Assessing Client Family Progress Paper
Assignment 2: Practicum – Assessing Client Family Progress
Learning Objectives
Students will:
• Create progress notes
• Create privileged notes
• Justify the inclusion or exclusion of information in progress and privileged notes
• Evaluate preceptor notes
To prepare:
• Reflect on the client family you selected for the Week 3 Practicum Assignment.
The Assignment
Part 1: Progress Note
Using the client family from your Week 3 Practicum Assignment (see attached assignment), address in a progress note (without violating HIPAA regulations) the following:
• Treatment modality used and efficacy of approach
• Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the treatment plan for 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 (e.g., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job)Assessing Client Family Progress Paper
• 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 (e.g., phone consultations with physicians, psychiatrists, marriage/family therapists)
• The 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 (e.g., 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
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 family from the Week 3 Practicum Assignment (see attached assignment).
In your progress note, address the following:
• 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 family’s progress note.
• Explain whether your preceptor uses privileged notes. If so, describe the type of information he or she might include. If not, explain why.
Required Readings
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.
• Standard 5G “Therapeutic Relationship and Counseling” (page 62)
Yalom, I. D., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.
The Theory and Practice of Group Psychotherapy, 5th Edition by Yalom, Irvin D. ; Leszcz, Molyn. Copyright 2005 by Hachette Books Group. Reprinted by permission of Hachette Books Group via the Copyright Clearance Center.
Chapter 5, “The Therapist: Basic Tasks” (pp. 117–140)
Chapter 8, “The Selection of Clients” (pp. 231–258)
Chapter 9, “The Composition of Therapy Groups” (pp. 259–280)
Crane-Okada, R. (2012). The concept of presence in group psychotherapy: An operational definition. Perspectives in Psychiatric Care, 48(3), 156–164.Assessing Client Family Progress Paper doi:10.1111/j.1744-6163.2011.00320.x
Lerner, M. D., McLeod, B. D., & Mikami, A. Y. (2013). Preliminary evaluation of an observational measure of group cohesion for group psychotherapy. Journal of Clinical Psychology, 69(3), 191–208. doi:10.1002/jclp.21933
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 March 18, 2017, from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health/
Introduction
The use of progress notes and privileged notes in counseling purposes to safeguard the privacy and confidentiality of patient documentation and analyzing the details collected during the sessions of therapy. It should clearly be understood that, a progress note is part of a medical record of a patient which they are also legally mandated to inspect. In contrast, privileged notes are always different from a client’s records. Therefore, even clients do not have any rights to view them. This paper is a comprehensive progress note and privileged note of a family that had been diagnosed with PTSD and is receiving psychodynamic therapy.
Part 1: Progress Note
Subjective Data
In Week 3, I assessed clients JH and EH who had been brought for mandatory therapy with complaints that they persistently abused their children which they saw nothing wrong in since they had been subjected to similar punishments when they were children. After a diagnosis of Post-Traumatic Stress Disorder for the clients was made; the client was placed on psychodynamic psychotherapy with an aim of ensuring that they understood the social, psychological, emotional and physical effects of corporal punishment to children and be able to adopt more effective parenting styles and acceptable ways of punishment (Levi et al., 2017). Psychodynamic therapy proved to be effective since the clients explained how they were able to develop more diplomatic ways of disciplining their children and making them understand any mistakes they made. Besides, the children had started to be more friendly, less anxious and fearful with their parents (Levi et al., 2017). Since the clients showed some progress in treatment, no modifications were made but it was highly recommended that they continue with therapy sessions as planned.
Objective Data
From a clinical perspective, based on the clients’ initial diagnosis of PTSD and clinical presentation of irritability, agitation and angered, today, the clients were not only well composed but also calm through the entire therapy session. The clients described the counseling sessions to be of benefit in changing thought patterns and individual behaviors through self-monitoring, to adopt more effective means of punishment. This far, the clients clearly expressed that, nothing would contribute to her withdrawal from the planned therapy sessions (Levi et al., 2017). However, it was notable that, upon mentioning taking legal action in case any reports about abuse were made, the clients appeared
Assessment
Although the clients had some concern for their children, there were significant improvements made in the general health status, personal behavior and decision making due to psychodynamic therapy. Besides, based on the fact that the clients attended all counseling sessions, it is undeniable that this is a good indicator towards compliance to treatment. Presently, the clients happened to be worrisome of their children’s wellbeing and whether they would understand and correct whenever they made any mistakes. Besides, the children found it much easier to stop question the love their parents had for them and automatically renewed their trust in their parents. The good outcomes in treatment could possibly be related to the fact that psychodynamic therapy was cheaper in comparison to other intervention approaches (Crane-Okada, 2012). Assessing Client Family Progress Paper
Plan
It was highly recommended that the therapy sessions schedule had to be re-scheduled to ensure the flexibility of all the parties involved based on days and time which they agreed to. The client was also referred to the local community support program which provided support to clients who had experienced PTSD in life which interfered with individual social and physical functioning. However, before the implementation of this recommendation, the client signed an informed consent.
The aim of this referral was to ensure that they receive moral and emotional support as well as any resources that would be needed for full recovery (Fonagy, 2015). Since the clients expressed no significant issues that would lead to early termination of therapy, a decision to continue with psychodynamic psychotherapy was done.
Part 2: Privileged Note for a Patients who have undergone Family Abuse
Based on week 3 practicum assignment and the client’s progress, the clients in this case were evidently individuals who got angered easily since during the session, they still revealed to be irritable, agitated and had varied mood status. The clients openly admitted to live in fear and anxiety of being punished in case they made any mistakes. Such patients receiving psychotherapy but show no or very minimal signs of improvement should be assessed further to find out the areas not being addressed in therapy (Busch & Milrod, 2018).
In psychotherapy, privileged notes detail some of the observations and changes which a therapist momentarily notices. The privileged note has no specific standards, form of writing or rules. Therefore, some of the items that would be included in the privileged note and not included in the family progress note are the client’s responses, moods and other physical observations. In comparison, the client’s progress note is more formal (Nicholson, 2002). I have realized that my preceptor prefers using progress notes as compared to privileged notes. This can be explained by the fact that progress notes are more comprehensive and discuss in details any clinical observations using a more formal and scientific language as compared to a privileged note which only includes quick observations (Nicholson, 2002).
References
Busch, F. N., & Milrod, B. L. (2018). Trauma-focused psychodynamic psychotherapy. Psychiatric Clinics of North America, 41(2), 277-287.Assessing Client Family Progress Paper
Crane-Okada, R. (2012). The concept of presence in group psychotherapy: An operational
definition. Perspectives in Psychiatric Care, 48(3), 156–164.
Fonagy, P. (2015). The effectiveness of psychodynamic psychotherapies: an update. World Psychiatry, 14(2), 137-150.
Levi, O., Shoval‐Zuckerman, Y., Fruchter, E., Bibi, A., Bar‐Haim, Y., & Wald, I. (2017). Benefits of a psychodynamic group therapy (PGT) model for treating veterans with PTSD. Journal of clinical psychology, 73(10), 1247-1258.
Nicholson, R. (2002). The dilemma of psychotherapy notes and HIPAA. Journal of AHIMA,
73(2), 38–39
Experiential and narrative family therapy
Part 1: Comprehensive client family assessment
Demographic information
The client family is presented as the ‘H’ family. This is a nuclear family comprised of four members and is of Latino origin. The father, JH, is married to EH (mother) and they have two male children, JrH and AH. JH is from a family of six members comprised of a father, deceased mother and three sisters. EH is from a family of seven members comprised of a father, mother, two sisters and two brothers.
Presenting problem
The H family has been presented for mandatory therapy. This is based on an initial welfare report that indicated signs of family abuse. In this case, the parents (JH and EH) are reported to have used corporal punishment on their children, contrary to child protection legislation. The report provides details that punishing the two boys (JrH and AH) would typically entail having them kneel down while holding up heavy reference books. While the parents see nothing wrong with this sort of punishment since they were subjected to the same as children, child protection legislation considers this as unnecessarily cruel and abusive punishment. The report further adds that there is a need to protect the children through one of two approaches. Firstly, having the parents change their parenting approach and use more acceptable forms of punishment. Secondly, withdrawing the two children from their home and placing them in foster care if the physical abuse continues (Cautin & Lilienfeld, 2015). The two parents are agitated by the report’s contents, insisting that they love their children and would not want them to be taken away. While despondent and crying, the mother mentions that she is doing the best that she can to raise good children and is only applying the approach that she best knows since this is how she was raised. She explains that she has always been considerate in ensuring that the punishment matches the offense. She becomes more agitated during the interview, stands up and paces around the interview office. The father is similarly agitated. He is animated and wildly gestures while stating that he is a good parent who follows the Bible by using the rod to raise good children. He further adds that it pains him to punish his children, but he must do so to condition them into becoming good people. He concludes that: “My parents raised me using the rod when I made mistakes, and I turned into a respectful, good and responsible adult. I want the same for my two sons”.Assessing Client Family Progress Paper
History of present illness
Both parents report that they were physically punished as children when they made mistakes. They were raised to link mistakes with punishment and that they punishment must be memorable enough to deter future thoughts of committing the same mistake.
Past psychiatric history
No history of psychiatric ailment.
Medical history
None of the family members is on any prescription medication. However, the father is a construction workers and he occasionally takes over the counter pain medication when he has had a long day at work.
Substance use history
The father and mother occasionally drink alcohol in social occasions. They have no history of recreational substance use.
Developmental history
The family members did not have any developmental delays.
Family psychiatric history
None of the family members suffers from a mental illness.
Psychosocial history
The family leads an active social life that revolves around going to work, attending school and spending time with friends and family in social events. JH works to meet the family’s financial needs. He mentions that his work as a construction worker does not pay well and he finds it a strain to meet his family’s financial needs. EH is a housewife who takes care of the domestic chores at home. She mentions that taking care of her husband and two children is a labor intensive endeavor that takes up most of time and leaves her with very little time for herself. JrH and AH are dependents who attend school.Assessing Client Family Progress Paper
History of abuse/trauma
JH and EH indicate and physical punishment was the norm when they were children and do not consider it abuse. They have been punishing their children from as early as they started school and feel that this is the right parenting approach.
Review of systems
General: All the family members have a straight posture.
Skin: They all have a good skin tone.
Head: JH has a history of headaches.
Eyes: They all have good vision.
Ears: No vertigo.
Nose: No running nose.
Mouth and Throat: No pain or sores.
Neck: No pain or masses.
Respiratory: No hemoptysis, sputum, wheezing, or cough.
Gatrointenstinal: No black stools, diarrhea, vomiting or nausea.
Genitourinary: No urination urgency or frequency.
Neurologic: No paralysis.
Musculoskeletal: JH has some joint and muscle pains that he attributes to his occupation.
Hematologic: No history of anemia or bleeding disorder.
Emotional: No history of psychiatric problems.
Physical assessment
General appearance: Alert appearance for all family members.
Skin: No abnormal lesions or moles.
Neck: No masses.
Cardiovascular: Regular rhythm and rate. No gallops, rubs or murmurs.Assessing Client Family Progress Paper
Lungs: No crackles or wheezes.
Mental status exam
All the family members were cooperative during the psychiatric assessment. JH was communicative and cooperative but easily irritated especially when his parenting style was questioned. He does not exhibit any discernible signs of mental or physical impairment. EH is similarly easily irritated when questions are raised about her parenting style.
Differential diagnosis
The diagnosis presented for the children is that they are suffering from abuse resultant from the corporal punishment they are routinely subjected to by their parents. They trust their parents to love and care for them, but they are forced to question the relationship when the punishment harms them (Thompson, 2016). The parents are diagnosed to have suffered some psychological harm as children, causing them to view harming their children as normal. They are transferring the harm to their children (Sadock, B., Sadock, V. & Ruiz, 2014). The differential diagnosis for both the parents and the children is PTSD. That is because they have been exposed to child abuse but have avoided the issue and considered it as normal. This implies that they have applied avoidance as a copying mechanism. DSM-V criteria supports the differential diagnosis, especially the fact that the whole family has been exposed to stressors that include directly experiencing physical abuse and witnessing others being abused (Sperry, 2016).
Case formulation
JH and EH express the opinion that children should be physically punished for mistakes so that they associate the pain from the punishment with the mistakes and it acts as a deterrence. The children question their parents love for them, especially when the punishment causes them physical pain.
Treatment plan
The children will be subjected to psychodynamic psychotherapy to enable them renew their trust in their parents. This is because this treatment approach is comparatively cheaper when compared to other approaches thus expected to reduce the financially anxiety that the patient exhibited (Sperry, 2016). The parents will be subjected to parenting classes that present them with alternative parenting styles. Additionally, they will be subjected to counselling that helps them to understand the harmful effects of physically punishing their children. Also, the counselling will address the psychological trauma they experienced from being physically punished as children (Wheeler, 2014).Assessing Client Family Progress Paper
Part 2: Family genogram
References
Cautin, R. & Lilienfeld, S. (2015). The encyclopedia of clinical psychology, volume II Cli-E. Hoboken, NJ: John Wiley & Sons.
Sadock, B., Sadock, V. & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Sperry, L. (2016). Handbook of diagnosis and treatment of DSM-5 personality disorders: assessment, case conceptualization, and treatment (3rd ed.). New York, NY: Routledge.
Thompson, R. (2016). Counseling techniques: improving relationships with others, ourselves, our families, and our environments (3rd ed.). New York, NY: Routledge.
Wheeler, K. (Eds.). (2014). Psychotherapy for the advanced practice psychiatric nurse: a how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.Assessing Client Family Progress Paper