Practicum – Assessing Client Progress Paper

Assignment-2 Practicum – Assessing Client Progress Learning Objectives Students will: • Assess progress for clients receiving psychotherapy • Differentiate progress notes from privileged notes • Analyze preceptor’s use of privileged notes To prepare: • Reflect on the client you selected for the Week 3 Practicum Assignment. (see attachment) • Review articles on guidance on writing case notes using the SOAP format. The Assignment Part 1: Progress Note Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations): • Treatment modality used and efficacy of approach • Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals) • Modification(s) of the treatment plan that were made based on progress/lack of progress • Clinical impressions regarding diagnosis and/or symptoms • Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.) • Safety issues • Clinical emergencies/actions taken • Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them) • Treatment compliance/lack of compliance • Clinical consultations • Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.) • Therapist’s recommendations, including whether the client agreed to the recommendations • Referrals made/reasons for making referrals • Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions) • Issues related to consent and/or informed consent for treatment • Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported • Information reflecting the therapist’s exercise of clinical judgment Note: Be sure to exclude any information that should not be found in a discoverable progress note. Part 2: Privileged Note Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment. • The privileged note should include items that you would not typically include in a note as part of the clinical record. • Explain why the items you included in the privileged note would not be included in the client’s progress note. • Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why. Practicum – Assessing Client Progress Paper.

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Assessing client progress

Part 1: Progress note

• Treatment modality used and efficacy of approach

The client attended psychodynamic psychotherapy sessions for once a week for four weeks as the treatment modality. She appears to maintain the treatment’s therapeutic gains and seems to continue improving over the course of the treatment.

• Progress and/or lack of progress toward the mutually agreed-upon client goals

The treatment plan is intended to address the client’s antisocial personality disorder. Although the client is still antisocial and exhibits disregard for others, she has made progress in acknowledging that she is wholly responsible for her financial situation. She remains irritable and aggressive, but has become more responsible in controlling her expenses and matching her income with her financial responsibilities.

• Modification(s) of the treatment plan that were made based on progress/lack of progress

Although the client has made some progress in taking financial responsibility for herself, she has made minimal progress in addressing her irritability and aggressiveness. As a result, an anger and violence management program has been included into her treatment plan.

• Clinical impressions regarding diagnosis and/or symptoms

The client seems to be a reliable source of information who exhibits sincere commitment to achieving the treatment goals by adhering to the treatment plan. In addition, she exhibits moderate difficulty in social functioning that is compounded by her irritability and aggressiveness.

• Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)

The client got a new roommate to help her with the bills at home. In addition, she changed jobs and got one that is less stressful although she now earns less. However, her financial situation has improved since she has better control over her expenses and her new roommate helps with the bills.

• Safety issues

None

• Clinical emergencies/actions taken

None

• Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)

The client is not on any prescription medication although she reports that she occasionally takes over the counter pain medication.

• Treatment compliance/lack of compliance

The client was ten minutes late for the first treatment session, but was punctual in the following treatment sessions. She is compliant with the treatment plan through following the sessions’ recommendations and actively seeks to achieve the treatment objectives.

• Clinical consultations

None

• Collaboration with other professionals

Collaboration to sign the client up for anger and violence management program to supplement the psychodynamic psychotherapy in addressing the client’s treatment needs.

• Therapist’s recommendations, including whether the client agreed to the recommendations

The recommendation was made that the client should be signed up for an anger and violence management program. The client consented to this recommendation since the present psychodynamic psychotherapy program has failed to address her aggressive and violent tendencies.

• Referrals made/reasons for making referrals

No referrals made

• Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)

The client reported that although she needs the therapy, she is only able to attend the next three sessions owing to her financial situation. She is currently trying to manage her expenses and is earning less from her new hob. Besides that, her medical insurance policy does not cover the sessions.

• Issues related to consent and/or informed consent for treatment

There are no issues with consent since the client voluntarily signed up for the treatment.

• Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported

There was no issue concerning abuse.

• Information reflecting the therapist’s exercise of clinical judgment

The client has gained awareness of how her antisocial behavior has alienated her from others within her social circle. She is taking responsibility for her antisocial behavior and the consequences of that behavior. Proceed with the anger and violence management program to complement the psychodynamic psychotherapy treatment program. Practicum – Assessing Client Progress Paper.

Part 2: Privileged note

The client seems to have had an inadequate response to the therapy. Her symptoms of antisocial personal disorder continue to be described. They remain unchanged through her continued irritability and aggressiveness. In addition, she has expressed a desire to get even with her ex-boyfriend through vandalizing his car and getting financial recompense from him since he is partially responsible for her unfavorable financial situation. This information is considered privileged because it shows that despite the treatment plan, the client has made very little progress except for addressing her financial situation. In addition, the information shows that she has some financial tendencies. This could be an indication that despite appearing enthusiastic and supportive in the treatment program, she has not internalized the treatment progress. She is simply attending the therapy sessions as evidence that she is seeking treatment, but is not really seeking treatment. Progress beyond what has been reported would have been seen if the client had been fully invested in the treatment. Given this awareness, there may be a need to subject the client to a fresh psychiatric assessment to determine if a new diagnosis is necessary or if there are comorbidities that hinder the treatment plan’s progress.

Assessing clients

Part 1: Comprehensive client family assessment

Demographic information

Patient’s Name: ‘Mary’

Sex: Female

Date of birth: 1985

Age: 33 years

Religion: Christian

Ethnicity: Hispanic

Marital status: Single.

Legal Status: Independent

Preferred Language: English

Presenting problem

The patient presents herself for the initial psychiatric assessment with the report that she is at the end of her rope and does not know what else to do. While despondent and crying, she mentions that she does not have many friends and most of the friends she previously made abandoned her. She explains that she is always considerate of the people she considerate her friends and tries to be nice to them, but this has not helped her in keeping her friends. She becomes more agitated during the interview, and stands up to begin pacing around the interview office. She becomes more animated, wildly gesturing while stating that her biggest concern is that she just broke up with her boyfriend and this is what made her to make the appointment. She describes the breakup as a traumatic experience, noting that he was very considerate when they started dating but was less considerate towards the end of the relationship. She adds that although he broke up with her, she is glad to see him go since she hates him. She then explains that her present financial situation is no favorable since she recently made some purchases to furnish the home she shared with her boyfriend who has since moved out. They shared the bills when he was around but now she has to deal with the home bills as well as the credit incurred from the furnishing purchases. She concludes that: “I do not like people who do not keep their word. He promised that he would be around to help me with the bills, but now he up and left me without considering how I will make the payments”.

History of present illness

The patient reports that she had a troubled childhood. She indicates that as a child, her peers would pick on her simply because they were stupid and did not know how to have fun. She acknowledges that she has always been impulsive, although this is targeted at having fun when other people want to become prudes. Her life motto is that life is only lived once and every person must make the best of that life.

Past psychiatric history

No history of psychiatric ailment.

Medical history

The patient is not on any prescription medication except for some over the counter pain medication that she takes when she has had a long day at work and school.

Substance use history

The patient occasionally drinks when she is at social functions, but does not use any drugs.

Developmental history

The patient did not have any developmental delays.

Family psychiatric history

The patient is not aware of any member of her family suffering from a mental illness.

Psychosocial history

The patient leads an active social life that revolves around going to work, attending school and spending time with friends and family in social events. Practicum – Assessing Client Progress Paper.

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History of abuse/trauma

The patient has no history of abuse or trauma.

Review of systems

General: Has a straight posture.

Skin: Good skin tone.

Head: No history of headaches.

Eyes: Good vision.

Ears: No vertigo.

Nose: No running nose.

Mouth and Throat: No pain or sores.

Neck: No pain or masses.

Respiratory: No hemoptysis, sputum, wheezing, or cough.

Gatrointenstinal: No black stools, diarrhea, vomiting or nausea.

Genitourinary: No urination urgency or frequency.

Neurologic: No paralysis.

Musculoskeletal: No joint or muscle pain.

Hematologic: No history of anemia or bleeding disorder.

Emotional: No history of psychiatric problems except for routine counseling as a soldier.

Physical assessment

Vital signs completed: 1:38

B/P: 128/74

Pulse: 68 BPM

RR: 17 BP

Temp: 37^oC

Pulse Ox: 99%

Weight: 67 kg

General appearance: Alert appearance.

Skin: No abnormal lesions or moles.

Neck: No masses.

Cardiovascular: Regular rhythm and rate. No gallops, rubs or murmurs.

Lungs: No crackles or wheezes.

Mental status exam

Cooperative during the psychiatric assessment.

Differential diagnosis

The patient suffers from antisocial personality disorder. The diagnosis is based on the patient’s tendency to disregard and violate the rights of the people around her. Her personal experiences and behavior show that she deviates from what would be considered normal behavior, with clear indications of pervasiveness and inflexibility. In addition, the patient is older than 18 years of age. Besides that she exhibits irritable, aggressive and irresponsible conduct with manipulative tendencies that make it difficult to differentiate her lies from truths (Black, 2013; Gilbert, 2015). Given the patient’s behavioral problems, it is clear that she is suffering from antisocial personality disorder.

Case formulation

The patient attended the psychiatric assessment to determine an appropriate diagnosis and seek treatment.

Treatment plan

The patient will be subjected to psychodynamic psychotherapy to address the antisocial personality disorder. This decision is based on two reasons. Firstly, this treatment approach is comparatively cheaper when compared to other approaches thus expected to reduce the financially anxiety that the patient exhibited (Widiger, 2012). Secondly, there is no FDA approved medication that can be prescribed to address the condition, thus leaving psychotherapy as the most appropriate treatment approach that stands the highest chance of producing the required results (Sperry, 2016).  In this respect, psychodynamic psychotherapy is expected to offer an inexpensive and effective treatment plan for the patient. Practicum – Assessing Client Progress Paper.

Part 2: Family genogram

References

Black, D. W. (2013). Bad boys, bad men: confronting antisocial personality disorder (sociopathy). New York, NY: Oxford University Press.

Gilbert, M. (2015). The mind of a sociopath: your guide to understanding the anti-social personality disorder of sociopaths. New York, NY: CreateSpace Independent Publishing Platform.

Sperry, L. (2016). Handbook of diagnosis and treatment of DSM-5 personality disorders: assessment, case conceptualization, and treatment (3^rd ed.). New York, NY: Routledge.

Widiger, T. A. (2012). The Oxford handbook of personality disorders. Oxford: Oxford University Press. Practicum – Assessing Client Progress Paper.