Address In A Client Termination Summary

Address In A Client Termination Summary (without violating HIPAA)

Using the provided client information, compose a comprehensive client termination summary that includes: client identifying information (e.g., hypothetical name and age), dates of initial contact, therapy start and end dates, total number of sessions including missed sessions, whether termination was planned or unplanned, presenting problem, major psychosocial issues, types of services rendered, overview of the treatment process, goal status, treatment limitations, remaining difficulties or concerns, recommendations, follow-up plan if applicable, instructions for future contact, and signatures. The summary should provide a thorough and professional overview of the therapeutic process and outcomes in compliance with HIPAA regulations.

Paper For Above instruction

Patient RA, a 42-year-old Caucasian male and retired military veteran, participated in a structured therapeutic process aimed at managing PTSD and anxiety symptoms. The initial contact with the therapist occurred on November 24, 2020, marking the beginning of a targeted treatment plan that commenced on November 30, 2020. The therapeutic intervention was scheduled for a total of 12 sessions, conducted twice weekly, spanning from the onset date until its scheduled conclusion on February 8, 2021. Throughout this period, the client attended 11 of the scheduled sessions, with one session missed due to personal circumstances. The termination of therapy was planned from the outset, reflecting a predetermined resolution strategy based on the achievement of specific therapeutic goals.

The presenting problems centered around coping difficulties related to PTSD and anxiety, compounded by psychosocial issues including intrusive flashbacks, dissociative episodes, irritability, anger, feelings of emotional detachment, hypervigilance particularly in crowded environments, concentration difficulties, and sleep disturbances. These factors significantly impaired the client’s daily functioning and overall well-being. The therapeutic services rendered encompassed individual psychotherapy as well as participation in group therapy sessions, fostering a comprehensive approach to address both personal and social aspects of mental health challenges.

The treatment process involved thorough initial evaluations, including medical assessments and psychosocial assessments, to tailor interventions effectively. Therapeutic techniques employed included psychoeducation about relaxation methods, training in coping skills, hypnotherapy, Prolonged Exposure (PE), Cognitive Processing Therapy (CPT), and Skills in Interpersonal Therapy (SIT). Medications were prescribed and managed collaboratively with a psychiatrist to augment therapeutic efforts, alongside self-help strategies to promote autonomy in managing symptoms.

Regarding goal achievement, all initial treatment goals were considered met, including improved symptom management and increased emotional resilience. Nonetheless, some limitations persisted, notably the inability to perform Eye Movement Desensitization and Reprocessing (EMDR) therapy due to the therapist’s lack of expertise in this modality. Remaining concerns involved enhancing the client’s comfort in social settings, particularly in crowds, and further improving sleep quality. The client was educated on maintaining gains during stressful periods and encouraged to access external resources, such as the U.S. Veterans Administration’s National Center for PTSD, for ongoing support.

The recommended course of action included continued engagement with mental health resources, regular follow-up with the psychiatrist, and participation in support groups. The client was instructed to utilize therapy as a resource for future help-seeking and to contact emergency services (call 911) if needed. The follow-up plan was primarily focused on psychiatric management, with no additional therapy sessions scheduled beyond the planned end date. The client was advised on future contact procedures, emphasizing comfort in seeking help whenever necessary, and was provided with contact information for relevant resources. The summary concludes with signatures from the therapist and client, affirming the documented process and outcomes, in accordance with ethical standards and confidentiality requirements.

References

  • American Psychological Association. (2020). Publication Manual of the American Psychological Association (7th ed.).
  • Foa, E. B., Hembree, E. A., & Rothbaum, B. O. (2007). Prolonged Exposure Therapy for PTSD: Emotional Processing of Traumatic Experiences. Oxford University Press.
  • Resick, P. A., Monson, C. M., & Chard, K. M. (2017). Cognitive Processing Therapy for PTSD: A Comprehensive Manual. Guilford Publications.
  • U.S. Department of Veterans Affairs. (2022). National Center for PTSD. Retrieved from https://www.ptsd.va.gov
  • Hayes, S. C., Strosahl, K., & Wilson, K. G. (2012). Acceptance and Commitment Therapy: The Process and Practice of Mindful Change. Guilford Publications.
  • Rothbaum, B. O., & Foa, E. B. (1999). Systematic desensitization and flooding. In C. R. Cloninger (Ed.), The Encyclopedia of Psychotherapy (pp. 157–159).
  • Kazak, A. E., & Noll, R. (2014). Ethical issues in pediatric trauma research and treatment. Journal of Pediatric Psychology, 39(2), 177-189.
  • McHugh, R. K., & Barlow, D. H. (2010). The dissemination and implementation of evidence-based psychological treatments: A review of barriers and facilitators. American Psychologist, 65(2), 105–113.
  • Hoge, C. W., et al. (2004). Combat duty in Iraq and Afghanistan, mental health problems, and barriers to care. New England Journal of Medicine, 351(1), 13-22.
  • National Institute for Health and Care Excellence (NICE). (2018). Post-traumatic stress disorder: Management. NICE guideline NG116.

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