Practicum Experience Journal Week 2 Student Name The Purpose

Practicum Experience Journal Week 2student Namethe Purpose Of This Jo

2practicum Experience Journal Week 2student Namethe Purpose Of This Jo

The purpose of this journal entry is to evaluate a client and develop an appropriate therapeutic plan of care. The treatment plan will utilize the DSM-5 criteria and evidence-based practice. The legal and ethical implications of counseling a client will also be explored as it applies to the mental health professional.

Demographics: GH is a 39-year-old married Caucasian female employed part-time at a local department store. Her husband is an engineer at a manufacturing company. Living in a housing development, GH resides with her husband and two children aged five years and six months. She communicates clearly and considers her faith and church community as part of her social support network.

Presenting Problems: GH reports increased depressive symptoms, stating, “I have been so sad since the birth of my youngest child. It scares me I just don’t know what to do.”

History of Present Illness: GH exhibits increased anxiety and depressed mood that began approximately six months ago. The symptoms are persistent and moderate in severity but worsen when her child cries. She reports no relieving factors. Her depression includes lethargy, decreased motivation, and anhedonia, but she denies suicidal or homicidal thoughts. She appears well-groomed, appropriately dressed, with a flat affect and inconsistent eye contact. GH states she enjoys reading and sewing but lacks motivation recently and feels drained, saying, “I am so drained and often have to force myself to take care of myself and family.” She sleeps about 8 hours nightly with naps during the day and has inconsistent therapy attendance due to feeling overwhelmed.

Current medications include Vistaril 50 mg PO every six hours PRN for anxiety. She reports no other medications, including over-the-counter or herbal supplements.

Past Psychiatric History

Medical History

Substance Abuse History

Differential Diagnosis

The client does not meet criteria for puerperal psychosis, which requires rapid onset, profound confusion, delusions, infanticidal thoughts, and often associated with bipolar disorder (Sit, Rothschild, & Wisner, 2006). Her age, lack of family history, and clinical presentation do not support this diagnosis (Sharma, Rai, & Pathak, 2015).

DSM-5 Diagnosis

The client qualifies for 296.32 (F33.1): Major Depressive Disorder, recurrent, moderate severity, with peripartum onset. This is supported by her symptoms of persistent depressed mood, anhedonia, hypersomnia, fatigue, and cognitive difficulties lasting for over two weeks, with onset within two weeks postpartum (American Psychiatric Association, 2013). The peripartum specifier is justified given the timing of her symptoms relative to childbirth.

Individualized Treatment Plan

Given her positive past response, Paroxetine CR is selected as her medication therapy, starting at 25 mg daily, with a maximum of 65.2 mg daily (Drugs.com, 2018). Since she does not intend to breastfeed, transmission concerns are minimal. Follow-up is scheduled in three weeks for monitoring and dose adjustment if necessary. Concurrently, she will be referred for weekly individual psychotherapy, with evidence supporting combined pharmacotherapy and psychotherapy for major depressive disorder to optimize outcomes (Sharma & Sharma, 2012).

Legal and Ethical Considerations in Counseling

Understanding and adhering to legal and ethical standards is essential. The American Psychological Association’s (APA) ethical code emphasizes protecting clients from harm (Section 3.04) and ensuring informed consent (Section 10.01) (APA, 2017; Pope & Vasquez, 2016). Providers must prioritize the client’s well-being, obtain informed consent, and verify capacity to give consent, particularly in depression-related contexts. Upholding confidentiality, avoiding dual relationships, and maintaining professional competence are also fundamental to ethical practice. These principles foster trust and protect both client and clinician legally and ethically.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
  • Ethical Principles of Psychologists and Code of Conduct. (2017). American Psychological Association. https://www.apa.org/ethics/code
  • Drugs.com. (2018). Paroxetine - FDA prescribing information. https://www.drugs.com
  • Pope, K. S., & Vasquez, M. J. (2016). Ethics in Psychotherapy and Counseling: A Practical Guide (5th ed.). John Wiley & Sons.
  • Sharma, V., & Sharma, P. (2012). Postpartum depression: Diagnostic and treatment issues. Journal of Obstetrics and Gynaecology Canada, 34(5), 445-448. https://doi.org/10.1016/S1701-2163(12)60109-0
  • Sit, D., Rothschild, A. J., & Wisner, K. L. (2006). A review of postpartum psychosis. Journal of Women's Health, 15(4), 352-358. https://doi.org/10.1089/jwh.2006.15.352
  • Sharma, I., Rai, S., & Pathak, A. (2015). Postpartum psychiatric disorders: Early diagnosis and management. Indian Journal of Psychiatry, 57(6), 216-222. https://doi.org/10.4103/0019-5545.161481
  • American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct. https://www.apa.org/ethics/code
  • Sharma, V., & Sharma, P. (2012). Postpartum depression: Diagnostic and treatment issues. Journal of Obstetrics and Gynaecology Canada, 34(5), 453-455. https://doi.org/10.1016/S1701-2163(12)60112-7
  • Sit, D., Rothschild, A., & Wisner, K. L. (2006). A review of postpartum psychosis. Journal of Women's Health, 15(4), 352-358. https://doi.org/10.1089/jwh.2006.15.352

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