissions/suicide or violent behavior):
Jose was diagnosed with depression when he was 12 years old and had some suicidal thoughts of killing himself which the client did not denied. Attended some brief counselling class for a period of time before his family relocated to a new environment and it was a difficult process to get sign up for counselling class since the list of clients was on a high range, this situation prevented the client from having any further intervention …show more content…
class.
MENTAL HEALTH MEDICATIONS (current or previous use including effectiveness): Prozac and Celexa.
MEDICAL CONCERNS: (Include history of conditions, current conditions, treatment for conditions & disability restrictions): Depression, Substance Abuse, Suicidal Ideation Anxiety and Trauma.
CURRENT MEDICATIONS: Paroxetine 100mg daily
DEPENDENCE/ADDICTION HISTORY (Include Present use/Drug of choice/Age of first use/ tobacco & caffeine use): Alcohol and Methamphetamine was the major dependence for the client.
Period of Abstinence from mood altering drugs (Include time period): Not certain
History of 12-step attendance (Include time period): None
History of Withdrawal Symptoms:
None Reported AM alcohol/drug use Agitation shakes
Hallucinations High Blood Pressure Suicidality Vomiting
Violence Seizures Excessive Sweating Nausea
Anxiety Insomnia DT’s Depression
Other: ___________________________
History of Intoxification:
None Reported Blackouts Bumps/ Bruises Chest or Heart Pain
Distended Abdomen Hallucinations High Blood Pressure Liver Problems
Loss of Appetite Confusion Paranoia Red Face or Nose
Slurred Speech Swelling Vision Problems Weight Loss
History of significant Incidents in relationship to Alcohol/ Drugs:
None Identified Family Problems Work Problems Legal Problems
Health Problems Money Problems Automobile Accidents Gambling
FAMILY HX OF PSYCHIATRIC/ADDICTION ILLNESS: Parents uses drugs but are not addicted and they neglect their children by not providing proper care and attention.
SPIRITUALITY: When the client was younger in was involved with religious activities, but presently the clients is not affiliated to any religious organization.
CULTURAL/ SOCIAL CONSIDERATIONS (Include sexual orientation issues or concerns): The feeling of depression overwhelmed the clients most times that the uses drugs is a way of finding relieve. Apart from this issue after the divorce with his ex-wife the clients state that is not interested in getting married again, so he engage in all manner of sexual satisfaction both in an heterosexual and homosexual way.
PERSONAL HISTORY: Childhood Hx (abuse/relationship w/parents):
Jose experiences a very unstable childhood, due to the fact that is parents do not have a permanent job and are financially struggling in providing for the family they keep on moving from Californian to Mexico in search for greener pasture. These movement affected Jose and siblings emotionally and academically. The changes of schools affected them in the sense that in Mexico they were expected to speak Spanish and in California to speak English this inter-switch contributed in their poor performance in school where they are not certain about what to expect.
He was discriminated and sexually abused in Californian where he was constantly bullied and was touched in a sexual, also his head was placed in the genital areas of the bullies, while in Mexico they called him names that is not a Mexican but a white child, urinated in his lunch meals and forced him to eat it. All these experiences traumatized Jose mentally which made him to start drinking early and indulging with the wrong set of people all because he wanted to forget the pain.
EDUCATION (including attending school/highest grade achieved/do you want more/ learning disabilities): Jose Fernando graduated from high school but was not able to further his education. He finds joy in writing poems and singing having the hope that he will become a musical one day.
DEVELOPMENTAL HISTORY (C&A only to include developmental age factors, motor development, and functioning): Motor development factor and functioning is slow.
LEGAL HISTORY (Include current involvement in legal action): Jose has been charge for drug possession, violence and shoplifting. He is still in probation for the violence attack he was involved in with some gang of friends.
MARITAL/RELATIONSHIPS (Include unstable relationships): Divorced, heterosexual and homosexual.
WORK HISTORY: (job history/ what are your aspirations) Client has worked in an auto-shop service, hair stylist and presently is working in a fast food joint. To become financially wealthy.
STRENGTHS, NEEDS, ABILITY, PREFERENCE (SNAP): Clients feels that he may overcome this substance abuse behavior if he could find a way of moving to a better environment.
Being surrounded by people who influence him negatively prevent Jose from taking the positive steps he desire to accomplish.
INTERPRETIVE SUMMARY: Living in an environment that is surrounded by substance abuse use and in trying to overcome such habit can be difficult for people like Jose, no matter how they are trying to avoid the use of it, there friends and community provides them with such opportunity. This also contribute towards the feeling that nothing good can happen in their life and the situation develop a means to be depressed, where the use of drugs and alcohol is a means to find relieve of the pain.
Most people who have been incarcerated find it difficult to get a good job and this may frustrate their desire to move out of the poverty line.
SHORT AND LONG TERM GOALS: Client will participate in counselling session to discuss some of his past experiences that is affecting his present situation, and to be registered into a rehabilitation facility, which will help in placing the client in an environment where he will not be influence by the drug and alcohol
use.
TRANSITION/DISCHARGE PLAN: (including person responsible for follow up)
SWI will provide client with the needed information on different support group’s contact and psycho-education to clients. Discuss with some family members who could be of assistance during the progressive stage of the client and recommend client to follow the instruction of the medical practitioners.
Invitation to Treatment Team: Consumer Response [X] Accepted [ ] Declined
Therapeutic Interventions Provided: Therapist will see Jose twice in a week.
Services Recommendations and Plan: It is recommended that client should be in a rehabilitation facility for proper medical services and support in assisting the client to overcome some of his addiction problems. Also, the services will aid client to develop new skills in addressing some of the issues that makes him behave in a violent manner and the suicidal thoughts, this services will be provided for a period of time to see the respond of the client towards the treatment received.
Jose Fernando is a 34 years old Hispanic male with a history of depression, substance abuse and domestic violence, was admitted to Gila regional medical center for overdose of drug after assaulting his ex-wife physically. During the time of the interview the client stated that his ex-wife was saying some provocative words and this made him reacted badly by beating her up and he never wanted to but he could not resist the urge, and how she keeps on comparing him with other guys by telling him to act responsible in providing for the family. Client said he felt remorse for his actions when he saw that his ex-wife was on the floor not moving he thought he has killed her, so taking his own life was the …show more content…
next option.
This is not the first time the clients as attempted to commit suicide, he has been provided with some medications and counselling services but as never participate actively in performing the requested tasks. The client is working in a fast food joint in Silver City and sharing an apartment with his sister who is also divorced.
PAYOR: Medicare
PRESENT PSYCHIATRIC ILLNESS/SYMPTOMS (Including current and past psycho-social stressors
The present psychiatric illness of the client is depression due to the past and current psychosocial stressors such as traumatic encounter, poverty, discrimination, alcoholism, tobacco intake and family related obligations.
BASIC NEEDS & CONCERNS (Include transportation & housing concerns):
Some of the basic need of the client is the provision of a support group for substance abuse patient, housing and good job to support himself and family. Addicted to alcohol prevent the client from performing his duties properly were most of his wages are spent on drinks, also working in a low paying job due to his criminal record.
PAST HX OF OUTPATIENT TX/COUNSELING (Including psychiatric admissions/suicide or violent behavior):
Jose was diagnosed with depression when he was 12 years old and had some suicidal thoughts of killing himself which the client did not denied. Attended some brief counselling class for a period of time before his family relocated to a new environment and it was a difficult process to get sign up for counselling class since the list of clients was on a high range, this situation prevented the client from having any further intervention …show more content…
class.
MENTAL HEALTH MEDICATIONS (current or previous use including effectiveness): Prozac and Celexa.
MEDICAL CONCERNS: (Include history of conditions, current conditions, treatment for conditions & disability restrictions): Depression, Substance Abuse, Suicidal Ideation Anxiety and Trauma.
CURRENT MEDICATIONS: Paroxetine 100mg daily
DEPENDENCE/ADDICTION HISTORY (Include Present use/Drug of choice/Age of first use/ tobacco & caffeine use): Alcohol and Methamphetamine was the major dependence for the client.
Period of Abstinence from mood altering drugs (Include time period): Not certain
History of 12-step attendance (Include time period): None
History of Withdrawal Symptoms:
None Reported AM alcohol/drug use Agitation shakes
Hallucinations High Blood Pressure Suicidality Vomiting
Violence Seizures Excessive Sweating Nausea
Anxiety Insomnia DT’s Depression
Other: ___________________________
History of Intoxification:
None Reported Blackouts Bumps/ Bruises Chest or Heart Pain
Distended Abdomen Hallucinations High Blood Pressure Liver Problems
Loss of Appetite Confusion Paranoia Red Face or Nose
Slurred Speech Swelling Vision Problems Weight Loss
History of significant Incidents in relationship to Alcohol/ Drugs:
None Identified Family Problems Work Problems Legal Problems
Health Problems Money Problems Automobile Accidents Gambling
FAMILY HX OF PSYCHIATRIC/ADDICTION ILLNESS: Parents uses drugs but are not addicted and they neglect their children by not providing proper care and attention.
SPIRITUALITY: When the client was younger in was involved with religious activities, but presently the clients is not affiliated to any religious organization.
CULTURAL/ SOCIAL CONSIDERATIONS (Include sexual orientation issues or concerns): The feeling of depression overwhelmed the clients most times that the uses drugs is a way of finding relieve. Apart from this issue after the divorce with his ex-wife the clients state that is not interested in getting married again, so he engage in all manner of sexual satisfaction both in an heterosexual and homosexual way.
PERSONAL HISTORY: Childhood Hx (abuse/relationship w/parents):
Jose experiences a very unstable childhood, due to the fact that is parents do not have a permanent job and are financially struggling in providing for the family they keep on moving from Californian to Mexico in search for greener pasture. These movement affected Jose and siblings emotionally and academically. The changes of schools affected them in the sense that in Mexico they were expected to speak Spanish and in California to speak English this inter-switch contributed in their poor performance in school where they are not certain about what to expect.
He was discriminated and sexually abused in Californian where he was constantly bullied and was touched in a sexual, also his head was placed in the genital areas of the bullies, while in Mexico they called him names that is not a Mexican but a white child, urinated in his lunch meals and forced him to eat it. All these experiences traumatized Jose mentally which made him to start drinking early and indulging with the wrong set of people all because he wanted to forget the pain.
EDUCATION (including attending school/highest grade achieved/do you want more/ learning disabilities): Jose Fernando graduated from high school but was not able to further his education. He finds joy in writing poems and singing having the hope that he will become a musical one day.
DEVELOPMENTAL HISTORY (C&A only to include developmental age factors, motor development, and functioning): Motor development factor and functioning is slow.
LEGAL HISTORY (Include current involvement in legal action): Jose has been charge for drug possession, violence and shoplifting. He is still in probation for the violence attack he was involved in with some gang of friends.
MARITAL/RELATIONSHIPS (Include unstable relationships): Divorced, heterosexual and homosexual.
WORK HISTORY: (job history/ what are your aspirations) Client has worked in an auto-shop service, hair stylist and presently is working in a fast food joint. To become financially wealthy.
STRENGTHS, NEEDS, ABILITY, PREFERENCE (SNAP): Clients feels that he may overcome this substance abuse behavior if he could find a way of moving to a better environment.
Being surrounded by people who influence him negatively prevent Jose from taking the positive steps he desire to accomplish.
INTERPRETIVE SUMMARY: Living in an environment that is surrounded by substance abuse use and in trying to overcome such habit can be difficult for people like Jose, no matter how they are trying to avoid the use of it, there friends and community provides them with such opportunity. This also contribute towards the feeling that nothing good can happen in their life and the situation develop a means to be depressed, where the use of drugs and alcohol is a means to find relieve of the pain.
Most people who have been incarcerated find it difficult to get a good job and this may frustrate their desire to move out of the poverty line.
SHORT AND LONG TERM GOALS: Client will participate in counselling session to discuss some of his past experiences that is affecting his present situation, and to be registered into a rehabilitation facility, which will help in placing the client in an environment where he will not be influence by the drug and alcohol
use.
TRANSITION/DISCHARGE PLAN: (including person responsible for follow up)
SWI will provide client with the needed information on different support group’s contact and psycho-education to clients. Discuss with some family members who could be of assistance during the progressive stage of the client and recommend client to follow the instruction of the medical practitioners.
Invitation to Treatment Team: Consumer Response [X] Accepted [ ] Declined
Therapeutic Interventions Provided: Therapist will see Jose twice in a week.
Services Recommendations and Plan: It is recommended that client should be in a rehabilitation facility for proper medical services and support in assisting the client to overcome some of his addiction problems. Also, the services will aid client to develop new skills in addressing some of the issues that makes him behave in a violent manner and the suicidal thoughts, this services will be provided for a period of time to see the respond of the client towards the treatment received.