Psychotherapy with individual
Running Head :Week 7 Follow Up 2
Week 7 Follow Up :2
Week 7 Follow Up
NURS-6640N Psychotherapy Individual
April 15, 2019
Part 1-Progress Note
Progress Note
The patient who is a 50-year-old African American woman; currently works in a corporation as a high-ranking business woman. She finds it hard to motivate herself to take her medication at times. The patient discussed with her doctors that for the past 3 months she’s been suffering from low energy, apathy, hopelessness, disinterest in activeness that she loves such as writing and insomnia. She reports that the symptoms begin soon after a death of a friend and have worsened over time to the point her performance at her job suffers and her coworkers are concerned.
Treatment Modality used and Efficacy of approach:
Efficacy of approach: After MI, the patient was able to adhere to her treatment plan.
Progress toward mutually agreed-upon client goals: Due to the motivational interviewing, the patient with the help of her loved ones, was able to keep up with the treatment. One thing that the patient does to motivate herself, was to write a journal entry every week about a thing that made her happy or tracking down negative thoughts. This was an activity that and the psychiatrist agreed on.
Modification of the treatment plan based on progress/lack of progress: No change in treatment plan. Still taking the 10mg of Escitalopram once a day.
Clinical Impressions regarding diagnosis/symptoms: An often-overlooked cause of depression is grief. “Grief, as a reaction to bereavement has been extensively studied from its typical manifestation to maladaptive forms during the past decades. Complicated grief, also labeled as "traumatic grief" or "prolonged grief," has been identified as a unique construct distinguished from major depression, generalized anxiety disorder, post-traumatic disorder, adjustment disorder, and acute stress disorder. It is characterized by intense painful, disabling, and persistent responses to bereavement with specific symptoms such as pervasive yearning or pre-occupation with the deceased and associated emotional pain, and lead to dysfunction (Tang, S., & Chow, A. Y. M. 2017).”
Relevant psychosocial information or changes from the original assessment: No new changes.
Safety Issues: Denies homicidal/suicidal thoughts or ideation. No safety issues
Clinical emergencies/ action taken: None
Medication:
10mg of Escitalopram once a day.
Treatment Compliance/lack of compliance: After the MI therapy, patient is complainant with treatment.
Clinical Consultation: Patient talks with the psychiatrist once a week and talks about any ongoing negative feelings.
Collaboration with other professionals: None.
Therapist recommendation: The therapist recommended for the patient to get back to writing stories in order to have more healthy ways to express her emotions. The patient was receptive to this and gave the therapist a short story she created.
Referrals/reasons for making referrals: As of now there is no need for a referral, but its recommended that the patient goes to a follow-up visit two weeks after the sessions have ended.
Terminations/issues that are relevant to termination process: Since the patient is keeping up with the 13-week CBT program, the topic of termination has not come up so far.
Issues related to consent/informed consent for treatment: Patient and therapist discussed the treatment plan and gave the informed consent. As a result, there were no issues related to consent.
Information concerning child abuse, and elder or dependent adult abuse: Patient has no history of child, elder or dependent adult abuse.
Information reflecting the therapist’s exercise of clinical judgment: The boundaries between patient and therapist must be kept. Regardless of the reason for the violation whether that would be erotic, affiliative, financial, dependency or authority it is usually exploitive of the patient’s needs and destroys autonomy (Bhola, P., & Raguram, A. 2016).
Part 2: Privilege Note
With the support of the client’s brother, friends, and coworkers, the patient was encouraged to seek treatment and her loved ones will support her every step of the way. The client has the full support of his family and friends. As the treatment goes on the most important thing to keep in mind is her grieving over her friend’s death. The patient should be able to grieve at her own pace and be able to express herself. In four weeks during the review of the treatment method, it is also important to receive input from her brother, friends, and coworkers.
In a privilege note, the above comments would not be included in a progress note. There are used for a guide for a therapist to select the best treatments and are based off the client’s history. Since the client has no history of mental illness till this incident and is currently getting treatment, the best thing for the therapist to do will be to go over with the patient the treatments that will work the best and go on from there. My preceptor uses privileged notes in her sessions with clients. The type of information she might include is her personal views on clients and their situations. The information is not part of the progress note but is essential when making an assessment and formulating a treatment plan.
References
Arehart-Treichel, J. (September 07, 2012). Psychiatrists Using Motivational Interviewing Say It’s Valuable Treatment Addition. Psychiatric News, 47, 17, 9-18.
Bhola, P., & Raguram, A. (2016). ETHICAL ISSUES IN COUNSELLING AND PSYCHOTHERAPY PRACTICE: Walking the line. Verlag,: SPRINGER.
Phillips, A., Frank, A., Loftin, C., & Shepherd, S. (2017). A detailed review of systems: An educational feature. The Journal for Nurse Practitioners, 13(10), 681-686. doi:10.1016/j.nurpra.2017.08.012
Tang, S., & Chow, A. Y. M. (2017). Subjective and objective traumatic death: Distinct roles in developing complicated grief and depression among older adults in hong kong. International Psychogeriatrics, 29(3), 409-417. doi:http://dx.doi.org.ezp.waldenulibrary.org/10.1017/S1041610216001873