Journal Entry

Introduction

The journal entry for this week will address effective documentation skills for group therapy sessions; I will develop diagnoses for 2 clients receiving group psychotherapy and evaluate the efficacy of cognitive behavioral therapy for groups using this group as a reference. Finally, I will analyze legal and ethical implications of counseling clients with psychiatric disorders.

Client #1

            MK is a 31-year-old Caucasian single mother, who is currently employed full time with USPS. She was raised with her siblings by their parents, her father is still living, but her mother is dead, cause of death is suicide following struggles with depression and anxiety. 

Presenting Problems

            Depression and Mood Disorders.

            MK is alert and oriented to person, place, time, and situation. Her clothing and hair are clean. She reported around four hours of sleep daily. She denies suicidal and homicidal ideation and denies any suicide attempts but admits struggling at work due to lack of concentration.

Medical History

            MK has struggled with depression for over 10 years; she sometimes isolates herself from family members and friends for days.  She does not report any incidence of abuse. She was first diagnosed with depression at the age of 19 and was placed on Fluoxetine 10mg once daily in the morning. She is currently on Zoloft 100mg daily.              

Diagnosis

Depressed mood and/or loss of interest or pleasure in life activities for at least 2 weeks and at least five of the following symptoms that cause clinically significant impairment in social, work, or other important areas of functioning almost every day

1. Depressed mood most of the day.

2. Diminished interest or pleasure in all or most activities.

3. Significant unintentional weight loss or gain.

4. Insomnia or sleeping too much.

5. Agitation or psychomotor retardation noticed by others.

6. Fatigue or loss of energy.

7. Feelings of worthlessness or excessive guilt.

8. Diminished ability to think or concentrate, or indecisiveness.

9. Recurrent thoughts of death (APA, 2000, p. 356). (American Psychiatric Association, 2013).

Group Therapy Progress Note

 Client:  Maria King                                                         Date: 6-17-2018

Group name:________________________________________________ Minutes: 45 

Group session # 4               Meeting attended is #: 2 for this client.

Number present in group 2 of 2 scheduled Start time:  11 AM              End time: 11:50 AM

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 ❑ AnxiousDepressed ❑ Angry ❑ Euphoric ❑ Other: _______________

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

5. Mental status: ❑ 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/fewer ❑ Different stressors ❑ More/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: Self introduction Expression of feelings and issues experienced Discussion on coping skills
 
 
 
   
Home Work:         Other Comments:            

Client #2

            CP is a 33-year-old married, Hispanic female who is employed as a nurse in a local level one trauma center. She lives with her husband and three children aged 10, 11 and 17 in a gated low crime community. She was previously married, but her husband who was a truck driver was killed in a road rage incident barely 3 months after their wedding. She immigrated to the United States with her parents at the age of 2; her father is a construction worker while her mother trained to become a certified nursing assistant.

The Presenting Problem

            PTSD, Anxiety, and Depression

The client is alert and oriented to person, place, time, and situation. Her clothing and hair are clean. She reported to around four hours of sleep daily. She denies suicidal and homicidal ideation and denies any suicide attempts but admits struggling at work due to lack of concentration.          

Medical History

            CP has never seen a therapist or seek psychological help as a child or adult. There is no relevant past psychological history until she lost her first husband and she slipped into depression. Her 17-year-old daughter is from her first marriage. She is currently on a combination of Paxil 40mg once daily and Xanax 1 mg twice daily as needed. She reports severe anxiety whenever her husband is late and has some phobia for driving. Recently her 15-year-old has requested to learn how to drive, and she opposed it but was convinced by her husband that road rage is not an everyday event.           

Diagnosis

Posttraumatic Stress Disorder (PTSD) is a form of anxiety disorder that is caused by an event that creates psychological trauma; to make a definitive diagnosis, clinical symptoms must be present for at least one month (American Psychiatric Association, 2013). The criteria for PTSD include specifying qualifying experiences of traumatic events, four sets of symptom clusters, and two subtypes. There are also requirements around duration of symptoms, how it impacts one’s functioning and ruling out substance use and medical illnesses.

Criterion* Description Specific examples
Criterion A Exposure to stressor • Direct exposure
• Witnessing trauma
• Learning of a trauma
• Repeat or extreme indirect exposure to aversive details
Criterion B Intrusion symptoms • Recurrent memories
• Traumatic nightmares
• Dissociative reactions (flashbacks)
• Psychological distress at traumatic reminders
• Marked physiological reactivity to reminders
Criterion C Persistent avoidance • Trauma-related thoughts or feelings
• Trauma-related external reminders such as people, places or activities
Criterion D Negative alterations in cognitions and mood • Dissociative amnesia
• Persistent negative beliefs and expectations
• Persistent distorted blame of self or others for causing trauma
• Negative trauma-related emotions: fear, horror, guilt, shame and anger
• Diminished interest in activities
• Detachment or estrangement from others
• Inability to experience positive emotions
     
     

Group Therapy Progress Note

 Client:  Clarisse Pearce                                                                  Date: 6-17-2018

Group name:________________________________________________ Minutes: 45 

Group session # 2               Meeting attended is #: 2 for this client.

Number present in group 2 of 2 scheduled Start time:  11 AM              End time: 11:50 AM

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 ❑ AnxiousDepressed ❑ Angry ❑ Euphoric ❑ Other: _______________

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

5. Mental status: ❑ 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/fewer ❑ Different stressors ❑ More/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: Self introduction Expression of feelings and issues experienced Discussion on coping skills
 
 
 
   
Home Work:         Other Comments:            

Legal and Ethical Implications of Counseling

            The Health Insurance Portability and Accountability Act (HIPAA), ensures that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high-quality health care and to protect the public’s health and well-being. Maintaining confidentiality in group therapy can be challenging, the psychologist/psychiatrists does not have absolute control on the confidentiality of information provided and therefore cannot assure group member that information provided during the session would be kept private. The provider should, however, make it clear that there is a risk of information shared in the group may not be secure. Every effort must be made to provide participants with education on the need to maintain confidentiality. Trust will ensure the flow of information and optimize therapy. The legal obligation to provide information to protect the patient and the community overrides confidentiality either in the individual therapy or group therapy.

Appropriateness of Cognitive Behavioral Therapy for this Group

            The cognitive-behavioral model of therapy proposes that clients with substance abuse problems lack the effective coping skills to deal with situations and give in to temptation (Marlatt & Donovan, 2008). Cognitive behavioral therapy (CBT) is based on three levels of cognition which includes dysfunctional assumptions, core beliefs, and negative automatic thoughts. CBT is that it emphasizes self-discovery in the client (McLeod, 2015) and would be beneficial for clients in this group because it will help them to conceptualize the reasons behind their thoughts and empower them to make positive changes. CBT would be appropriate for this patient, but a comprehensive approach to treatment to increase the client’s chance for success (Keane, 2018).

Reference

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

Fenn, K., & Byrne, M. (2013). The key principles of cognitive behavioral therapy. Education and inspiration for general practice, 6(9), 579-585. doi:10.1177/1755738012471029

Keane, H. (2018). Facing addiction in America: The Surgeon General’s Report on Alcohol,           Drugs, and Health U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, OFFICE OF THE SURGEON GENERAL Washington, DC, USA: U.S. Department of     Health and Human Services, 2016 382 pp. online (gre. Drug and Alcohol Review, 37(2),      282-283. doi:10.1111/dar.12578

Marlatt, G. A., & Donovan, D. M. (2008). Relapse prevention: Maintenance strategies in the treatment of addictive behaviors.

McLeod, S. A. (2015). Cognitive behavioral therapy. Retrieved from  www.simplypsychology.org/cognitive-therapy.html