1-(Fem,18-64, Mood Disorder)
The patient is 44 years old with depression disorder and today she came to a group psychotherapy session. The patient reported, “I have been feeling better these pasted two weeks. I got up and enjoyed the yoga class at a shopping center near my home.”
In today’s psychotherapy session, I observed that the patient’s condition improved since the last session evidenced by a better mood and increased motivation to carry out her day-to-day activities. During our last session the patient completed her tasks to alleviate the recommended depression. The patient showed a good understanding of the cause of her depressed mood and subsequent improvements.
The patient managed to improve her mood as the main objective. The patient’s mood has constantly improved over the past two weeks. The symptoms of depression have decreased and there has been an increase in her daily activities.
The patient continues with follow-up psychotherapy this week. Individual psychotherapy was scheduled for next week to continue to decrease depression.
2-(Mas,18-6,4 Mood Disorder)
54-year-old patient with depression disorder related with family issues, who attended a group psychotherapy session today. The patient reported “I feel less sad and anxious this week, I have been less stressed.”
In today’s psychotherapy session, the patient performed all of the activities to further decrease anxiety. The patient showed improvements in mood, which was the main goal to achieve this week.
The patient’s mood has constantly improved over the past three weeks. Symptoms of depression and anxiety have diminished according to the patient which reports that music therapy has greatly helped him control his anxiety.
The patient was encouraged to continue with follow-up psychotherapy. Group psychotherapy was scheduled for next week to continue to decrease the patient’s condition.
3-(Fem,18-64, Eating Disorder)
30 -year-old patient with depression disorder secondary to being overweight; She came for a family psychotherapy session this morning accompanied by her mom. The patient reported, “I feel less sad this week, because I am more motivated after I saw the dietician and have been having therapy”
In today’s psychotherapy session, the patient carried out all the activities such as controlling her behaviors more through support to make the patient feel more secure. Patient showed improvements in her self-esteem.
The patient’s mood has improved over the past three weeks. The symptoms of depression have decreased as she reports that she feels better with herself and more euthymic.
The patient was encouraged to continue with follow-up psychotherapy. Family psychotherapy was scheduled for next week to continue decreasing the patient’s condition.
4-(Mas,65, Neurocognitive disorder)
75-year-old patient with depression disorder due to being forgetful. Patient assisted to a psychotherapy session this morning. The patient reported, “I feel more content ever since I started writing notes and pasting them on my refrigerator.”
In today’s psychotherapy session, the patient performed all the activities requested, he felt less frustrated since he can perform journal writing exercises where the patient journals his daily experiences during the therapy session. The patient in encouraged to write more journal entries outside of therapy. Patient showed improvements in mood.
The patient’s mood has improved in the past six weeks. The symptoms of depression have decreased as per his reports such as life feels more organized.
Encourage the patient to continue with follow-up psychotherapy so that he continues to train in his writing journal. Group psychotherapy is scheduled for next week to continue improving the patient’s quality of life.
5-(Fem,68, Anxiety disorder)
71-year-old patient with anxiety disorder and sleep deprivation due to financial problems; came for a psychotherapy session this afternoon with his son. The patient reported “I feel less anxious and have been sleeping better this week.”
In today’s psychotherapy session, the patient performed all the verbalized understanding of sleep hygiene activities, patient reported feeling less anxious since he is performing his daily relaxation exercises during the therapy session. Patient showed improvements on his quality of life.
The patient’s mood has improved in the past four weeks. Symptoms of anxiety have decreased as his perform exercises.
The patient was encouraged to continue the follow-up psychotherapy, patient will continue managing his anxiety, teaching the patient the better copy skills with stressors. Family psychotherapy was scheduled for next week to continue improving patient’s quality of life.
6-(Mas,58, Sleep Disorder)
61-year-old patient with sleep disorder due to problems with his daughter came for a psychotherapy session today. Patient reported “I’m sleeping better since I began the music therapy ”
Today in the psychotherapy session, the patient participated in relaxation sleep hygiene activities to assist with his poor quality of sleep patterns. After implementing techniques, patient has been done to fall asleep. Patient was able to relax as therapy progress. Patient demonstrated improvements on relaxation techniques using soft and instrumental music.
The patient’s mood has improved in the past three weeks. Symptoms of irritability decreased as patient was able to sleep better.
The patient was encouraged to continue psychotherapy follow-up, patient will find out other coping skills to improve sleeping. Patient will practice different abilities to sleep more hours. Patient will communicate with his therapist about sleeping progress. Group psychotherapy was scheduled weekly to continue improving patient’s sleeping time.
7-(Fem,27, Mood Disorder)
34-year-old patient with mood disorder due to depression related with her eating disorder. Patient attend a psychotherapy session this morning. Patient stated “I’m feeling better and have more self-esteem since I started therapy ”
In this psychotherapy session, the patient improved the way of acceptance related to her image. Patient accepted different recommendations to gain weight and improve overall health.
The patient’s self-esteem has improved in the past four weeks. The patient was encouraged to continue psychotherapy follow-up to evaluate continuous progress as it relates to her acceptance. The patient was encouraged to continue eating a healthy and balanced diet.
Patient will continue diet and psychotherapy apart of plan to improve self-imagen and self-esteem. Group psychotherapy is scheduled weekly to continue improving patient’s mood.
8-(Mas,59, Psychotic Disorder)
61-year-old patient with psychotic disorder as evident auditory hallucination. Patient attended a Family psychotherapy session today with his wife that is worried about her husband . Patient stated “The voices have been disappearing in the last couple week”
During this psychotherapy session, patient improved his heath, and verbalized “the voices are not real.” Patient will decrease and eliminate auditory hallucination, compliance with treatment and psychotherapy will be encouraged in every session.
Patient’s auditory hallucination have decreased for the past three weeks. The patient is encouraged to continue psychotherapy follow-up and treatment to keep wellness. Psychoeducation regarding medication compliance was provided and patient was receptive.
Patient will continue participating in individual psychotherapy for reality testing and compliance with treatment to assess progress. Family psychotherapy is scheduled for next week to evaluate patient’s progress.
Patient is a 53 y/o with depression disorder, who came for a group psychotherapy session today. Patient reported “I have been feeling better the last 3 days. I got up, exercised, and enjoyed exercising at the gym”
During the psychotherapy session today, I observed that the patient’s condition improved since last session evidenced by happy mood and increase energy. Patient showed good insight into the cause of his depressed mood and subsequent improvements. During her trip she will use stress management techniques learned today and journal outcomes to share during session upon her return.
He was active and participated fully in discussions today. A normal amount of physical activity was exhibited today the patient managed to improve his mood as a primary objective. Depression symptoms have decreased. Therapist provided psychoeducation regarding clarifying areas of difficulty and identifying coping skills. Involved all group, kept the group focused.
Patient continues with follow up psychotherapy this week. Group psychotherapy was scheduled for the next week. Assigned worksheet/activity will be programmed for the group.
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A family meeting was conducted with the patient’s parent’s, the patient and the clinician in order to discuss treatment plan and follow-up care as well as to address any current concerns.
Patient’s mother discussed patient’s emotional and psychological decompensation over the past four months. Reportedly, patient’s unstable relationship with the girlfriend became the psychological stressors for the patient. Patient’s parents reported a healthy and positive relationship with their son (a contrast compared to son’s statement which included significant anymosity between son and father). When discussion patient’s history of non-suicidal self-injurious behaviors, patients reported not being aware of this taken place and they were provided psychoeducation regarding the red flags regarding this behavior. Furthermore, psychoeducation regarding medication compliance and the need for continuity of services was discussed with patient’s parents and they were receptive to this. They expressed understanding and appeared receptive of treatment recommendations.
The patient presented to the family session. He appeared with euthymic mood and congruent affect. He was cooperative and forth coming. His speech was normal in rate, tone, and volume. He adamantly denied current suicidal/self-harm/homicidal ideation, plan, or intent. The treatment plan and follow-up care were reviewed with the patient. Psycho-education regarding the importance of treatment adherence was provided. Interventions were implemented to bring further awareness and insight into the reasons for his admission and demonstrated good insight into his psychological treatment. The Columbia Suicide Severity Rating Scale (C-SSRS) was completed with placed and his scored this placed patient on the low risk for suicide. He discussed future oriented goals upon discharge which consist of complying with his treatment and becoming a police officer.
Plan:
1. Patient will be continue outpatient psychotherapy.
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