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Psychiatric Psychotherapy with Individuals Practicum – Client Termination Summary

                                                        Learning Objectives

Students will:

· Develop client termination summaries

To prepare:

· For guidance on writing a Client Termination Summary, review pages 693–712 of the Wheeler text in this week’s Learning Resources.

· Identify a client who may be ready to complete therapy.

                                                           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

· Instructions for future contact

· Signatures

PLEASE DO NOT FORGET TO INCLUDE INTRODUCTION, CONCLUSION AND  REFERENCES

                                                           Learning Resources

Required Readings:

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). New York, NY: Springer Publishing Company.

• Chapter 18, “Psychotherapy With Older Adults” (pp.      625–660)
• Chapter      20, “Termination and Outcome Assessment” (pp. 693–712)

American Psychiatric Association. (2013). Diagnostic research paper writing help and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

McGuire, J. (2009). Ethical considerations when working with older adults in psychology. Ethics & Behavior, 19(2), 112–128. doi:10.1080/10508420902772702

Swift, J. K., & Greenberg, R. P. (2015). What is premature termination, and why does it occur? In Premature termination in psychotherapy: Strategies for engaging clients and improving outcomes (pp. 11–31). Washington, DC: American Psychological Association. doi:10.1037/14469-002

Client Termination Summaries

Student’s Name

Institutional Affiliation

Course

Professor’s Name

Date

Client Termination Summaries

Identifying Information

• “Beverly Myra,” a 25-year-old Caucasian female. Diagnosis: Major Depressive Disorder (MDD) (F32).
• The initial step in case formulation is diagnosis and treatment planning.
• MDD is a mental condition characterized by hopelessness, sadness, emptiness, and hopelessness. Loss of interest is another primary symptom. It is associated with thoughts of sadness. The condition can occur in mild, moderate, and severe levels.

Date

• She came for therapy on 10th September 2020 after a referral by a friend. The therapy began the following day. Each of the planned sessions was 60 seconds. It was agreed that the therapy would be terminated after the 10th session.

Number of Sessions

• The treatment plan involved ten sessions. She only missed one session after a heavy rainfall that affected transport.

Termination

• The treatment plan involved terminating the relationship after the 10th session. Planning for termination of a counselor-client relationship is essential to prepare for the future.

Presenting Problem

• The client has been feeling hopeless, sad, and lacks interest in daily activities. For instance, she does not interact with friends like before. She has lost her appetite for a month. The situation has not improved despite various attempts. Friends and family members have tried to help without success. The client denies a history of drug, alcohol, and substance abuse. She had a similar incident last year in June.

Major Psychosocial Issues

• The client feels a lack of interest in socializing with friends, colleagues at work, and family members. She attends a local mission church, but she has missed various Sundays of late. She lacks passion in her work and plans to find another job to give her a new purpose.

Types of Services Rendered

• The case scenario required individual therapy to address emotional, mental, and behavioral problems identified in the diagnosis. Cognitive behavior therapy is crucial in the individual therapy approach, especially for mental problems such as MDD.

Overview of Treatment Process

• Cognitive behavior therapy is effective in addressing the symptoms of MDD. The use of various techniques such as journaling and finding new hobbies is essential in improving the client’s social life.

Goal Status

• The goals of the treatment are set at the beginning of the treatment.

Treatment Limitations

• No treatment limitations have been identified.

Remaining Difficulties

• The client is dating a boyfriend who abuses drugs. When he is high on drugs, he can be abusive to her, but no physical abuse. She is not sure if she should quit the relationship for a better future. She does not feel adequate appreciation and love from her boyfriend.

Recommendations

• The client should join a support group to enhance the recovery process. Support groups will provide the appreciation and love she requires to boost her emotions. She should find new friends at the local church and strive to improve the ability to socialize. The local church is a resource for support and self-care groups.

Follow-up Plan

• The client should finish all sessions and later terminate the therapy according to the treatment plan.
• A follow-up after a month is essential to avoid relapse.

Instructions for Future Contact

• The client should maintain the contacts of the therapist for future engagement. Future contact will be made a month after completion of all sessions.

Signatures

• The client is aware of all the contract agreements. She is aware of what is required during and after therapy. She knows her responsibility for completing homework tasks. All agreements are fully signed.