w11 ASSGNMENT Prac

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Assignment 1: Client Termination Summary

University

Psychotherapy with Client in Groups

Instructor:

Date

Practicum: Client Termination Summary

Patient Information: 

The client, ED, is 17 years old Caucasian female. ED, who lives with mom in her single home with her boyfriend, presents to therapy with mom and boyfriend for counseling sessions. Mom seeks ED therapy due to the impact of alcohol and drug on her life and the family. ED reports a history and diagnosis of depression after her dad left home for another woman. ED believes she is not loved. ED reports she started drinking heavily and smoking Marijuana to alleviate her depression. The client reports due to poor performance at school, she dropped off from school. ED reports depression worsens after she became pregnant and had her son. The client reports recent challenges and stress between her and her boyfriend after having her baby. The client reports excess alcohol drinking to control emotions. ED reports her alcohol addiction is causing communication problems, difficulty in parenting, and trust issues. The client denies recent psychiatric hospitalizations; denies SI/HI/AVH; reports not on medications and has no significant medical history. The client is not working but is a stay at home mom. 

The Date the Client Initially Contacted the Therapist: 

Mom reached out to the therapist on 01/06/21. Therapy started on 01/07/21. The family will have therapy sessions twice weekly for six weeks.

Duration of therapy: the entire time patient was outpatient, six weeks. The client was consistent in attending therapy sessions.

Date Therapy will end: 02/04/21

Total number of sessions: 12

Number of missed sessions: 0

Whether Termination was Planned or Unplanned: Discharge was planned. The family did not continue with therapy on termination because they are making significant progress.

Presenting Problem

ED has a history of depression after dad left home for another woman. ED started indulging in drinks and Marijuana. ED reports depression worsened after having her son. There is also a financial challenge and stress between Ed and her boyfriend.  

Major Psychosocial Issues: ED has a prior history of depression diagnosis as a teenager after dad separated from mom while in high school. The client reports relationship and financial stressors related to childminding. The client reports current feelings of depression and anxiety related to the stressor within the family. The client resorts to drug and alcohol usage as a coping mechanism to handle her problem leading to alcohol abuse. 

Types of Services Rendered: Family therapy, Individual CBT, Group CBT, Psychiatric Evaluation, medication initiation, medication management. The therapist uses discretion to recommend CBT, which is the best treatment approach, in group or family therapy. According to Jung, Wiesjahn, Rief & Lincoln (2014), the therapist recommends using their discretions to recommend CBT approach to group and family when it becomes essential.

Overview of Treatment Process

The client will benefit from participating in CBT therapy. Skills the client acquires from CBT strengthens the client in maintaining commitment and consistency in the newly acquired change in behavior (Bass, van Nevel, & Swart, 2014). The therapist applies CBT in individual therapy, group therapy, and family therapy due to the support client receives from family members. CBT helps to correct and treat behaviors triggered by maladaptive thoughts (Wheeler, 2014). An example of behavior that manifests due to maladaptive thoughts is alcohol/substance abuse. The cognitive therapeutic model’s substance abuse treatment process includes what substance abuse entails, the impact on social interaction, living without substance, strategies to learn to decline substance use, other forms of relaxation techniques, change in behavior, and handling relationships (Wheeler, 2014). It is also essential that therapy occurs in a family setting with a client that abuses alcohol due to the impact of the client’s behavior on other family members. The family members’ impact will help in the client’s recovery in maintaining sobriety (Foundations Recovery Network, 2018). ED and boyfriend with mom participated in the therapy to provide support to ED and for appropriate behavior. 

The client completed the therapy sessions with psychopharmacological medications and is consistent in treatment strategies. The client has sessions in individual therapy and also group sessions with mother and boyfriend. The client and family members were consistent in attending the sessions. 

Goal Status:

The goal was for ED to recognize triggers and manage them appropriately. The patient was able to maintain sobriety. The patient utilized resources from therapy to develop positive coping mechanisms to handle stressors. The patient verbalized a decrease in anxiety and depression levels. The patient denied current audiovisual hallucinations. The client responded positively to treatment and ready for discharge in three days. ED reports positive change intellectual reasoning and verbalized ability to recognize triggers and manage them appropriately.

Treatment Limitations: No treatment limitations noted, the client has adequate family support. 

Any Recommendations

ED and the boyfriend were informed to attend Alcoholics Anonymous (AA) group and use positive skills to support each other. 

Follow-up plan:

The client will follow up with the primary psychiatrist that she visits. 

Instructions for Future Contact:

None. 

References:

Bass, C., van Nevel, J., & Swart, J. (2014). A comparison between dialectical behavior therapy, mode deactivation therapy, cognitive behavioral therapy, and acceptance and commitment therapy in the treatment of adolescents. International Journal of Behavioral Consultation and Therapy, 9(2), 4-8. doi:10.1037/h0100991

Foundations Recovery Network. (2018). Family Therapy and Substance Abuse. Retrieved from

https://www.dualdiagnosis.org/family-therapy/

Wheeler, K. (ED.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice. New York, NY: Springer. 313-339.

Jung, E., Wiesjahn, M., Rief, W., & Lincoln, T. M. (2014), Perceived therapist genuineness predicts therapeutic alliance in cognitive behavioural therapy for psychosis.

Students will:

· Develop client termination summaries

To prepare:

· For guidance on writing a client termination summary, review pages 693–712 of Wheeler (2014) in this week’s Learning Resources.

· Identify a client who may be ready to terminate therapy.

Assignment

With the client you selected in mind, address in a client termination summary (without violating HIPAA regulations) the following:

· Identifying information of client (e.g., hypothetical name and age)

· Date the client initially contacted therapist, date therapy began, duration of therapy, and date therapy will end

· Total number of sessions, including number of missed sessions

· Whether termination was planned or unplanned

· Presenting problem

· Major psychosocial issues

· Types of services rendered (e.g., individual, couple/family therapy, group therapy)

· Overview of treatment process

· Goal status (goals met, partially met, unmet)

· Treatment limitations (if any)

· Remaining difficulties and/or concerns

· Recommendations

· Follow-up plan (if indicated)

· Instructions for future contact

· Signatures