Group Therapy Documentation

Group Therapy Documentation

Students will:

  • Develop effective documentation skills for group therapy sessions *
  • Develop diagnoses for clients receiving group psychotherapy *
  • Evaluate the efficacy of cognitive behavioral therapy for groups *
  • Analyze legal and ethical implications of counseling clients with psychiatric disorders *

* The Assignment related to this Learning Objective is introduced this week and submitted in Week 10.

Select two clients you observed or counseled this week during a group therapy session. Note: The two clients you select must have attended the same group session.

Then, in your Practicum Journal, address the following:

  • Using the Group Therapy Progress Note in this week’s Learning Resources, document the group session.
  • Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.
  • Using the DSM-5, explain and justify your diagnosis for each client.
  • Explain whether cognitive behavioral therapy would be effective with this group. Include expected outcomes based on this therapeutic approach.
  • Explain any legal and/or ethical implications related to counseling each client.
  • Support your approach with evidence-based literature.



Group Therapy Documentation


Documentation of sessions in psychotherapy is considered an essential aspect for practitioners. The act enables psychotherapists to have a strong foundation for their clinical decisions. Moreover, documents act as a source of reference. Therefore, they may have legal and ethical implications (Amico et al., 2019). The paper develops documentation of a group therapy session, explains viability of a therapy, and depicts legal and ethical consequences regarding the clients.

Group Session Documentation

Jake reveals that he has fear and nightmares based on his experience in Iraq. He shows that he feels regretful for not keeping his friend’s last request of letting him to kill him. He also shows that many veterans are suffering, with a high rate of suicidal incidences. Bill also reveals that he is facing fear due to their bombing experience. In his words, none was supposed to see the images that occurred during the bombing period. He also suffers from hallucinations as he hears mortar rounds and tries to reach for his helmet and weapons. His narration shows that he has not adjusted well to civilian life (Fulton, 2016).


Jake and Bill show that their fear has led to other social problems. For instance, they both drink heavily to forget about the images. In addition, they have problems interacting with other people. Jake shows that he has gotten into fights with his wife after the Iraq incident. The clients reveal that they want to have a normal life. Jake shows that he is expecting a baby. Therefore, his situation is making it difficult to make suitable goals with his family. Bill shows that he is having problems in making decisions concerning his feeding habits (Fulton, 2016).

Clients’ Description

Both Jake and Bill are marine veterans who experienced a similar traumatizing incident in Iraq. They are ex-marine soldiers. Jake is married and has an expectant wife. Bill’s family life is unknown. There is no previous medical record indicating that the clients have had fear issues in their lives before (Kalisch et al., 2017).

Clients’ Diagnosis

The subjective information shows that Jake has fear-related issues. He also feels anxious at times.  It is evident that his major fear emanates from the bombing incident in Iraq. This shows that the incident may have traumatized his psychology. Therefore, Jake is diagnosed of post-traumatic stress disorder (PSD). Bill is also diagnosed of PSD. This issue is revealed in his revelation of nightmares related to the Iraq incident. He also has some severe anxiety and difficulty in speaking about the incident. These features are associated with the disorder (Kalisch et al., 2017).

Effective Therapeutic Approach

Cognitive behavioral therapy is effective for the situation. While assessing the scenario, it can be seen that the clients seem to very emotional when they recollect the incident. Cognitive therapy is essential in improving their emotional processing. Since the clients also engage in addictive behaviors, the approach is suitable in shaping their behavior to enhance better outcomes. Cognitive behavioral therapy is also important in developing self-efficacy for the clients. This will make them believe that they can overcome their anxiety and post traumatic stress disorder with strength (Patterson, 2014).

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Legal and Ethical Implications

The practitioner needs to ensure that the clients have enough information regarding the session and techniques used in managing their problems. Any underlying   health issues that emanate from the analysis need to be reported to the relevant therapists. The practitioner is also obliged to offer quality treatment for clients. Therefore, he or she needs to maintain professionalism to maintain the audience. The practitioner is also mandated to report the clients’ problem in case they show signs of threatening others (Fulton, 2016).



Amico, K. R., Miller, J., Balthazar, C., Serrano, P. A., Brothers, J., Zollweg, S., & Hosek,

  1. (2019). Integrated next step counseling (iNSC) for sexual health and PrEP use among young men who have sex with men: Implementation and observations from ATN110/113. AIDS and Behavior23(7), 1812-1823.

Fulton, C. L. (2016). Mindfulness, self-compassion, and counselor characteristics and

session variables. Journal of Mental Health Counseling38(4), 360-374.

Kalisch, R., Baker, D. G., Basten, U., Boks, M. P., Bonanno, G. A., Brummelman, E., … &

Geuze, E. (2017). The resilience framework as a strategy to combat stress-related disorders. Nature Human Behaviour, 1(11), 784-790.

Patterson, T. (2014). A cognitive behavioral systems approach to family therapy. Journal of

            Family Psychotherapy, 25(2), 132–144. doi:10.1080/08975353.2014.910023.


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