Assessing Client Progress HW

To prepare:

• Reflect on the client you selected for the Week 3 Practicum Assignment.
• Review the Cameron and Turtle-Song (2002) article in this week’s Learning Resources for guidance on writing case notes using the SOAP format.

The Assignment

Part 1: Progress Note

Using the client from your Week 3 Assignment, address the following in a progress note (without violating HIPAA regulations):

• Treatment modality used and efficacy of approach
• Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
• Modification(s) of the treatment plan that were made based on progress/lack of progress
• Clinical impressions regarding diagnosis and/or symptoms
• Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
• Safety issues
• Clinical emergencies/actions taken
• Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
• Treatment compliance/lack of compliance
• Clinical consultations
• Collaboration with other professionals (i.e., phone consultations with physicians, psychiatrists, marriage/family therapists, etc.)
• Therapist’s recommendations, including whether the client agreed to the recommendations
• Referrals made/reasons for making referrals
• Termination/issues that are relevant to the termination process (i.e., client informed of loss of insurance or refusal of insurance company to pay for continued sessions)
• Issues related to consent and/or informed consent for treatment
• Information concerning child abuse, and/or elder or dependent adult abuse, including documentation as to where the abuse was reported
• Information reflecting the therapist’s exercise of clinical judgment

Note: Be sure to exclude any information that should not be found in a discoverable progress note.

Part 2: Privileged Note

Based on this week’s readings, prepare a privileged psychotherapy note that you would use to document your impressions of therapeutic progress/therapy sessions for your client from the Week 3 Practicum Assignment.

• The privileged note should include items that you would not typically include in a note as part of the clinical record.
• Explain why the items you included in the privileged note would not be included in the client’s progress note.
• Explain whether your preceptor uses privileged notes, and if so, describe the type of information he or she might include. If not, explain why.

 

 

Comprehensive Client Assessment

Walden University

PRAC 6640: Psychotherapy with Individuals 

06/20/20

 

 

Comprehensive Client Assessment

            Develop a suitable treatment plan; a comprehensive client assessment is needed during the initial appointment (Wheeler, 2014). Assessment is a detailed report that evaluates the social, physical, family, and mental history of the client and, therefore, can help create a client relationship. Proper client evaluation guides the treatment plan (Phillips, Frank, Loftin, & Shepherd, 2017). This paper aims to include a detailed client evaluation that provides for a client’s differential diagnosis and treatment plan identified or advised. Additionally, a family genogram will be shown.

Demographics Information:

JJ is a 35-year-old Hispanic male. Reports English as its primary language but speak Spanish. He has been married for four years, said his wife is very supportive and has a 3-year-old son. Both coupes are were brought up as lone children in their families. One of the grandmothers of the client is still alive, while for the client’s wife, all grandparents are still alive. Both parents, coupes parents, are alive. The client Attended and graduated from high school, and he’s currently employed full time as a store manager.

Presenting Problem:

             Client report incidences of being exposed to traumatic events during his childhood. More specifically, he was exposed to harsh forms of punishment, which included carrying books for a prolonged time after being found irresponsible for any act. The presenting problem was the high level of trauma-exposed to JJ. The client was also left with the encyclopedia, which he used to carry around as a form of punishment. Both parents would exert the same punishment over and over again, even though the client indicated being harmed by the procedure.

History of Present Illness:

The client does not provide any detailed history of any illness.

Past Psychiatric History

The client denies any psychiatric problems. Nonetheless, it is essential to point out that the client did not receive any form of treatment after being exposed to the current traumatic events in his life. The client’s mother suffered from postpartum depression after birth. There are no substance abuse issues, Denies suicide attempts, or a history of alcohol abuse in her family. The client denies a family history of seizure.

Medical History:

Asthma and Migraine

Developmental History:

The client was born and raised by both parents in New York. The client reported born at 40 weeks without any complications in a vaginal birth. He doesn’t recall any developmental delays. He walked by eight months and enrolled in pre-school at the age of three. Patient dated a girl at age 17 and lost his virginity at age 18 but ended the relationship after graduating high school on mutual grounds. He denies emotional distress. The client denies any sexual abuse/ physical abuse in relationships, and has chosen to practice abstinence until marriage, denies legal history.

Substance use History:

The client denies drug use or abuse and denies alcohol problems. He only drinks occasionally.

Psychosocial History:

The client is from a family of three: Father, mother, the patient. Mother is 60 years old, and Father is 65 years old, was diagnosed with heart disease, took many medications, and had a pacemaker. Father never had mental illness nor abusing drugs. Mother has Asthma and taking medication. Mother was diagnosed with depression and anxiety and presently taking medications. The mother never used illicit drugs.

 

Family Psychiatric History:

Mother has depression

Father’s an alcoholic

 

History of Abuse/Trauma

The client provided a detailed explanation of the incidences of trauma in his life. More specifically, when he was required to give information on how to discipline his son and whether the client would prefer using comparative methods used to punish him. The client indicated that when his father was mad at him, he would send him to get books from the encyclopedia and would make him hold them out straight for a while until he would tell him to stop.  The client indicated feeling high levels of pain in his arms to the point of breaking off.  The client also indicates that his mother did the same thing, except that when the mother was mad, he made him carry more books than his father. The client indicates hating the books and never goes near the books, although the client inherited the books.

Review of Systems

A physical exam was carried out to assess whether some of the observed effects could be visibly observed in different systems of the body.

Constitution:   indicates feeling traumatized every time he sees books that were used to punish him during the childhood phase.

Eyes:  No visual loss, blurred vision, double vision, or yellow sclerae.

Ears: Client indicates hearing everything well, denies hearing loss

Nose: Denies sneezing, congestion, runny nose, or a sore throat.

Throat and Mouth: No dysfunction is reported in either the mouth or throat.

Head and Neck:  Denies any headaches or neck pain.  She also denies any injuries to the head.

Respiratory: Denies shortness of breath, cough, or sputum.

Cardiovascular: Denies chest pain, chest pressure, or chest discomfort. No palpitations or edema.

Gastrointestinal: The client indicates having a better appetite. However, every time he thinks of past traumatic events, he indicates a reduced feeding habit.

Genitourinary: Denies burning on urination.

Musculoskeletal: Denies any musculoskeletal problem.

Neurologic:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities

Psychiatric: The client is still angry at the methods that were used to punish him at a relatively young age. He also indicates feeling sad or hopeless when he looks at the books that were left behind by his parents, considering the same books were used to punish him.

Mental Status Exam:

Appearance:  The client was healthy for his weight and appeared to have been fed properly. The body weight was also proportional to their weight.

Attitude and Behavior: the client was calm and composed and did not fidget at any point. However, the client started fidgeting when explaining trauma conditions in their life.

Speech:  A normal tone was used to during the entire interview session

Motor Activity: The client did not report any form of motor issues during the entire period the interview was being carried out.

Affect and mood:  Mood slightly changed when talking about traumatic events in his life. His mood also lightened when talking about family members and their generation.

Temperament: The client was quite inattentive and did not report any frequent distractions.

Perception: The client reported incidences of hallucinations a number of times.

Thought Processes: The client answered the question in the required manner without deviating from the main problem being asked by the interview.

Thought Content: The client’s response was well understood.

Sensorium and Cognition: Client did not report any trouble in concentrating on one idea

Memory: The client remembers all aspects of their life without showing any incidences of memory loss.

Abstract thought: The abstract, though the patient was not tested.

Intelligence: The intelligence levels of the patient was within the required standard.

Insight: The patient’s insights were not reported.

Judgment: The client showed incidences of trauma-based on past experiences.

Physical Assessment and Neurological Examination

Vital Signs:  BP-90/60, HR-70, RR-18, T-97.5F

Height/Weight: Ht: 5.9”, Wt: 170 lb

BMI: 25.1

Pain:  The client denies any pain/discomfort

Neurological Exam: No syncopal episodes or dizziness, no paresthesia, headaches. No change in memory or thinking patterns; no twitches or abnormal movements; no history of gait disturbance or problems with coordination. No falls or seizure history.

Mental Exam: The client was alert during the entire course and did not seem to be distracted by any objects present in the room. The client’s attention was fixed on the interview asking all the required questions.

Lab/Diagnostic Testing

There is no specific laboratory test that could be carried out to assess trauma in the patient. However, the patient was provided with a set of validated questionnaire tools used to evaluate the patient’s levels of trauma.  The Complex Trauma Questionnaire indicated by Vergano et al. (2018) is commonly used to assess levels of trauma in adults related to previous incidences in children.

Differential Diagnosis:

The diagnostic criteria for PTSD indicate that the patient must have been exposed to some stressful events or situations which must be exceptionally threatening to the patient  (Kessler et al., 2017). Another common symptom associated with PTSD includes persistent remembering or relieving some of the frequent intrusive flashbacks related to the stressor (Wynn & Ursano, 2016). The client reported increased levels of trauma while remembering the nature of punishment meted out during his childhood.  The other symptom is the patient exhibiting preferred or actual avoidance in the presence of the stressor. The client also indicated the inability to recall some essential aspects related to exposure to the stressor. For instance, he failed to provide information regarding the type of mistake made—other persistent symptoms including hypervigilance, difficulty in concentrating as well as irritability outbursts in anger. PTSD differs severally from other conditions including that are associated with trauma.  However, these conditions differ based on specific aspects.

1. Depression is characterized by low predominance mood, loss of interest, suicidal ideation, and lack of energy.
2. Adjustment disorders which are characterized by different patterns of symptoms
3. Specific phobia which is linked to avoidance and fear of specific situations
4. Neurological damage is associated with having sustained trauma during a specific event.

Case Formulation

The client showed high levels of trauma-based on past childhood abuses. Unfortunately, he was not provided with any form of treatment and was also forced to inherit the same books that were associated with the trauma. Thus, he has been continuously exposed to the same trauma over a defined time and may explain the current exacerbations in the observed symptoms.

Treatment Plan

Trauma-focused cognitive behavioral therapy, commonly abbreviated as TF-CBT, can be used in the management of trauma. The approach is evidence-based and has been used successfully in managing incidences of childhood trauma among various populations, including among adults, adolescents, and children. The approach is commonly associated with specific components including parenting skills and psychoeducation, relaxation, cognitive coping, conjoined parent and child sessions, narrating and processing trauma, and enhancing safe practices (Rosaura Polak et al., 2015). One key component that will be essential in dealing with the trauma observed in the current patient involves having the parents as being part of the therapeutic process provided the parent admits that the approaches used were associated with an increased incidence of trauma in him.

Medication/Medication Adjustment:

The client could be provided with selective serotonin reuptake inhibitors (SSRI) as a drug aimed at reducing some of the adverse effects associated with high levels of trauma. The approach can be used in combination with psychotherapy measures. Combinational treatment in the management of trauma has proven to be one of the effective approaches in the management of trauma.

Assessment Tools with Rationale:

Specific tools, including Complex Trauma Questionnaire, suggested by Vergano et al. (2018), measures the levels of childhood trauma among adults. The tools could be used before the start of the study to assess the level of trauma in him. The approach should then be used to assess the trauma level after the application of TF-CBT and the provision of pharmacological treatment.  The assessment can be done quarterly to allow continuous monitoring of the patient’s condition.  The results of the assessment tools can be used to provide information on whether the applied treatment is effective.

Referrals and Rationale:

Client condition will be monitored progressively after the application of the treatment. In case the condition of the patient does not significantly improve after the application of the treatment, he could be referred to other treatment approaches commonly used in the management of trauma or PTSD. Some conventional approaches include the use of behavioral therapy as well as eye movement desensitization and reprocessing (EMDR). These two approaches have proven effective in PTSD management and in reducing levels of trauma among adults.

Therapy and Rationale:

TF-CBT has been chosen as the main psychotherapy approach since it provides an opportunity for the patient and parent to directly meet and address issues related to the patient’s traumatic incidences from a tender age. The client’s father, who has been accused of being part and parcel of the related traumatic occurrences in the client, will be part of the study. The client’s father will only be included in the approach if it is proven that the father shows a change in attitude and behavior regarding the trauma events reported by him. Having both the parent and the victim in the treatment process plays an essential role in addressing some of the common symptoms and, at the same time, could aid in resolving the existing issues related to past traumatic events. Failure to mend the relationship between the two parties is most likely to exacerbate some of the commonly observed symptoms.

Legal Issues:

The client is above 18 years of old and, therefore, does not require any form of parental consent in accessing any type of preferred treatment.

Patient Education:

The client will be educated on the various approaches that can be used to reduce the incidence of trauma in their life. He will be provided with alternative educational material that will provide information on how to cope with trauma. He will also be educated on more effective approaches that can be used as disciplinary measures considering that intergenerational incidences of abuse are common among individuals who reported different forms of abuse during childhood.

Family Genogram

	Key *Alcohol Abuse +  Depression

 

KEY

+Depression

*Alcohol Abuse

 

References

Kessler, R. C., Aguilar-Gaxiola, S., Alonso, J., Benjet, C., Bromet, E. J., Cardoso, G., … Koenen, K. C. (2017). Trauma and PTSD in the WHO World Mental Health Surveys. European Journal of Psychotraumatology, 8. https://doi.org/10.1080/20008198.2017.1353383

Phillips, A., Frank, A., Loftin, C., & Shepherd, S. (2017). A detailed review of systems: An educational feature. The Journal for Nurse Practitioners, 13(10), 681-686. doi:10.1016/j.nurpra.2017.08.012

Rosaura Polak, A., Witteveen, A. B., Denys, D., & Olff, M. (2015). Breathing Biofeedback as an Adjunct to Exposure in Cognitive Behavioral Therapy Hastens the Reduction of PTSD Symptoms: A Pilot Study. Applied Psychophysiology Biofeedback, 40(1), 25–31. https://doi.org/10.1007/s10484-015-9268-y

Vergano, C. M., Lauriola, M., & Speranza, A. M. (2018). The Complex Trauma Questionnaire (ComplexTQ): Development and preliminary psychometric properties of an instrument for measuring early relational trauma. Frontiers in Psychology, 6. https://doi.org/10.3389/fpsyg.2015.01323

Wynn, G. H., & Ursano, R. J. (2016). Posttraumatic stress disorder. In The Curated Reference Collection in Neuroscience and Biobehavioral Psychology (pp. 373–378). https://doi.org/10.1016/B978-0-12-809324-5.05378-5

Wheeler, K. (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

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