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Progress Note

Date: 02/24/2020

Client: T.M

Location: Keep Smiling Therapy

Presenting Problem:

Client is suffering from depression. She is seeking help to deal with anger and emotions towards individuals in her life who has let her down countless times during her times of need. Client feels lonely and desire a companion.

Progress note:

T.M appeared in an upbeat spirits. Client mentioned how she felt closer to her goal of making self-care a priority in her life after her first session. Student therapist reviewed a few concerns/topics in the previous session. The main focus of the session was to get a better understanding of her relationship with her parents. At the age of 13 years old client was taken by her Aunt who believed client was being mistreated by other family members. Client expressed how she never really lived with their parents. Client parents emigrated from Jamaica for a better life. She was left in Jamaica until she received proper documentation to come live in the states. When she got her documents to live in the states she moved in with her mother and father for a very short time. Client tried to describe her feeling of abandonment in regards to her parent but got extremely emotional. Client expressed that while living with her aunt her parents lived closed by. However, her parents never came to visit and never attended any of her sport games. Intern explains that her feeling of wanting to be belonged and loved maybe contributed to the lack of presents of her parents during her childhood. Once, again client became extremely emotional and asked for a change of topic. Later, in the session client expressed that she does not feel present when doing most activities. Client feels as if she’s walking aimlessly without a goal.

Diagnosis:

Intermittent Explosive Disorder 312.34 (F63.81)

Major Depressive Disorder, recurrent episode ICD-10 F33.41

Instructions / Recommendations / Plan:

Intern recommended mindful mediation to help her feel more present and grounded.

Next session Intern will follow up on how effective mindful mediation exercise.

Client

Return once week, or earlier if needed.

Notes & Risk Factors:

Client expressed that she has had suicidal thoughts be has no plan and wants to seek help.

Short Term Goal:

Encourage Client to change her perspective towards unrealistic expectations

Provide client with insight to her anger and outbursts.

Long Term Goal:

Cognitive behavioral therapy:

Encourage Client to change her perspective towards unrealistic expectations she has placed on individuals that are closet to her.

Encourage client to preform mindful mediation exercise.

Lifestyle Intervention:

Student Intern will try to encourage Client to incorporate different tools to reduce her stress.

Mindful meditation.

Debra’s Goal: Improve communication with her son by increasing the number of positive conversations over the next two months. Debra will use a journal to log their conversations to track her efforts.– Action Step 1: Debra will participate in the parenting class to learn about age and stage, self-care, and communication. The class meets for 12 weeks, once a week.– Action Step 2: Debra will attend the parent support group for the next three months to find support and understanding