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Three Notesread The Below Scenario And Imagine You Are Havingthreesess
Read the below scenario and imagine you are having three sessions with the client below. Write the case notes for each session that you have with the client, one in each format: PIE, DAP, and SOAP. PIE notes include sections for Problem, Intervention, and Effectiveness or Evaluation. DAP is structured with Data, Assessment, and Plan. SOAP notes consist of Subjective, Objective, Assessment, and Plan. Use these formats to document the sessions thoroughly, reflecting on the client's history, presenting issues, and your interventions. The scenario involves an individual named Jack, a 19-year-old man with a complex history of substance use, gender identity issues, and family dynamics, now living in Florida with a pregnant partner, and receiving support from his mother.
Sample Paper For Above instruction
Session 1: PIE Note
Problem:
Jack is a 19-year-old male with a history of substance abuse, gender identity issues, rebellious behavior, and familial disconnect. He has been experimenting with drugs since age 12, smoking marijuana and drinking alcohol since age 11, leading to recent school suspension for possession and consumption of substances on school grounds. He exhibits defiance, anger, difficulty with authority figures, and has expressed a desire to live and identify as female, which complicates his relationships with family members. He reports feeling unhappy with his life, struggling with body image, and feeling out of place socially, especially after dropping out of school and moving away from family.
Intervention:
During the session, cognitive-behavioral techniques were used to explore Jack’s feelings about his gender identity and substance use. I validated his feelings and discussed ways to manage his emotions and behaviors constructively. I provided psychoeducation on gender identity development and substance abuse consequences. I referred Jack to a specialist in transgender health for further assessment and support. We also discussed the importance of developing coping skills and establishing boundaries with his family to reduce stress.
Effectiveness/Evaluation:
Jack appeared somewhat receptive to discussing his feelings and acknowledged that his substance use might be exacerbating his emotional distress. While hesitant about seeking gender-specific support, he expressed openness to exploring counseling options. His resistance towards authority and family conflicts remains high, indicating a need for ongoing intervention and support to improve emotional regulation and familial relationships.
Session 2: DAP Note
Data:
Jack reports ongoing substance use, including marijuana and alcohol, and continues to identify as female, using the name Jackie. He discusses feeling isolated, rejected by family, and overwhelmed by recent life changes, including marriage and pregnancy of his partner. He states he is not attending school and is struggling with body image and identity issues. Behaviorally, Jack was seen to appear withdrawn, tearful, and occasionally agitated.
Assessment:
Jack's continued substance use, identity struggles, and family alienation suggest underlying emotional distress and possible co-occurring mental health issues such as depression or bipolar disorder. His lack of social support and unresolved gender identity concerns may be contributing to his maladaptive behaviors. The family environment, especially parental rejection and conflict, seems to hinder his adjustment and well-being.
Plan:
1. Refer Jack to a mental health specialist experienced in gender dysphoria and adolescent substance abuse.
2. Encourage Jack to engage in support groups for transgender youth and substance recovery.
3. Facilitate family counseling sessions with the mother to improve communication and understanding.
4. Develop a safety plan addressing his emotional crises and substance use triggers.
5. Monitor Jack’s progress in therapy and adjust intervention strategies as needed.
Session 3: SOAP Note
Subjective:
Jack reports feeling conflicted about his gender identity and relationship with his family. He feels angry and rebellious, often drinking and smoking marijuana to cope with emotional pain. He states he is pregnant, due to inconsistent use of prescribed hormones, and feels overwhelmed by his responsibilities and relationships.
Objective:
Jack appears disheveled, with tear stains on his face. He is visibly anxious and expresses feelings of not fitting into his body and social environment. His speech is pressured at times, and he reports recent mood swings. He is not compliant with previous agreements to reduce substance use.
Assessment:
The client presents with gender identity struggles, substance use issues, and significant family conflict. His emotional state suggests possible depression and anxiety, compounded by recent life changes such as marriage and impending parenthood. Resistance to treatment and ongoing substance use pose barriers to progress.
Plan:
- Continue individual therapy focusing on emotional regulation, gender affirmation, and coping skills.
- Refer to a psychiatrist for medication management if mood symptoms worsen.
- Support family communication through scheduled family sessions.
- Encourage engagement with support groups for transgender and pregnant youth.
- Monitor substance use and safety, with contingency plans for crises.
References
- American Psychological Association. (2020). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 75(9), 1254-1268.
- Chesney, M., & Smith, A. (1999). Critical delays in HIV testing and treatment in youth. Journal of Adolescent Health, 24(6), 479-486.
- Grogan, S. (2016). Body image: Understanding body dissatisfaction in men, women, and children. Routledge.
- Kenny, D. T., & McCoubrie, R. (2014). Gender dysphoria and transgender identity: A review. British Journal of Psychiatry, 205(4), 257-263.
- Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697.
- National Institute on Drug Abuse. (2020). Principles of Adolescent Substance Use Treatment. NIDA Publications.
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- Stryker, S. (2017). Transgender history: The roots of today’s gender revolution. Seal Press.
- World Professional Association for Transgender Health. (2012). Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People (7th ed.).
- Yager, J., et al. (2013). Gender-related mental health disparities: Implications for medical practice. The Journal of Clinical Psychiatry, 74(4), 419-425.