Patricia_Dougherty-Gahm_Unit 10_assignment 1

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Capella University *

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5261

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Psychology

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Oct 30, 2023

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SOAP NOTE FORM Client: Alex G. Date: June 11, 2023 Subjective: The client presented in the office to complete an assessment. He spoke to staff about recent DUI charges, current drinking patterns, family history, employment concerns, and family situations. Objective: Alex was anxious when starting the assessment but seemed to relax as the assessment proceeded. His affect was flat, and his speech was quiet at times. He is a poor historian and had difficulty identifying and distinguishing recent substance-use timelines. Alex became emotional when we discussed his relationship with his wife and children. He is unsure if he can deal with life stressors without using substances, he stated: "I am not sure I can quit smoking and drinking without having a panic attack." His appearance was clean and neat.

Assessment: Alex's current stage of change is pre-contemplation. He is unsure if he sees a reason for stopping his everyday substance use. He reports being unable to handle stress and using substances to stop the panic attacks. I observed a level of anxiety when the assessment started that did quell as we proceeded. It is recommended that he attend a detox/ inpatient treatment facility and undergo a psychiatric evaluation to make a determination for treatment of his anxiety and panic attacks. Alex's DSM-V diagnosis: F10.20 - Alcohol Use Disorder - Severe, F12.20 - Cannabis Use Disorder - Moderate. Plan: We discussed making a pros/cons list for entering treatment. Alex wants to speak to his wife about her attending family sessions with him while inpatient. We decided to review an completed his treatment plan during our next session. Therapist: Patricia Dougherty-Gahm, MS Date: 6/11/2023

Client: Alex G Date: 6/14/2023 Subjective: Alex came to my office direct;y from work. He apologized for not having time to change before our appointment. He was a little frazzled and had a hard time calming down. so we completed a quick relaxation technique. He was optimistic about the possibility of inpatient treatment. He was goal-oriented and future-focused. We discussed the next steps and reviewed any questions he may have about how the program works. We reviewed treatment goals. Objective: We discussed Alex's pros/cons list for entering into treatment. His pros: keeping his family together, helping with anxiety and panic attacks, saving money by not buying substances, not feeling sick all the time, and getting his license back. His Cons: being away from his kids, but he pointed out he is not living with them now so it is kind of the same, possibly losing his job. We discussed each of the items on the pros/cons list. He reports that making the pros/cons list helped him look at his life in a future-focused way. Alex reported that he did not drink as much the

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last two nights as before, but still used Marijuana. He reports that making the pros/cons list helped him think about his future. Alex was not able to speak to his wife about attending family sessions while he was inpatient. He reported having a hard time approaching the subject. We used role-playing to figure out the best way to talk about the subject. Assessment: Alex's current stage of change is contemplation. He is considering the inpatient stay which will give him the coping skills needed once back in the community. Alex did not speak to his wife about the possibility of family sessions while inpatient, but since role-playing the conversation he feels more confident. He had several treatment goals in mind and we discussed these and devised a plan. Alex's DSM-V diagnosis: F10.20 - Alcohol Use Disorder - Severe, F12.20 - Cannabis Use Disorder - Moderate. Goal 1: Speak to a psychiatrist about anxiety and panic attack - look at different treatment options. Goal 2: Work on why he uses substances - triggers, and coping skills. Goal 3: Work on his relationship with his family. Plan: Alex will speak to his wife about her attending family sessions with him while inpatient. Alex wants to talk about his upbringing the next time we speak. He would like help with looking closer at his early childhood days and his mom's death.

Therapist: Patricia Dougherty-Gahm Date: 6/14/2023

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