Assignment Part 1 Progress Note Using The Client Family From

Assignmentpart 1 Progress Noteusing The Client Family From Your Week

Assignment Part 1: Progress note using the client family from your Week 3 practicum assignment. Address in a progress note (without violating HIPAA regulations) the following: treatment modality used and efficacy of approach, progress and/or lack of progress toward mutually agreed-upon client goals (referencing the treatment plan for progress), modifications of the treatment plan based on progress or lack thereof, clinical impressions regarding diagnosis or symptoms, relevant psychosocial information or changes since the original assessment, safety issues, clinical emergencies/actions taken, medications used by the patient, treatment compliance or non-compliance, clinical consultations, collaboration with other professionals, therapist’s recommendations and client’s agreement, referrals made and reasons, issues related to termination or insurance, informed consent considerations, reports of child abuse or elder/dependent adult abuse, and the exercise of clinical judgment. Ensure that no information that should not be discoverable is included.

Paper For Above instruction

This comprehensive progress note aims to document various aspects of a client's therapeutic journey, adhering strictly to confidentiality and professional standards, as well as providing a nuanced understanding of clinical considerations within the context of a family dynamic. In this case, the client family consists of multiple members engaged in ongoing therapy sessions, with interventions guided by an evidence-based approach tailored to their unique needs.

Introduction and Treatment Modality

The primary treatment modality employed was systemic family therapy, which emphasizes understanding relational patterns and communication dynamics within the family. This approach has shown efficacy in addressing issues such as conflict resolution, emotional regulation, and improving family cohesion. The therapeutic methods included genogram work, communication skills training, and emotion-focused interventions, all aimed at fostering healthier interactions.

Progress Toward Goals and Modifications

Based on the latest sessions, the family has displayed gradual progress toward their identified goals, including improved communication and reduced conflicts. However, certain areas such as emotional expression remain challenging. According to the treatment plan, measurable improvements in family interactions were anticipated within three months. While some progress is evident, reassessment revealed the need to incorporate additional behavioral tasks and individual sessions focused on emotional regulation strategies. Accordingly, the treatment plan was modified to include these elements to enhance overall efficacy.

Clinical Impressions and Psychosocial Changes

Clinically, the family continues to present with symptoms characteristic of relational stress, including elevated anxiety levels and occasional expressions of hopelessness, particularly from the mother. Diagnostic impressions remain consistent with adjustment disorder with anxiety features. Since the initial assessment, several psychosocial changes have occurred, including the mother securing a new job, which has impacted family routines, and the teenage son moving out temporarily for college, contributing to shifting family dynamics.

Safety and Emergencies

There are no current safety concerns or clinical emergencies reported during this period. The family has a safety plan in place, and there have been no documented instances of harm or risk.

Medications and Compliance

The client family members are not currently on psychiatric medications. The older daughter reports adherent participation in individual therapy sessions, while the father has missed two scheduled appointments without prior notice, indicating partial compliance.

Clinical Consultations and Collaboration

Coordination with the family’s psychiatrist involved a phone consultation to discuss possible medication adjustments for the mother, who has been prescribing her own SSRIs without prior consultation. Collaboration with a school counselor was initiated to address behavioral concerns of the teenage son, facilitating a holistic approach to treatment.

Therapist’s Recommendations and Client Agreement

The therapist recommended continued family sessions with an emphasis on emotional regulation and conflict resolution skills. The family expressed understanding and agreement with these recommendations, committing to the revised treatment plan.

Referrals and Termination Planning

A referral to individual trauma-focused cognitive-behavioral therapy was made for the mother due to unresolved childhood trauma impacting current family interactions. Discussions regarding future termination and potential insurance coverage issues are ongoing, with plans to reassess in the next session.

Informed Consent and Abuse Reporting

All family members provided updated informed consent during the current session. No disclosures or reports of child or elder abuse have been made; however, the therapist remains vigilant and prepared to follow mandated reporting procedures if any disclosures occur.

Clinical Judgment and Confidentiality

Throughout client interactions, careful clinical judgment guides the scope of information documented, ensuring that only data relevant for ongoing care and compliant with legal standards are included. Sensitive issues unrelated to treatment goals or that could compromise confidentiality are discussed in supervision but are not documented in the progress note.

Conclusion

This progress note encapsulates the ongoing therapeutic process with a family, adjusting interventions based on observed progress, psychosocial changes, and clinical considerations. Such documentation upholds professional standards, safeguards client confidentiality, and supports effective treatment planning.

References

• Goldenberg, H., & Goldenberg, I. (2012). Family Therapy: An Overview (8th ed.). Cengage Learning.
• Nichols, M. P. (2013). Family Therapy: Concepts and Methods (10th ed.). Pearson.
• Farber, B. A. (2018). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. Routledge.
• Sprenkle, D. H., Davis, S. D., & Lebow, J. (Eds.). (2013). Common Factors in Couple and Family Therapy: The Overlap. Guilford Publications.
• Kaslow, N. J. (2014). Handbook of Family Therapy. Springer Publishing Company.
• Bertalanffy, L. V. (1972). General System Theory. George Braziller.
• Sanchez, L., & Romo, L. (2020). Ethical considerations in family therapy practice. Journal of Family Therapy, 42(3), 319-336.
• American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct. APA.
• Knobloch-Fedders, L. M., & Jung, S. (2014). Couples therapy and the therapeutic alliance. Journal of Marital and Family Therapy, 40(1), 94-107.
• Waltz, B., & Feldman, M. (2019). Integrating systemic and individual approaches in family therapy. Clinical Psychology Review, 74, 101766.