Teller of stories

It's been a while since I've last posted...a long while. It's not as if I haven't been writing - to the contrary, actually. My whole existence these days is based on writing. I am an assessor. When a person comes to my agency seeking help I am the one who conducts an interview to determine the person's needs and links her with the appropriate services. There's financial paperwork to complete, releases to sign, and all of that other fun stuff that gives one the impression she is signing her life away; then, there's completing the treatment plan, asking for information ranging from one's childhood through what mental health symptoms/signs of drug abuse one is experiencing, and then scheduling appointments to meet with the psychiatrist, case manager, and/or substance abuse treatment counselor. It amazes me how people are usually trusting enough to share their most intimate details with someone they have just met. I feel honored at the amount of times people have said to me, "I've never told anyone this before" or "I feel very comfortable with you." It validates my role as a caring professional. It makes me feel good about myself; however, the work can be overwhelming. The easy part is the interview. The difficult part is writing the bio-psycho-social narrative that will accompany that person's chart at this agency and beyond. I am always cognizant that the mental health diagnosis I give a person who has never sought mental health services before will follow her forever.

I have often wondered how I would appear on paper if I was on the other side of the desk and coming to my agency for an assessment. Since I write about other peoples' lives for a living, I thought I'd write one for myself on this blog.
------------
Presenting Problem:
Client is a 34 year-old married bi-racial female who is seeking to engage in mental health services due to a history of depression. She reports that she has been dealing with depression since childhood and has engaged in multiple mental health treatment programs. She expresses her desire to engage in pharmacologic management, behavioral health counseling, and anger management. She states that her goal for this assessment is “to learn to effectively manage my depression in order to lead a happy and productive life.”

Biomedical conditions:
Client reports that she has medical insurance and receives her medical care through University Hospitals and has a primary care physician and a chronic pain management physician. She reports that she has fibromyalgia, an ulcer, and hypoglycemia. She reports that she has had 2 surgical procedures - a dilation and evacuation procedure to remove a polyp in her uterus in 2008 and an excision to remove a 3rd degree chemical burn from her left buttock in 1996 (an aside, I accidentally sat in 6M HCl in O-chem lab as a sophomore in college). She denies ever sustaining head trauma. She denies having any advanced directives. She reports that she is taking the following medications - over-the-counter Prilosec (dosage unknown, qd) for an ulcer; Lyrica (60mg, bid) for fibromyalgia; and Zanaflex (6mg, hs) for fibromyalgia. She reports that she is also taking Loesterin 24 for birth control. She reports that she is allergic to Morphine and Compazine. She describes her appetite as "fair" and her sleep as "good."
 
Recovery Environment:
Client reports that she has been living in her own home with her husband for the past 7 years. She denies having access to firearms.

Client reports that she was born in Akron, OH, and raised in various cities in Ohio and in Belle Plaine, Iowa, by her mother, who is a retired nurse, and her father, who is a retired physician. She reports that the relationship with her mother is strained, and the relationship with her father is "okay - only because I don't get to speak with him often. If I talk with my dad I have to talk with my mom." She reports that she has 2 siblings - a younger sister, who lives in California, and a younger brother, who lives in the area. She states that she has an "excellent" relationship with her siblings. She describes her childhood as “dysfunctional.” She reports that, for the most part, her basic needs were met. She denies having any children. She denies ever serving in the military.

Client reports that she became sexually active at the age of 18. She identifies herself as heterosexual. She reports that when she has engaged in sexual activity, she has sometimes used condoms. She reports currently engaging in a sexual relationship. She reports that she was tested for HIV a year ago, and the results were negative.

Client reports that the highest level of education she has completed was obtaining a Masters degree in social work. She reports that she is currently employed part-time as an assessor at a local mental health/substance abuse treatment agency. She reports that she has income.

Client denies a history of legal involvement.

Client reports that her family, her friends, and God are her support system. She reports that she believes in a Higher Power and identifies herself as Roman Catholic.

Intoxication/Withdrawal:
Client reports that she has used alcohol in her lifetime. She reports that she first drank at the age of 21 and regards herself as a casual drinker. She denies endorsing criteria for abuse or dependence. She reports that she last drank in 10/09. She denies ever engaging in a substance abuse treatment program. She denies ever attending 12-step meetings. She reports a history of gambling, sheepishly admitted to gambling away her Christmas bazaar money by losing at chess in the 4th grade. She reports a familial history of substance abuse that includes her mother and her maternal aunt, who have been addicted to opioids.

Emotional Health:
Client reports a history of mental health treatment that began at the age of 8 when she first engaged in counseling at school for family issues. She reports that she first engaged in pharmacologic management at the age of 12. She reports that she was diagnosed with depression and given "happy pills" as neither her psychiatrist nor her parents informed her the name of the medication. She reports that the medication did not help as it did not improve her mood, and it made her mouth very dry. She reports that she re-engaged in counseling as an undergraduate at Case Western Reserve University and also briefly engaged in counseling 10 years ago when she was living in Dayton, OH. She reports that she has most recently been engaged in counseling for the past 5 years through University Hospitals. She reports that she briefly received pharmacological management services 10 years ago while living in Dayton, OH, and had been taking Effexor XR, Prozac, and Paxil. She reports that the Prozac was helpful but the Paxil gave her nightmares and the Effexor made her very aggressive, stating "I was looking for fights." She reports that she lost her medical insurance and did not resume pharmacologic management services until 5 years ago when she got married and was put on her husband's medical insurance. She reports that she was receiving services at University Hospital; however, her psychiatrist has taken a fellowship and she is in need of obtaining a new psychiatrist. She reports that she is currently taking Wellbutrin XR (450mg qd) and Lamictal (qd) 300mg for depression. She reports that the medications are helping but feels that their efficacy has been steadily decreasing and is not averse to trying something new.

Client denies a history of hospitalizations for mental health reasons. She reports a history of suicidal ideation and 2 past suicide attempts. She reports the first time was when she was 8 years old when she almost stabbed herself in the chest with a butcher knife; however, she reports that one of her paternal aunts caught her before she could harm herself. She reports that shortly before the age of 10 she attempted suicide by overdosing on Valium, but only succeeded in taking 2 pills before stopping, stating "God gave me a sign to stop." She reports the attempt at the age of 10 was the last time she experienced any suicidal ideation. She denies a history of homicidal ideation.

Client reports that she first experienced depression when she was 6 years old. She reports that her mother was constantly ill when she was young, and the pressure of having to take care of her younger siblings, her mother, and herself was too much to handle sometimes. She reports experiencing at least 4 distinct periods of depression that have lasted at least 6 months each. She reports that the last time she experienced depression lasting for 2 weeks or longer was a month ago. She reports endorsing the following criteria for major depressive disorder: sadness; feelings of worthlessness and hopelessness; lack of appetite; excessive sleep; racing thoughts; excessive worry; increased irritability; impaired concentration; and lack of energy. She reports that her longest period of depression lasted almost consistently for 9 years - from 1996, that was triggered by the break-up from her first boyfriend, through 2005, when she re-engaged in mental health treatment. As she did not meet full criteria for major depressive disorder consistently for 9 years but admits to being depressed, she does endorse criteria for dysthymic disorder.

Client denies ever experiencing symptoms indicative of (hypo)mania; therefore, she does not endorse criteria for bipolar disorder. She denies experiencing anxiety or panic disorder. She denies experiencing hallucinations that were not medication-induced. She denies experiencing any delusions. She does experience periods of paranoia in which she feels that catastrophic events will occur and harm her or her family. She reports that she will get upset with her husband for not locking the car doors or back door for fear that someone will open the door and harm them. Although she denies experiencing suicidal ideation, she reports that a year ago she was experiencing terrible thoughts of turning the steering wheel sharply while speeding down I-71 and wondering what would happen.

Client reports experiencing periods of anger that negatively impact her relationship with family and friends, and she is also reports problems with "road rage." She expresses her interest in anger management.
 
Client reports an extensive familial history of mental illness as her sister and father have depression. She expresses her belief that her mother, maternal grandmother, and one of her maternal great-grandmothers may have (had) borderline personality disorder. She reports that her mother has a history of anxiety disorder. She reports that a maternal cousing also suffered from depression and committed suicide 11 years ago.

Client denies a history of physical abuse; however, she reports a history of sexual abuse as she reports that she was repeatedly molested by a neighbor between the ages of 7 and 8 and date-raped by her first boyfriend. She reports that she was also emotionally abused by her first boyfriend. She reports that this behavior continues to affect her today.

Mental Status Evaluation:
Client presented for the assessment appearing well-groomed and displayed euthymic mood with full range of affect. She was alert and oriented x3, and her thought process was tangential. She was able to provide an organized history, and her speech was normal in tone, volume, and content. Her psychomotor activity was within normal limits. Her fund of knowledge was appropriate for her age and education level. No internal stimulation was noticed. She denied any suicidal/homicidal ideation.

DIAGNOSIS
Axis I:   300.04, Dysthymic disorder, full remission; R/O 296.32, Major depressive disorder, recurrent, moderate
Axis II: 799.9, Diagnosis deferred
Axis III: Fibromyalgia; hypoglycemia
Axis IV: none reported by client
Axis V: 70

The rest basically consists of a summary and the treatment recommendations. In my case, I would refer myself for behavioral health counseling, pharmacologic management, and anger management.
 
This exercise has given me a much greater appreciation for the trust bestown upon me by my clients. I don't think I could share so much to a person I just met for an hour. I feel vulnerable sharing all of this; however, I feel that it was also a cathartic experience to see how my life is similar to those I meet everyday. Some are worse off than I am, and others are more well-adjusted - that or they are minimizing their disclosure. It also helps me to see that while I have issues, I have come a long way. I have a good, even wonderful, life. I am sitting in my house with my baby kitty sitting next to me. My best friend and husband are playing Mario Galaxy. U2's "Discotheque" is playing on my iPod. Life is good. :)