Practicum – Client Termination Summary.
The Assignment With the client you selected in mind, address the following in a client termination summary (without violating HIPAA regulations): Identifying information of client (i.e., hypothetical name, age, etc.) Date initially contacted therapist, date therapy began, duration of therapy, and date therapy will end Total number of sessions, including number of missed sessions Termination planned or unplanned Presenting problem Major psychosocial issues Types of services rendered (i.e., individual, couple/family therapy, group therapy, etc.) Overview of treatment process Goal status (goals met, partially met, unmet) Treatment limitations (if any) Remaining difficulties and/or concerns Recommendations Follow-up plan (if indicated) Instructions for future contact Signatures Note: Please include a purpose statement. Also, all references must be less than 5 years.
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The purpose of this termination summary is to provide an overview of the treatment provided to the client during therapy sessions. The treatment came to an end after the treatment goals for the client were achieved as exhibited by reduced symptoms.
Name: SophiaWilliams, 31-year-old African-American female
Date of Termination Summary: 15/9/18
Date of First Consultation: 5/5/18
Date of the Last Consultation: 8/9/18
Duration of treatment: 4 months
Total Number of Sessions and Missed Sessions: 2 sessions missed, 24 sessions attended.
Termination Status: Planned termination since the client met therapeutic goals
Presenting problem: Macario Williams, a 31-year-old African-American female, presented with complaints about excessive worry regarding various situations, activities, relations, and also other people’s opinions about her. The client sought psychotherapy because she felt that her life was problematic and unsatisfying. For example, she reported that her marital problems were overwhelming and at one time she considered divorce. However, she thought that divorce would have adverse financial effects, especially on her children. However, she reported that her sons were very close with the dad and this extremely worried her, because she does not want such a role model for her sons. The client further admitted to always being overwhelmed and anxious when performing any task and getting easily frustrated.
Major Psychosocial Issues: Marital problems with the husband. Excessive worry and anxiety,and feelings of lack of control
Type of Service Rendered: Individual therapy (CBT & interpersonal/emotional processing I/EP) with the goal to reduce anxiety symptoms and develop effective coping skills and improve the client’s ability to manage and cope with life stresses.
Overview of Treatment Process:During the first 45 minutes of the two-hour sessions, the client received CBT. The CBT targeted the intra-personal features of anxiety and worries that the client was experiencing. The client was trained to monitor environmental, real, imaginal, feelings and thoughts cues that elicit feelings of anxiety and worry; emphasis was put on early detection of the cues. The client was also trained about progressive relaxation and how to challenge the automatic thoughts and assumptions that seem to be the underlying cause of anxiety and worries. The client readily engaged in the treatment and consistently performed the between-session homework tasks. The start of every CBT segment involved reviewing homework and in most cases, she complied.
During the second 45 minutes of every session, the client received I/EP interventions. This was an integrative treatment component that aimed to treat the client’s interpersonal challenges in accessing the key emotions important in generating anxiety and worry. This component included guiding the client to reflect o emotional situations in order to identify the interpersonal needs of interpersonal behavior in order to produce a more efficient interpersonal behavior to satisfy the needs better.
The client was cooperative during all therapy sessions and significant improvement was noted as manifested by reduced anxiety symptoms and increased self-confidence.
Goals: The client’s goals of reduced anxiety symptoms and the development of effective coping skills were met during the therapy sessions. The client manifested reduced apprehensiveness and worry, as she became more resilient and gained skills to cope with many life situations. She reported that her marital problems had reduced as she stopped being overly worried about what the husband was up to.
The client was reminded about the approaching end of therapy sessions 20th session.
Remaining Difficulties: None
Recommendations: It was suggested that the client continue practicing the learned coping skills even after the therapy.
Follow up Plan: There was no specific plan, although the client was informed thatshe could freely contact, any of our therapists or visit the facility if need be.
Instructions for Future Contact: The client was given our contact can and advised to contact us anytime necessary.
Signatures: XXXXXXXX
Total Number of Sessions and Missed Sessions:No sessions missed, 28 sessions attended.
Termination Status: Planned termination client has met his goals
Presenting problem:James Daily is a 27-year-old Caucasian male, who at the time of the consultation was using heroin for seven years. The client sought out psychotherapy for feelings of depression and anxiety cause by his drug abuse. The client stated, “I just can’t do this on my own.” He expressed how periods of extreme anxiety over quitting heroin is too overwhelming for him to deal with at this time. This is the second time he has sought help for his addiction with the first being another local outreach program. The client expressed how his drug abuse has put a strain on his relationship with is father. The familial strain has intensified since the client has moved back into his father’s house.
Major Psychosocial Issues:Loss of family relationships and fiancé. Increased anxiety and feeling of hopelessness.
Type of Service Rendered: Individual therapy and CBT with the goal to maintain abstinence from heroin and improve his familial relationships.
Overview of Treatment Process:The client was seen bi-weekly with one day devoted to individual therapy and relationship building and the other day devoted to CBT and heroin abstinence. A good therapeutic relationship was established, and this relationship was maintained throughout treatment. Even though one of the clients presenting problems is anxiety he was, in fact, very open, insightful about his addiction, and his feelings of loss. The client was able to articulate all of his feels with minimal redirection.
During initial treatment the client gained awareness of the causes of his anxiety and the root cause to his familial issues. The other focus of treatment was the client’s sobriety from heroin. CBT was used in conjunction to Suboxone with positive effect. At week 4 the client submitted to a urine drug test and tested negative for all drugs except Suboxone. At this phase of treatment, the client’s relationship with his father started to improve even though his father refused to attend the client’s therapy sessions.
During the last two weeks of therapy we discussed with the client a plan of termination and what his goals for the future were. He expressed that he wants to start group therapy and continue to attend AA meetings. The client’s suggestions were agreeable and found to be therapeutic and supportive of his sobriety. The client agreed as of 5/3/18 he would no longer be seen for individual therapy and CBT but start group therapy and continue with AA meetings.
Goals: The client goals of sobriety and improved familial relationships were met during his therapy sessions. The client also exhibited a significant decrease in his anxiety and depression as he became sober, sobriety continues, and his relationship with his father improved. The client reported that his depression and anxiety is so minimal that he doesn’t even notice it anymore.
Remaining Difficulties:The client’s continuing fight to maintain sobriety and continuing pursuit to regain his family’s trust.
Recommendations:It was recommended to the client to start group therapy for his drug addiction and to continue with his AA meetings. The recommendation for family therapy for the client and his father was also made during the last week of therapy sessions.
Follow Up Plan:No specific follow up needed at this time but the client was informed that he could contact us if needed.
Instructions for Future Contact:The client can contact the office anytime necessary and as needed.
Signatures:Flask III J., RN-BSN, PMHNP Student
Summary
The client presented with psychological and substance abuse problems. The implementation of CBT and individual therapy allowed the client to gain the tools needed to combat addiction. Through treatment he was able to remain sober and improve his family relationships. Due to the diligence of the client, the therapist, and myself the client is now a functioning part of society.