Assignment 1: Practicum – Client Termination Summary

With the client you selected in mind, address in a client termination summary (without violating HIPAA regulations) the following:

· Identifying information of client (e.g., hypothetical name and age)

· “Autumn,” Female, Age 46, Diagnosis: Generalized Anxiety Disorder (GAD) (F41.1), Seasonal Depression Disorder (SAD) F32.9, Post Traumatic Stress Disorder (PTSD) (F35.10), Obsessive Compulsive Disorder (OCD) (F42).

· Depression occurs more often in women than men. In women depression tends to manifest as sadness, worthlessness, and guilt (Anxiety and Depression Association of America, 2020).

· Generalized anxiety disorder is characterized by excessive, debilitating worry about life situations for at least six months.  The symptoms of generalized anxiety disorder include being unable to stop worrying, even after the stressor has been resolved. Generalized anxiety disorder is treatable with a combination of lifestyle changes, therapy, and medication. Feeling anxious, worried, or concerned is a normal part of life. However, people with generalized anxiety disorder (GAD) worry so intensely that it interferes with their daily life (American Psychiatric Association, 2020).

· Date the client initially contacted therapist, date therapy began, duration of therapy, and date therapy will end

· Session 8/10, Contacted office in April to discuss anxiety and depression, First session was April 1st, 60 minutes sessions, plan to terminate in beginning of September after 10th session.

· Total number of sessions, including number of missed sessions

· 10 Sessions planned, client has been consistent, on time, and is active in each session.

· The first step in any case formulation and treatment plan is an accurate diagnosis (Wheeler, K. (Ed.)., 2014). 

· Whether termination was planned or unplanned

· Termination planned at the beginning of treatment sessions in plan.

· Presenting problem

· Anxiety and depression related to coping with husband going to rehab, client was taking care of 5 children, work, and go to school on her own with no family support. All her family was out of state as she resided in Wyoming and family was in Utah.

· Major psychosocial issues

· Only having church for support, while intimate family, friends, and spouse were out of state, client was extremely anxious and needed confidential support.

· Types of services rendered (e.g., individual, couple/family therapy, group therapy)

Individual Cognitive Behavioral Therapy (CBT).

· CBT is the most widely researched psychotherapeutic model with demonstrated effectiveness in the treatment of a wide range of emotional and behavioral problems. CBT is a “system of psychotherapy based on a theory which maintains that how an individual structures his or her experiences largely determines how he or she feels and behaves” (Beck & Weishaar, 1986). 

·

· Overview of treatment process

· Client adapting and applying coping skills with cognitive behavioral therapy through implementation of grounding techniques, journaling, and finding new hobbies.

· Goal status (goals met, partially met, unmet)

· Goals have been met by client.

· Treatment limitations (if any)

· None

· Remaining difficulties and/or concerns

· Husband was still in rehab, no physical contact allowed, only phone calls and letters allowed, client still is having stress of balancing everyday life with balancing life with 5 children and financial difficulties.

· Recommendations

· Finding support outside of therapeutic sessions such as support groups, contacting church for financial and emotional support, and self-care time.

· Follow-up plan (if indicated)

· Continue with therapy to conclusion of scheduled therapy sessions.

· Instructions for future contact

· Call for follow up appointments as needed. Client will be assessed by case managers 30 days post conclusion of therapy sessions.

· Signatures

· Client signed therapy contract agreement with this therapist and is aware of all recommendations. She has been given homework throughout her sessions.

References

American Psychiatric Association (2020). Help with Anxiety Disorders. Retrieved from:

https://www.psychiatry.org/patients-families/anxiety-disorders

Anxiety and Depression Association of America (2020). Depression. Retrieved from:

https://adaa.org/understanding-anxiety/depression

Beck, A. T., & Weishaar, M. E. (1986). Cognitive therapy (p. 43). Philadelphia, PA: Center for

Cognitive Therapy.

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

guide for evidence-based practice. New York, NY: Springer.

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