Assessing Client Family Progress

Practicum Assessing Client Progress

Name

University

Part 1: Progress Note

The patient selected in week 3 was J.J, a 27 year-old African American female who presented symptoms of- and diagnosed with moderate post-partum depression (PPD).

Treatment modality used and efficacy of approach

The treatment modality used is Cognitive Behavioral Therapy (CBT) and support groups. CBT is a talk psychotherapy which aids in modifying a patient’s negative behaviors, thoughts, attitudes, as well as emotional response associated with psychological distress (Huang, Zhao, Qiang, & Fan, 2018). CBT is highly effective in helping patients suffering PPD which is mental health disorder characterized by onset of negative thoughts, attitudes, behaviors and emotional responses related to stress that comes with new born responsibilities (Huang et al., 2018).

Support group on the other hand involves interaction with others going through the same situations. It is highly crucial for individuals with PDD symptoms to seek support as it significantly contributes a lot in lifting the fog of PDD and keeping it far away (Morikawa et al., 2015). Isolation and loneliness usually worsen depression as patients that stay on their own find it considerably difficult to maintain and sustain perspective and effort needed to deal with depression. As such, it is highly crucial for PDD patients to maintain close relationships as well as social activities to be able to cope with their health situation (Morikawa et al., 2015).

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

From assessing the patients progress, the agreed upon goals were met. The therapy significantly improved the patient’s stress, anxiety, and depressive symptoms. The scores in PHQ 9 mental test reduced from 10 to 5 in four weeks of check up and from 5 to 2 in eight weeks. The patient’s symptoms had improved in that, at the 4th week the patient reported positive effects of the treatment. She had employed a nanny to help her with the babies and thus felt less fatigued and full of energy in the morning. More so, she managed to improve on her sleeping patterns as she would sleep at night when the babies slept. Patient further reported that her support group was very helpful and it helped a lot in dealing with her feelings of hopelessness, helplessness, and worthless. In addition, the patient no longer had suicidal ideations and was excited about taking care of her newborns. These are key indicators of the efficacy of the treatment modalities used as well as positive progress of the patient.

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

Due to the observed and reported effects of CBT and support groups in dealing with the patient’s PPD symptoms, there were no modifications done to the initial prescribed treatment plan to use CBT and support group.

Clinical impressions regarding diagnosis and/or symptoms

The clinical impressions include use of clinical judgment in assessing the symptoms and deducing treatment modalities. A further clinical impression is on the use of the PHQ-9 score in order to confirm the diagnosis for PDD and to also exclude bipolar disorder, and other medical health disorders that cause depression.

Relevant psychosocial information or changes from original assessment

The patient is a single mother. There are no changes.

Safety issues

Considering her suicidal ideations, the patient was advised to take a nanny to help in caring for her babies to ensure the safety as well as her babies’ safety was monitored.

Clinical emergencies/actions taken

No emergencies taken

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

No medications prescribed

Treatment compliance/lack of compliance

The patient was substantially compliant to the treatment approaches prescribed. She attended all her CBT sessions as well as support group sessions and events timely and efficiently.

Clinical consultations

To ensure effective treatment of the patient’s treatment, the patient was allowed to consult through phone calls, emails, as well as physical consultations to her primary provider and therapist in the event she needed clinical guidance.

Collaboration with other professionals (i.e. phone consultations with physicians, psychiatrists, marriage/family therapists etc. )

Other professionals involved in the care for the patient included a pediatrician, nutritionist, and a family therapist. The pediatrician helped and guided the patient on how to care for her newborns; the nutritionist guided the patient on the best diet and activities to help in managing her weight and also addressing the issue of weight loss where she reports having lost 8 pounds in 2 months.

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

The therapist’s recommendations included:

· To seek help especially from a family member, friend or nanny

· To consult a nutritionist and a pediatrician

· To join a support group

· To adhere to the CBT sessions

· To consult primary care provider for any medical concerns

The patient agreed to each recommendation

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)

No termination issues occurred in this patient.

Issues related to consent and/or informed consent for treatment

Prior to being prescribed to CBT and support group, the patient was educated on how the two treatment approaches and their treatment goals. She confirmed her acceptance of the treatment approaches by signing an informed consent form.

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

N/A

Information reflecting the therapist’s exercise of clinical judgment

As defined by Shaban (2015), clinical judgment is reasoning under vagueness during patient care. The principle aspect of clinical judgment is that providers act without solely relying on evidence-based practice but also on scientific theory, own expertise, patient views, and other insights (Shaban, 2015). Clinical judgment is reflected in the therapist’s collection and analysis of the patient’s chief complaint, subjective data, and objective data which lead to conclusion that the patient is suffering PPD. Clinical judgment is further reflected on the therapist’s deduction of treatment plan based on the patient’s presented signs and symptoms.

References

Huang, L., Zhao, Y., Qiang, C., & Fan, B. (2018). Is cognitive behavioral therapy a better choice for women with postnatal depression? A systematic review and meta-analysis. PloS one, 13(10), e0205243.

Morikawa, M., Okada, T., Ando, M., Aleksic, B., Kunimoto, S., Nakamura, Y., ... & Furumura, K. (2015). Relationship between social support during pregnancy and postpartum depressive state: a prospective cohort study. Scientific reports, 5, 10520.

Shaban, R. (2015). Theories of clinical judgment and decision-making: A review of the theoretical literature. Australasian Journal of Paramedicine, 3(1).

Part 2: Privileged Note

Name of Patient: J.J

J.J suffers from mental distress particularly post-partum depression (PDD) as a result if being a single parent and in an abusive relationship with the newborn babies’ father. J.J had dated her babies’ dad for two years without knowing that he is married and only knew about it when she was 3 months pregnant. Her “boyfriend” demanded for her to abort the pregnancy but she refused and moved to another town as he threatened to kill her if she kept the pregnancy. In addition to the expected hormonal changes upon delivery, being a single mother taking care of newborn twins without any support and with deep emotional pains about her relationship with the babies’ father is one main cause of her PDD. Going through her medical history, I have established that the patient suffered depression in her teen years when she lost her siblings to road accident. The depression was treated with Prozac (fluoxetine) and psychotherapy. The family history contributing to her health condition is her mother’s history of anxiety and major depressive disorder and her father’s alcoholism. Further, the patient is a loner since she has no friends.

Her physical exam shows that she is in distress by the fact that she cannot complete a sentence without bursting into tears. The patient appears pale and fatigued.

The cognitive behavioral therapy (CBT) treatment sessions conducted on Mondays, Wednesdays, and Fridays and support group have shown productivity. J.J is collaborative, willing to heal from her mental condition, compliant to recommendations, and is improving day by day. She is now open and feels okay to talk about her babies’ dad without negative attitudes, emotions, or thoughts. She no longer bursts into tears when talking, looks fatigued, had suicidal ideas, or feels helpless, hopeless, or worthless like she did when the treatment sessions commenced. She is now calm, hopeful, lively, joyful, and happier. Her health is improving and out of the 8 pounds lost in two months, she has regained 6 pounds.

I find it highly useful to involve a relationship counselor in her therapy in order to help her learn on how to make friends and also how to handle her current situation with her twin’s father. I suggested it to her and she gave her consent recommend. I equally helped the patient to get a child support lawyer to legally advise her about her current situation with her twin’s father as well as rights and her children rights to the man in question. The patient agrees to this as it is not only good for her newborns’ safety but also for their well-being and her safety.

From the above information collected at the initial encounter, the client was troubled and could not give information about her twin’s father. She did not disclose that he abused and threaten to kill her if she kept her pregnancy. He also lied to her as he did not disclose to her about his marital status prior to getting involved with her. The patient after giving birth encountered various challenges as a single mother and which made her develop PDD. Her attitude, behaviors, thoughts, and emotional response had improved significantly upon completion of the CBT therapy used in combination with support.

Why the items in the privileged note would not be included in the client’s progress note.

The above-privileged note consists of vital information in regards to J.J’s abusive and dishonest relationship with her ex-boyfriend who is the father to her twins. Such sensitive information like threats to one’s life should be kept private and confidential and should not be disclosed to other parties (Mueller, Kirkpatrick, & Richter, 2018). This is in order to maintain the patient’s safety and protect her from any harm either from her “ex-boyfriend” or even the wife to her ex-boyfriend.

Explain whether your preceptor uses privileged notes

Yes, my preceptor makes use of privileged notes. The preceptors can include his hypothesis on diagnosis, observations, and any other thoughts or emotions he has about patient’s condition. The privilege notes ought to be kept away from medical records as well as billing information as it contains sensitive information about the patients. Other items included in privilege note include provider’s observations, hypothesis, and questions to ask preceptors of supervisors (Mills, 2015).

References

Mills, J. (2015). Psychotherapist-Patient Privilege, Recordkeeping, and Maintaining Psychotherapy Case Notes in Professional Practice: The Need for Ethical and Policy Reform. Canadian Journal of Counselling and Psychotherapy/Revue canadienne de counseling et de psychothérapie, 49(1).

Mueller, C. B., Kirkpatrick, L. C., & Richter, L. (2018). § 5.35 Psychotherapist-Patient Privilege. C. Mueller, L. Kirkpatrick, & L. Richter, Evidence, 5.