How to Write Psychotherapy Progress Notes

Patricia C., Ph.D.
Clinical Psychologist
notedesigner.com

Sample Intake Note:

What follows is a sample of an intake note. All of the details are fictional, although based on one or more actual cases. This note is likely longer than most intake notes would be, so as to fully demonstrate the types of material that could be included. Information about writing an intake note can be found here.

INTAKE NOTE
Name: John Smithish Date of Intake Session(s): April 12,18 1997
Date of Birth: May 15, 1953 Date of Report: April 19, 1997
Marital Status: Married 7 y.Living Arrangement: lives with spouse & son
Occupation: Teacher Home Address: 222 Shamrock Cres. Ottawa, ON, S1J5k5
Tel. Number(s): 555-555-2121 OK to leave a message: Yes
Emergency Contact and Number: Jane Smithish (wife) 555-777-5544
Referral Source: Dr. Granger (GP)

Presenting Difficulties:

The client appeared on time for both assessment appointments but reported that he had been very rushed getting to my office. He was polite and appropriate in his interactions with me. He did come across as somewhat anxious and uncomfortable speaking candidly at first and shared with me his nervousness about doing so. By the second assessment session he did appear somewhat more relaxed and was able to engage more readily. A good preliminary rapport was established.

The client reports feeling very anxious and irritable much of the time and would like to gain a better understanding of this and “other things” that he has been dealing with throughout his life. It seemed apparent that the client had much more he wanted to say about these “other things” but that he was not yet comfortable doing so. In particular, he expressed a wish to understanding and deal with his issues better so as to better address marital problems he has been having. Specifically, he reports feeling a tremendous amount of, what he referred to as “irrational and crazy jealousy”. He explained that his wife has encouraged him to seek help for many years and that she has threatened to leave the marriage on different occasions if he does not change. Though a significant part of his motivation for seeking treatment at this time appears to be related to his marital difficulties, he also expressed a wish to understand himself and what prevents him from being happy and content in his life in general. In particular, he told me that he is worried that his irritability may affect not only his relationship with his wife and family but with his relationships at work and with friends. He explained that he feels he has been holding in a lot of anger, and that he is afraid he will explode one day if he doesn’t take care of it.

History of the Presenting Difficulties:

The client explained that though he has always felt like an anxious person, his anxiety has increased profoundly since marrying his wife 7 years ago. He recalled that everything was “going smoothly” between them until the first month after marriage. It was then that he began to experience extreme jealousy regarding other men that his wife paid attention to (in particular, her colleagues at work) and convinced himself that she was going to have an affair and leave him. As he spoke, he communicated an understanding that his suspicions and worries are unfounded, but that despite his attempts at reassuring himself he explained that he remains “paranoid” about his wife’s behavior. He had hoped that having children would ease his worries, but found that his anxieties, irritability, and jealousy became somewhat worse when his son was born (5 years ago). He described also feeling increasingly left out and distant from his wife after the birth as she was preoccupied with the baby and seemed less interested in him.

Significant Life History and Background Information:

The client is the only child born to immigrant parents from Eastern Europe. He was brought up in a middle class environment and explained that his parents worked very hard so that he could attend the best private schools in the city. His father worked in construction for several years and then returned to school and became a teacher; the client explained that he wanted to “follow in his footsteps” and so pursued a career in teaching as well. During the interview, he described his father in very positive terms as humble, strong, and intelligent, though somewhat remote and distant from his feelings. He explained that although he had a good relationship with him, he had hoped they could have been “closer”.

In contrast to his feelings about his father, he reported having a very difficult relationship with his mother who he described as intrusive, suspicious, critical of others and being a huge “worry wart”. He felt that she was overprotective and is worried that this has had an impact on him and how he feels about himself and life in general. He further explained that both his parents grew up during the war and that he knows they each went through some very negative experiences but that these remain secrets in the family.

Towards the end of the second assessment session, the client explained that his own parent’s marriage had had some difficulties. He explained that they would often fight and that this mother would throw things at his father. The client wasn’t certain, but expressed that he thought he once overheard his mother accusing his father of having an affair. He recalled that this worried him terribly and that he himself became convinced that his father was actually in love with a colleague (one of the client’s own teachers in elementary school). To this day, the client remains uncertain about his father’s fidelity to his mother.

Also towards the end of the second session, the client explained that his father is currently undergoing some medical and neurological tests to determine if recent changes in his behaviour (e.g., forgetfulness, outbursts of anger, withdrawal) are related to the beginning of dementia. He is very worried about his father and what this will mean for himself and his mother.

The client described himself as being a rather unhappy child, something he attributes to having spent much of his time studying at home and not engaging enough with other children. He recalled his sadness hearing other children playing outside in the street while he was being made to go to bed while it was still light out in the summer time. He explained that he felt left out most of the time and derived most of his pleasure through gaining the approval and praise of his teachers in school. Despite his unhappy childhood, the client explained that he eventually became engaged in art work (drawing and cartooning) and that this gave him some joy and a chance to engage with other children who admired his talents. The client remarked that, in general, he has difficulty remembering his childhood experiences.

The client explained that during his adolescence (14-15 years) he recalls having gone through a period of depression and withdrawal that he has never understood. He remembered wanting to stay in his bed all day and not having the energy to go to school. He was too ashamed to tell anyone how sad he had felt. He explained believing that if his mother had known she would have “freaked out” and become hysterical, so he tried to keep his feelings to himself. He is not sure how he overcame this period, but remembered feeling very relieved when it was over.

He described his college years as a very positive time in his life and that this corresponds with leaving home and making some very dear friendships. He found leaving his parents' house liberating. He reported experimenting with drugs and alcohol for the first time during college. One very bad experience while taking a strong drug (he did not know what it was) scared him and he swore off doing drugs ever again. As based on his experience (that included some visual hallucinations and distortions in his sense of time, color perception and sense of self) he wonders whether the drug may have been LSD.

The client met his wife 9 years ago having been introduced by a mutual friend. He explained that at first he was not really attracted to her physically but connected with her on an intellectual level. He recalled being drawn to her kindness and the way in which she attended to him. She works as a nurse and he jokingly commented that perhaps he wanted someone to take care of him. He explained that he felt very secure with her up until after they married. In describing their sexual life, though hesitant to speak about this at first, he eventually explained that he struggles with intrusive fantasies about his wife being in bed with other men and that he finds this strangely arousing and upsetting at the same time.

With respect to his work life, the client describes taking great satisfaction in his job. He explained that he has won a number of teaching awards and that he seems to be highly regarded among his colleagues. He tends to feel very pressured to excel and explained that he does not allow himself make mistakes. He often feels riddled with guilt when he knows he has not done his best and will ruminate about this after a class, sometimes interfering with his ability to work. At times, he explained, he also worries that his colleagues secretly dislike him and that they may do things to “trip him up” or make him look bad in the eyes of their superiors. This leads him to withdraw from others and not share too much about himself at work.

He has not seen a therapist in the past, but has consulted with a medical practitioner for anti-depressant medication that he used during a period of depression and lethargy a few years ago. He and his wife also attended some couple counselling sessions during periods of crisis in the marriage. He reported that he did not find the couple’s therapy very useful as he felt the therapist was taking the side of his wife.

Significant Medical History:

The client explained that his physical health is “ok”. He suggested that there may be some issues in this area that he did not feel comfortable discussing as of yet. I did not pursue this further.

Clinical Observations and Impressions:

The Client is a high functioning professional man who experiences anxiety, irritability, and mild obsessional traits (e.g., strong internal demands for efficiency, perfection, intellectualization, self-criticism, guilt) that appear to limit his enjoyment of work and family life. The client also experiences intense feelings of jealousy and is very insecure regarding his wife’s fidelity. He does have insight into the exaggerated nature of his suspiciousness and that his jealousy is unfounded in fact. There was some suggestion that the client struggles with a more general difficulty trusting others (for example, in the work place). This was also evident during the assessment process itself in that the client was apprehensive about disclosing certain details regarding his life to the therapist. The client appears to be struggling with chronic difficulties with mood and his affective life, having experienced sadness and anxiety throughout much of his childhood and adolescence. Potential underlying core conflicts appear related to issues of trust, anxieties surrounding success, and inhibitions and anxiety surrounding aggression and aggressive urges. The client appears to have a strong need for self-sufficiency and may be uncomfortable depending on others (including the therapist) for assistance. (Note that client demonstrated some difficulty with self-disclosure during our interviews, was able to indicate that there are issues that he would like to keep private until he feels more comfortable). The client's estimated global assessment of functioning indicates a mild level of difficulty with some problems in relationships, work, or school functioning. The client is nonetheless functioning well and has some significant relationships.

Diagnostic Impressions:

The client’s clinical presentation suggests a dysthymic condition with chronic anxiety. Perfectionistic tendencies and some obsessional qualities also appear evident. The client also struggles with suspiciousness regarding others that appear to be interfering with his marital and work relations (he does not, however, meet the criteria for paranoid personality disorder). The client demonstrates insight regarding the exaggerated nature of his suspiciousness of others. A good observing capacity was evident and the client was readily able to engage in a preliminary exploration of the nature of his difficulties. He expressed curiosity about impact of his childhood experiences in response to some trial interpretations drawing potential links between his past and present struggles.

There was no evidence of serious psychopathology or substance abuse difficulties.

Preliminary Clinical Formulation (psychodynamic formulation):

The client appears to be struggling with intense jealousy, anxiety, and underlying anger that is possibly related to an identification with his mother’s distress that he experienced throughout his childhood (which included her own jealousy and suspicions regarding his father’s fidelity). Indeed, he expressed feeing linked to his mother in a” special way” and that he was somehow responsible to take care of her. His experience of his father’s emotional detachment and distance from him has also likely contributed to his feelings of worry about the potential loss of love from a much-needed figure. That his father is presently in ill health may be stimulating further his sense of insecurity. The experience of being an only child who often felt left out while others were “having fun” also seems to have contributed to his anxiety about having a secure place with others and possibly with his wife. That his jealousy and worry regarding his wife’s fidelity increased after the birth of their child may in some ways relate to a revival of his own childhood jealousies and anxieties with his own parents (worries stimulated by the presence of a relational triangle; mother-father-baby).

There is some suggestion that the client experiences anxiety regarding his underlying aggressive wishes and feelings that he fears will be destructive and come into conflict with his intense wish for approval and acceptance. The client is aware that he has likely been repressing his anger and that this may be contributing to his irritability and feeling that he could “explode”. His perfectionism and need to be pleasing to others also appears to come into conflict with his needs for assertion and expression of anger.

The client’s suspiciousness regarding others (his wife as well as his colleagues) is another important feature of his character that appears to reflect a more general sense of insecurity regarding basic trust in relationships. This may impact how the client will experience the therapeutic relationship and setting and will be an important avenue for further exploration.

Recommendations and Preliminary Treatment Plan:

Exploratory psychodynamic-psychotherapy at a frequency of twice per week with an emphasis on better understanding and working through his anxieties, jealousies, depressive affect, areas of conflict, and coping with his current marital situation is recommended. Increased awareness of the potential links between his marital distress and his experience of his parent’s marriage and his own potential identification with his mother will be an important preliminary goal with the aim of helping him resolve his jealousy with respect to his wife. Exploration and working through of painful childhood and adolescent experiences (alluded to during intake) and their links to his current anxiety is also recommended to further his self-understanding and self-acceptance. An exploration of his experience relating to the therapist may provide an important avenue for working through of his more general anxieties regarding trust in relationships.

It is also recommended that the client and his wife pursue couple therapy as an adjunct to the client’s individual treatment to deal with their recent and past marital difficulties. Note that I offered a referral source for such services (Harmony Couples and Family Clinic).

Description of Treatment Contract and Informed Consent / Additional Comments:

After explaining the nature of a psychodynamic treatment, its goals and methods, alternative treatment approaches and the therapy contract the client consented to beginning a course of twice per week psychodynamic therapy (with the possibility of increased frequency as needed), to be conducted in an open-ended fashion. (Signed consent to treatment is here included). Given that the client will be attending twice weekly sessions, it was agreed that the fee will be reduced to $90.00 per session.

 

_______________________________
Patricia C., Ph. D.
Clinical Psychologist

Note: Recommendations and examples presented are intended to provide a general overview of how to write psychotherapy progress notes and do not constitute nor can they substitute for legal counsel or official guidelines mandated by any particular professional order or other regulatory body; please be sure to consult and familiarize yourself with the guidelines and rules regarding record keeping in your particular mental health field and/or as stipulated by your profession.

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