Assignment 2: Practicum – Assessing Client Progress

Treatment Modality Used and Efficacy of Approach

The client in this case is undertaking cognitive behavioral therapy to help manage her anxiety and other mental disturbances. This psychological approach is effective in treating virtually all the mental health disorders and hence presents an appropriate approach for the case (Kaczkurkin & Foa, 2015).

Progress

The client demonstrates significant improvement in managing her anxiety and though patterns. She has been able to identify anxiety triggers, learnt breathing and relaxation techniques and other non-pharmacological interventions. Her depressive and anxiety symptoms have also reduced significantly over the course of treatment.

Modifications

Minimal modifications were done to the treatment plan since the client was cooperative and willing to get better. Having a family therapy can help change the attitude of the family members and the spouse and help them provide social support by understanding her situation (Jadav & Sharma, 2018). Assignment 2: Practicum – Assessing Client Progress

Clinical Impressions

The client’s symptoms included poor performance in academics demonstrated by her failure in the nursing class. She presents moderately dysphoric mood, lack of attention and concentration, negative thoughts, low self-esteem associated with her past failures, decreased interest in activities, feelings of unimportance, poor energy and severe impaired in concentration and psychomotor retardation (Gazzillo, Dimaggio & Curtis, 2019). She has increased worry and muscle tension.

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Psychosocial Information

The client is a nursing student and unemployed. She is not married but dating a spouse who does not approve of her studies. She lives with her family that does not provide any social support and feels that she should have chosen a different major. None of the family members has been to college.

Safety Issues

The safety issues associated with the client’s condition include the risks of self-harm and suicidal thoughts associated with depression (Bruns & Letcher, 2018). In addition, she could become a drug addict since she drinks socially during the weekends which can aggravate her mental and physiological condition.
Clinical Emergencies

            There are no clinical emergencies associated with the patient’s condition.

Medications

The client is under no prescribed or unprescribed medications.

Treatment compliance

The patient adheres to the treatment plan as required. She is determined to seek counselling and engage in cognitive behavioral therapy to promote her recovery. She has taken measure to recognize her stressors and dysfunctional thoughts, record them and device a healthier thought pattern and put them into practice by week three of CBT.

Clinical Consultations

Clinical consultations were conducted through phone calls, emails and messages. The client also visited the clinic for follow up appointments with the psychiatrist.
Collaboration with other Professionals

Treatment involved collaboration between the psychiatrist, physical therapist, physician and the family therapist. This helped monitor the progress of the client, device appropriate CBT activities and involve the family in the treatment plan (Tzur Bitan & Lazar, 2019). Assignment 2: Practicum – Assessing Client Progress

Therapist’s Recommendations

The therapist recommendations include compliance and consistency with the CBT and maintenance of positive thought processes. The client was in agreement with the recommendations.

Referrals

No referrals were made. The client was very responsive to the treatment plan.

Termination/issues

The client termination was unscheduled. Following her positive recovery within a short time, she decided to end the session due to the financial constrains associated with her lack of job and insurance cover that would cover her continued attendance.

Informed Consent, Child Abuse and Therapists Exercise of Clinical Judgment

The client consented to her treatment plan. The practitioner provided information regarding her condition, the treatment plan and the expected consequences. This supported informed consent as required by the psychiatrist nursing guidelines.

Abuse

            The client has not experienced any form of child or elder abuse.

Therapist’s exercise of clinical judgment

The clinical judgment was conducted based on the objective and subjective information obtained from the client. As such, the clinical judgment involved informed and collaborative decision making between the client and the therapist.

Part 2: Privileged Note

A privilege notes was utilized in documenting and analyzing the therapeutic session conversations. It provided the basic information outline concerning what was addressed during the session. In this case, the items excluded from the note include the initialization and completion of the session, the treatment frequency and modalities, the patient’s clinical test results, diagnostic and prescription medication summary and monitoring. In addition, the treatment plans and status of functioning, symptoms, prognosis and summary of the progress note are not included. Assignment 2: Practicum – Assessing Client Progress

The reason for exclusion of the above items was to prevent turning the privilege note into a progress note. Typically, the privilege note should contain the items left out from  the progress note and they provide more details regarding the patient’s condition for privacy purposes, the Health Insurance Portability and Accountability Act of 1996 protects this information considering its sensitivity and confidentiality.

The preceptor utilizes privilege noted to document their conversations during the sessions they have with their patients. The preceptor includes the observations made during the therapy session, thoughts and feelings regarding situation of the clients’ psychiatric diagnosis hypothesis and the uniqueness of the patient’s condition. This document assists in the documentation, analysis of the issue and the formulation of effective plans for treating the client. However, the preceptor’s notes do not follow a particular format.

References

Bruns, K. L., & Letcher, A. (2018). Protective Factors as Predictors of Suicide Risk Among Graduate Students. Journal of College Counseling, 21(2), 111–124. https://doi-org.ezp.waldenulibrary.org/10.1002/jocc.12091

Gazzillo, F., Dimaggio, G., & Curtis, J. T. (2019). Case formulation and treatment planning: How to take care of relationship and symptoms together. Journal of Psychotherapy Integration. https://doi-org.ezp.waldenulibrary.org/10.1037/int0000185

Jadav, R., & Sharma, A. (2018). Effectiveness of Non-Pharmacological Management of Anxiety for Patients going for General Anaesthesia-A Literature Review. International Journal of Nursing Education, 10(4), 104–108. https://doi-org.ezp.waldenulibrary.org/10.5958/0974-9357.2018.00113.7

Kaczkurkin, A. N., & Foa, E. B. (2015). Cognitive-behavioral therapy for anxiety disorders: an update on the empirical evidence. Dialogues in clinical neuroscience, 17(3), 337–346.

Tzur Bitan, D., & Lazar, A. (2019). What do people think works in psychotherapy: A qualitative and quantitative assessment of process expectations. Professional Psychology: Research and Practice, 50(4), 272–277. https://doi-org.ezp.waldenulibrary.org/10.1037/pro0000241

Assignment 2: Practicum – Assessing Client Progress