18-year-old white male is interviewed at the school at the request of the principal. Patient states that he has "temper problems. I get angry and black out. I usually don't remember much of what I do when I get angry. I can be completely calm and then flip out. I think I am bipolar." He is referred by the principal for poor school attendance.
NOTES
Patient was born and raised in the southern part of the United States, he is now living in the rural midwest for four years. His parents were divorced five years ago. He lived with his mother for a year but "we fought a lot. So, I moved here to live with dad. I liked living with mom because there was so much more to do there." Out of these current nine weeks, he has only been present for five days. "There is nothing I like about school and I only have one friend." He does have a girlfriend of 6 months who attends the opportunity school. He continues, "I can't stand this school, I want to go to the opportunity school."
Patient enjoys writing his own music, mostly rap. "No one around here seems to like the music I write or listen to."
Patient does not acknowledge a personal or family history of psychiatric concerns, outside of his belief that he is "bipolar." He denies any previous counseling history.
HEALTH
Patient states he is in good physical shape. He does not take any medication. He says that averages two to three hours of sleep a night, usually not retiring until about 3:00 am. "I toss and turn a lot in my sleep. I sleep better during the day." Patients says he "doesn't drink much alcohol" and denies the use of other drugs. He believes his father is an alcoholic. He acknowledges that he does cut himself to relieve stress (self-injurious behavior, SIB)
MENTAL STATUS EXAMINATION
Affect: Depressed
Appearance: Neat and clean, age appropriate
Mood: Irritable
Activity: Slowed
No apparent psychotic phenomena
No noticeable body odor
Denies suicidal/homicidal ideation and intent, SIB noted
Appears to be of average intelligence
Judgement and insight appears to be adequate
Speech: Fluid, no idiosyncratic features noted
Sleep: Reversed, prefers day sleeping
INITIAL DIAGNOSES
309.0 Adjustment disorder with depressed mood
305.00 Alcohol use disorder, mild
307.45 Circadian Rhythm Sleep-Wake Disorder, Unspecified type, persistent
TREATMENT PLAN
Understand angry outbursts
Decrease self-injurious behavior (SIB)
Improve school attendance
Improve sleep pattern
COURSE OF TREATMENT (4 sessions)
Client brought in some music that he had written and performed some of the raps in the session (he seemed to enjoy doing this in the sessions)
Discussed how thoughts chain on each other, to help him understand his anger (he no longer thought he was "bipolar" but rather seemed to understand at a rudimentary level that he could choose his reactions to his feelings/thoughts)
He made appointments with the school nurse to check on his SIB and also to see if he needed to see a physician for his depression (which he denied)
Made goal of attending school a minimum of 3 times a week (he did not do)
Chronotherapy - helped him to adjust his sleeping schedule to one that was more reasonable (he made some progress in this area)
DISCHARGE DIAGNOSES
309.0 Adjustment disorder with depressed mood
305.00 Alcohol use disorder, mild,
307.45 Circadian Rhythm Sleep-Wake Disorder, Unspecified type, episodic
POSTSCRIPT
This is an example of how, sometimes in counseling, the patient doesn't make the gains that you hope. The school principal pulled the plug after four sessions, having the client face truancy charges and the court then intervened. The student was sent to the opportunity school (which is what the student stated he wanted). Once, he was enrolled in the opportunity school, his attendance was mandated by the Judge and enforced by an officer of the court who drove him to school every morning and he graduated. The Judge also ordered him to get a physical to check out possible physical reasons for his depression and also his SIB. At that point, my involvement with him ceased. My hope is through his interactions with me in the counseling sessions, that he experienced enough positivity so when he decided he wanted to change his behavior further, he would seek me or another counselor out. ADDITIONAL THOUGHTS
Consistent with Adlerian theory, whenever a patient expresses interest in singing, music, poetry, song writing, writing stories, journaling, photography, etc, have the patient bring such to the session. That is where there emotions are residing and we want to tap into that.
It seemed that I made a connection with this patient over his song writing. We had our appointments at the school and the four days we had appointments, he attended school. He didn't miss/reschedule our four appointments...and...I intentionally made the appointments in the morning during his first period.