Discharge Report_Case 1
DISCLAIMER!
Any of the names used in this sample are for the purposes of the shared report writing skill. As a therapist, I have never met a client of such a name or such a case.
DISCHARGE REPORT
Henry is a 40 year old male struggling with alcoholism having four unsuccessful treatment for alcoholism. He is married to one wife and blessed with three (3) children. He is checked in for addiction treatment by the father and two of his brothers. At admission, he is unstable mentally and the family seeks his rehabilitation against his wish (involuntarily) for three months. He presents with anxiety issues, mind clogging, compromised liver function test results among other issues. Being the treatment is involuntary, Henry got issues with denial claiming the brothers who happen to be using drugs like bhang are the ones who need to be in rehab and reservations.
As a counselor, the following sample would best suit to fit Henry’s discharge report:
Henry Ongwalo
AGE: 40
MARRITAL STATUS: MARRIED
D.OA: 21ST FEBRUARY, 2002
D.O.D: 20TH MAY, 2002.
CHIEF COMPLAINT: Alcohol Use Disorder
Other Underlying Issues
i). Poor communication and interpersonal skills with family members and other people.
ii). Resentments towards family members.
iii). Desire to learn how to clarify one’s beliefs and values and strengthening religious or spiritual beliefs.
iv). Neglected/poor medical needs, healthy diet and personal hygiene.
v). Worries and depression about self and generally life.
vi). Self -awareness and low esteem issues.
vii). Poor decision making and problem solving.
viii). Dealing with anger or other upsetting emotions.
ix). Poor financial management skills.
From the above identified issues affecting the client, the following objectives of treatment were arrived at;
i). To enable the client develop a lifestyle free from drugs or any other mood altering substance that is congruent to sobriety and recovery.
ii). To empower the client with better communication and interpersonal skills with family and other people.
iii). To assist the client resolve his resentments towards some family members.
iv). To help the client understand, clarify his beliefs, values and strengthen his religious and spiritual beliefs.
v). To boost the client’s knowledge on taking care of one’s medical needs, healthy diet and personal hygiene.
vi). To assist the client acquire skills to manage worries and depression that may affect him on his day to day life.
vii). To boost the client’s self-esteem and self-awareness.
viii). To psycho-educate the client on better decision making and problem solving skills.
ix). To assist the client better his management of anger and other upsetting emotions.
x). To empower the client with better financial management skills.
Achieved Objectives
i). Abstinence from any mood altering substance for the period he has been on treatment.
ii). His personal physical hygiene and health has improved.
iii). The client’s interpersonal and communication skills have improved as seen in his interactions within the facility.
iv). The client’s decision and problem solving skills have improved.
v). Resolutions of resentments towards family members.
vi). Acquisition of anger and other upsetting emotions management skills
vii). The client’s self-esteem and self-awareness have tremendously grown and better as compared when the client checked in.
Unmet Objectives
i). Recovery- addiction being a chronic illness, the client is not cured. He is just but empowered with the tools of a way of life that will assist in keeping clean and sober. He has to practice them for the rest of his life if he desires to do so.
ii). The client’s physical hygiene and health is an area he must keep working on a day-day basis.
iii). The client needs to put more effort in the clarification of his beliefs and challenge any irrational tunnel visioning.
iv). Even for the rest of the identified objectives or goals of treatment, he must continue on working on them. The program did not make a perfect individual but a better version of the client who checked in. Vigilance will keep the client within the tracks of recovery.
How the goals were achieved
i). One-one/individual counselling.
ii). Group therapy (12-steps of AA/NA).
iii). Family therapy.
iv). Food therapy.
v). Life-skills sessions
vi. Peer to peer interactions.
vii). Therapeutic community duties.
viii). Confrontation of irrational beliefs.
At the onset of treatment, the client had a difficult time always insisting on an early discharge. With various interventions, but later the client appeared so good and cooperative. He attended all the activities of the program with lots of ease. The only fear with a client of such nature is the fear of compliance. As a therapist, I believe every person in this world can recover in the light of being honest with him/herself and the right guidance. I want to extend this thought to Henry.
I recommend the following to assist him in his recovery journey;
i). The client to continue taking a personal inventory to keep within the tracks of recovery to avoid veering off and being reluctant.
ii). The client should observe strict adherence to follow-ups with the recovery counselor or a counselor of his choice to help handle day to day issues affecting his life.
iii). Identify and join AA fellowship to working on the recovery.
iv). The client to consider going to church to reinforce, instill and restore spiritual principles or values.
v). The client needs to avoid people, places and things (PPTs) that would trigger relapse having in mind that his triggers are his own responsibilities and the world cannot tiptoe behind him.
Prepared by:
{Omondi}
Counselling Psychologist
Our Standard Review
Date created: 16 Aug 2024 09:20:35
Critical Evaluation:
The article presents a detailed discharge report for a client named Henry, who is undergoing treatment for alcoholism. The arguments made regarding Henry's condition and treatment are generally logical and coherent. The report outlines both the client's struggles and the objectives of his treatment, providing a clear framework for understanding his situation. However, the reasoning could be strengthened by including more specific examples of the therapeutic techniques used and their direct impact on Henry's progress.
One notable issue is the potential bias in the report. The counselor's perspective may influence the portrayal of Henry's family dynamics and the client's initial resistance to treatment. While the counselor expresses a belief in the possibility of recovery, it is essential to consider the complexities of family involvement in addiction treatment. The implications of this bias could affect how readers perceive the effectiveness of the treatment and the role of family support.
In the real world, the ideas presented in the report highlight the importance of a supportive environment for individuals in recovery. The acknowledgment of ongoing challenges, such as the need for continuous effort in maintaining sobriety, reflects the reality of addiction as a chronic illness.
Quality of Information:
The language used in the report is mostly straightforward, making it accessible to a broad audience. However, some technical terms, such as "abstinence" and "psycho-education," could benefit from brief explanations to enhance understanding. For example, abstinence refers to refraining from using substances, while psycho-education involves educating clients about their conditions and coping strategies.
The information appears accurate and reliable, with no evident signs of fake news or misleading content. The report adheres to ethical standards by maintaining confidentiality and focusing on the client's well-being. However, the article could improve by introducing more recent research or theories related to addiction treatment, as it primarily reiterates established concepts without presenting new insights.
The report adds value to the field of addiction counseling by emphasizing the importance of individual effort and ongoing support in recovery, but it could delve deeper into innovative treatment approaches or emerging trends in addiction therapy.
Use of Evidence and References:
The report lacks specific references to external sources or studies that could support its claims. While the therapeutic methods mentioned, such as individual counseling and group therapy, are widely recognized, citing relevant research or statistics would strengthen the arguments made. Additionally, the absence of evidence regarding the effectiveness of the treatment techniques used leaves a gap in understanding how these methods specifically benefited Henry.
Further Research and References:
Further exploration could focus on the following areas:
- The long-term effectiveness of various addiction treatment modalities.
- The role of family dynamics in the recovery process.
- Innovative approaches to addiction therapy, such as mindfulness or cognitive-behavioral therapy.
- The impact of socioeconomic factors on addiction recovery.
Questions for Further Research:
- What are the most effective long-term strategies for maintaining sobriety after treatment?
- How does family involvement influence the recovery process for individuals with addiction?
- What innovative therapies are emerging in the field of addiction treatment?
- How can counselors better support clients who are resistant to treatment?
- What role does spirituality play in the recovery journey for individuals with addiction?
- How do socioeconomic factors affect access to addiction treatment and recovery resources?
- What are the psychological effects of involuntary treatment on clients?
- How can peer support groups enhance the recovery experience?
- What specific skills are most beneficial for clients in managing their emotions during recovery?
- How can technology be utilized to support individuals in their recovery journey?
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