Group Therapy Progress Note – Mr & Mrs WW

Group Therapy Progress Note – Mr & Mrs WW

Students will:

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

NOTE TO WRITER:  You can make up the family session and please use initials when talking about the individuals

Select two clients you observed or counseled this week during a family therapy session. Note: The two clients you select must have attended the same family session. Do not select the same family you selected for Week 2.

Group Therapy Progress Note – Mr & Mrs WW

Then, address in your Practicum Journal the following:

• Using the Group Therapy Progress Note in this week’s Learning Resources, document the family session. (See the progress note downloaded in the additional materials area).
• 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 solution-focused or cognitive behavioral therapy would be more effective with this family. Include expected outcomes based on these therapeutic approaches.
• Explain any legal and/or ethical implications related to counseling each client.
• Support your approach with evidence-based literature.

SAMPLE ANSWER

Group Therapy Progress Note American Psychological Association

Client: Mr. and Mrs. WW                                                   Date: 10/10/19

Group name:  God’s people                                         Minutes: 45

Group session: 1                                                Meeting attended for this client: 1

Number present in group 2 of 2      scheduled Start time: 10:00 AM           End time: 10:45

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 Participation level: ❑ Active/eager ❑ Variable ❑ only responsive ❑ Minimal ❑ Withdrawn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 ❑ Anxious ❑ Depressed ❑ 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:

The group session is made up of two people who are an older couple and is experiencing challenges in their marriage. The presenting problem is that the couple have been having challenges in the past few years and arte unable to enjoy their marriage. Mrs. WW is a 59 year old woman who is a born again Christian and lives with her husband Mr. WW. She explains that the she feels neglected by the husband whom she accuses of preferring to be in church instead of being at home with her. This makes her to feel lonely and sad because there is no one else at home. She has been feeling depressed for some time and even had a session with a counseling psychologists and psychotherapy was offered. She was also given some pills and she confesses that she took more pills than prescribed. She also describes that she came from a family where the parents had a divorce that was turbulent and it has affected her over the years. She is so afraid of having a divorce because she does not want to go through what her parents went through.

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Mr. WW is a 60 year old man who is also passionate about serving Jesus Christ and is committed to the church. He has been married to Mrs. WW for the last thirty years and he says that although there have been challenges; the two have remained together because divorce has never been an option. He expresses that he prefers to stay away from home because his wife is always negative, which pushes him away. He therefore seeks solace in church by getting involved in church activities. He says that eh recently feels sad about his marriage as they are always arguing although he loves the wife so much. He has no history of substance abuse and has not been treated for any mental issue.

An assessment into the family genogram brings out that the two are from families that had experienced tumultuous divorces. The events in their life may have had an impact on them and may have caused trauma hence assessment will be done in consideration of stress-related issues. According to the diagnostic and statistical manual of mental disorders, (2013), the clients have mental issues that arise from their past. Mr. and Mrs. WW are both diagnosed with post-traumatic stress disorder, which is as a result of the tumultuous divorce that the parents went through. The first criterion for diagnosis of PTSD is when the clients have experienced an actual exposure to a stressful event. In this case, the couple has both been exposed to a situation where their parents had to separate and this may have had negative effects on them Individuals with PTSD have high chances of exhibiting another mental issue such as depressive disorders, anxiety-related disorders, and substance use (Smith, Goldstein, and Grant, 2016). It therefore come out that Mrs. WW also has anxiety and she is excessively worried that her marriage may come to an end.  For this session, there is anxiety and there are also some complains about the symptoms still being prevalent.

Group Therapy Progress Note – Mr & Mrs WW

In-session procedures:

For this couple Cognitive-behavioral therapy (CBT) will be employed and it involves activities that will aim at exploring the negative thoughts that an individual has and replaces them with thoughts that are positive and that will play a role in creating favorable behaviors and emotions ( Patterson, 2014). It expounds on the fact that numerous issues in the lives of people arise from the distortions that they have had.  The main goals is to establish better relationships by improving the quality of interpersonal relationships and social function (Cuijpers et al. 2016), the focus for these couple is on the  distress that they face and therapy seeks to will provide an opportunity for them to resolve their problems.

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The in session procedures include:

• After assessment and history taking, agenda-setting will be considered
• Interviews that will focus on identifying the interpersonal issues that are prevalent and addressing them in order of importance.
• The couple will verbalize the issues that they would like to be addressed. The family and the therapist will then have a collaborative decision about the issues that will be tackled and the time frames
• Practice of interpersonal skills including leadership, active listening, teamwork and patience among others.
• A religious item such as prayers since the couple is religious.

Homework:

1. To think about the things that they love about each other and those that they don’t
2. Come up with a comparison of the things they enjoy versus those that they dislike
3. Carry out activities together to ensure that they tolerate each other and engage each other
4. Appreciate each other more

Group Therapy Progress Note – Mr & Mrs WW

Other comments:

Legal and ethical issues have been considered. The couple has signed an informed consent and has shown that they are willing to go ahead with the treatment procedure. Privacy and confidentiality has been ensured as this is a requirement for psychotherapists hence everything that is discussed will be kept secret and will not be disseminated to any other person. In addition, although marriages have challenges, old age also presents challenges since the couple is older. There is a need to discuss the issue of the empty nest.

Signatures     …………………………                              Date………/………../……….

References

American Psychiatric Association (2013).   Diagnostic and Statistical Manual of Mental

Disorders, DSM-5.   (5th edition).   Washington, DC   American Psychiatric Association.    ISBN-13: 978-8123923796

Betan, E. J., & Binder, J. L. (2016). Psychodynamic Therapies in Practice: Time-Limited

Dynamic Psychotherapy. Comprehensive Textbook of Psychotherapy: Theory and Practice, 45.

Cuijpers, P., Donker, T., Weissman, M. M., Ravitz, P., & Cristea, I. A. (2016). Interpersonal

Psychotherapy for mental health problems: a comprehensive meta-analysis. American Journal of Psychiatry, 173(7), 680-687. doi.org/10.1176/appi.ajp.2015.15091141

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

Smith, S. M., Goldstein, R. B., & Grant, B. F. (2016). The association between post-traumatic

Stress disorder and lifetime DSM-5 psychiatric disorders among veterans: data from the National Epidemiologic Survey on Alcohol and Related Conditions-III (NESARC-III). Journal of psychiatric research, 82, 16-22.

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