Client Information/ Presenting Issue
Client is a 16-year-old Hispanic and African American male from Jacksonville, Fl. He lives with his mother and has a younger sister. His step father and mother are divorcing. The daughter is the step father’s child and will be living with him, while client stays with his mother. He joined the dentention center due to charges of substance use/diagnosis/ possession and theft. I joined therapist, Mr. Sanchez in an individual session to follow up on a suicide precaution assesment. Right now Client is on a one to one precaution where staff signs off that he is okay every 30 minutes. Mr. Sanchez is meeting with him to see if he needs to be taken off or continue to be watched. During this session the client displayed symptoms of depression over the choices that he has made in the past. He is afraid that his step father doesn’t love him any more due to these choices and the present circumstances at home. Also during the session he switched his answer when asked if he continued to have thoughts of suicide. His appearance showed that he was either having a rough morning or a rough night. His eyes were red. Not the eyeballs, but his skin. This could possibly happen due to crying, rubbing, or lack of sleep. After analysing his responses and appearance, I believe that is was necessary to continue to keep a watchful eye on him.
|Dialogue||Identify skills, techniques and theories||Analysis/assessment of dialogue||Personal reactions and self-reflections to the interaction|
|Therapist: Hey do you know Mrs. Green
|I have seen this youth and recognized that he is fairly new. I’m not sure if he would let me sit in on his session.|
|Therapist: Do you mind if she joins us in our session today?
Client: No. I don’t mind
Therapist: Great let’s go to the control room and talk
|Therapist: How are you feeling today?
Client: (Smirks) I’m straight.
|Therapist: Are you still thinking of harming yourself?
|Therapist: Why are you wanting to harm yourself?
Client: My dad doesn’t love me anymore.
|His mouth is shaking. I hope he doesn’t cry because my eyes are getting watery just watching him.|
|Intern: The word “love” is an action word. Has your dad done anything to show you that he doesn’t love you?
Client: No. I guess not.
|Engagement Skills||Providing Information|
|Intern: I believe he still loves you based on your response.
Therapist: Tell me two positive things about yourself.
|Client: I am loyal and support my family
Therapist: That’s good that you support your family.
|Therapist: Have you been thinking of harming yourself today?
Client: No. Not today.
|Therapist: How is your sleep? Having you been sleeping well?
Client: No. I constantly wake up in the middle of the night.
|He looks depressed and his eyes are extremely red.|
|Intern: I see that your eyes are red. Is it due to the lack of sleep or rubbing?
|Intern: What do you do when you’re awake in the night.
Client: I write about how I’m feeling and what I’ve done in the past.
|Intern: What are some of those decisions that you’ve made that bother you?
Client: I would go steal stuff with friends or if I ask my mom for something and she doesn’t give it to me then I would go out and get it.
|Intern: Do you think your mom isn’t able to give you what you want or that she just won’t do it?
Client: She don’t give me stuff because of my behavior.
|Engagement Skills||Building rapport|
|Therapist: So, you have trouble with impulse. Why do you think you have trouble with just taking things?
Client: I don’t have any patience and I should be punished for the things that I’ve done.
|Engagement skills||Building rapport|
|Intern: Everyone makes mistakes. No one is perfect. I have done things that I regret. I’m sure Mrs. Sanchez has too.
Therapist: Yes. I have done many bad things.
|Intern: It is normal for people to make poor decisions, but we must learn from them and continue, not allow them to beat us up and leave us unhappy.
Client: (Shakes his head to say yes.)
|Therapist: Are we going to try to be positive today?
Therapist: Would you like to call your father.
Client: (smiles) Yea.
|Therapist: Why are you smiling.
Client: Because I love talking to my dad. He’s the only one that understands me.
|Therapist: What do you think Mrs. Green, should we keep him on precautions?
Intern: Yes, because I want to make sure you’re doing okay because we care about you Client.
Clients: (starts laughing and shakes his head that he understands)
Therapist: I agree.
|I believe that he is a good kid. From our conversation, he is unsure of his future, but wants to do great things. He just needs a little push.|
Kirst-Ashman, K. K., & Hull, G. H., Jr. (2015). Understanding generalist practice (6th ed.). Stamford, CT: Cengage Learning
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