Psychotherapy and Art Therapy Progress Note RW

Clinical Interview: Subjective Presenting problem(s): - The client presents with symptoms of anxiety and depression, which began approximately six months ago following a job loss. The client reports feeling overwhelmed, experiencing difficulty sleeping, and withdrawing from social activities. The client reports that the symptoms have been persistent and have worsened over the past month. - The client reports feeling hopeless and experiencing frequent negative thoughts. The client is seeking support to manage their symptoms and improve their overall well-being. History and Current Functioning: - Mood: The client reports experiencing a depressed mood, with frequent feelings of sadness, hopelessness, and irritability. The client notes that these feelings are often triggered by thoughts about their job loss and financial concerns. The client reports using deep breathing exercises to cope with these feelings. - Energy Levels: The client reports low energy levels throughout the day, feeling fatigued and lacking motivation. The client notes that these feelings are often worse in the morning. - Sleep: The client reports difficulty falling asleep and staying asleep, with frequent awakenings during the night. The client reports feeling tired and unrested upon waking. The client reports using over-the-counter sleep aids occasionally. - Employment/Education: The client is currently unemployed following a recent job loss. The client is actively seeking new employment opportunities. - Family: The client reports a supportive relationship with their immediate family, but they also report feeling isolated from extended family members. - Social: The client reports withdrawing from social activities and feeling isolated from their friends. The client reports a desire to reconnect with their social network. - Exercise/Physical Activity: The client reports engaging in light exercise, such as walking, for approximately 30 minutes, three times per week. - Eating Regime/Appetite: The client reports a decreased appetite and has lost some weight recently. - Recreational/Interests: The client reports enjoying reading and listening to music, but has not been engaging in these activities as frequently due to their symptoms. - Homework/Changes: The client reports feeling more anxious and depressed since the previous session. The client reports that this is related to increased financial stress. - Previous Assessments & Interventions: The client has previously participated in individual therapy for six months, but discontinued due to financial constraints. - Psychiatric History: The client has no prior psychiatric history. - Physical Health: The client reports no significant physical health ailments. - Current Medications: The client is not currently taking any medications. - Supplements, Vitamins: The client is taking a daily multivitamin. - Substance Use: The client reports no substance use. - Developmental History: The client reports a normal developmental history. - Relevant Cultural/Religious/Spiritual Issues: The client identifies as Christian and reports that their faith provides them with comfort and support. - Forensic and Legal History: The client has no forensic or legal history. Risk Assessment: - Suicidal Ideation: The client reports passive suicidal ideation, but denies any active plans or intent. - Self-harm: The client denies any history of self-harm. Objective Mental State Exam: - Appearance: The client appears their stated age and is dressed in casual attire. - Behaviour: The client is cooperative and engaged in the session. - Speech: The client's speech is normal in rate and rhythm. - Mood: The client's mood is depressed. - Affect: The client's affect is constricted. - Thought Process: The client's thought process is linear and goal-directed. - Orientation: The client is oriented to time, place, and person. - Memory: The client's memory is intact. - Concentration: The client's concentration is intact. - Judgement: The client's judgement appears intact. - Insight: The client demonstrates some insight into their condition. Assessment Assessment, Clinical Formulation, and Findings: - Worksheets, Assessments, Tests, Infosheets: The client completed the Beck Depression Inventory (BDI-II), which indicated moderate levels of depression. - Art Therapy: The client was asked to create a self-portrait using various art supplies. The client used dark colours and expressed feelings of sadness and isolation through their artwork. The client reported feeling a sense of release and catharsis during the art-making process. - Progress: The client has made some progress in identifying their triggers and developing coping mechanisms. - Modalities: Cognitive Behavioral Therapy (CBT) techniques were used to challenge negative thoughts and promote positive self-talk. Art therapy was used to facilitate emotional expression and self-exploration. - Predisposing Factors: The client's predisposing factors include a history of anxiety and a perfectionistic personality. - Precipitating Factors: The client's precipitating factors include job loss and financial stress. - Perpetuating Factors: The client's perpetuating factors include negative thought patterns and social isolation. - Protecting Factors: The client's protecting factors include a supportive family and their faith. Plan Treatment Plan: - Current Goals: The client will continue to work on identifying and challenging negative thoughts, developing coping mechanisms, and increasing social engagement. - New Goals: The client will explore career options and develop a plan for financial stability. - Homework: The client will complete a thought record daily and practice relaxation techniques. - Referrals or Letters: The client will be referred to a career counsellor. Date: 1 November 2024