Discharge Report_Case Two
DISCHARGE REPORT
CLIENT'S NAME: Songi Abas
D.O.A: 21ST MAY, 1992
D.O.D: 19TH AUGUST, 1992
Songi is a 36 year-old male, married, was born and raised in Toki County. His referral for treatment was done by the family.
PRESENTING PROBLEM: ALCOHOL USE DISORDER
KEY UNDERLYING ISSUES
• Denial whether he needs help
• Poor decision making skills
• Poor problem solving skills
• Regressed spiritual/religious beliefs
• Low self esteem
• Poor financial management
• Poor communication and interpersonal skills
TREATMENT GOALS
• Stopping alcohol use- developing a program of recovery congruent with a sober lifestyle.
• To empower the client with better decision making skills
• To improve the client’s problem solving skills
• Improving/ nourishing the client’s spirituality
• To boost the client’s self esteem
• To help the client develop proper financial management
• To assist the client develop proper communication and interpersonal skills.
ACHIEVED GOALS
• Abstinence from alcohol for three months
• Resolving ambivalence to change
• The client’s self-esteem improved
• Helping the client to open up more
• Ability to regain good decision making
• Improved physical health-hygiene and grooming
HOW THE GOALS WERE MET
• One on one counseling sessions
• Group therapy (12 steps of AA/NA)
• Cognitive behavioral therapy
• Challenging irrational beliefs
• Life skills Training
• Family therapy
• Therapeutic community duties
• Spiritual nourishment
• Peer to peer interactions
UNMET GOALS
• Maintaining sobriety - This is a journey that he will continue to pursue in life. Songi has stayed clean throughout his time in rehabilitation and therefore with the correct support he can maintain it.
• Songi need to continue working on himself to better resolve the challenges in his day to day life.
At the onset of treatment, the client had a difficult time always insisting on an early discharge. With various interventions, 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 with the right guidance. I want to extend this thought to Songi. I recommend the following to assist him in the recovery journey;
• Create a Support Network like family, friends, support groups, sponsors, or counselors who understand your journey and can offer encouragement when challenges arise.
• Attend Support Groups, do consider joining support groups that focus on maintaining sobriety.
• Develop a Routine, where you fill your schedule with activities that are meaningful, fulfilling, and conducive to your sobriety.
• Set Realistic Goals by breaking down your recovery journey into manageable steps and set achievable goals.
• Avoid Triggers by identifying and avoiding situations, places, and people that may trigger cravings or temptations.
• Healthy Lifestyle by eating nutritious meals, exercising regularly, and getting enough sleep. Physical well-being contributes to mental and emotional strength.
• Counseling by continued therapy sessions on an outpatient basis to address any underlying psychological or emotional factors that may contribute to relapse.
• Mindfulness and Self-Awareness by being aware of your thoughts, emotions, and triggers. To help manage cravings and make conscious choices in challenging situations.
• Hobbies and Interests where you engage in activities that bring you joy and fulfillment. Pursue hobbies and interests that provide a positive outlet for your energy and focus.
• Emergency Plan where you create a plan for how you will handle moments of intense cravings or triggers. Have a list of people to call, activities to distract yourself with, and coping strategies to employ during these times.
• Celebrate Milestones by acknowledging your achievements along the way, whether it's one week, one month, or one year of sobriety. Celebrate these milestones as a way to reinforce your commitment.
• Stay Informed by educating yourself about alcoholism, addiction, and relapse prevention. Understanding the challenges you may face can better equip you to handle them.
• Forgive yourself, if you do experience a setback, remember that relapse is a common part of recovery for many individuals. Be compassionate with yourself, seek support, and recommit to your sobriety journey.
Generally, He actively attended group therapy sessions, life skills training, and individual counseling sessions as expected from him in the program offered at {treatment facility}. In addition, he has made tremendous progress in his psychological, emotional, physical, and social well-being. I believe that he is capable of going back to the society as a fully functional individual but within the bounds of his condition.
Any assistance accorded to him is highly appreciated.
Prepared by:
{Omondi}
Counselling Psychologist
Our Standard Review
Date created: 16 Aug 2024 09:15:34
Critical Evaluation: The discharge report presents a clear and structured overview of the client's treatment for alcohol use disorder. The arguments made regarding the client's progress and the treatment methods employed are logical and well-supported by evidence from the treatment process. However, the report could benefit from a more in-depth exploration of the client's ongoing challenges, particularly regarding maintaining sobriety. While the report acknowledges the client's achievements, it could strengthen its arguments by providing specific examples of how these goals were met and the impact of each intervention. The tone is generally fair, focusing on the client's potential for recovery, though it could be perceived as overly optimistic without addressing the complexities of long-term sobriety. The implications of the report suggest that with continued support, the client can reintegrate into society, which is a realistic and hopeful perspective.
Quality of Information: The language used in the report is accessible and straightforward, making it easy for a broad audience to understand. Technical terms, such as "cognitive behavioral therapy" and "support groups," are used without extensive explanation, which may leave some readers unclear about their meanings. The information appears accurate and reliable, with no evident signs of misinformation or logical fallacies. The report adheres to ethical standards by respecting the client's confidentiality and focusing on their well-being. While it does not introduce groundbreaking ideas, it effectively summarizes established practices in addiction treatment. The report adds value by providing a comprehensive view of the client's journey and the therapeutic interventions employed.
Use of Evidence and References: The report relies on the client's progress and the therapeutic methods applied as evidence to support its claims. However, it lacks citations or references to external sources that could lend additional credibility to the treatment approaches mentioned. While the evidence presented is relevant, there are gaps in providing empirical support for the effectiveness of the interventions listed. More detailed evidence, such as statistics on success rates for similar cases or references to established research in addiction treatment, would enhance the report's reliability.
Further Research and References: Further exploration could focus on the long-term effectiveness of the treatment methods used, particularly in maintaining sobriety after rehabilitation. Research on the role of family support in recovery and the impact of community resources on relapse prevention could also be beneficial. Additional literature on the psychological aspects of addiction and recovery may provide deeper insights into the client's ongoing challenges.
Questions for Further Research:
- What are the long-term success rates for individuals who complete similar rehabilitation programs?
- How does family involvement influence the recovery process for individuals with alcohol use disorder?
- What specific strategies are most effective in maintaining sobriety after rehabilitation?
- How do different therapeutic approaches compare in their effectiveness for treating alcohol use disorder?
- What role does spirituality play in the recovery process for individuals with addiction?
- How can support groups be optimized to better assist individuals in maintaining sobriety?
- What are the common triggers for relapse, and how can they be effectively managed?
- How does the socio-economic background of an individual affect their recovery journey?
- What are the psychological factors that contribute to alcohol use disorder?
- How can mindfulness practices be integrated into addiction recovery programs?
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