How to write a SOAP note as the psychologist  in the video Suicide assessment of Client with initially Subtle Warning Signs of Suicide by Dr Todd Grande

How to write a SOAP note as the psychologist  in the video Suicide assessment of Client with initially Subtle Warning Signs of Suicide by Dr Todd Grande

SOAP Note

Subjective

Subjective data are the information from the patient’s viewpoint. The patient has a drinking problem evident from what she says. She verbalized various signs and symptoms in their life. She has a drinking problem. She reports that she has been drinking a lot and cannot count how much alcohol she takes. She reports keeping a bottle of alcohol by the bedside to take it to assist her in functioning when she wakes up. The patient says that “I drink as much as it takes me to function.” She reports that she currently has more time, and what she does all day is drink. She indicates that drinking helps her to come up with her current distressing situation. She also reports that she drinks so much because she has nothing to lose, and nothing matters anymore. The patient also reports that she is seeing the therapist because her drinking has gotten worse, and she did not want her life to become any worse than it is.

The patient reports various changes in her life that have contributed to her current status. The patient reports that currently, she has lost her job. Due to that, she says that she cannot pay her bill and that she is about to lose their job. When the patient is asked about what she is planning after she loses her job, she reports that “I have no plans about what will happen to me when I lose my job” she also feels that things have taken a turn and that her situation is irredeemable.

The client is suicidal. She reports that she has a plan laid out to commit suicide.  She reports that things are getting so bad that she would not cope even if she were sober.  She reports that she currently has many things to take care of and that if she dies, there wouldn’t be anything to worry about. Additionally, she does not care about a family member missing her after she dies.  She feels that nothing is left to lose. She feels that she has no way out of her situation as her life is ruined.

                                                           Objective Data

These are the signs that I observed with my senses. Firstly, the patient is hopeless.  The hopelessness is characterized by a lack of passion, optimism, and hope. The patient has lost so much and probably feels there is no way out of her current situation. Previously the patient was enthusiastic and resilient. She experienced problems in her life, but she could cope with them due to her resiliency. Currently, she does not care about her drinking, losing her job, and current state.

The patient is also suicidal. The patient has various suicidal ideation. She reports already has a plan to commit suicide. Additionally, she feels that nothing is working out for her. The patient is also stressed. The patient’s tone and behavior during the therapy indicate that she is stressed out. It feels like she has reached the worst possible point in her life. The patient also feels ashamed. She did not bring up her suicidal thoughts and behaviors until the therapist asked her. She felt that if she told me her suicidal plan, I would become disappointed in her. The patient is also antisocial. Currently, she is free for long periods. What she can do is wake up, drink and go to the liquor store for more drinks. She has lost her desire to live. She indicates that she does not care about what her family would think or feel after her death.

Assessment

Analysis of the objective and the subjective data indicates that the patient is suffering from various mental disorders. Firstly the patient has depression. This is because she has lost her job, cannot pay her bills, and is about to lose her house. The patient is sad, feeling down, and has lost interest in doing anything. All these are common signs of depression (Friedrich, 2017). The patient is at risk of committing suicide, and the risk is increased as she currently sees death as her only way out. Finally, the patient has alcohol use disorder. She does not even know how much alcohol she drinks. She also reports that alcohol helps her cope with her current situation and cannot cope without taking alcohol.

Plan

I would recommend for the patient to be admitted for inpatient care. The type of therapy I would involve the patient in is interpersonal counseling. The therapy will focus on the patient’s depression, suicidal thoughts, and alcohol use disorder. The therapy will enable her to make sense of and relate what is happening to her and the psychiatric conditions she has.

Warning signs for suicide

The patient has various warning signs of suicide. Firstly the patient is talking about wanting to die or dying. The client says that if she dies, there wouldn’t be anything that would need taking care of, and the suffering will be gone. The patient tells me that she did not want to talk to me about suicide because she feared that I would stop or ruin her plan. The patient does not care about what the family members feel or would say if she dies.

Secondly, the patient talks about feeling hopeless, empty, and having no way out of her problem.  She feels very helpless, and there is no way back for her (Ramchand et al., 2019). Additionally, she indicates that she has nothing to lose. She reports that she has lost so much and does not have even one scrap of dignity. Thirdly the patient has mentioned a feeling of shame. She feels that she has disappointed me and that I am not responsible for her current state. The fourth warning sign is social withdrawal. The patient says she feels lonely and all she does with her life is drinking only. Finally, the patient verbalizes having no reason to live. She feels she has reached the limit.

Interpersonal therapy will enable the patient to rediscover his purpose in life.  The psychotherapeutic approach can be used to improve the functioning of the patient by relieving her current symptoms. The treatment is effective as it will address the current problems the patient is facing (CAMH, 2021). Additionally, it will enable the patient to rediscover other ways of coping with her condition rather than chronic alcohol intake. Effective coping will boost his mental health status.

                                                                  References

The center For Addiction and Mental Health (CAMH) (2021) Interpersonal psychotherapy (IPT). https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/interpersonal-psychotherapy

Ramchand, R., Franklin, E., Thornton, E., Deland, S., & Rouse, J. (2017). Opportunities to intervene? “Warning signs” for suicide in the days before dying. Death Studies, 41(6), 368-375.

Friedrich, M. J. (2017). Depression is the leading cause of disability around the world. Jama, 317(15), 1517-1517.

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