Practicum Journal Entry
Practicum Journal Entry
Learning Objectives
Students will:
- Apply documentation skills to examine family therapy sessions *
- Develop diagnoses for clients receiving family psychotherapy *
- Analyze legal and ethical implications of counseling clients with psychiatric disorders *
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.
NOTE TO WRITER: You can make up any two clients that are related that were seen for drug or alcohol addiction therapy along with making up their histories or medications. And please use the group therapy progress note in the additional materials.
Then, address in your Practicum Journal the following:
- Using the Group Therapy Progress Note in this week’s Learning Resources, document the family session.
- Describe (without violating HIPAA regulations) each client, and identify any pertinent history or medical information, including prescribed medications.
- Using the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5), explain and justify your diagnosis for each client.
- Explain any legal and/or ethical implications related to counseling each client.
- Support your approach with evidence-based literature
SAMPLE ANSWER
Practicum Journal Entry
The journal entry focuses on documentation skills during a therapy session. The paper diagnoses two clients under psychotherapy and analyzes the legal and ethical implications of the therapy used to counsel the patients.
Client #1
Michael Darwin is a 30-year-old Caucasian male working at APS. He was raised by a single parent, and her mother is dead after committing suicide due to anxiety and depression.
Presenting Problems: Depression and Mood Disorders
Michael is a withdrawn individual during therapy sessions. His hair and clothes are clean, and he denies suicidal ideation. However, he admits struggling working due to lack of concentration due to lack of enough sleep.
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Medical History
The patient struggles with depression and often isolates himself from friends and family members. There are no issues of both psychological and physical abuse, but he was diagnosed with depression at 17 years old. The patient uses Zoloft 100mg daily for depression.
Diagnosis
The patient has experienced a loss of pleasure and depressed mood for about two weeks. The symptoms cause lack of concentration at work and other activities during the day. Impairment in social work-related activities is caused by depressed mood, recurrent thoughts of death, insomnia, diminished interest and agitation (American Psychiatric Association, 2013).
Group Therapy Progress Note
Client: Michael Darwin Date: 9-21-2019
Group name: Psychological Health Group
Minutes: 45
Group session: # 2
Meeting attended is #: 4 for this client.
Number present in group: 2 of 4 scheduled
Start time: 11: 00 AM
End time: 11: 50 AM
Assessment of client
- Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn
- Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive
❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________
- Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________
- Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other:_______________
- Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused
❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other:__________________
- Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt
- Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic
- Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able
- Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse
- Other observations/evaluations:_________________________________
In-session procedures
Expression of feelings experienced
Discussion on coping skills
Home Work
Provision of a book on psychological and physical coping mechanisms
Other Comments
Anger management, loss of mood, and withdrawal are critical issues that the patient need to manage through Cognitive Behavioral Therapy.
Practicum Journal Entry
Client #2
Lynn Turner is a 34-year-old Hispanic female working as a nurse in a Community Center of Trauma. She has two children and lives in a gated community with low levels of crime. Her husband died in a rock accident while working as a truck driver.
Presenting Problem: Depression, Anxiety, and PTSD
The patient is alert, oriented, and attentive during therapy sessions. His mood seems depressed and anxious. However, she denies having thoughts of committing homicide or suicide. But the client admits having memory problems and lack of awareness during work.
Medical History
The client mentions that she has seen a psychological therapist as a child. Ever since there have never been issues with depression and anxiety until she lost her husband in a truck accident. The client uses Xanax 1 mg and Paxil 40mg daily to relieve severe stress.
Diagnosis
The client is suffering from a Posttraumatic Stress Disorder due to the psychological trauma and other clinical symptoms she faces. PTSD is caused through the following experiences of traumatic events: exposure to stressor, intrusion symptoms, persistent avoidance, and negative alterations in mood and cognition (American Psychiatric Association, 2013).
Group Therapy Progress Note
Client: Lynn Turner Date: 9-21-2019
Group name: Psychological Health Group
Minutes: 45
Group session: # 2
Meeting attended is #: 3 for this client.
Number present in group: 2 of 4 scheduled
Start time: 11: 00 AM
End time: 11: 50 AM
Assessment of client
- Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn
- Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive
❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________
- Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________
- Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other:_______________
- Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused
❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other:__________________
- Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt
- Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic
- Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able
- Change in symptoms: ❑ same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse
- Other observations/evaluations:________________________________________________________
In-session procedures
Expression of feelings experienced
Discuss what relaxation means
Discussion on coping skills
Home Work
Provision of a book on psychological and physical coping mechanisms
Practicum Journal Entry
Other Comments
Anger management, loss of mood, and withdrawal are critical issues that the patient need to manage through Cognitive Behavioral Therapy.
Legal and Ethical Implications
The Health Insurance Portability and Accountability Act (HIPAA) is a health care act that ensures client health information is protected during the provision of healthcare services. Confidentiality is critical during the provision of group therapy. However, psychiatrists do not have control of the patient’s information and ensuring patients privacy often become challenging. Therefore, the psychiatrists need to educate their patients on the importance of group therapy. Trust among group members ensures good relations and flow of information to guarantee quality care and counseling.
Appropriateness of Cognitive Behavioral Therapy
Cognitive-behavioral therapy (CBT) is a critical therapy for clients with psychological needs. It aims to develop coping requirements that help in the management of anxiety, PTSD, and depression (Keane, 2018). CBT is made up of three levels: negative automatic thoughts, core beliefs, and dysfunctional assumptions (McLeod, 2015). Thus, CBT focuses on self-discovery and help patients conceptualize and understand the reason behind their mental conditions and thoughts, thereby encouraging positive changes.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders.
Washington, DC: Author.
Fenn, K., & Byrne, M. (2013). The key principles of cognitive-behavioral therapy. Education
and inspiration for general practice, 6(9), 579-585. DOI:10.1177/1755738012471029
Keane, H. (2018). Facing addiction in America: The Surgeon General’s Report on Alcohol,
Drugs, and Health U.S. Department Of Health And Human Services, Office Of The Surgeon General Washington, DC, USA: U.S. Department of Health and Human Services, 2016 382 pp. Drug and Alcohol Review, 37(2), 282-283. DOI:10.1111/dar.12578
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