PRAC w10_Assgn2

2

Do not change the story line please.

Don’t work on the progress note below, but remember to add add reference.

Assignment 2 Practicum: Week 10 Journal Entry

University

NURS 6650: Psychotherapy with Groups and Families

Instructor:

January 30, 2021.

Client 1

This paper is on the clinical assessment of a 23-year old client undergoing therapy sessions. The paper will discuss subjective, objective, assessment, and plan notes utilizing the progress notes. GM is a 17-year-old African American girl who lives with the mom and stepfather. GM reports feelings of depression, lack of motivation, low energy, inability to sleep, and interest in previously enjoyed activities. GM reports feelings of hopelessness, helplessness, and worthlessness. GM reports self-harm by cutting herself with a knife in both arms and thighs. GM reports breaking up with her ex-boyfriend because he was cheating on her with another girl. GM reports thinking or seeing her ex-boyfriend sleeping with the other girl makes her crazy, and she does not know how she will conduct herself the next time they will meet.

GM feels she is not loved and appreciated as a person, and that weighs on her. GM reports a previous suicidal attempt by overdosing on medication. GM is awake, alert, appropriately dressed with flat affect. GM denied any prior hospitalization. GM denied prior use of alcohol, illicit drugs, and tobacco. GM appears calm, cooperative, and pleasant. Speech is clear. GM has a body language, and attitude is consistent with mood. Thoughts content appears appropriate. Knowledge and cognitive functioning appear intact and age fitting. Judgment and insight appear fair. GM is currently on Zoloft 50mg twice daily and has a PMHNP working with her.

Diagnosis: Major Depressive Disorder (MDD):

GM presents with depressed mood and flat affect. According to the diagnostic and statistical manual of mental health disorders, 5th edition (DSM-5), a client has diagnoses of MDD when the client presents with one significant signs indicative of depressive mood and or sustains no interest or derive pleasure in activities that previously pleasure the client within two weeks (Tolentino, & Schmidt, 2018). GM reports sadness, emotional breakdown, loss of interest in last enjoyable activities, reports feelings of hopelessness, worthlessness and inadequacy, and previous attempt to harm himself. Client presenting with feelings of incompetency, lack of cheerfulness, has no interest in activities, withdraws from other people and social events, and developing thoughts of harming self indicates depression and meets the criteria for the diagnosis of major depressive disorder (American Psychiatric Association, 2013).

Client 2:

B is a 17-year-old Hispanic American that presents for therapy with mom. B reports she broke up with her ex-boyfriend five months ago. B reports she has been dating ex-boyfriend for over two years. B reports she was pregnant for him but has no emotional support from him, plus that her ex-boyfriend's mom disapproved of their relationship at the beginning of the relationship. B reports the ex-boyfriend talked her into aborting the baby, which was contrary to what she wanted to do because she wanted to keep the baby. B reports she did not tell her mom about this development. B reports ex-boyfriend was both emotionally and physically abusive because he beats her up.

B reports anxiety, worry, and persistent guilt due to the ex-boyfriend's abuse and for terminating the pregnancy. B reports difficulty establishing another relationship with another man, feels irritable towards men, and increases heartbeat when approached for friendship. B reports the persistent guilt about the abortion, and the ex-boyfriend's abuse is causing difficulty to sleep and occasional nightmares due to the persistent cry of a baby when she sleeps or sees a strange man beating her up. B denies any known medical condition.

Diagnosis: Post Traumatic Stress Syndrome (PTSD):

According to the Diagnostic and Statistical Manual of Mental Health Disorder, 5th edition (DSM-5), the client meets the criteria for the diagnosis of PTSD since exhibiting at least four symptoms from the following categories, intrusion symptoms, avoidance symptoms, negative alterations in mood, and arousal symptoms for a minimum of one month (American Psychiatric Association, 2013). B manifest symptoms that are consistent with these criteria.

B exhibits the symptoms in each category, according to DSM-5. B continuously thinks about her past relationship, the nightmares due to the abortion, and the abuse (intrusion symptom). B is having some challenges establishing a new relationship (avoidance symptom); B reports irritability towards (negative mood) and experiences an increase in heart rate when men approach her (arousal symptom). The patient has been going through these symptoms for more than six months.

Legal and Ethical Implications:

Studies have shown that MDD and PTSD can relate to the inability to go to work and job loss, causing the client to become a burden to society (Moses, 2019). The practitioner will need to provide adequate support, love, and empathy. Before initiating assessment and interview, the practitioner will need to obtain consent from the youngster and the parent(s) in order to promote a therapeutic alliance between the youngster, the parent(s), and the healthcare professional (Fivecoat, Cos & Possemato, 2017). The practitioner must provide privacy during the assessment, reassuring the client of maintaining the confidentiality of sensitive information during treatment. The practitioner must evaluate for suicidal ideation during the assessment as a diagnosis of MDD and PTSD can be challenging due to different presenting symptoms and comorbidities of the client. Therefore, the need for the practitioner to avoid breaching the confidentiality of the client's information. Establish a treatment plan involving the adolescent and parent(s) to ensure active participation and identify factors that will prevent drop-out from eliminating untimely withdrawal from the treatment.

Do not change the story line please.

Don’t work on the progress note below, but remember to add add reference.

Group Therapy Progress Note

Client: GM (Client # 1)

Date: 11/4/2020

Group name: Family therapy session

Minutes: 45

Group session # 9 Meeting attended is # 4 for this client.

Number present in group 1 of 3 scheduled

Start time: 10:00 a.m. End time: 10:45am

Assessment of client

1. Participation level: ❑ X Active/eager ❑ Variable Only responsive ❑ Minimal ❑ Withdrawn

2. Participation quality: ❑ Expected ❑ Supportive ❑ X Sharing Attentive ❑ Intrusive

❑ Monopolizing Resistant ❑ Other: _____________________________________

3. Mood: ❑ Normal ❑ anxious ❑ Depressed ❑Angry ❑ euphoric ❑ Other: _________

4. Affect: ❑ Normal ❑ Intense Blunted ❑ Inappropriate ❑ Labile ❑ Other: Sad

5. Mental status: ❑X Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑Confused ❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑Other: __________

6. Suicide/violence risk: ❑X Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt

7. Change in stressors: ❑Less severe ❑ Different stressors ❑ More severe ❑ Chronic

8. Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able

9. Change in symptoms: ❑Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse

10. Other observations/evaluations:________________________________________________________

In-session procedures:

 Introductory phase for the therapist and clients

 Clients discussed their week activities since the last session.

 Clients denied any new development or behavioral episodes since the last session

 Clients were encouraged to reflect and participate on the session and ask questions where necessary.

Homework:

1. Clients identified coping skills; exercise, meditation, and deep breathing exercises.

2. Journaling their stressors.

3. Encourage clients to verbalize more about where they picture themselves in the future.

Other Comments: ____________________________________________________________________________

_____________________________________________________________________________________

Signatures: Oluchi Onebunne PMHNP-student

Date: 11/4/2020.

Group Therapy Progress Note

Client: B (Client # 2).

Date: 11/4/2020

Group name: Family therapy session

Minutes: 45

Group session # 9 Meeting attended is #5 for this client.

Number present in group 2 of 3 scheduled

Start time: 10:00am. End time: 10:45 a.m.

Assessment of client

1. Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn

2. Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive

❑ Monopolizing Resistant ❑ Other: _____________________________________

3. Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑Angry ❑ euphoric ❑ Other: _______________

4. Affect: ❑ Normal ❑ Intense Blunted ❑ Inappropriate ❑ Labile ❑ Other: ❑ Sad

5. Mental status: ❑X Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused ❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other: _______

6. Suicide/violence risk: ❑Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt

7. Change in stressors: Less severe ❑ Different stressors ❑ More Severe ❑ Chronic

8. Change in coping ability/skills: ❑X No change ❑ Improved ❑ Less able ❑ Much less able

9. Change in symptoms: ❑X same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse

10. Other

In-session procedures:

 Introduction of preceptor/therapist to the clients.

 Clients discussed their week activities since the last session.

 Clients experienced behavioral issues since the last session

 Clients were encouraged to reflect and participate on the session and ask questions where necessary.

Homework:

1. Client identified coping skills; exercise, meditation, and deep breathing exercises.

2. Journaling their stressors.

3. Encourage clients to verbalize more about where they picture themselves in the future.

Other Comments: ____________________________________________________________________________

_____________________________________________________________________________________

Signatures: Oluchi Onebunne PMHNP-student

Date: 11/4/2020

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Fivecoat, H. C., Cos, T. A., & Possemato, K. (2017). Special ethical considerations for behavioral health consultants in the primary care setting. Professional Psychology: Research and Practice, 48(5), 335.

Moses, T. E. (2019). Erasing Trauma: Ethical Considerations to the Individual and Society. AJOB Neuroscience, 10(3), 145-147. 

Tolentino, J. C., and Schmidt, S. L. (2018). DSM-5 Criteria and Depression Severity: Implications for Clinical Practice. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6176119/