Group 8 PRAC

2

THIS NEEDS TO BE REWORDED TO PREVENT MATCH...

Assessing Client Family Progress

Walden University

NRNP 6650- Psychotherapy Group, and Families

, 2021.

Vincent’s behavior changed after his notice his father worsening health condition. His behavior affected his grades/performance at school; he became withdrawn/isolated at home and exhibited frequent emotional outbursts, aggressive behavior towards siblings, and frequent school fights. His guardians are seeking psychotherapy to help him.

Treatment plan/Modality: 

Cognitive-behavioral therapy is the best suitable treatment plan. CBT approach promotes communication skills, thereby improving the interpersonal relationship among family members. The efficacy of this treatment approach emphasizes how youths and parents interact to gain specific skills in handling challenges, gain insights into conflict situations, learn problem-solving skills, acquire assertiveness skills, learn different anger management skills, and brief strategic functional family therapy (Ghosh, Ray & Basu, 2017). CBT is also highly effective in reducing PTSD symptoms (Tricola & Gill, 2018).

Progress and Modifications of the Treatment Plan:

Vincent and his guardians are consistent in attending therapy. The family is open to seeing improvement in his general behavior and relationship between him and others, have less angry outburst, socialize with people appropriately, keep up with his school attendance and have improved school performance. Vincent has learned to communicate with his siblings, he is regular in attending class, with lots of improvement in his scores and performance, and minimized emotional outbursts and fights with his sister and other kids at school.

Modification:

Vincent has a follow-up appointment with the psychiatrist. Vincent is currently not on any medication. The family has resources and articles to strengthen the relationship among the family members.

Clinical Impressions Regarding Diagnosis and Relevant Psychosocial Changes

Vincent and mom report steady improvement in their communication and relationship by complying with the treatment plan. Vincent reports that his behavior is much better. Vincent reports that his relationship with his siblings and friends has improved, and he is no longer isolating from others. Vincent reports that his mom and uncle are supportive and have significant concerns about seeing Vincent completely stabilized in his behavior, academic performance, and relationship with siblings and other kids at school.

Psychosocial Changes

Vincent’s mom indicate interest in him another chance at the therapy session. They indicated an interest in family therapy counseling since they were unaware that the loss of Arnold would significantly impact Vincent.

Safety issues, Clinical Emergencies, and Actions Taken

Vincent and his mom deny any safety concerns or emergencies. No safety issues currently. Vincent reports his parents have learned better alternative ways to handle their differences utilizing resources from the treatment plan without getting verbally, emotionally, and physically abusive.

Vincent denies any thoughts or plans of wanting to hurt himself. Vincent acknowledges his mom’s effort to assist him in his schoolwork. Vincent plays piano and guitar as a hobby and participates in basketball twice weekly to cope effectively.

Medications:

Vincent is currently not on any medications.

Treatment compliance/Clinical Consultation & Termination

The clients are consistent and punctual in attending the session to meet with the therapist. The family members are compliant with the treatment plan. Vincent has a referral to meet with the PHMNP for medication management. The PMHNP dims it unnecessary to place him on medications since Vincent responds positively to the psychotherapeutic treatment plan, as evidenced by lots of improvement behaviorally and academically. Vincent has developed positive coping strategies he utilizes during a challenging time.

Therapist’s Recommendations and Referrals

The therapist recommended cognitive behavioral therapy to recognize triggers and develop appropriate positive coping skills to manage stress. CBT helps the individual coordinate the link between self, distorted thoughts, and the world (Wheeler, 2014). Through the therapist's recommendation, Vincent and his parents participated in Parenting skills classes to help boost relationships and communication styles among family members. Vincent has a referral to meet with the PMHNP for psych evaluation and medication management. Also, Vincent and the mom were given the hotline number to the National Suicide Prevention to aid individuals with suicidal ideations and emotional distress.

Termination/Issues Relevant to the Termination Process

There are no termination issues currently. The family has existing medical insurance through Mr. Arnold’s job. Mom signed a consent form allowing Vincent to participate in the treatment plan. Mom and the patient were content with their progress and agreeable to continue without change.

Information Concerning Child Abuse

Vincent denies any form of child abuse.

Therapist’s exercise of Clinical Judgement

The family seems to be responding positively to the treatment modality. The family will need to continue with the therapy sessions to further Vincent and his siblings' relationship utilizing the CBT approach. Vincent is steady and compliant with attending therapies and keeping up with his follow up appointments with his psychiatrist/PMHNP. CBT helps the family develop new ways of thinking when dealing with family concerns, thereby ensuring a healthier mental, emotional, and behavioral response (Turner, & Swearer Napolitano, 2010).

Part2: Privileged Note

Vincent has a strong attachment to his parents. Vincent did not know how to express his feelings when he knew about his father worsening health condition, resulting in abnormal behavior and school performance change. Vincent appeared depressed at the start of treatment but has since been very receptive and attentive as the sessions progressed, leading to improvement and changes in his behaviors, academics, and relationship to people.

Not all information communicated by the client in the privileged note will need to be in the client’s progress notes and clinical records because a portion of the data is private and for legitimate objectives.

The client’s progress notes, and medical records will not contain sensitive information the client shared with the therapist on trust and confidentiality. This vital sensitive information is contained in the therapist privilege note because they are personal and legitimate objectives. Examples of such sensitive information include but are not limited to medical history, sexual orientation, sexual history.

The preceptor utilizes his privilege note in his interaction with the clients. Not all the client's information shared with the therapist in the privileged noted will contain in the client’s progress note and medical record. The privilege note allows the preceptor to document confidential information that is insignificant, not safety concerns, and is unnecessary to be in the client’s legal records.

References

National Suicide Prevention Lifeline (2018). Retrieved from https://suicidepreventionlifeline.org/

Nichols, M. (2014). The essentials of family therapy (6th ed.).  

Turner, R., & Swearer Napolitano, S.M. (2010). Cognitive Behavioral Therapy (CBT). Educational Psychology Papers and Publications University of Nebraska - Lincoln, pp 226-229. Retrieved from https://digitalcommons.unl.edu/edpsychpapers/147/

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice.