week 7 6630

Running head: ASSESSING CLIENT PROGRESS 1

ASSESSING CLIENT PROGRESS 7

Assessing Client Progress

Psychotherapy with Individuals

Week 7

Assessing Client Progress

Introduction

The case study that is being considered is that of MK. M.K has been brought to the healthcare facility as a result of the mental issues that he is suffering from due to the separation of the parents. The child is seen to have had challenges in relation to the fact that his parents had divorced. The child is suffering from separation and anxiety disorder. This paper provides progress information of the patient.

Part 1: Progress Note

Treatment Modality

The process of treatment of the patient involves the use of supportive psychotherapy and integration of the psychodynamic. In this case, the patient is supposed to be able to ensure that there is an ease in reaching out to the psychiatrist and opening up on the issue that he is facing. The child is, therefore, able to help in the process of provision of information on the process of care.

Progress or lack of progress

There has been progressing in the process of treatment of M.K. There has been ease in the process of provision of an effective process of development of a reliable living standard with his mother. The child has been able to ensure that there is an ease in the process of opening up to his mother on what he is feeling and his opinion.

Modification of treatment

There is a need for the modification of the process of treatment of M.K in small parts including the fact that there is a need for the changes in the process of development of effective communication. This implies that there is a need for the enhancement of the process of communication of the healthcare provider and the patient on his condition as pointed out by Busch and Sandberg (2016).

Clinical impression regarding diagnosis and symptoms

There has been a change in the healthcare standards of the patient called M.K in that there have been changes in the process of communication with the parents. In addition, there has been an improvement in the standard of treatment of the patient. There has been a change in the case where he had mixed reaction with issues of sadness, angry, happy and excited. The child has also become free with the child and hence allow for ease in the process of development of the healthcare changes.

Relevant psychosocial information or changes from original assessment

One of the changes that have arisen in relation to the psychosocial information is that the patient has had a chance of not being angry as he was in the past. This is an implication that there has been a change in the process of development of the standard of care and that he is able to relate well with the mother. The other relevant psychosocial change is that there has been an improvement in the process of development of the communication skills of the child.

Safety Issues

One of the safety issues that has been faced is that the child has become violent at some point during the process of treatment. The patient has not been able to provide information that is necessary for the enhancement of the process of communication. The process of change as well as allow for the enhancement of the standard of care of patient health.

Clinical emergencies/ actions taken

One of the actions taken as a result of the change in the healthcare processes is that there has been a change in the process of development of the reliable measures of communication. The effectiveness in communication has been useful for the ease in the provision of information by the child. The ease in the process of communication is expected to ensure that one is able to eliminate cases of ineffective processes of the provision of resources to ensure that the child is in a position to learn of the changes occurring and the ways that they can cope with the changes.

Medication used by the patient

The issue that M.K is suffering from is not supposed to be useful for the development of an effective process of change that could allow for an enhancement of the standard of patient care processes. The patient will be in a position to ensure that there could be an important aspect of care that will allow the patient to avoid the use of medication. Selective serotonin reuptake was used by the patient for management of effective patient care.

Treatment compliance/ lack of compliance

The management of the patient care processes will allow for the effective process of development of care. The healthcare providers are supposed to be in a position to manage the compliance that one will have. The case of lack of compliance may be challenging and that one may end up facing challenges in relation to the adherence to the use of medication as pointed out by Lee et al. (2016). Since the mother has been the guardian offering services for the patient, there is an ease in the provision of information for effective patient care.

Clinical consultations

There is a need for the patient to have reliable information on the process of care and the necessary standard of care that should be put in place. Typically, the mother is supposed to be involved in the process of treatment of the patient at all times. This attributed to the fact that with effective communication the parent can be able to ensure that the child is able to adhere to the medical processes needed.

Collaboration with other professionals

There is a need for healthcare providers to have effective information on collaboration. Healthcare providers should collaborate with the teachers in the process of monitoring changes in the health of the patient. This is attributed to the fact that teachers will be close to the children at all times.

Therapist’s recommendations

The recommendation for the healthcare provider is to ensure that the child is informed of the importance of having effective communication. The therapist should be able to get reliable information on the challenges that may be faced.

Referrals made/ reasons for making referrals

The child should be referred to a physician to ensure that there is a checkup made on the important health that may be faced.

Termination/issues that are relevant to the termination process

The process of treatment of the child is expected to be carried out for a period of 3 months.

Issues related to consent and/or informed consent for treatment

The mother is allowed to give consent on the treatment of M.K. The mother is allowed to make the decision on the challenges that may be faced by the child and the need for health services being provided.

Information concerning child abuse, and/or elder or dependent adult abuse

The abuse of children should be assessed at all times. In the case of M.K, it is evidence that the main cause of his condition is the separation of the parents.

Information reflecting the therapist’s exercise of clinical judgment

There is a need for the consideration of the judgments that are made by the therapist since this will help in the enhancement of the standard of patient care. The process will as well help in the decision making on whether there is a need for the patient health to be improved. This is as well an important process that will ensure that one is able to manage the challenges that pertain to the issues that are facing in the process of treatment. The challenges may end up causing a deterioration in the standard of patient care. In this case, one will have to take into account the need for an effective communication process as pointed out by Breger (2017).

Part 2: Privileged Note

One of the things that will be considered in the treatment of the patient is seeking the audience of the father. This will allow for the determination of the comfort that they have in getting in touch with the child. This will as well be an important part in the process of provision of healthcare issues of concern and hence one will have a chance of elimination of effective processes of care.

References

Breger, L. (2017). Psychotherapy: Lives Intersecting. Routledge.

Busch, F. N., & Sandberg, L. S. (2016). Psychotherapy and medication: The challenge of integration. Routledge.

Lee, D. J., Schnitzlein, C. W., Wolf, J. P., Vythilingam, M., Rasmusson, A. M., & Hoge, C. W. (2016). Psychotherapy versus pharmacotherapy for posttraumatic stress disorder: Systemic review and meta‐analyses to determine first‐line treatments. Depression and anxiety, 33(9), 792-806.