Group therapy journal entry

Group therapy journal entry
Journal Entry

This journal entry serves to describe two psychiatric clients of the same family after comprehensive observation and counselling. Full psychiatric history of both clients gets taken, and group therapy notes included.

Demographics of client #1

MM is a 35-year-old American from the veteran community. MM is married with two children. He has been serving in the military in the last ten years ago after completing his higher-grade learning. Both his parents are alive, and they live together. MM had been on a war mission in which many people got killed. The family is well supportive.

Presenting Problem of MM

CC: Mr. MM chief complaints are fear, aggression and trauma memories. The client answers questions only when asked. He has difficulties in concentrating.

History of Presenting Illness of MM

After coming back from the war, her wife noticed behavior changes in her husband. He avoided conversations with other people and involved less in activities, unlike usual.The client was taken to hospital and put on treatment and later referred for group therapy by the psychiatrists. The patient has difficulties in concentrating. The patients report difficulties in sleeping. The client gets oriented to place and time.

Past Psychiatric History of Mr. MM

It’s the first time Mr. MM got diagnosed with a psychiatric illness. He was recently admitted for one week due to his aggressiveness, fear and hallucinations. He got diagnosed with PTSD. He’s currently on medication.

Medical History of Mr. MM

The patient has no history of hospitalization before the recent one. He has no history of surgery. The client completed all scheduled immunizations. There are no known food or drug allergies.

Substance Abuse of Mr. MM

The client has no history of tobacco smoking or use of alcohol. He denies the use of any illicit drugs.

DSM-V Diagnosis of Mr. MM

According to DMS-5, Posttraumatic Stress Disorder is an anxiety disorder that results from an event that brings psychological trauma in response to the occurrence of death, threatened death, severe injury or sexual abuse. (Michopoulos, Norrholm, & Jovanovic, 2015). PTSD gets defined by the presence of at least one stressor, an intrusion symptom, evidence of avoiding the trauma-related stimuli, at least two negative alterations in cognition and mood, a change in arousal and reactivity and the symptoms must last for more than a month. The signs ought to create functional impairment and should not be related to medication, illness or substance abuse. (Blevins et al. 2015). Mr. MM meets the DSM-5 diagnosis criteria having experienced flashbacks of the traumatic events at war, which resulted in isolation, irritability and lack of sleep.

Demographics of client #2

The second client, FN, is 25 years old American from the veteran community too. His parents are both alive. He’s a university student but currently not enrolled due to mental issues. He comes from a middle-level economic class, but the family is quite supportive. The patient is a part-time work at a food processing industry when away from school.

Presenting Problem of FN

CC: The client had complaints of insomnia, talkativeness and wandering away from home. The client felt like he might die if he continues to stay at home.

History of Present illness of FN

The family noticed his strange behavior and took him to the psychiatrist for treatment. He became aggressive on efforts to prevent him from going away from home. He even destroyed properties and threatened to harm his parents. Sometimes he would decline to eat and keep quiet. The patient is compliant to medication and showing improvements, although his hygienic state is still pathetic. His looks confused and his speech is disorganized with concentration troubles.

Past Psychiatric History of FN

The client has got no history of mental issues before this. There’s a history of mental illness in the family where here cousin has PTSD.

Medical History of FN

FN has never gotten admitted in hospital due to any other medical conditions. He has got no history of surgery. He has no known allergies to food or drugs. FN received all scheduled immunizations.

Substance Abuse of FN

The client denies smoking tobacco or drinking alcohol.

DSM-V Diagnosis of FN

According to DMS-V criteria, FN’s diagnosis is schizophrenia. It’s defined by; the presence of 2 or more of symptoms including; delusions, hallucinations, disorganized speech, catatonia, and negative symptoms present for a significant period in one month and reduced level of functioning below the level before onset for a considerable period of the disease. (Kendler, 2016). Other criteria are recurrent symptoms for more than six months associated with delusions and hallucinations; it’s not associated to medication or substance abuse and rule out of schizoaffective and bipolar disorders with psychiatric characteristics because of inadequate features for a significant period. (Morrison, 2017). FN had hallucinations, disorganized speech and poor hygienic state that had been lasting for ten months. The symptoms were not related to any substance or medication.

Cognitive Behavioral Therapy

Cognitive behavioral therapy is a suitable intervention for this group to help arrive at improved cognitive behaviors. There will be a psychological balance of ideas, beliefs, attitude, and practice. (Dobson & Dozois, 2019). The therapy results in restored appropriate behavior and improved coping strategies

Legal and ethical implications of counselling families

The PMHNP ought to ensure privacy and protect the client’s information. Client welfare should get maintained despite being difficult in a group since the individual interests of the clients might differ. (Gutheil & Appelbaum, 2019). There should be informed consent from the patient in every aspect of treatment.

References

Blevins, C. A., Weathers, F. W., Davis, M. T., Witte, T. K., & Domino, J. L. (2015). The posttraumatic stress disorder checklist for DSM‐5 (PCL‐5): Development and initial psychometric evaluation. Journal of traumatic stress, 28(6), 489-498.

Dobson, K. S., & Dozois, D. J. (Eds.). (2019). Handbook of cognitive-behavioral therapies. Guilford Publications.

Gutheil, T. G., & Appelbaum, P. S. (2019). Clinical handbook of psychiatry and the law. Lippincott Williams & Wilkins.

Kendler, K. S. (2016). Phenomenology of schizophrenia and the representativeness of modern diagnostic criteria. JAMA psychiatry, 73(10), 1082-1092.

Michopoulos, V., Norrholm, S. D., & Jovanovic, T. (2015). Diagnostic biomarkers for posttraumatic stress disorder: promising horizons from translational neuroscience research. Biological Psychiatry, 78(5), 344-353.

Morrison, J. (2017). DSM-5 made easy: The clinician’s guide to diagnosis. Guilford Publications.

Group Therapy Progress Note

American Psychological Association | Division

Client: #1 MM Date: 14/7/19

Group name: BEHAVIORAL GROUP THERAPY X Minutes: 60MINS

Group session # 3 Meeting attended is #:3 for this client.

Number present in group 5 of 5 scheduled Start time: 10AM End time: 11AM

Assessment of client

Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn

Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive

❑ Monopolizing ❑X Resistant ❑ Other: _____________________________________

Mood: ❑ Normal ❑Anxious ❑Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________

Affect: ❑ Normal ❑Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other:_______________

Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused

❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other:__________________

Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt

Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic

Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able

Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse

Other observations/evaluations:

In-session procedures:

Self-introduction

Sharing of the details of the day’s discussion and expression of feelings

Discussion of coping skills

Homework

involvement in activities

Socialization

Other Comments:

Client cooperates

Group Therapy Progress Note

American Psychological Association | Division

Client: #2 FN Date: 14/7/19

Group name: BEHAVIORAL GROUP THERAPY Y Minutes: 60MINS