Xanax crisis soap note
Xanax crisis soap note
Instructions:
Xanax-Seeking Client
You are seeing a new client but have completed the majority of the initial interview. As you wrap up, you will move through some psychotherapy utilizing motivational interviewing to collect the remainder of the data.
Motivational interviewing (MI) practitioners are similar to guides; that is, someone who does not choose the destination but offers information about the paths the client might choose. The evoking (immediacy) phase of MI focuses on recognizing and reinforcing change talk and eliciting and strengthening change talk. It utilizes techniques for rolling with resistance. This week, you will be introduced to question-asking techniques that will elicit and clarify change talk using the OARS and DARN-CAT techniques.
Case Study
Because a patient, 36-year-old Hispanic-American male, Kevin, has been showing signs of addiction to Xanax, the primary care provider decides to discontinue the patient’s Xanax prescription and refer for psychotherapy. The patient responds with anger, pleading that he can’t function without the medication.
As you move through the initial assessment, the patient states that he had a back injury on the job. He works for a concrete company and fell into a prepped basement area before the concrete was poured. He had some pain meds during recovery and was given Xanax for increased anxiety. He states he enjoys his job very much and that he cannot lose it as he is the sole provider for his family.
He lives with his wife and twin boys, age eight. He stresses again that he works hard for his family and can’t afford to miss work due to anxiety so he needs the Xanax to function. He denies any substance abuse or past medical history other than the back injury eight months prior. He has no legal history and no military history. His extended family lives near, and he reports a pleasant childhood with continued support even still.
Vitals:
BP 138/90
HR 76
R 20
T 97.2
O2 99%
Pain 5 on 0–10 scale (back pain)
