Assignment: What is Psychotherapy?
Assignment: What is Psychotherapy?
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Assessing Client Progress
Learning Objectives
Students will:
Assess progress for clients receiving psychotherapy
Differentiate progress notes from privileged notes
Analyze preceptor’s use of privileged notes
To prepare:
Reflect on the client profile below
Review the Cameron and Turtle-Song (2002) article in the Learning Resources for guidance on writing case notes using the SOAP format. (Template uploaded)
The Assignment
N/B: PLEASE Addressed each of the bullets with a subtopic, please you can add other good references related to the assignment. All must be cited as an in-text citation in each paragraph. If you have to use other articles, they must be within last five years only that is from 2014 to 2018.
 
Part 1: Progress Note
Using the client profile below, 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 profile below.
Addressed each of the bullets with a subtopic
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.
REFERENCES
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.
Chapter 5, “Supportive and Psychodynamic Psychotherapy” (pp. 238–242)
Chapter 9, “Interpersonal Psychotherapy” (pp. 347–368)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
Abeles, N., & Koocher, G. P. (2011). Ethics in psychotherapy. In J. C. Norcross, G. R. VandenBos, D. K. Freedheim, J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 723–740). Washington, DC: American Psychological Association. doi:10.1037/12353-048
Cameron, S., & Turtle-Song, I. (2002). Learning to write case notes using the SOAP format. Journal of Counseling and Development, 80(3), 286–292. Retrieved from the Academic Search Complete database. (Accession No. 7164780)
Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA, 73(2), 38–39. Retrieved from http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4http://library.ahima.org/doc?oid=58162#.V5J0__krLZ4
 
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-topics/mental-health/
Required Media
Sommers-Flanagan, J., & Sommers-Flanagan, R. (2013). Counseling and psychotherapy theories in context and practice[Video file]. Mill Valley, CA: Psychotherapy.net.
Note: For this week, view Reality Therapy, Feminist Therapy, and Solution-Focused Therapy only.
Stuart, S. (2010). Interpersonal psychotherapy: A case of postpartum depression [Video file]. Mill Valley, CA: Psychotherapy.net.
The approximate length of this media piece is 110 minutes.
Client profile that must be used to write the above paper (you can add information that might be useful to make the story flow)Please do not copy and paste client profile to SOAP note(Plagiarism)
: Comprehensive Client Family Assessment
Demographic information: This covers the characteristics of a population. Some of the characteristics examined are race, ethnicity, gender, age, education, profession, occupation, income level and marital status (Mabey, 2015). Juan Hernandez is a 45-year-old Mexican male a married to Elena Hernandez who is also a 43-year-old Mexican lady. (Not real client names)
Presenting problem: This refers to the initial symptoms that lead someone to seek help from a doctor or other provider (American Psychiatric Association, 2013). The Juan Hernandez as the head of his family is seeking counseling to address his frustrations and worries he experiences, parenting his children. He is accompanied by his wife Elena who is encouraging him to seek help because she is stressed out as well. He expressed feeling anxious, depressed, and angry most times which makes him harsh to his children. He is also worried that he might have inherited some traits from his parents on hard parenting methods.
History or present illness: Juan Hernandez reports having an anger outburst since middle school which was never evaluated and treated because it was “normal” for his family. He reports that the feelings resurfaced after he started feeling stressed out and frustrated with his children. They have no serious, severe illness as well.
Past psychiatric history: Juan Hernandez has never been diagnosed with any mental health problem.Hence, the client has had no case of mental illness other than the current instance of uncontrolled anger, anxiety, and depression. His wife Elena has no mental health history.
Medical history: Juan Hernandez was recently diagnosed with hypertension and he reports that his father is hypertensive as well. Elena his wife has no medical problems.
Substance use history: Juan Hernandez denies any use of illegal drugs. There are no substance use incidences in the past of Juan or Elena.
Developmental history refers to a person’s growth. Both clients have not reported any case of developmental complications. Juan and Elena were born full term and grew normally.
Family psychiatric history refers to cases of any mental illness in the family and relatives of the clients. Juan has not reported any cases of family psychological history. Despite the fact that Juan’s parents were hard on him with angry tones most times, they were never diagnosed with mental health problems. Elena as well has not reported any case of family physiological history.
Psychosocial history, this is the client’s background on matters relating to the interrelation of social factors and individual thought and behavior. Juan is a construction worker and has few friends that he chats with occasionally.
History of abuse/trauma refers to cases of repeated treatment of an individual in cruelty or violence (Wheeler, 2014). Juan has had instances of trauma out of violence treatment from both his parents. This made him hate schooling and hence become severely affected. Something that he is worried might happen as well to his family. Elena expresses no history of trauma.
Review of systems, this is a technic used by healthcare providers for eliciting a medical history from a patient (Mabey, 2015). Juan reported general fatigue and difficulties sleeping at night. Neurologic; dizziness sometimes. Gastrointestinal: decreased appetite and constipation. Psychiatric; stress and depression. Elena ROS; General: Neurologic: No issues reported. Gastrointestinal heartburn and constipation
Physical assessment refers to the structured examination perform by any health provider to collect the complete data about a patient. In this assessment, the provider used observation, inspection, palpation, auscultation, and percussion. Juan proved to be physically fit and no case of complications as well as Elena.
The mental status exam is the evaluation of the individual’s current mental capacity through the evaluation of general appearance, behavior, any great belief and perception, mood and all aspects of cognition. Juan is alert, and oriented x3, neatly groomed, has appropriate affect and mood, speech clear and coherent and sufficient cognition noted. No sign of abnormality noted. Elena’s mental state also proved to be fit as well. Juan and Elena deny suicidal and homicidal ideations.
Differential diagnosis, this refers to the process of distinguishing a particular disease or disorder from the others that share similar clinical features. Juan was evaluated to have generalized anxiety with anger symptoms, a Depressive disorder associated with insomnia and decreased appetite, and lastly hypertension.
Case formulation means problems formulation that involved a theoretically based explanation of the information obtained from a clinical assessment (Mabey, 2015). Juan presented a problem of being too angry, and this problem was contributed by trauma that he had as a child from his parent’s punishment when they were angry. The client has been in this state by repetition of the same situations. The client has access to the medical care as a way of accessing health. Elena presented her situation as being stressed by Juan actions and fearful attitudes of their children.
Treatment plan involves guidelines for helpful ways of ensuring that the client has been saved from the disorder shown (Young, & Solomon, 2009). Juan is an intelligent man the clinic will support him by offering psychoeducation. The interventions involve talk therapy, client will explore feelings and coping skills in life situations, explore measures of self-control and remain safe, be able to express self calmly without anger, develop holistic self-care to manage life stressors, explore his experiences and how they impact his relation to himself and others and how it contributes to experienced anxiety and, explore sleep hygiene ways to improve sleep. Juan and Elena will explore helpful and good parenting strategies to help guide their children upbringing.
References for client profile above
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders(5th ed.). Washington, DC: Author.
Mabey, L. (2015). Psychotherapy for the Advanced Practice Psychiatric Nurse: A How-to Guide for Evidence-Based Practice. Journal of EMDR Practice and Research, 9(1), 71.
Waters, I., Watson, W., & Wetzel, W. (2014). Genograms. Practical tools for family physicians. Canadian Family Physician, 40, 282.
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.
Assignment: What is Psychotherapy?
Assignment: What is Psychotherapy?
Assignment: What is Psychotherapy?
Assignment: What is Psychotherapy?
Assignment: What is Psychotherapy?
Young, J. M., & Solomon, M. J. (2009). How to critically appraise an article. Nature Reviews Gastroenterology and Hepatology, 6(2), 82.
You must proofread your paper. But do not strictly rely on your computer’s spell-checker and grammar-checker; failure to do so indicates a lack of effort on your part and you can expect your grade to suffer accordingly. Papers with numerous misspelled words and grammatical mistakes will be penalized. Read over your paper – in silence and then aloud – before handing it in and make corrections as necessary. Often it is advantageous to have a friend proofread your paper for obvious errors. Handwritten corrections are preferable to uncorrected mistakes.
Use a standard 10 to 12 point (10 to 12 characters per inch) typeface. Smaller or compressed type and papers with small margins or single-spacing are hard to read. It is better to let your essay run over the recommended number of pages than to try to compress it into fewer pages.
Likewise, large type, large margins, large indentations, triple-spacing, increased leading (space between lines), increased kerning (space between letters), and any other such attempts at “padding” to increase the length of a paper are unacceptable, wasteful of trees, and will not fool your professor.
The paper must be neatly formatted, double-spaced with a one-inch margin on the top, bottom, and sides of each page. When submitting hard copy, be sure to use white paper and print out using dark ink. If it is hard to read your essay, it will also be hard to follow your argument.

ADDITIONAL INSTRUCTIONS FOR THE CLASS
Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, include a minimum of one scholarly source, and be at least 250 words.
Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source.
One or two sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words.
I encourage you to incorporate the readings from the week (as applicable) into your responses.

Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately.
In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies.
Participation posts do not require a scholarly source/citation (unless you cite someone else’s work).
Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

APA Format and Writing Quality

Familiarize yourself with APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required).
Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation.
I highly recommend using the APA Publication Manual, 6th edition.

Use of Direct Quotes

I discourage overutilization of direct quotes in DQs and assignments at the Masters’ level and deduct points accordingly.
As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content.
It is best to paraphrase content and cite your source.

 
LopesWrite Policy

For assignments that need to be submitted to LopesWrite, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me.
Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes.
Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own?
Visit the Writing Center in the Student Success Center, under the Resources tab in LoudCloud for tips on improving your paper and SI score.

Late Policy

The university’s policy on late assignments is 10% penalty PER DAY LATE. This also applies to late DQ replies.
Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances.
If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect.
I do not accept assignments that are two or more weeks late unless we have worked out an extension.
As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

Communication

Communication is so very important. There are multiple ways to communicate with me:

Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class.
Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

 

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