Psychotherapy Progress Notes
This client had a diagnosis of borderline personality disorder. He talked of always fearing being abandoned, engaging in risky unprotected sex, unstable relationships, wide mood swings and at times threatening his partners on suicide if they leave him. Cognitive-behavioral therapy was used where the client was educated on avoiding negative thoughts and focusing on more positive thinking patterns. He was also advised to engage in hobbies and relaxation exercises. He is cooperative and determined to recover.
Client B had insomnia. She reported difficulties falling asleep, waking up too early, fatigue during the day, and being stressed and anxious about her sleep problem. Sleep hygiene was used as therapy as the client was educated to always ensure her bedroom is dark, quiet, and relaxing. She was also advised to avoid coffee, tea, and large meals before bedtime and always ensure she does not use a phone, computer, or TV in the bedroom. She has stopped taking coffee in the evening and removed the television from the bedroom.
The client had a diagnosis of antisocial personality disorder. The mother and father were present and were concerned about their son’s callous behavior. He disregarded rules, was stealing, beat up his siblings, persistent lying, had no empathy, and was very manipulative. Contingency management was used where parents were advised to use positive reinforcement to reward the client’s positive behaviors.
The client’s diagnosis was alcohol addiction. He had even lost employment and his marriage due to the addiction. Motivational interviewing was used. During the session, the client listed his motivation to stop drinking as his children, health, finances, and his work. He stated he would stop interacting with his drinking friends and would instead keep himself busy spending time with his children and working on his research project as he looked for work. He is progressing well as he has not taken alcohol for the last 3 weeks.
The client had a diagnosis of post-stress traumatic disorder (PTSD). Exposure therapy was used where the client reminisced and recanted on the traumatic event where he watched his two cousins being shot dead during a robbery incident. He has been able to re-enter the traumatic event in a safe setting. Flashbacks and nightmares have since reduced.
The client had a diagnosis of adjustment disorder with depressed 犀利士
mood after the loss of her husband. She reported feeling sad, hopeless, crying spells, and losing interest in her hobbies. Group CBT was used where a group of 5 clients with similar mental problems were educated on how to identify their maladaptive thinking patterns and replace them with more positive thoughts. Group members also told each other their experiences, socialized, and encouraged each other. The client is improving as she reported reduced sad moods.
The client had major depressive disorder. He reported a sad mood, insomnia, anhedonia, irritability, hopelessness, and suicidal thoughts. CBT was used where the client was educated to avoid thinking about negative events in his life and focus on positive thoughts. He was also encouraged to socialize with friends and avoid being alone.
He was diagnosed with type 1 bipolar disorder. He reported sometimes feeling sad and other times being energetic, impulsive, engaging in risky behaviors, spendthrift, and lack of sleep. Family therapy involved the partner and the client who were educated to identify triggers to mood changes for the client and how to support the client during the treatment period. Both were cooperative.
The client’s diagnosis is bipolar type 2 disorder. He reported cyclic episodes of extreme depressive mood and happy moods. CBT was used as he was educated to avoid thinking about negative events in his life and focus on positive thoughts. The client was cooperative and he reported he would engage more in his hobbies and interact with friends to avoid overthinking.
The diagnosis for the client is substance use disorder. He reported having used cocaine for the last 5 years and this had negatively impacted his education and relationship. Through motivational interviewing, the client was determined to stop drug abuse as he wanted to complete his university education and start working like his peers. He promised not to interact with friends who were taking drugs and spend more of his time reading books and watching documentaries as these were his hobbies.
Bollu, P. C., & Kaur, H. (2019). Sleep Medicine: Insomnia and Sleep. Missouri medicine, 116(1), 68–75.
David, D., Cristea, I., & Hofmann, S. G. (2018). Why Cognitive Behavioral Therapy Is the Current Gold Standard of Psychotherapy. Frontiers in psychiatry, 9, 4. https://doi.org/10.3389/fpsyt.2018.00004
Miklowitz, D. J., & Chung, B. (2016). Family-Focused Therapy for Bipolar Disorder: Reflections on 30 Years of Research. Family Process, 55(3), 483–499. https://doi.org/10.1111/famp.12237
Neufeld, C. B., Palma, P. C., Caetano, K., Brust-Renck, P. G., Curtiss, J., & Hofmann, S. G. (2020). A randomized clinical trial of a group and individual Cognitive-Behavioral Therapy approaches for Social Anxiety Disorder. International journal of clinical and health psychology: IJCHP, 20(1), 29–37. https://doi.org/10.1016/j.ijchp.2019.11.004
Polcin, D. L., Korcha, R., & Nayak, M. (2018). Development of Intensive Motivational Interviewing (IMI) and Modifications for Treating Women with Alcohol Use Disorders. Journal of contemporary psychotherapy, 48(2), 51–59. https://doi.org/10.1007/s10879-017-9370-y
Write short psychotherapy progress notes on ten (10) different clients who came in for individual or group counseling/ psychotherapy with the following diagnosis:
- PERSONALITY DISORDER
- SLEEP DISORDER
- SUBSTANCE-RELATED AND ADDICTIVE DISORDER
- TRAUMA AND STRESS- RELATED DISORDER
- ADJUSTMENT DISORDER
- MOOD DISORDER
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