Ms. Alana, a 24-year-old married female Muslim client was referred for psychological intervention in the Psychiatry Outpatient Department. She was assigned to the present therapist and was diagnosed as depression by the psychiatrist.  She and her husband would like to build a new life not associated with her past. In the assessment sessions she presented her problems along with history. Her problems are presented in the following summary in clustered fashion according to different areas of functioning.

 

The client believed that she was suffering from psychological illness. The client complained lack of concentration, lack of self-confidence, and indecisiveness. She also complained of depressed mood, feeling of guilt, lack of pleasure, anger and hopelessness. She felt irritability and fear. She avoids social gathering, friends and sometimes occasionally she used to cry. The client complained of headache, palpitation. She also complained that family members usually irritate her especially eldest brother. Her dress up, appearance and behavior appeared to be culturally appropriate. At the initial interview she spoke willingly about her problems. She was well motivated and interested to work collaboratively with therapist.

 

Exploration of history revealed that the client was in a middle-class family of a rural area with three brothers and three sisters. Her father is 57 year old and he was a small business man. Her mother is a 45 year old house wife. From her childhood she experienced that the relationship between her parents was not good. The eldest son of their family maintains everything of the whole family. Her eldest brother was very dominating. She had to lead her life as to his liking. She was the last issue of her parents. Though she was meritorious student from childhood she was always underestimated instead of being encouraged. The senior most brothers always used to apply pressure on her for studies. They were not happy with the results she obtained. During any bad occurrence in her family if she protested, she had been termed as “disobedient”. She likes reading story, listening to music and reciting poetry which are not supported by her elder brother. Her brother doesn’t even like her writing skills. She was physically tortured several times for doing these. She was sexually abused for several times. At the age of five or six years old, some of her playmates abused her. When she was in class seven her cousin tried the same way. During college life one of her uncles tried to abuse her also. She couldn’t tell these to her family with a fear of receiving disbelief of the family. When she was 15years, she had an affair with a boy. Then due to misunderstanding that broke up. When she was in college she again got involved with a boy only to pass time with that boy. Now she is having third affair. She is a graduate student. Since having all these she thinks that if she had got family support enough, there wouldn’t be so many problems. There was no history of psychiatric problem in her childhood and adolescence.

 

She is recently married and expecting her first child.  She reports her husband is patient and caring and understands her past as a block in their relationship.  She reports being hopeful for the future since she has been in America for 5 years now and wants a better life for her children.  She currently works as an assistant advocate at the local college in the cultural and community center helping minority women navigate the college experience.

 

In clinical interview the client was asked the reason for referral, why she sought for help and how long the main complaint had persisted, when did the problem first occur, what was the subsequent development in her life (occupation, living with parents, at school), what were the impairments that have been produced by the her difficulties, how have she and others coped with the problem, what her belief about the problem, what was the attitude to her difficulties, what was her cognitive functioning, what was her prevailing mood, what was her background history, early development history, occupational and educational history, sexual history and what previous psychiatric, psychological or medical help she had taken. The client asked to find out and list up her main problems. Thought diary was applied to assess situation specific negative automatic thoughts (NATs) and corresponding emotion, physiological changes and behavior for the client. It was administered to identify the NATs about the social situation and the relation to changes in emotion, physical reaction, and behavior

 

Therapist conducted both type of measurement, subjective & objective measurement. In assessment session client mentioned her overall problems severity at ‘100’ point on (0-100) rating scale. For objective measure Depression scale was used to assess the severity of depression. The highest possible score of 30 items form of depression scale was 150 and the lowest possible score was 30. Higher score on the scale indicates high level of depression and lower score indicates low level of depression. Her anxiety was assessed on a scale of 0-10 through objective measurement questions as well.  She scored an 8.

 

 

 

 

Consider what psychotherapy plan you would develop for this client.  Incorporate additional therapy modalities with CBT if you feel they are valid in this case.

 

The plan should follow the template supplied.  Fill in as much information as you have, for any other not provided state “information not provided”.

 

 

 

 

 

THIS IS A TEMPLATE THAT YOU HAVE TO FOLLOW BUT DO NOT TAKE ANY WORD FROM THEM>

 

 

Psychiatry/Psychotherapy follow-up SOAP note 

and

Psychotherapy Treatment Plan

TEMPLATE

 

Replace all highlighted sections with your data for the assignment (***insert an APA formatted title page as well)

 

Follow-up Session SOAP Note

 

Patient Name:  XXX

MRN: XXX

 

Date of Service:         01-27-2020

 

Start Time:                10:00

End Time:                  10:54

 

Billing Code(s):         90213, 90836

(be sure you include strictly psychotherapy codes or both E&M and add on psychotherapy codes if prescribing provider visit)

 

Accompanied by:     Brother

 

CC: follow-up appt. for counseling

 

HPI: 1 week from inpatient care to current partial inpatient care daily individual psychotherapy session and extended daily group sessions

 

S- Patient states that he generally has been doing well with depressive and anxiety symptoms improved but he still feels down at times. He states he is sleeping better, achieving 7-8 hours of restful sleep each night. He states he feels the medication is helping somewhat and without any noticeable side-effects.

Crisis Issues:  He states he has no suicide plan and has not thought about suicide since the recent attempt. He states has no access to prescription medications, other than the fluoxetine. He believes the classes he participated in while inpatient have helped him with coping mechanisms.

            Reviewed Allergies: NKA

            Current Medications: Fluoxetine 10mg daily

            ROS: separate psych and all other ROS (what patient states) full list not by exception

 

O-

Vitals:

Ht: 61”, Wt: 127lbs, BMI: (calculate), T 98.4, P 82, R 16, BP 122/78, Pain: 0/0-10 scale

 

PE: (not always required and performed, especially in psychotherapy only visits)

Heart- RRR, no murmurs, no gallops

Lungs- CTA bilaterally

Skin- no lesions or rashes

 

Labs: CBC, lytes, and TSH all within normal limits

 

Results of any Psychiatric Clinical Tests: BAI=34

 

MSE:

Gary Davis, a 36-year-old white male, was disheveled and unkempt on presentation to the outpatient office. He was wearing dirty khaki pants, an unbuttoned golf shirt, and white shoes and appeared slightly younger than his stated age. During the interview, he was attentive and calm. He was impatient, but polite in his interactions with this examiner. Mr. Davis reported that today was the best day of his life, because he had decided he was going to be better and start his own company. His affect was labile, but appropriate to the content of his speech (i.e., he became tearful when reporting he had “bogeyed number 15” in gold yesterday). His speech was loud, pressured at times then he would quickly gain composure to a more neutral tone. He exhibited loosening of associations and flight of ideas; he intermittently and unpredictably shifted the topic of conversation from golf, to the mating habits of geese, to the likelihood of extraterrestrial life. Mr. Davis described grandiose delusions regarding his sexual and athletic performance. He reported no auditory hallucinations. He was oriented to time and place. He denied suicidal and homicidal ideation. He refused to participate in intellectual- or memory-related portions of the examination. Reliability, judgment, and insight were impaired.

 

A – with (ICD-10 code)

Differential Diagnoses:

1. choose 3 differential diagnoses (give rationale for diagnoses to support DSM5 criteria)

2.

3.

 

Definitive Diagnosis:

Major Depressive Disorder, recurrent, without psychotic features F33.4

Generalized Anxiety Disorder F41.1

 

P-

Pharm: Continue Fluoxetine increasing dose to 20mg.

 

Non/Pharm: Continue outpatient counseling: partial inpatient program continued with individual and group sessions

Psychotherapy Modality used: CBT

Interventions/Homework:  2 distortion worksheets, keep track of physical symptoms of anxiety or depression and triggers associated

 

(Full Psychotherapy Treatment Plan attached)

 

 

Educations: discussed smoking cessation

Reviewed medication side effects and adherence importance

 

Safety Plan: gave hotline and clinic numbers to patient

 

Follow-up: in one week or earlier if any depressive symptoms worsen.

Outpatient counseling sessions to continue weekly until further notice.

 

Referrals: none at this time

 

Provider Signature:  ANNA SMITH, PMHNP-BC.   Date: 01-23-2021

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychotherapy Treatment Plan

 

Risks– isolated, no close family or relationships, high pressure family environment and expectations, full schedule with school and work.

 

Strengths- XX

 

Outcome tool used and results:  Beck anxiety inventory (BAI): 24

https://res.cloudinary.com/dpmykpsih/image/upload/great-plains-health-site-358/media/1087/anxiety.pdf

 

Psychotherapy Modality:        Cognitive Behavioral Therapy

Frequency:                               Weekly sessions until further notice

 

 

 

Long Term Goals:       

1.     Reduce overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.

                Short Term Goals:

a.      Reduce daily frequency of anxiety by recognizing patterns in thought processes.

b.     Implement behaviors to recognize triggers for anxiety.

2.     Learn and implement coping skills that result in a reduction of anxiety and worry, and improved daily functioning.

                Short Term Goals:

a.      Learn deep breathing exercises.

b.     Implement daily mediation exercises.

 

OBJECTIVES

INTERVENTIONS

1.  Describe situations, thoughts, feelings, and actions associated with anxieties and worries, their impact on functioning, and attempts to resolve them.

 

  1. Focus on developing a level of trust with the client; provide support and empathy to encourage the client to feel safe in expressing his/her GAD symptoms. 

2. Ask the client to describe his/her past experiences of anxiety and their impact on functioning; assess the focus, excessiveness, and uncontrollability of the worry and the type, frequency, intensity, and duration of his/her anxiety symptoms (consider using a structured interview such as The Anxiety Disorders Interview Schedule–Adult Version).

 

2. Verbalize an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.

 

1. Discuss how generalized anxiety typically involves excessive worry about unrealistic threats, various bodily expressions of tension, overarousal, and hypervigilance, and avoidance of what is threatening that interact to maintain the problem (see Mastery of Your Anxiety and Worry—Therapist Guide by Zinbarg, Craske, and Barlow; Treating GAD by Rygh and Sanderson).

 

2. Discuss how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively, reduce overarousal, and eliminate unnecessary avoidance. 3. Assign the client to read psychoeducational sections of books or treatment manuals on worry and generalized anxiety (e.g., Mastery of Your Anxiety and Worry—Workbook by Craske and Barlow; Overcoming Generalized Anxiety Disorder by White).

 

3. Learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.

 

1. Teach the client calming/ relaxation skills (e.g., applied relaxation, progressive muscle relaxation, cue controlled relaxation; mindful breathing; biofeedback) and how to discriminate better between relaxation and tension; teach the client how to apply these skills to his/her daily life (e.g., New Directions in Progressive Muscle Relaxation by Bernstein, Borkovec, and Hazlett-Stevens; Treating GAD by Rygh and Sanderson).

 

2. Assign the client homework each session in which he/she practices relaxation exercises daily, gradually applying them progressively from non-anxietyprovoking to anxiety-provoking situations; review and reinforce success while providing corrective feedback toward improvement.

 

4. Learn and implement a strategy to limit the association between various environmental settings and worry, delaying the worry until a designated “worry time.”

 

1. Explain the rationale for using a worry time as well as how it is to be used; agree upon a worry time with the client and implement.

 

2. Teach the client how to recognize, stop, and postpone worry to the agreed-upon worry time using skills such as thought stopping, relaxation, and redirecting attention (or assign “Making Use of the Thought Stopping Technique” and/or “Worry Time” in the Adult Psychotherapy Homework Planner by Jongsma to assist skill development); encourage use in daily life; review and reinforce success while providing corrective feedback toward improvement

 

5. Verbalize an understanding of the role that cognitive biases play in excessive irrational worry and persistent anxiety symptoms.

 

1. Assist the client in analyzing his/her worries by examining potential biases such as the probability of the negative expectation occurring, the real consequences of it occurring, his/her ability to control the outcome, the worst possible outcome, and his/her ability to accept it (see “Analyze the Probability of a Feared Event” in the Adult Psychotherapy Homework Planner by Jongsma; Cognitive Therapy of Anxiety Disorders by Clark and Beck).

 

6. Identify, challenge, and replace biased, fearful self-talk with positive, realistic, and empowering self-talk.

 

1. Explore the client’s schema and self-talk that mediate his/her fear response; assist him/her in challenging the biases; replacing the distorted messages with reality-based alternatives and positive, realistic self-talk that will increase his/her self-confidence in coping with irrational fears (see Cognitive Therapy of Anxiety Disorders by Clark and Beck).

 

2. Assign the client a homework exercise in which he/she identifies fearful self-talk, identifies biases in the self-talk, generates alternatives, and tests through behavioral experiments (or assign “Negative Thoughts Trigger Negative Feelings” in the Adult Psychotherapy Homework Planner by Jongsma); review and reinforce success, providing corrective feedback toward improvement.

 

 

Provider Signature:  ANNA SMITH, PMHNP-BC

 

 

Patient Signature:  Jill Smith

 

Notes:

 

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