Process Recording
Tolulope I. Moses
Master of Social Work, Walden University
SOCW 6311
Dr. Ashley Nazon
April 20, 2022
1). Description of Client(s): The client lives with her mother, stepfather, and 16-year-old sister.
2). Presenting Problem: The client, a young adult, is a junior at Madison High School. Currently, the client is in 9th grade and attends virtual class three times a day. The patient has been diagnosed with a dissociative personality disorder. The patient has also tested positive for teen pregnancy. Family history shows that her mother has bipolar disorder, which increases her unborn child’s risk. She has exhibited signs related to that indicated extremity regarding behavior, citing the need for early intervention.
3). Purpose of Session (why is the client being seen). The purpose of the session was to establish the nature of the client’s health status considering the demanding health factors at her age. Being a teenager and showcasing signs of dissociative personality disorder, it is important to closely monitor the client’s health status and provide the best care for her and the unborn child.
4). Objectives/Goals of this session: To ascertain the provision of comprehensive and holistic care to the client and improve the client’s overall health.
5. After spending time with the client’s nurse, I took part in the session as it commenced with a casual introduction.
Dialogue/Content
Skills/Theory/Conceptual Framework Used Assessment of Patient/Client
(Dialogue Analysis) Student’s impressions, feelings, and reactions to the client’s interview
The clinician commenced with the usual introduction to the client. The clinician inquired from the client if she was okay with me taking part in the session. Engagement and Empowerment Frist, formally asking for the client’s consent before commencing the session was important to assure her of the confidentiality. Second, it is important to empower the client and provide guidance which is vital in social work. The nurse played a crucial role by allowing me to participate in the session through the formal introduction and ensuring the client was willing to share her feelings in my presence.
The clinician started by asking if the client participated in extracurricular activities which she responded with a ‘no’ response. The client further states that she has performed exceptionally well in her academics with straight ‘As’ and ‘Bs.’ Open-ended questions communication strategy (Kim et al., 2019). Asking the client whether she participates in extracurricular activities sets the direction of the conversation, making her open up about things she loves. For instance, her academic performance. This allows me to know more about the client and her prowess in her studies.
Active communication is essential in getting information from the client. The clinician enquired further from the client whether she was aware of BC, which said she does not but knows about condoms. Communication Approach: Active Listening At this point, the client can freely disclose personal information regarding her sex life. And although she aspires to become a mortician, she keeps abreast with changes in other areas, especially things that affect teens. An active listening approach is ideal for understanding the client’s perception, especially through nonverbal cues.
As the clinician engages the client and educates her about the BC shot, the client shows interest and states that she would like to get the shot. Further exploration of the Client’s feelings Focusing on the positive things that the client associates with is essential in boosting her morale. Reflecting on the client’s experiences, I realized that she is an above-average student with plans for her future. She mentions that she would like to complete school and get a job and an apartment to take care of the newborn.
Considering the overwhelming symptoms of mental health and family history of ADHD, it is important to set goals in the session to help the client overcome these problems b provide needed care and support. Setting Goals and Self-Motivation Encouraging the client to continue her studies and pursue her career is a great point to boost her self-esteem. I agree with the clinician to continue monitoring the client’s condition and recommend the best care and support for her as she deals with her health condition and pregnancy.
Summary Assessment/Analysis of the Session
A. Identify the stage of work with the client/client system (i.e., pre-engagement, engagement, assessment, intervention, Assessment). Why?
Intervention; at this point, the client needs medication and behavioral therapy to help her cope with pressures associated with teen pregnancy and ADHD (Faraone & Larsson, 2019).
B. What did you learn from the session that adds to your understanding of the client?
I learned that despite the client being young, she is ambitious and looks forward to taking control of her life.
C. What were the major themes of the session?
The clinician educates the client on teen pregnancy and dissociative personality disorder. The client needs to understand the risks of engaging in teen sex as it can disorient the direction of her life.
D. What were the challenges presented during the session?
The client does not confide in her mother as she thinks her mother told doctors she likes to play dress up and act like different people. This further complicates her situation since she has a small circle of people close to her.
E. What was accomplished during the session?
The clinician empowered the client by educating her on teen pregnancy and dissociative personality disorder and encouraging her to pursue her career dreams.
F. What concepts or theories, or interventions did you apply? And what were the results–what worked and didn’t give the socio-cultural context of the client’s presenting problem(s) and underlying issues?
I employed strength and empowerment theories to aid the client in overcoming low self-esteem. The strength theories are effective in counseling the client by leveraging positive things accomplished or looking forward towards (Kirst-Ashman & Hull., 2019).
G. A summary of the student’s impression
The clinician was direct in her approach and employed practical skills and tools to communicate, counsel, motivate and inspire the client.
H. Questions for Supervision
The parent’s relationship lacks; thus, the client does not have the necessary family support. How frequently should the client’s ADHD be monitored? Should the client continue with her studies or take some time off to care for the newborn? Should the client consider other maternal options to take care of her unborn child?
Future Plans
The client should be scheduled for regular checkups regarding her pregnancy and psychotherapy sessions for the next month to establish her she is coping and provide any other needed care and support.
References
Faraone, S. V., & Larsson, H. (2019). Genetics of attention deficit hyperactivity disorder. Molecular psychiatry, 24(4), 562-575. https://www.nejm.org/doi/full/10.1056/NEJMra1917069
Kim, S., Krishna, A., & Dhanesh, G. (2019). Economics or ethics? Exploring the role of CSR expectations in explaining consumers’ perceptions, motivations, and dynamic communication behaviors about corporate misconduct. Public Relations Review, 45(1), 76-87 http://creativecommons.org/licenses/by‐nc‐nd/4.0/
Kirst-Ashman, K. K., & Hull, G. H., Jr. (2019). Understanding Generalist Practice (8th ed.). Cengage Learning.
