Description
I am attaching a Therapy Journal #1 initial notes Word document that we must transform to look like the Therapy Journal Sample with scholarly references cited using proper APA no older than 5 years old.I recommend using at least 4-5 references with in-text citations, overcitation and use of references is even better.There is no such thing as overcitation for me
You can also use the references I shared with you from the course syllabi last time.I have included them again here for your convenience or you can use entirely scholarly referenced as in the Therapy Journal Sample.
I am also attaching the Therapy Journal template and rubric.As you can see the Therapy Journal Sample is about 6 pages, if it were double-spaced, as it should be, and 7 pages, if we add in a title page.
Let me know if you have any questions.
References
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental
Disorders DSM 5-TR (5th ed. Text Revision). American Psychiatric Association: Arlington, Virginia. ISBN-10: 0890425760
Carlat, D. (2017). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins: Philadelphia, ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Stahl, S.M. (2020). Stahl’s Essential Psychopharmacology Prescriber’s Guide (7th Ed.). Cambridge University Press: New York, NY. ISBN-13: 978-1108926010 ISBN-10: 1108926010
Zimmerman, M. (2013). Interview Guide for Evaluating DSM-5 Psychiatric Disorders and the Mental Status Examination. Psych Products Press: East Greenwich, RI. ISBN-13: 978-0963382115 ISBN-10: 096338211X
American Psychiatric Association (2022). Desk Reference to the Diagnostic Criteria from DSM- 5TR. Arlington, Virginia: APA ISBN-10 : 089042580 ISBN-13 : 978-0890425800
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins: Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders DSM 5 (5th ed.).America Psychiatric Association: Arlington, Virginia
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
Carlat, D. (2016). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Wheeler K. (2022). Psychotherapy for the Advanced Practice Psychiatric Nurse: A
How-To Guide for Evidence-Based Practice. 3rd Edition. Springer Publishing; New York,ISBN-13: 978-0826193797 ISBN-10: 082619379X
American Psychiatric Association (2013). Desk Reference to the Diagnostic Criteria from DSM-5 Arlington, Virginia: Author.
American Psychological Association. (2020). Publication manual of the American Psychological Association (7th ed.). Washington, DC: Author.
Corey, G. (2015). Theory and Practice of Counseling and Psychotherapy (10th ed.). Brooks/Cole Publishing Company: Belmont, CA.
Unformatted Attachment Preview
Therapy Clinical Log FA21
Therapy Clinical Log
Criteria
Ratings
Pts
This criterion is
linked to a
Learning
OutcomeGoals
clearly identified
10 pts
Goal fully
idenitifed
10 points
5 pts
Goal partially
identified
9-5 points
0 pts
Little to no Goals10 p
Identified
ts
4-0 points
This criterion is
linked to a
Learning
OutcomeThemes
Idenitifed
10 pts
Themes fully
idenitfied
10 points
5 pts
Themes partially
identified
9-5 points
0 pts
Little to no themes
10 p
identified
ts
4-0 points
This criterion is
linked to a
Learning
OutcomeType of
Therapy defined
and described
20 pts
Therapy
defined and
described in a
thorough and
complete
manner
20 points
12 pts
Type of
therapy with
main concepts
and techniques
are mostly
identified
19-12 points
5 pts
Less than
partial
descriptions of
therapy type,
concepts and
techniques
11-5 points
0 pts
Poor
description of
the type20
of p
therapy,tsit’s
concepts and
techniques
4-0 points
This criterion is
linked to a
Learning
OutcomeExplana
tion of why this
therapy was an
appropriate
choice
20 pts
Explanation is
through and
complete
20 points
12 pts
Choice is
partially
explained
19-12 points
5 pts
Choice is less
than partially
explained
11-5 points
0 pts
Explanation of
20 p
choice is poorly
ts
explained
4-0 points
This criterion is
linked to a
Learning
OutcomeDescrip
tion of
therapeutic
intervention
20 pts
Description
is thorough
and
complete
20 points
12 pts
Description
of therapeutic
intervention
is described
with fair
detail
19-12 points
5 pts
Description
of
therapeutic
intervention
is vague
11-5 points
5 pts
Poor
description
of
therapeutic
intervention
4-0 points
0 pts
No
Marks
20 p
ts
Therapy Clinical Log
Criteria
This criterion is
linked to a
Learning
OutcomeAssess
ment of the
therapy
intervention
This criterion is
linked to a
Learning
OutcomeMechan
ics of writing,
use of
professional
refrences
Total Points: 100
PreviousNext
Ratings
15 pts
Thorough
assessment
effectiveness of
this type of
therapy. If not
effective
disucssion of
what should be
changed
15 points
8 pts
Mostly
complete
assessment
with
discussion of
changes
14-8 points
5 pts
Journal is written in a
professional and neat
manner, no errors in in
APA Citation and writing
mechanics
5 points
Pts
4 pts
Missing
assessment
of therapy or
suggestions
for change
0 pts
No assessment of
the intervention or
recommendation
for change
15 p
ts
4 pts
Writing mechanics need
improvement and/or use
APA citations need
improvement
4-1 points
0 pts
No APA
citations or
references
5 pts
0 points
Individual, Family, Group or Couple’s Therapy Log
DATE: 2/4/2020
TIME: 1300-1330
SITE: Taravista Behavioral Health Center (Devens, MA)
LEVEL OF SUPERVISION: Observation
THERAPISTS/Co-THERAPISTS: Kate NP
CPT CODE/TYPE of VISIT: Individual
PATIENT INITIALS: KM
DIAGNOSIS: MDD, Borderline Personality Disorder
AGE: 22
GENDER: Transgender Female to Male, prefers He/Him pronouns
GOALS FOR THERAPY: Emotion Regulation, Interpersonal Effectiveness
THEMES TO BE ADDRESSED:
KM reports conflict with girlfriend’s family who he lives with. He engages in NSSI by cutting
self frequently after interactions with specifically her mother; this type of therapy will help him improve
relationship with girlfriend’s family and learn positive coping strategies to manage stress. KM also has
engaged in SIB while inpatient. SIB occurs after staff redirects patient and sets limits with patient.
THERAPY UTILIZED (Define and describe therapy. Include important techniques used with this
therapy):
Dialectical behavior therapy (DBT) is a subtype of cognitive behavioral therapy developed in the
late 1980s by Dr. Marsha Linehan and her team. CBT alone is ineffective for the treatment of Borderline
Personality Disorder. The team developed techniques that would be helpful for meeting the specific
needs of this personality disorder based on the Linehan Biosocial Theory of emotional dysregulation. The
Biosocial Theory explains that emotional dysregulation develops from repeated exchanges between
biological vulnerabilities and a rejecting environment that occur during childhood development. No one is
born with borderline personality disorder, this maladaptive pattern of thinking and perception develops
typically after traumatic experiences. The term dialectical is based on defining reality, using the
assumptions that every thing is interconnected, change is a constant that cannot be fought, opposites can
be brought together to be closer to reality. For borderline personality d/o, there is difficulty between
accepting oneself and change, and DBT works to close the contradiction between the two to benefit the
person by accepting reality and changing destructive behaviors. The four treatment modes include
individual therapy, group therapy, phone coaching, and therapist consultation team (Prada et. al, 2018).
DBT functions to improve coping/grounding skills, integrate these skills to the person’s
environment, enhance and maintain patient’s motivation for change, improve therapist’s motivation and
skills, and providing a supportive environment to optimize the implementation of this treatment. DBT
strives to change maladaptive patterns in regulating emotions, impulses, identity, and interpersonal
relationships by learning new skills. The four skill modules are mindfulness, distress tolerance,
interpersonal effectiveness, and emotion regulation (Prada et. al, 2018).
Completing a behavior change analysis helps the patient identify patterns of interactions and
environment that lead to destructive behaviors. This helps the patient understand what is going on, what is
needed to change, provides validation, and also helps the provider better understand the behavior as well
(Landes, 2016). Identifying emotions and the actions linked to that emotion will help identify the opposite
action to complete. Mindfulness can be achieved using sensory items, such as a frozen orange or frozen
washcloth. When a patient places a frozen item on their wrists, this has assisted them in combating
dissociative symptoms, grounding themselves. A weighted blanket can be used to help ground a patient as
well. Sensory items are helpful in bringing a person back to reality. Distress tolerance worksheets are
helpful resources.
Improving interpersonal skills can be done by first completing a skills assessment handout that
one rates themselves on a scale of 1 to 5 (very poor to always good). Skills include introducing oneself,
listening, responding to praise, and responding to negative feedback. This baseline will help the patient in
seeing improvements and identifying communication skills that need work. The patient can also complete
interpersonal effectiveness skills handouts, which outlines how to effectively communicate with others
through objective, relationship, and self respect effectiveness (Ackerman, 2019).
THERAPEUTIC INTERVENTIONS (Describe how this therapy was implemented for this client,
be specific):
DBT was implemented for this client by having him first complete a behavior chain analysis. KM
is able to identify that staff working on the unit saying, “No”and girlfriend’s mom’s expectations to be
precipitating factors to cutting. KM was able to identify three emotions (anxious, angry, sad) and then
action urges (run away, attack, isolate). Emotion regulation involves having the opposite action of what
one feels they should do. Instead of cutting, KM is interested in trying a frozen item which would help
found him. KM also expressed interested in drawing on oneself with a red marker instead of cutting as a
step towards being able to reach out to staff and asking for a frozen wash cloth or orange. The NP worked
with the patient to identify three opposite actions (Stick with whatever is happening, walk away or
approach staff kindly, stay out in community area) as alternatives and integrate using sensory items to self
soothe.
EXPLANATION (Why this therapy was an appropriate choice for this client?):
KM reports feeling “filled with rage” when his girlfriend’s mom tells him he is a bad influence
and engages in SIB after most interactions with her. This client has exhibited frequent emotion
dysregulation while inpatient. Even though KM is on a sharps restriction, KM has still had access to
pencils, plastic knife, and has engaged in cutting behaviors after staff has set limits and boundaries with
patient. KM has an extensive SIB history, the introduction of emotion regulation and alternatives could be
the start for KM to decrease SIB. KM should follow up on discharge continuing to work on DBT skills
with an outpatient therapist or attending a day program that has DBT groups.
ASSESSMENT OF THERAPY (Include effectiveness and suggestions for change):
The average length of stay at TV is 5-10 days, typically people with borderline
personality disorder have tried to sabotage their discharge and regress. Chronic NSSI such as
cutting is unlikely to be resolved during an inpatient stay. KM could benefit from learning DBT
skills, yet to see a real change, this will most likely happen outpatient from individual
psychotherapy and group therapy. KM should work on distress tolerance skills, as he endorses
several misperceived slights from staff, and one cannot be sure of the dynamic living with his
girlfriend and her family has as KM is not a reliable historian per clinical referral. KM was able
to tolerate a half hour meeting and had a bright affect while completing worksheets.I did not find
this to be a very effective session as evidenced by KM making several provocative comments
during the meeting about obtaining an undisclosed item during lunch that he could use to cut.
While inpatient, KM will benefit from group therapy more than individual 1:1 therapy, as he
seems to act out more after 1:1 attention.
References
Ackerman, C. E. (2019, June). Interpersonal effectiveness: 9 worksheets & examples. In Positive
Psychology. Retrieved from https://positivepsychology.com/interpersonal-effectiveness/
Landes, S. J. (2016, May). Chain analysis . In Central Arkansas Veterans Healthcare System.
Retrieved from https://www.ptsd.va.gov/professional/consult/2016lecture_archive/
05182016_Chain_Analysis.pdf
Prado, P., Perroud, N., Rufenacht, E., & Nicastro, R. (2018, December 17). Strategies to deal
with suicide and non-suicidal self-injury in borderline personality disorder, the case of DBT.
Frontiers in Psychology, 9. doi:http://0-dx.doi.org.lib.rivier.edu/10.3389/fpsyg.2018.02595
Individual, Family, Group or Couple’s Therapy Log
DATE:
TIME:
SITE:
LEVEL OF SUPERVISION: Observation/Collaborative/Autonomous
THERAPISTS/Co-THERAPISTS:
CPT CODE/TYPE of VISIT: Individual/Family/Group
PATIENT INITIALS:
DIAGNOSIS:
AGE:
GENDER:
Goals for THIS therapy session:
Themes to be addressed during THIS session:
Therapy utilized (Define the type of therapy being utilized. Include important concepts and
techniques used with this therapy):
Therapeutic interventions (Describe how this therapy was implemented for this client/group be
specific):
Explanation (Why this therapy was an appropriate choice for this client?):
Assessment of therapy (Are there drawbacks to this kind of therapy? Include the effectiveness for
the client/group and suggestions for change):
I am attaching a Therapy Journal #1 initial notes Word document that we must transform
to look like the Therapy Journal Sample with scholarly references cited using proper APA
no older than 5 years old. I recommend using at least 4-5 references with in-text citations,
overcitation and use of references is even better. There is no such thing as overcitation for
me
You can also use the references I shared with you from the course syllabi last time. I have
included them again here for your convenience or you can use entirely scholarly referenced
as in the Therapy Journal Sample.
I am also attaching the Therapy Journal template and rubric. As you can see the Therapy
Journal Sample is about 6 pages, if it were double-spaced, as it should be, and 7 pages, if
we add in a title page.
Let me know if you have any questions.
References
American Psychiatric Association (2022). Diagnostic and Statistical Manual of Mental
Disorders DSM 5-TR (5th ed. Text Revision). American Psychiatric Association:
Arlington, Virginia. ISBN-10: 0890425760
Carlat, D. (2017). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins:
Philadelphia, ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Stahl, S.M. (2020). Stahl’s Essential Psychopharmacology Prescriber’s Guide (7th
Ed.). Cambridge University Press: New York, NY. ISBN-13: 978-1108926010 ISBN10: 1108926010
Zimmerman, M. (2013). Interview Guide for Evaluating DSM-5 Psychiatric Disorders and
the Mental Status Examination. Psych Products Press: East Greenwich, RI. ISBN-13: 9780963382115 ISBN-10: 096338211X
American Psychiatric Association (2022). Desk Reference to the Diagnostic Criteria from
DSM- 5TR. Arlington, Virginia: APA ISBN-10 : 089042580 ISBN-13 : 9780890425800
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental
Disorders DSM 5 (5th ed.).America Psychiatric Association: Arlington, Virginia
Boland, R., Verduin, M.L & Ruiz, P. (2022). Kaplan and Sadock’s Synopsis of Psychiatry:
Behavioral Sciences/Clinical Psychiatry (12th Ed,). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1975145569; ISBN-10: 1975145569
Carlat, D. (2016). The Psychiatric Interview (4th Ed.). Lippincott Williams & Wilkins:
Philadelphia, PA. ISBN-13: 978-1496327710 ISBN-10: 9781496327710
Wheeler K. (2022). Psychotherapy for the Advanced Practice Psychiatric Nurse: A
How-To Guide for Evidence-Based Practice. 3rd Edition. Springer Publishing; New
York, ISBN-13: 978-0826193797 ISBN-10: 082619379X
American Psychiatric Association (2013). Desk Reference to the Diagnostic Criteria from
DSM-5 Arlington, Virginia: Author.
American Psychological Association. (2020). Publication manual of the American
Psychological Association (7th ed.). Washington, DC: Author.
Corey, G. (2015). Theory and Practice of Counseling and Psychotherapy (10th ed.).
Brooks/Cole Publishing Company: Belmont, CA.
Individual, Family, Group or Couple’s Therapy Log
DATE:
10/10/2023
TIME: 10:00 am
SITE: Integrated Healthcare Systems
LEVEL OF SUPERVISION: Observation/Collaborative/Autonomous
THERAPISTS/Co-THERAPISTS:
CPT CODE/TYPE of VISIT: Individual/Family/Group
PATIENT INITIALS: RD
DIAGNOSIS: Schizoaffective Bipolar Type and
AGE:
22
GENDER: Male
Goals for THIS therapy session:
Mental Health
Themes to be addressed during THIS session:
Medication Compliance
Therapy utilized (Define the type of therapy being utilized. Include important concepts and
techniques used with this therapy): Therapist utilized CBT, Motivational Interviewing, and Person
Centered techniques to gather information and provide support to client when needed.
Therapeutic interventions (Describe how this therapy was implemented for this client/group be
specific): Therapist psycho educated client about Medication Compliance involving: the meaning,
it’s purpose, benefits, how it correlated with Mental Health, and different ways to improve and
maintain Medication Compliance. Therapist and client processed information with client, stating
his thoughts, feelings, and experiences with Medication Compliance. Afterwards, client brain
stormed with Therapist different approaches he will utilize to consistently comply to his
Medication. Client was given homework to journal daily his daily commitment to Medication
Compliance.
Explanation (Why this therapy was an appropriate choice for this client?): Client stop taking his
medication for a week without speaking to his psychiatrist and being tapered down which puts
client at risk for major side effects.
Assessment of therapy (Are there drawbacks to this kind of therapy? Include the effectiveness for
the client/group and suggestions for change): Client therapy session was successful and he had an
encouraging response. Client developed a better understanding of the importance of Medication
Compliance and now has a plan that can improve his compliance along with support.
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