How to Write Psychotherapy Progress Notes

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

Sample Termination Summary:

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

TERMINATION SUMMARY
Name: Mr. Carlo Jonese Date of Termination Summary: Nov. 3, 2012
Date of First Consultation: Nov 5, 2011 Date of Last Consultation: Nov 2, 2012
Duration of the Treatment: One year

Summary of the Presenting Difficulties:

The client is a 35 year-old man of Italian origin who, at the time of consultation, had recently left home to live with his girlfriend (whom he plans to one day marry). The client sought psychotherapy for feelings of social discomfort and a life long experience of feeling that he cannot express himself. He had explained that this was interfering with his work life and he feared it would limit his ability to advance in his profession (business consultant). He also described periods of intense anxiety that came on suddenly and which sometimes led to panic attacks. These periods of anxiety began shortly after having decided to move in with his girlfriend of 3 years. He explained that he grew up in a very traditional Italian household and that leaving home before marriage was frowned upon and created conflict between he and his parents as well as with his girlfriend. This was his first consultation with a mental health professional, having no previous experiences in psychotherapy.

Other Areas Addressed During Treatment:

Through the course of treatment, it became evident that the client was experiencing serious insomnia. Addressing his insomnia also became a focus of our work together. Issues of mourning and grief surrounding the death of his girlfriend’s father (who died mid-way through our work together) also became an important focus of the treatment.

Overview of the Treatment Process:

The client was seen on a once per week basis in supportive-dynamic psychotherapy with the incorporation of cognitive-behavioral techniques to address his panic attacks and insomnia. A good therapeutic alliance was easily established and maintained throughout the course of our work together. Though the client’s presenting difficulty included a subjective sense of not being able to express his thoughts and feelings, our early work revealed that he was, in fact, quite an insightful, emotionally sensitive, and expressive person who, when given sufficient space, could articulate his inner state quite clearly. Continued exploration of this revealed that there had long been a lack of “psychological space” in which he could express himself and listen to his own needs and desires.

During the initial phase of treatment, the client gained significant awareness regarding his psychological/emotional position within his family of origin - as “translator” ,“mediator” and “go-between” and how this was re-enacted in different triangular relationships in his present life that were causing him distress (e.g., girlfriend-himself-mother; girlfriend-himself-friend; father-himself-uncle). Working through of his sense of responsibility for “keeping the peace” allowed him to disentangle from this pattern and freed him to begin to better tend to his own needs. Improvements in his relational life (with family and friends) were evidenced following this period of therapeutic work.

Another major focus of the treatment was support of the client’s movement toward greater emotional autonomy and psychological independence from his family of origin and building of his own sense of himself as an adult/man. In exploring this area, it became evident that the client felt strong underlying pressure to fulfill the family’s expectation and aspirations for him and that he had set aside his own wishes and desires in response. His moving out of the family home was found to represent an important attempt at asserting his need for independence that conflicted with the emotional demand to fulfill the desires of his family. His panic attacks also appeared to be linked to the intense guilt and conflict he experienced over leaving his family of origin. His panic attacks were however addressed more specifically via psycho-education regarding the panic response, self-monitoring of precipitating thoughts and emotional responses, and the employment of relaxation techniques (i.e., deep breathing and muscle relaxation exercises). Over time, the client was able to better clarify and separate his authentic desires and wishes from those tied to (his experience of) the expectations of those around him. Preliminary working through of this issue helped the client better understand his dissatisfaction in working for the family business and led to an important re-examination of his career goals. It should be noted that the client was extremely over qualified for the type of work he was doing in the family business and his talents and potentials were being underutilized.

Another important aspect of the therapy involved support of the client’s coping and self-care during the terminal illness and eventual death of his girlfriend’s father, to whom he was also very attached. Therapy provided a place within which he could express and explore his own grief, while being available as support to his bereaved girlfriend. That the death of his girlfriend’s father also led him to experience worry and sadness regarding the potential death of his own parents was also explored.

Through the course of treatment it became evident that the client experienced significant insomnia (sleeping only 3 or 4 hours per night and feeling very restless). The onset of his sleep difficulties were found to be linked to a particular work related stress that involved having to fire a number of employees. His anxieties about asserting his authority were explored in this regard. To address his insomnia, the client was provided information on “sleep hygiene” and relaxation techniques that included a combination of guided imagery and progressive muscle relaxation. He also began a workout regime (self-initiated) that he found very satisfying and which had a positive impact on his sleep in a short period of time.

Nature of the Termination:

The client experienced significant improvement and gains throughout the treatment. He expressed the wish to terminate treatment based on feeling satisfied with his level of improvement and the beginning of new life projects that will place new demands on his time and finances (e.g., new career plans, up-coming engagement with girlfriend). A termination date was set for January 30th 2012. The client did not attend his planned termination session , but called to express his appreciation for our work together and to say good-bye.

Gains Made/Progress:

Client made significant gains during the course of treatment and reported being satisfied with his progress. Early on, he came to appreciate and value his capacity to express his needs, thoughts, and feelings when feeling entitled to do so. He also experienced enhanced relational functioning with family and friends following a period of working through of underlying feelings of responsibility for other’s feelings and his role as “mediator” between those in conflict. Throughout the course of therapy, the client gained greater awareness of a tendency to neglect his own needs and wishes and developed improved balance between his work, relationship life, and leisure/creative/play time. The client was also able to use the space of the therapy to explore and better clarify his career aspirations and the factors that had been preventing him from making decisions in this regard. The supportive features of the therapy appeared to be very helpful in enhancing the clients coping with his girlfriend’s depression and their loss of her father. The behavioral and cognitive interventions appeared to adequately address the client’s difficulties with panic and insomnia, both of which were fully resolved by the end of treatment. Overall, the client’s mood and self-confidence appeared to improve over the course of treatment. The client reported feeling a new-found sense of freedom and was satisfied with our work together. The client's estimated "global assessment of functioning" at the end of treatment appeared to be in the "high functioning" range with minimal symptoms upon termination.

Limitations of the treatment:

Though explored to some extent during our sessions, the therapy did not sufficiently address the client’s underlying conflicts regarding his cultural identity (e.g., his wish to better establish his own positive Italian identity).

Remaining difficulties and/or concerns:

There were no significant remaining difficulties or concerns observed or expressed by the client at the end of treatment.

Recommendations:

Though the client made tremendous progress and met his main goals during the course of treatment, in the interest of maximizing his psychological well-being and self-understanding, the client may benefit from ongoing exploratory psychodynamic/analytic therapy in the future.

Follow-up:

No specific follow-up plan is indicated; the client was informed he is free to contact me in the future if needed.

Additional Comments:

Note that the client has one outstanding bill (for the month of January) and has arranged to send this payment by the end of February.

 

_______________________________
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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