Read the below scenario and imagine you are having THREE sessions with the client below. Write the case notes for each session that you have with the client one in each format PIE, DAP, and SOAP.
PIE notes, which means the note will cover section that include (Problem), (Intervention), and (Effectiveness or Evaluation).
DAP is an acronym for Data, Assessment, and Plan. It is a simple and comprehensive template to help organize your notes. It is important to recognize that a DAP note is a progress note, not a personal psychotherapy note.
The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient’s chart, along with other common formats, such as the admission note
Jack or Jackie?
Jack is a 15-year-old white male. He is a freshman at the local high school. He doesn’t normally get into any trouble at the high school. He plays the guitar. He used to be in the band, and he used to sing choir when he was in grade school, but when he left middle school he left all school activities behind. He has been referred to you because he was suspended from school for possession of pot and smoking pot in a car on the parking lot school. When you meet him, his mother brings him. She reports that she and her husband have been married for 20 years. They have Jack, and they have Jack’s older brother named David. David is 19 and attending school at a community college learning how to be a mechanic. Jack has no plans on going to college at this point. Mom is a school teacher. She teaches English as a second language at one of the local public school districts different from the one she lives in and that Jack goes to, and her husband is an auto mechanic working in someone else’s garage but is trying to save up enough money to start his own garage. There have been no problems at home before this, there have been no problems at school before this, and mom just thinks that Jack has just had common experimental issues with pot. In talking with Jack, you recognize that he has been smoking pot since he was 12, he’s been drinking alcohol since he was 11.
When his mother was teaching summer school, and his dad was working, he and his friends would go in the backyard, and they would go into the woods behind the house, and they would get drunk and get high ever since the middle of sixth grade. Jack has been using a lot more than mom believes she has been, but Jack reports that he is very unhappy with his life. So as you start to talk to Jack about his drug and alcohol use, you try to contract with him for decrease use and definitely no use at school and no possession of alcohol or pot at school. He’s agreed to do this as he and his friends have already made a plan for where they can high marijuana and alcohol and how they can get high before going to school. This was a good plan for Jack, because they started to bring in dogs snooping in lockers and one of the places they were checking regularly was Jack’s locker.
Over the months that you’re seeing Jack, you realize that he’s somewhat defiant and rather angry. He has a problem with authority, and he is not concerned about any of the consequences that he may receive over the behaviors at school. He would like to disregard them, but his mother, as a school teacher wants him to abide by them and not cause any problems in school. Jack does not talk much to his father or his brother, and at some point while very drunk on a Friday night, Jack calls his mother and asked to get picked up. That was an ongoing agreement they had that she would ask no questions, and she would come pick him up no matter where he was and what he was doing if he called, and he needed a ride. Mom picked him up from the party where Jack was drunk, he was so compulsively sobbing about the fact that he didn’t fit in his body.
He didn’t feel comfortable with his body, and he really thought that he should have been born a girl. Jack’s mother was upset, didn’t know really how to help him, talked to his father about it; his father wanted nothing to do with it. His father believed that if he were supposed to be born a girl, he would have been born a girl, and this was very early on in transgendered world in the mid-1990s. There were a few hospitals, one being John Hopkins in Maryland, that were doing the successful transgender surgeries and they have requirements that Jack sees somebody and talks about his desire to be a female. He wanted to already call himself Jackie, and he also wanted to wear female clothes to school. His school was uncooperative with these issues, and you were out of your area of expertise as a social worker.
So the NASW code of ethics says that you need to refer out when you do not have knowledge of the topic, a practice that is sound advice for your client’s benefit as well as your own. So you found somebody in the geographical region who does specialize in helping kids transition and transgender issues. Mom asks you to stay on and talk with her through the issues and helping dad understand what’s going on. Fast forward, four years later, mom shows up again and asks to speak with you. She took Jack through the preliminary stages which were getting him hormones, getting him female clothes, getting him ready to talk to a new therapist. He dropped out of school and maintained a full time job waiting tables in a restaurant. While he was working, he did try to see some of his old friends. They were giving a hard time, and it he didn’t feel like he fitted in. Jack started talking to a girl online who lived in Florida. He announced that he was bisexual. He was going to date this girl, and he goes to Florida to meet her. While in Florida, he decides to get married to her and stay down there. So now, 19-year-old Jack is now married and has a wife in the state of Florida and mom is at a loss as to how to help him. She still feels like his transgender issue is not the only issue, and neither was substance abuse. She thought he had ADHD and a learning disability, but Jack refused to get tested by anybody while he was in high school. Jack is calling weekly asking mom for money. He reports that his girlfriend is pregnant, and mom is quite surprised because he’d been taking hormones that would have him be impotent and so she was stunned that this happened, but in further research, although Jack was filling his prescriptions, he wasn’t always using them.
Mom is at a loss for what to do. She’s worried about the baby, she’s worried about the girlfriend, she’s concerned about Jack, but she also doesn’t want him to return home. While he was living at home and dressing and acting female, it put much strain on her relationship with her husband because she was trying to support Jack when Jack’s father was not willing to support Jackie. His brother also was not willing to support and recognize that he has a sister now instead of a brother.
So your question here is, how do you support mom to get her to be able to keep relationship with her son, keep him at bay in terms of distance, but also get along with the family? Side stressor is that mom’s having a hard time at work. They keep changing the English as a second language laws, and she has more and more responsibilities, more and more students, and not as much help. She is really not liking the school district that she’s in, and she’s trying to figure out how she can leave, but she really needs the excellent pension plan that’s offered if she stays in that school district. Mom is struggling with a couple issues now, but the main point that we want to look at here is how do you support mom in supporting her adult child in Florida, both financially, emotionally, and socially?