CLIENT NOTES & FORMULATION

Part A: Client notes

Client name:: ALI DALE And PETER WRIGHT

Presenting problem/s:

Presenting Problem of ALI DALE

The patient is having issues with her concentration power. She is not able to perform her assignments due to a lack of concentration. For the last 6 months, she has been feeling stupid including concentrating on anything. She has called herself “stupid” again and again while describing her issues as she is not able to perform even simple tasks anymore. The patient is having anxiety issues. The patient had a feeling that her heart could go out of her chest due to the nervousness. She couldn’t breathe properly due to the symptoms. She has a feeling that everything is closing around her at this point. Patients also had a feeling of Clummy hands.

Presenting Problem of PETER WRIGHT

He has a problem with excessive drinking issues and still, he is in denial mode that he does not think he is drinking excessively. He had an accident 7 months ago and due to his habit of excessive drinking, the medication is not working properly. Peter has pain in his arms and that arm is not functional anymore. He is currently facing anger issues as well that are destroying his relationship with his wife.

History of problems:

Ali Dale has no history of problems and she was completely fine before a sensitive personal event happened to her 6 months ago. On the other hand, Peter Wright has always been a drinker even before his accident happened 7 months ago.

Relevant personal and family history:

Ali Dale is a working professional who keeps herself busy to avoid her mental state issues. She did not have any history of mental health issues before that incident. Peter Wright was a miner and he used to mine regularly. Peter always used to drink after his working hours buyer ever since he had faced that accident he had started drinking even more to reduce his pain. Peter has a wife who is concerned about his condition now and her name is Joan. He has to stay at home now after his accident and his wife works and earns for themselves and somehow that is hurting his male sentiments.

Social and occupational factors:

Ali is a busy working lady who has to deal with several assignments and other factors of her work. On the other hand, Peter is a miner who has to mine to earn money for his livelihood. Ali used to drink occasionally and date people which caused her this anxiety issue after the night of her dating an unknown person. On the other hand, Peter’s accident has escalated his drinking ritual even more than before.

Client goals for counselling:

Ali wants to solve her anxiety attack issue by using this counselling program. Peter wants to solve his excessive drinking problem under the pressure of his doctor and wife.

Other details:

Ali is feeling stupid lately as she is not able to perform even the simplest works. She wants to get rid of this condition as soon as possible. She also wants to get rid of using the substances that she has taken to increase her speed. On the other hand, Peter is still dilutional about his severe drinking issues condition which is affecting his relationship with his wife. He has a fear that probably his wife will leave him as they cannot communicate with each other anymore.

Summary/Outcome of session:

This session has helped analyse the conditions of two different patients where the lady is suffering from anxiety issues and substance abuse issues. On the other hand, the gentleman is having issues with anger issue and excessive drinking issues,

Part B: MSE

Appearance

Mental status examiners can take note of their client’s appearance which is General. In this case, observations are generally limited at a primary level to observe the physical characteristics but demographic information can also be included sometimes. Physical characteristics commonly noted on the Mace include personal grooming people dilation contraction facial Express height weight and different body signs. In this session as well, the body signs and behavioural patterns of the clients have been noted down for further study.

Clients’ age, sex, gender, ethnic background and even working background have been noted during MSc to characterise and understand the core region for the mental health issues as well as to plan a proper treatment planning. That has also been done during this interview session for both the concerned patients.

 Behaviour/Psychomotor Activity

Mental status examiners notice the physical movements, odd and repetitive gestures, organic brain conditions and drug-induced stupor.  Clients who have paranoid symptoms can able to scan their visual field to get a barrier against external threats. During the interview, the same things were noticed for both Ali and Peter as they had shown several behavioural activities due to their dependence on speeding substances and alcohol respectively.

Attitude toward interviewer

The attitude toward the interview can be described as a settled way of thinking about a patient or a thing and is usually evident through subtle behaviour. This range of attitudes of clients towards their interviews can provide a sense of complex cognitive interpersonal components and effective features of an attitude physical characteristics can be the foundation of client attitude but the behaviour towards their examiner or interviewer can be examined in a detailed manner to understand their core problems. Here, as well it can be seen that Ali was uncomfortable while sharing her root cause of issues and was not at all delusional about her problems. On the other hand, Peter was a lot dilutional about his drinking issues and showed a little bit of an aggressive nature.

Affect and mood

The effect can be described in terms of content or type range and duration. Mood can be written in different ways for different clients as clients can show various kinds of expression during the interview or MSE process which can be an expression of their internal issues and mental state of the current time.

Speech and thought

The overall speech and thoughts of every patient are noticed during the MSE process to understand their mental state at the current state and their behavioural patterns.

perceptual disturbances

Perceptual disturbance can involve several difficulties in the perception and interpretation of sensory inputs. It is important to understand the nature of clients’ perceptual disturbances to help them establish a diagnosis so then examiners can help them to solve these issues This perceptual disturbance can be hallucination illusions and flashbacks. Even for this provided interview, these disturbances were identified for both the patients.

 Orientation and consciousness

Mental status examiners routinely examine whether the clients are oriented to other people, places or situations. This can include several questions based on their daily routine their name the name of the date and the situation around them. this helps the examiners to understand the condition of the mental state of the patients

Memory and intelligence

During the examination session, the memory and intelligence of the patients have been checked by asking several questions about their family profession and past life to understand their memory retention power even during such stage of Mental Health conditions. This was done during the interview as well.

Reliability, judgement, and insight

Examiners check the judgemental power of the patients by asking them for several insights into their cells and their surrounding situation to understand their condition and reliability factors.

Part C: Formulation of 5Ps and biopsychosocial factors

There are 5Ps and Biopsychosocial factors present in such cases and those factors are:

Predisposing factor: Here the attachment style personality traits isolation insecurities different fares and abdomen since childhood have been observed. Incidents like domestic violence poverty and other social issues have been addressed here.

Presenting problem: According to Salimy et al. (2023), different questions have been asked to the patients to address their history along with the root cause of current mental state issues of the patients.

Precipitating factor: Here, loss of recent time, fears have been noticed. Loss of significant relationships and loss of home has been noticed as well.

Perpetuating Factor: Personality traits, coping mechanisms, and self-belief have been noticed. The role of different stigmas in accessing treatment is also noticed here.

Protective Factor: According to Patel et al. (2023), issues like cognitive behaviour strategies and coping skills for psychologically minded people are addressed here. Community family faith and support and GP support are also part of this.

Part D: Intervention Plan

Intervention Plan for ALI DALE

Client issue/s	Client goals	Intervention	Rationale for intervention
1. Anxiety issue	To solve anxiety issue-related symptoms.	A relaxation technique can be used here.	The relaxation technique involves several steps that help to calm down the disabled mind of the patient and can help her to calm herself down.
2. Nervousness	To solve her issues related to nervousness.	Breathing technique can be used here.	Breathing exercises can be extremely helpful whenever the patients feel nervous while working. She can take deep breaths to calm her down.
3. Concentration power	To complete her regular assignments properly	Meditation can be helpful here.	Meditation helps to calm a person’s mind and increase concentration power (Varambally & Gangadhar, 2020)

Table 1: Intervention Plan for ALI DALE

Intervention Plan for PETER WRIGHT

Client issue/s	Client goals	Intervention	Rationale for intervention
1. Excessive drinking issues	To stop drinking	Being productive and engaging with personal hobbies	Engagement with personal hobbies can help the client to reduce and stop their drinking problem.
2. Anger issues	To control his anger about small things.	Meditation daily	A daily routine of meditation can help the client to become more self-aware and control their anger issues (Gorman et al. 2021)
3. Issues in communication	To be able to communicate with people, especially his wife.	Social inclusion	Social inclusion can help the client to enhance their communication skills

Table 2: Intervention Plan for PETER WRIGHT

Reference list

Gorman, J. M., Reist, C., Aamar, R., & Steiner, L. (2021). Anger among Health Care Professionals. Psychiatric Times. Available online: https://www. psychiatric times. com/view/anger-among-health-care-professionals (accessed on 7 April 2022). https://besthealthideas.com/anger-among-health-care-professionals.html

Patel, K., Barter, M. J., Soul, J., Clark, P., Proctor, C. J., Clark, I. M., … & Shanley, D. P. (2023). Systems analysis of miR-199a/b-5p and multiple miR-199a/b-5p targets during chondrogenesis. bioRxiv, 2023-03. doi https://doi.org/10.1101/2023.03.31.535081;

Salimy, S., Lanjanian, H., Abbasi, K., Salimi, M., Najafi, A., Tapak, L., & Masoudi-Nejad, A. (2023). A deep learning-based framework for predicting survival-associated groups in colon cancer by integrating multi-omics and clinical data. Heliyon, 9(7). https://doi.org/10.1016/j.heliyon.2023.e17653

Varambally, S., & Gangadhar, B. N. (2020). Yoga and Traditional Healing Methods in Mental Health. Mental Health and Illness in the Rural World, 297-326. https://link.springer.com/referenceworkentry/10.1007/978-981-10-2345-3_20