Privileged psychotherapy note example

Part 1: Comprehensive Client Family Assessment ❖ Demographic information Mr. James Morgan is a 45 years old Hispanic male who lives in San Jose, California with his family – his wife and two children. Mr. Morgan is a Brazilian American together with his wife. They are a middle-income family where Morgan works as an animal-food consultant and technician. He has a diploma certification in animal-food processing. ❖ Presenting problem The presenting problem is continued bad mood and thoughts of suicide, which have haunted Morgan for the past three months. He has also become restless and has lost 16 pounds so far due to lack of proper feeding. He has also lost interest on regular activities and complains of lacking sleep most of the nights, where he is forced to stay awake from around 3:00 a.m. He also has extreme guilt for failing to mix food components in the required ratios, which he fears could lead to deaths of animals in various firms. This would lead to his arrest, possible incarceration and other financial expenses due to fines. He has given up on life and he wants to end his life. ❖ History or present illness The illness has persisted for three months now. The patient has been undergoing pharmacological interventions to help ease the problem but it has persisted. The inability of the client to concentrate has led to him losing his job. It is thus a major problem for the family and quicker interventions are needed. ❖ Past psychiatric history The history of the patient indicates that Morgan was once taken to a psychiatric clinic when his grandmother died, whom they had formed very close bonds. The therapeutic interventions that were undertaken were however successful and he managed to remain normalcy in one week. ❖ Medical history The client has been undertaking antidepressants, mainly Asendin medication, which he has undertaken for the past three months. Although there have been positive improvement in motor skills, the client still manifests problems in cognitive abilities and ❖ Substance use history The client reports of no substance abuse. He has never engaged in drinking or any use of hard drugs including cigarettes and bhang. ❖ Developmental history The client had a normal childhood. However, he became too much saddened and depressed when his grandmother passed on when he was 15. This has equally led to him being taken for psychiatric counselling to help and solve the problem. The client is mainly talkative and is able to make friends with new people easily. However, he only has few close people he confided in – his father and his grandmother, both of whom have died, leaving him without a close confidant. The wife reports that he is not very expressive when they are together but they usually enjoy staying together. ❖ Family psychiatric history The family has had episodes of depression. This firstly affected the grandfather when the grandmother died and he was enrolled in a psychotherapeutic clinic for clinical interventions. The client was also once take for psychiatric counselling during the same period when their grandmother passed on. This reveals that the family has a history of suffering depression due to grief and loss. ❖ Psychosocial history The client is usually very social when meeting with colleagues and family members. He is also kind and loving and likes sharing with others. However, the client is also introverted such that he is not very expressive. This could also be affecting his openness to share the trauma and guilt that is affecting him. ❖ History of abuse/trauma The client does not have any history of abuse, neglect, or trauma. He has lived a normal life with love and care from his parents. The death of his father also caused him some trauma and sadness. ❖ Review of systems A review of the systems of the patient indicates that he has good motor skills. He is able to move effectively from one place to another. The cognitive system is the one that has major problems, where the client cannot concentrate on tasks as well as offer critical reasoning on issues. The digestive system is also under scrutiny following his lack of appetite and low food consumption. The renal and reproduction systems are in perfect condition and the client is responding appropriately. ❖ Physical assessment The client does not have any marks, muscle strains, or unusual growths. He also has a stable respiratory system and cardiovascular system. He has stable palpitations and normal breathing system. The client also states that he does not smoke or engage in any substance abuse practice. However, he rarely exercises due to work schedules. ❖ Mental status exam The patient appears stable and conscious, able to answer simple questions. He also appears calm and reserved, not taking initiative to engage in any physical activity. Although the client is conscious, he seems to be carried away by thoughts and worry. The speech is clear, although lacks coherence and flow. The patient states that he feels a bad mood most of the time. He also states that he has thoughts of suicide and difficulty forming meaningful reasoning. The client also lacks apt judgement. ❖ Differential diagnosis Although the client has mainly been diagnosed with major depressive disorder, it can be probable that the client is suffering from schizophrenia, schizoaffective disorder, delusional disorder or other psychotic disorders (Leahy, Holland & McGinn, 2012). However, these alternative diagnoses have been ruled out due to the lack of manic episodes. ❖ Case formulation The case presented is of a 45 years old man with major depressive disorder. The condition has persisted for the past three months without much improvement. The patient will be given three major types of psychotherapeutic interventions including supportive therapy, cognitive behavioral therapy, and interpersonal therapy. ❖ Treatment plan The best treatment plan for the client is to use interpersonal therapy. This therapy entails finding out whether the problem of the client might be cause by social bonds and equally help in resolving possible conflicts. This will also entail meeting the managers of the firm to help and restore his self-esteem and self-worth (Leahy, Holland & McGinn, 2012). Another intervention is the use of cognitive behavioral therapy. This therapy mainly entails coaching the client know how to handle negative emotions and thoughts, as well as knowing how negative thoughts affect his wellbeing. It will also involve coaching the patient to know how to handle and control temper. Supportive therapy will also be used to help the patient understand that all individuals are concerned about his development and progress. Increasing the frequency of meeting friends will also help him to regain his self-identity and understanding.