Self injurious patient and soap note

You are seeing a current client for a follow-up session with new developments of self-harm. This is not an initial interview. For this session, focus on the psychodynamic therapy modality to engage with the teen. Use empathy and other skills you have reviewed..

Psychodynamic psychotherapy – This type of therapy helps individuals explore issues lurking at the subconscious or unconscious level that often stem from negative childhood experiences and painful memories.

A 17-year-old female patient named Stella Jess, who recently broke up with her boyfriend, reveals she has been cutting her arms. While rolling up her sleeves to display the cuts, she expresses suicidal ideation. She has a suicidal plan, overdosing on her depression medication (Prozac) and alcohol, but says she doubts she would ever actually attempt to take her life. She reports no serious previous attempts. Her history includes some neglect from her parents when she was a younger child, and she now lives with her grandmother. Her mother is still involved in her life, but not on a daily basis. She is an A student, does not miss school, and states she has a group of close friends with whom she enjoys spending free time.

Vitals:
BP: 122/68
HR: 74
R: 18
T: 97
O2: 99%
Pain: 2 on 0–10 scale

Consent to treat the minor signed by parents.

II

Instructions

Your reflection should address all of the following questions with between 750 to 1,000 words. Appropriate spelling, grammar, and punctuation are required. Complete sentences are expected. All writing should be in your own words. Use APA references as needed to support your ideas; there is no requirement on the number of references to include. Be sure to use APA format.

• Which skills did you use in the session? How?
• How did the assigned Corey readings, PowerPoints, Handouts, and videos inform your therapy session? Please explain in detail.
• What were your strengths in the interview?
• What were your weaknesses/areas in need of further development in the interview?
• How could you improve your interviewing skills? Are there steps you plan on taking? What are those steps?
• Was there any time when you felt stuck or uncertain how to respond? Describe what was happening then. Were there times you felt more confident in your responses with the client? Times you were less confident? How? Does this come through in the session?
• How were you impacted by the client…your emotions, thoughts, physical reactions, transference, and countertransference, body language?
• What was your overall response to the interview? Did you feel connected to the client? Distracted? Disengaged?
• • What was the quality of your engagement, your empathy?
  • If you were to continue seeing this particular client, what future directions would you take? How would you conceptualize the case and what would be some of your treatment goals? How would you pursue these goals?

  In relation to your partner:

• What were your partner’s strengths in the interview?
• What were your partner’s weaknesses/areas in need of further development in the interview?
• How could your partner improve his/her interviewing skills?

SOAP Note:

• Fill in the SOAP note in the template based on your session visit. This should be a follow-up note, as this session was NOT an initial interview.
• Create a Session Reflection & SOAP Note based on your session with the client.