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PRAC 6650: Psychotherapy with Groups and Families
July 26, 2020
Part 1: Progress Note
Client from Week 3 Assignment
Client was a 16 years old CJ from multicultural family who was referred for therapy by the school social worker and brought to counseling by her mother who was worried the child may involve in delinquent activities. Client had no prior diagnosis of mental illness. CJ who was a respectful little boy, began exhibiting defiant behavior about 6 months ago, not doing his schoolwork, constantly playing video games, smokes marijuana, lying to his parents and had become very disrespectful. Since then, his parents became concern of his poor school performance and imposed stricter rules thinking that it may help CJ abstain from the use of marijuana, limit the time he spends on playing video game and get him to focus on his schoolwork. Because of the strict rules imposed by his parents CJ decided to leave the house and went to stay with one of his friends without the parent’s knowledge. His drug use was worse that he would experience the following symptoms when he can’t get his marijuana: irritability, anger, sleep difficulty, feelings of emptiness and loneliness and restlessness which gets worst if he does not use marijuana. CJ’s parents were worried that CJ might involve in delinquent activities.
Treatment modality used and efficacy of approach
The treatment approach used for this client was brief strategic family therapy (BSFT) with CBT techniques. BSFT approach is based on the believe that dysfunctional family patterns of behavior are deeply rooted within the family and that the family’s misguided attempt to sole the problems my perpetuate the pattern (Wheeler, K. (Ed.)., 2014). Also, BSFT is flexible that it can be adapted to many different situations, cultures, and clinical dilemmas as it focuses on the process of how families interact in adaptive or maladaptive ways, with the view that specific interactional styles may vary across cultures and family compositions (Szapocznik, J., & Hervis, O. E., 2020).The mutually agreed goal of brief strategic family therapy (BSFT) for this client was to address his behavior problem including drug use. It was also intended to help address family aversive stimulus (punishment reinforcement), and maladaptive family functioning that are related with his drug use and other behavior issues including his poor performance at school and his defiant behavior. Treatment plan for this client includes 12 therapy sessions delivered once a week and lasting for 45minutes to hour per session. According to Horigian, V. E., Anderson, A. R., & Szapocznik, J. (2016), BSFT is usually done in 12–16 sessions, once a week for 1–1½ hours per session for over four months. Therapy started with a few orientation sessions with the family on the therapy and treatment approach. This was to help create a therapeutic relationship with the family and explain the treatment approach used. Client had attended up to 6 sessions out of the 12 sessions already. Strategic interventions to help change the dysfunctional family pattern were identified. Interventions were aimed at tracing individual family members’ beliefs and emotions, with much attention to the preexisting family processes presented early in treatment and implementing change strategies necessary to transform the family. Such strategies include changing the meaning of family interactions and using cognitive restructuring interventions. The interventions were also focused on helping his dad deal with his social and cultural pressures. On the part of the child, the issue targeted was abstinence behaviors such as participation in therapy, adherence to medication, and abstaining from marijuana use. Thus, the therapy was to help this family develop their abilities, consistent with the family’s culture and composition that may enable each family members to reach their potential.
Progress toward the mutually agreed-upon client
With the weekly brief strategic family therapy (BSFT) sessions, client attended all his therapy sessions with his parents and showed progress since client had reported decrease use of marijuana and improvement in his academic performance for this summer. His parents on the other hand began to realize how their strict rules used, to try to solve their son’s problem might have perpetuated his behavior patterns. His parents also admitted that they no longer use strict rules on the child as they had mutually agreed to use strategies suggested during the therapy session. That is, the parents had stop using what was discussed in the therapy as the negative enforcer, (that is taking away TV time and financial support) that had pushed him to ally more with his peers.
Modification(s) of the treatment plan that were made based on progress/lack of progress
Based on the progress made by this family, the therapy was modified to be held bi- weekly and not weekly a previously decided. Also, the client had seen a psychiatrist and agreed to stop self-medication and to start using prescribed medication. He was started on Prozac 10mg daily for one week which will be increased to 20mg daily if well tolerated to help with his symptoms (irritability, anger, sleep difficulty, feelings of emptiness and loneliness and restlessness).
Clinical impressions regarding diagnosis and or symptoms
Client is a 16-year-old multiracial male. CJ presents with a 6-month history of marijuana use, disrespectful and defiant behavior, and poor performance at school related to refusal to do his schoolwork. He is not on any prescribed medication at this time but reported self-medication with Benadryl for sleep. Denied involvement in any delinquent activity and there is no current indication that he is at risk for either violence or self-harm. He also has persistent symptoms of depression including irritability, anger, and feeling of loneliness and emptiness which gets worst when he does not get to use marijuana. He seems motivated to receive treatment and had actively participated in treatment decisions.
Relevant psychosocial information or changes from original assessment: Client’s behavior has improved, and he seems to focus on improving his academic performance.
Safety issues: None
Clinical emergencies/actions taken: None
Medications: Started on Prozac 10mg daily
Treatment compliance: Client is compliant with his prescribed medications and remains adherence and actively participates in family therapy.
Clinical consultations: Client continue to work with his psychiatrist, primary health provider and consult with his counselor during routine therapy sessions.
Collaboration with other professionals: Client encouraged to consult with his family physicians to monitor patient’s physical health.
The therapist’s recommendations
The therapist recommendation for this client is to continue brief strategic family therapy bi-weekly until he completes all twelve sessions per initial plan of care. This is because BSFT is usually done in 12–16 sessions, once a week for 1–1½ hours per session for over four months (Horigian, V. E., Anderson, A. R., & Szapocznik, J., 2016). Completing the necessary therapy sessions may further improve client’s symptoms and behavior. Therapist will continue to evaluate clients progress and amend plan of care as needed. Client is very open-minded and had expressed his willingness to continue family therapy with his parents. Since CJ belong to a different developmental stage, using family based psychotherapy approach may increase the likelihood of therapeutic efficacy and treatment adherence (Devlin, J. M., Toof, J., West, L., Andrews, N., & Cole, J., 2019). This recommendation was based on the mutual agreement between client, client’s family and the therapist.
Referrals made/reasons for making referrals: Client will continue to follow-up with his psychiatrist and primary care physician after completing his therapy. This may ensure continues monitoring, and effective management of client’s symptoms, promote adherence to treatment and improve functioning.
Termination/issues that are relevant to the termination process: There are currently no pertinent issues related to termination process since client is still receiving treatment. Client understands the benefits of being compliant with treatment and he is fully engaged, actively participates in therapy and is making progress.
Issues related to consent and/or informed consent for treatment
There are no issues related to informed consent at this time. Issues related to informed consent for treatment were address during the intake process. During the intake process, confidentiality and privacy issues were discussed and limits of confidentiality explained to all family members including their teenage son. All family members were provided with notice of privacy rules, patients right forms and the parents signed the authorization for disclosure giving the therapist permission to share client’s information with other stake holders involved in clients care as needed. Client was also informed of the treatment approach, the goal for treatment was mutually agreed on and client signed informed consent to agree to treatment.
Information concerning child abuse: There are no reports of child abuse at this time.
Information reflecting the therapist’s exercise of clinical judgment
The use of clinical judgement is a key element in clients care especially when it comes to assessing client’s mental health needs, diagnosing, determining the necessary intervention and how those needs can be met (Kienle, G. S., & Kiene, H., 2011). The therapist use of clinical judgement in this case is seen from how the patient was assigned the right diagnosis and on choosing the right psychotherapy approach to treat this client. Also, the decision to refer client for medication treatment in addition to psychotherapy also showed good clinical judgement. The therapist further monitored client for effectiveness of interventions and treatment plan was modified as based on client’s progress.
Part 2: Privileged Note
Psychotherapy notes are therapist private notes that include information recorded by the therapist during a counseling session with a client and often kept separate from the rest of the patient’s medical record (U.S. Department of Health & Human Services). Therefore, privileged psychotherapy note are the therapist observations about a client unique problem that may guide the therapist in monitoring clients progress. Since they are private, the notes are kept confidential because they contain sensitive information and may only be share with others involved in clients care with client’s authorization and are protected under Health Insurance Portability and Accountability Act (HIPAA) privacy rule. Unlike client family’s progress notes that can be shared with others involved in patients care, with privileged psychotherapy note, the therapist can still decide whether to release a patient’s psychotherapy notes even with a signed consent (DeLettre, J. L., & Sobell, L. C. ,2010).
Client Privilege psychotherapy note
During individual session with the client, client had revealed to the therapist that he is not comfortable being around his father because he thinks the father would not get it even with the therapy since he is too rigid. Client had also shared with the therapist that he steals money from his parents to buy drugs. He also mentioned that he might want to get away from the parents if the father continues to use his strict rules which according to the client is very aggressive and punitive. Clients father had also revealed that his dad use to spank them if they did something wrong and he thinks cutting of funds and imposing strict TV time for his son is not punitive. These note are important because it will help that therapist to identify client problem, prioritize and individualize treatment and monitor client’s problem so that they can be attended to in a timely manner (Cameron, S., & Turtle-Song, I. ,2002). My preceptor said she does not use privileged note as all necessary information and client’s therapy sessions are documented in the progress note.
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of counseling & development, 80(3), 286. https://doi-org.ezp.waldenulibrary.org/10.1002/j.1…
DeLettre, J. L., & Sobell, L. C. (2010). Keeping psychotherapy notes separate from the patient record. Clinical psychology & psychotherapy, 17(2), 160–163
Devlin, J. M., Toof, J., West, L., Andrews, N., & Cole, J. (2019). Integrative family counseling. The family journal, 27(3), 319–324. https://doi-org.ezp.waldenulibrary.org/10.1177/106…
Kienle, G. S., & Kiene, H. (2011). Clinical judgement and the medical profession. Journal of evaluation in clinical practice, 17(4), 621–627. https://doi.org/10.1111/j.1365-2753.2010.01560.x
Szapocznik, J., & Hervis, O. E. (2020). Applying brief strategic family therapy to different circumstances. In brief strategic family therapy. (pp. 157–172). American Psychological Association. https://doi-org.ezp.waldenulibrary.org/10.1037/000…
U.S. Department of Health & Human Services. (n.d.). HIPAA privacy rule and sharing information related to mental health. Retrieved from http://www.hhs.gov/hipaa/for-professionals/special…
Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.