PRESENTING ISSUE
41-year-old white male presents in the office on referral from his pastor. Patients relays that he has been "living a bad life" and has decided he wants to change. "I want to straighten out and have a good life. God has a plan for me and I want to change."
NOTES
Patient has just moved to the area about four months ago to be near his children, an 11-year-old son and a 9-year-old daughter who currently live with their mother. He says that he has a CPO (civil protection order) from his children and ex-wife due to "drinking on Labor Day last year." He has a High School diploma and graduated from trade school but cannot get licensed due to having committed a violent crime. "I had a knife and had a fight with a guy and now I have a felony. I also have drunk and disorderly charges as well as domestic violence charges. My alcoholism has cost me jobs and relationships." He attends a conservative Christian group to discuss his drinking and also attends Alcoholics Anonymous. He does not have a sponsor in the local AA community.
HEALTH HISTORY
Patient states he has had alcoholism for 25+ years. He also has a history of drug usage: marijuana, speed, downers, cocaine, hash, etc. He denies the use of all mood altering chemicals except alcohol for the last 10 years. He has been hospitalized for alcohol poisoning. He takes medication for hypertension. His sleep and appetite are mildly disrupted.
PREVIOUS COUNSELING
Patient has had episodic outpatient and inpatient treatment for alcoholism. He has been receiving outpatient counseling at the local mental health center. No psychiatric inpatient admissions are noted.
MENTAL STATUS EXAMINATION
Affect: Depressed
Appearance: appropriate to age, season, occupation
Mood: Dysphoric
Psychomotor activity is calm
No apparent psychotic phenomena
No noticeable body odor
Denies suicidal/homicidal/violent ideation and intent
Appears to be of average intelligence Judgement and insight appears to be adequate
Speech: Fluid, no idiosyncratic features noted
Sleep: Occasional insomnia, sometime drinks to get to sleep
Appetite: No recent weight change, eats mostly fast food
INITIAL DIAGNOSES
312.89 Alcohol use disorder, severe (by patient report)
301.7 Antisocial personality disorder
780.52 Insomnia disorder, occasional
V61.10 Relationship distress with ex-spouse
300.4 Persistent Depressive disorder (rule out)
TREATMENT PLAN
Encourage patient to get a local AA sponsor
Encourage abstinence from alcohol, consult a physician to see if detox is needed
Reinforce to patient the results of a CPO
Teach relaxation skills for bedtime, set a bedtime schedule
Explore if patient's possible depression is related to drinking (alcohol is a depressant)
Encourage continued spiritual growth
COURSE OF TREATMENT (approx 3 sessions)
The patient did get a local AA sponsor and signed a release of information for me to work in conjunction with the sponsor
Patient was reluctant to follow the CPO but said he would comply
His physician placed him on an SSRI to treat his depression
No change in insomnia but did stop drinking to help him sleep, set a sleep schedule
Continued to see his pastor in counseling and signed a release of information for me to work in conjunction with the pastor
Treatment came to an abrupt end when he showed up drunk at his ex-wife's house. She activated the CPO and patient was eventually placed in a long-term detention facility. I would have liked to have continued to work with him as he did seem to show some short-term progress.
CONCLUDING THOUGHTS
This patient moved to the area to be near his ex-wife, who I discovered was in hiding from him. He had located her and was observing his children from a distance. In a drunken and depressive state, he became angry when his ex-wife rebuffed his attempts to connect with his children.
I'm frequently skeptical about people who seemingly attempt to use a church/pastor/AA to demonstrate that they are wanting to change or have changed. Unfortunately, in the minds of these individuals, they believe that a change of a few months somehow erases the years of damage done to a family and then get upset when their family doesn't see how they have changed. In these instances, such individuals are changing so that they can get back in a good relationship with others; hence, they need to see that change is necessary for their own well-being regardless if people in their previous relationships never allow reentry.
This pastor was a good referral source and was deeply concerned about this patient's life and attempted to help him but would not allow himself to be used as a pawn to help the patient connect with his family. He was my informant for what happened to the patient as from my perspective the patient just abruptly ended treatment. It's good to stay in contact with the referral source if the patient has signed a release of information.