Case Presentation #1

Summary of Presenting Problem

Patient was brought into the Emergency Department by police under ECO(emergency custody

order) and referred to us for Suicidal ideation. Patient was initially a COVID+ psych patient. He

eventually stabilized on Celexa. When I first entered the room, patient was on a 24-hour watch care.

Patient was euphoric and agreed with enthusiasm when asked if he wanted to have a session with me.

Brief Psychosocial History

Patient is a 23-year-old single African American male who has one sibling (a sister) who lives

independently. Patient lives at home with his mother and step-father. Patient notes he does not get

along with step-father as they do not see “eye to eye” most of the time.

According to the patient, he was under a lot of stress physically, emotionally, and financially. His

mother has some medical problems, and he is worried about his mother's medication and health. He

works for a landscaping company but states he does not make enough money to pay bills and make a

living for himself. Patient stated he felt overwhelmed, became angry, and started throwing things in his

room. His mother called 911, and he told the police officer that "he did not want to live anymore" and

had a firearm on him in the car when the police arrived. He denies homicidal ideation. He denies any

actual attempt to hurt himself. Patient stated that he had the same problem in 2019. Patient was seen in

the emergency department for suicidal ideation on social media, making statements. He then was sent

to a "home" for three days, where he had to talk to a judge before going home. Patient denies any other

symptoms or concerns. He denies tobacco or alcohol use but says he does smoke marijuana. Patient

stated he had never been to therapy before, but he was open and desired to do so.
Relevant Mental Health Information

 Orientation: Pt was oriented to time, place, situation, and person.

 Appearance: Pt appeared neat for the setting.

 Speech: within normal limits but, tone was soft at times

 Psychomotor Abnormalities: within normal limits

 Substance Use: No mention of substance use but states he smoke marijuana

 SI/HI: denied any SH and SI

 Hallucinations: No mention of hallucinations

Intervention Plan and Goals for Client

I used a person centered approach with emotional support and active listening, coping

strategies, and conducted a safety plan. Goals were to help patient recognized and implement coping

skills when faced with life difficult challenges.   

Course of Presented Session

The session was focused on listening to the patient's concerns and feelings. Most of the

concerns were aspects of bettering himself and trying to navigate through his emotions once he gets

overwhelmed. I focused on the client "here and the now" to help with the anxiety of everything that has

taken place and what things would look like post-hospitalization. I.e. (safety plan)

Theory and Skills

I used a person-centered approach and active listening. I used the basic skills, genuineness and

congruence, empathetic understanding, coping skills, and unconditional positive regard. I also included

some role-playing when faced with suicidal ideation thoughts.

Challenge Areas

The biggest challenge I had with this patient was trying to decide on what would be the right

intervention/skills for him at that moment. While he denied having SI, I knew that was something I

wanted to address, and I tried to do it in a way that would allow the patient to be open and honest.