Table of Contents
For this discussion, I choose the vignette for mental health counseling to write a case note using DAP format. This particular format is chosen in this context as this format normally includes information and data in context to the individual and their arrangement in the session, the assessment of the therapist's and the issues and progress, and a plan regarding the sessions in the future. The component of data regarding DAP notes subjects the whole thing that is heard and observed in context to the session. It is generally the review of all the gathered data and information from the client. The majority of this information is the self-report by the client but the observations made by the clinician also subject valuable information. It has been conferred that most of the data in this context will be objective, the clinician, at times, may insert to bring in some kind of subjectivity into the process (Chimowitz et al., 2020).
For instance, the clinician or the therapist may subject that a client appears restless or disturbed. On the whole, a question that summarizes this particular section is what is seen by me. The portion of assessment in context to the DAP note subjects clinician understanding. Certain questions are very imperative to answer in the section of assessment: Is effort is being made by the client to address their issues? How does the information mirror attention to their treatment goals? Is progress seen in the context of the client? Does the information subject a particular diagnosis or issue that is required to be addressed? In other words, what does the information mean? The last portion in context to the DAP note is the plan regarding the treatment in future terms. It may engage with the thought that what the therapist wants the client to do subsequently as well as what he or she will do, and what he or she wants to accomplish. However, it is very imperative to be kept in mind that the intention of this segment is not the entire plan of treatment. It is only the goal from one session to the next session. On the other hand, it can also subject changes or new directions in context to the whole plan of treatment. It answers the question, what is needed to be done next (Shepherd & Beail, 2017).
The vignette is about a man called Ken who has been sending me (as a counselor) series of emails requesting my help. In his emails, the client confesses that he is struggling with his gender identity. The client further discloses that he is in the beginning stages of depression. He is not reporting any sexual or relationship problems.
In the context of this paper, the topic is instrumental in presenting the problem in regards to a person called Ken. Ken at present is a middle-aged man who is having several problems with his wife. The matter of primary concern for him, in this case, is that he is not willing or can be said, does not want to get separated from his wife. On the other hand, his wife eventually wants to get a divorce or get separated from him as she accuses him of continuing his bad habit associated with drinking alcohol with his friends and associates. As his wife seems to have got fed up with his repetitive aspect of continuing the habit of drinking with his friends and is highly disliked by her. Ken seems to be very upset with the present ongoing situation in context to his personal life. He seems to love his wife whose decision of moving away or separation is not acceptable for him at least from a psychological point of view (Jesus et al., 2016). The couple has 2 children and both of them obligatorily take good care of them. On the verge of doing so, they distribute their family responsibilities as well as are instrumental in sharing family expenses by working together.
His wife has taken day work on the other hand he does work in the night shift. In terms of the household responsibilities Ken while being at home in the day time usually handles as well as takes care of their children (Falkenström et al., 2013). Now, on the contrary, it is also depicted in the case study that his wife also drinks and enjoys going around with her friends. Here, Ken does not seem to be getting bothered with or does not mind his wife’s going out hence support her unconditionally. He only drinks with his friends especially on weekends being on the equal platform he is getting confused about the fact that why his wife is taking his form of recreation as a negative aspect and hence wants a separation. He is also getting confused about the fact that why a person ((in this case his wife) engaged in the same act of choosing a way of getting entertained (drinking with her friends) can consider as an act of offense on his part and appeal for a separation. He does not want to separate from his wife and is very much disturbed (Denneson et al., 2017).
20/04/2020 Client: KEN
(D) In the first session of his psychological counseling, I met with Ken for an hour. In the due course of the 1st session, Ken stated that he was very disturbed with the decision of his wife. As stated by him, the wife of Ken wanted separation for the reason of his drinking habit. Her decision was drawing his mental state toward utter darkness and in turn getting him more depressed. On the verge of finding an answer he also added that both he and his wife had two children and they deliberately took care of them beautifully with utter concern and delicacy. Although he mentioned a fact that the act of getting engaged into work of day and night shift was creating a psychological barrier in between their relationship psyche and was dividing them from each other. The work toward earning their bread and butter for the day was generally taken care of by his wife on the other hand he opted to work in the night shift to serve the same purpose. As for him, they were equally responsible to promise their family with a better financially secure lifestyle.
The only thing that was interrupting or creating a psychological barrier in the minds of his wife or their relationship at this time was the drinking habit of Ken. Justifying the fact Ken reported that he only drank at the weekends to get some refreshments with his friends. This was only a matter of concern on the part of his wife and was causing major problems and issues in his relationship with his wife. During the discussion, he also mentioned that his wife also drank with her friends to which Ken did not subject nay problem. It was also confirmed by Ken that he loved his wife unconditionally and the decision of her Separation was affirmed by his wife. This makes him highly disturbed that too psychologically vulnerable as he was not ready for separation. It seems after the first session that he is not ready to support the decision of his wife as he loves his wife as well as his family very much.
(A)It is in my opinion to this context that, Ken is experiencing a state of conflicting feelings in his mind about the decision of his wife and was desperately looking for the answer as to why his wife wants a separation from him. During the session, while I was talking to him I also understood that he must be thinking that the act of his drinking serves as the only reason for his wife wants a separation. It was also noted by me that he was quite hesitant and was not spontaneously ready to spill all the information concerning his wife at first. Though, in due course of the session, he gradually became comfortable in talking about the complexities in his relationship. It was clear from the analysis of the patient’s expressions as well as the thought process that it was quite appropriate for him to get his psyche on the verge of going into depression. At this point, I was instrumental in advising Ken to rebuild communication with his wife. Besides that, I also advised him to work on their trust issues and safety issues. Lastly, I advised him to go out with his wife instead of spending time with his friends. This way they would be talking and will eventually complement each other which in turn will help them reinventing the touch of concern and ignite affection in their heart and minds. My suggestion was to reduce the growing distance and reinvent them falling in love once more by spending quality time.
(P) After looking and analyzing all the aspects of Ken’s psychological state I prescribed his next session, to be scheduled on 20/05/2020 at 6 pm. In which I requested his wife to come up and wanted to discuss with Ken along with his wife about their relationship status. I will be discussing the whereabouts of the facts that had happened over this month and sort out the fact of whether or not his wife still wants a separation.
12/05/2020 Client: KEN
(D) In the context of this 2nd session, I met with Ken and his wife for one hour. Ken was quite enthusiastic about the session and reported that they had a spend quality time with each other describing this week as a ‘great week’ after a gap of few years. Ken noted that they quarreled for the first two days following the last session, but later on he explained his wife about the reasons for his willingness to spend time with other peoples (friends). He also described the fact that in no way he is escapist in terms of his relationship and how much he loves her and even fears the thought of getting separated from his wife. On Friday night both of them started to talk about their feelings and addressed the reasons for getting hurt as well as upset from each other. There was no way they did not care for each other which in turn has resulted in an emotional outburst followed by the act of snuggling the whole night. Ken further subjected to report that the previous few days was similar to memories when they first met before and even after their marriage. His wife acknowledged that she too had been enjoying their time together, but was frightened that it was just a phase and that it would gradually go away. They talked about the changes in their relationship over the years and came up with ideas on how they can start spending more time with each other. Except going out with their friends at the weekends or the middle of the week they started to spend time with each other easing their hearts off, over a glass of wine.
(A) Ken is no longer subjecting any symptoms of disturbance or depression, but still at times does think that situations might change and his wife may ask for separation again. His wife seems reserved at times and appears to be reacting to Ken’s overjoyed state in context to the relationship. For me, it subjected to be fact that it was virtually instated in her mind that the act of Ken to avoid her and engage in the act of getting drunk with his friends may come back in the future.
(P) The subsequent session was planned for 20/06/2020 at 6 pm. This session is required to need to prepare Ken and his wife for when the state of euphoria goes away. They still need to continue to work on trust and safety issues from coming back and restate a permanent picture of staying together in both of their minds. They need to spend quality time and talk about their insecurities to each other. Since they are spending a lot of time with themselves on the weekends now, his wife also needs to psychologically accept just like Ken when both of them will go out with their friends. Rebuilding relationships require a lot of time, trust, love, and mutual respect a misbalance in any of the mentioned aspects can create a permanent scar and that's the thing I suggested both of them to take care of.
Case notes are sequential records of the actions, observations, and interactions that involve a particular individual or/and family. To create the case notes therapists or clinicians need to decide on the data and information to exclude or include (Kahn et al., 2014). In the context of this case, I decided to subject only details relevant to the assessment, investigation, and provision of service. For instance, I decided to include brief information on what was said and my analysis after speaking with Ken and his wife was to preserve the most important topics of the conversation. This will be very helpful for me in the future if I ever need to go back and review or analyze what happened in context to our first session. Nevertheless, I decided to exclude the information about monitoring and prescription, frequencies and modalities of treatment, and prognosis. I debarred the above information to safeguard the privacy of the client. Ethically also protecting and safeguarding the privacy of the clients is very imperative. Legally as practitioners, clinicians, and therapists we are bound to protect the data and information of the clients fairly and respectfully. Customer goodwill very much depends concerning this particular attribute and in turn, also reduces the risks in legal terms (Hartmann et al., 2016).
Chimowitz, H., O’Neill, S., Leveille, S., Welch, K., & Walker, J. (2020). Sharing Psychotherapy Notes with Patients: Therapists’ Attitudes and Experiences. Social Work, 65(2), 159-168. https://doi.org/10.1093/sw/swaa010
Denneson, L. M., Cromer, R., Williams, H. B., Pisciotta, M., & Dobscha, S. K. (2017). A qualitative analysis of how online access to mental health notes is changing clinician perceptions of power and the therapeutic relationship. Journal of medical Internet research, 19(6), e208. doi: 10.2196/jmir.6915.
Falkenström, F., Granström, F., & Holmqvist, R. (2013). Therapeutic alliance predicts symptomatic improvement session by session. Journal of counseling psychology, 60(3), 317. http://dx.doi.org.ezaccess.libraries.psu.edu/10.1037/a0032258
Hartmann, A., Zeeck, A., Herzog, W., Wild, B., de Zwaan, M., Herpertz, S., ... & Löwe, B. (2016). The intersession process in psychotherapy for anorexia nervosa: Characteristics and relation to outcome. Journal of clinical psychology, 72(9), 861-879. doi:10.1002/jclp.22293
Jesus, T. S., Bright, F., Kayes, N., & Cott, C. A. (2016). Person-centred rehabilitation: what exactly does it mean? Protocol for a scoping review with thematic analysis towards framing the concept and practice of person-centred rehabilitation. BMJ open, 6(7), e011959. doi:10.1136/bmjopen-2016-011959
Kahn, M. W., Bell, S. K., Walker, J., & Delbanco, T. (2014). Let’s show patients their mental health records. JAMA, 311(13), 1291-1292. doi:10.1001/ jama.2014.1824.
Shepherd, C., & Beail, N. (2017). A systematic review of the effectiveness of psychoanalysis, psychoanalytic and psychodynamic psychotherapy with adults with intellectual and developmental disabilities: progress and challenges. Psychoanalytic Psychotherapy, 31(1), 94-117. https://doi.org/10.1080/02668734.2017.1286610
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