Client I Use In Week 3 Practicum Assignment

Client I Use In Week 3 Practicum Assignmenta 14 Year Old Male African

Client I use in week 3 practicum assignment: A 14-year-old male African American came in with his mother. He was alert and oriented to person, place, and time. He was dressed appropriately for the weather and observed as being hyperactive, restless, and irritable. He exhibited symptoms of agitation, feelings of worthlessness, worry, and lack of focus and concentration. The client denied suicidal or homicidal ideations, no drug or alcohol abuse, had never been arrested, and is not involved in gang activity.

He further denied any physical, sexual, or emotional abuse. The client reported an altercation with his mother concerning his disrespectful behavior toward her because he rejects any authoritative control and engaged in a disruptive altercation. Subsequently, he left the home seeking assistance from the police.

Diagnosis: Adjustment disorder with mixed anxiety and depressed mood.

Paper For Above instruction

Introduction

Effective psychotherapy relies on the careful documentation of client progress, treatment modalities, and clinical observations. This paper presents a comprehensive progress note for a 14-year-old African American male experiencing adjustment disorder with mixed anxiety and depressed mood. It also discusses the use of privileged notes as a tool for maintaining confidentiality and facilitating nuanced clinical documentation.

Part 1: Progress Note

Client Presentation and Clinical Symptoms

The client presented with hyperactivity, restlessness, irritability, agitation, and feelings of worthlessness. These symptoms are characteristic of mood dysregulation and anxiety, which are typical in adjustment disorders. The client’s denial of suicidal or homicidal ideations and absence of substance abuse or gang involvement are important protective factors. The disruptive behavior and conflict with his mother, leading to his leaving home and seeking police intervention, highlight the severity of his emotional dysregulation.

Treatment Modality and Efficacy

The primary treatment modality used in this case was cognitive-behavioral therapy (CBT), combined with family therapy to improve communication and address familial conflicts. CBT was chosen because of its proven efficacy in treating mood and anxiety disorders in adolescents (Kendall & Hedtke, 2006). The therapy focused on helping the client develop coping skills, manage anger, and improve emotional regulation. The efficacy of this approach was evident as the client engaged actively in sessions, demonstrating insight into his emotional experiences.

Progress Toward Goals

Based on the treatment plan, specific goals included reducing irritability and agitation, improving anger management, and enhancing communication with family members. There was modest progress: the client reported decreased feelings of irritability, although episodes of restlessness persisted. Family sessions revealed improved understanding; however, conflicts with his mother remained, indicating a need for ongoing family interventions.

Modifications to Treatment Plan

Given the partial progress, the treatment plan was modified to include more focused anger management techniques and to incorporate a behavioral contingency plan to reinforce positive behaviors at home. Additional sessions with the family were scheduled to address communication patterns and authority issues effectively.

Clinical Impressions and Symptoms

The client’s symptoms align with the diagnosis of adjustment disorder with mixed anxiety and depressed mood. His hyperactivity and irritability suggest underlying difficulties in emotional regulation, possibly exacerbated by familial conflict. No signs of psychosis or severe depression were observed, but ongoing monitoring is essential for developmental and safety reasons.

Psychosocial Factors and Changes

Since the initial assessment, there have been no significant changes in the client’s psychosocial environment. The family remains resilient despite ongoing conflicts. However, the child's conflict with authority figures suggests underlying issues with impulsivity and emotional regulation. The recent incident involving police indicates external stressors influencing his mental health.

Safety and Emergency Considerations

During the session, the client expressed frustration and anger but did not demonstrate intent or plans for self-harm or harm to others. Safety planning was reinforced, and the family was advised on signs of escalating risk. No immediate safety concerns were identified, but close monitoring continues.

Medications and Compliance

The client is not currently on medication; therefore, medication management was not addressed during this session. The client expressed willingness to explore medication if recommended in the future. Therapy compliance has been consistent with attendance at scheduled sessions.

Collaborations and Consultations

Collaboration with the client’s school counselor was initiated to monitor behavioral progress and support interventions at school. A phone consultation with the pediatrician was conducted to review the need for further assessment, although no medication was prescribed at this stage.

Therapist’s Recommendations

The therapist recommended continued CBT focusing on emotional regulation and anger management. Family therapy sessions were also recommended to improve communication and establish boundaries. The client agreed to participate in these interventions, acknowledging the importance of family involvement in his recovery.

Referrals and Termination

Referrals to a psychiatrist for medication evaluation were discussed but deferred for reevaluation in subsequent sessions. Termination planning included preparing the client for future sessions and addressing potential barriers such as transportation or school pressures.

Informed Consent and Confidentiality

Initial informed consent was reaffirmed, emphasizing confidentiality limits, especially regarding safety concerns or mandated reporting. The client and family understood and agreed to the treatment plan.

Additional Considerations

No issues related to child abuse or neglect were reported or observed during the session. The therapist exercised clinical judgment, considering the client’s developmental stage and family dynamics in planning ongoing care.

Part 2: Privileged Note

Privileged notes serve as a confidential tool to record detailed impressions and nuanced thoughts that are not meant for inclusion in the standard clinical record. In this context, the privileged note might include personal reflections on the client's emotional reactions, subtle cues observed during therapy (e.g., microexpressions indicating underlying distress), or detailed hypotheses about the client’s familial dynamics that are only relevant for the therapist’s understanding.

I would include items such as the client’s specific non-verbal behaviors, unconscious emotional responses, or in-depth interpretations of transference phenomena that could compromise therapeutic neutrality if documented openly. These notes help the therapist process complex clinical material while maintaining client confidentiality and are particularly useful when planning interventions or discussing cases with supervisor or colleagues.

My preceptor might use privileged notes to document sensitive impressions, such as thoughts about potential risks, unspoken client fears, or reactions during therapy that could influence treatment strategies. If my preceptor does not use privileged notes, they might prefer to integrate such insights directly into the formal progress notes with careful language or document them separately in case notes for internal use only.

Conclusion

Confidential documentation through privileged notes enhances the clinician’s ability to deliver nuanced, patient-centered care while safeguarding sensitive information. Clear understanding and judicious use of privileged notes are essential for ethical and effective psychotherapy practice.

References

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