Develop effective documentation skills for group therapy sessions

Assignment 1: Practicum – Week 8 Journal Entry

Learning Objectives

Students will:

· Develop effective documentation skills for group therapy sessions *

· Develop diagnoses for clients receiving group psychotherapy *

· Evaluate the efficacy of cognitive behavioral therapy for groups *

· Analyze legal and ethical implications of counseling clients with psychiatric disorders *

*

Select two clients you observed or counseled this week during a group therapy session. Note: The two clients you select must have attended the same group session.

Then, in your Practicum Journal, address the following:

· Using the Group Therapy Progress Note in this week’s Learning Resources, document the group session (see attachment).

· Describe each client (without violating HIPAA regulations), and identify any pertinent history or medical information, including prescribed medications.

· Using the DSM-5, explain and justify your diagnosis for each client. (very important to use

· Explain whether cognitive behavioral therapy would be effective with this group. Include expected outcomes based on this therapeutic approach.

· Explain any legal and/or ethical implications related to counseling each client.

· Support your approach with evidence-based literature.

Group Therapy Progress Note

American Psychological Association | Division 12 http://www.div12.org/ 1

Client: __________________________________________________ Date: ___________ Group name:________________________________________________ Minutes:________ Group session # ______ Meeting attended is #:______ for this client. Number present in group _____ of _____ scheduled Start time:________ End time: ________

Assessment of client

1. Participation level: ❑ Active/eager ❑ Variable ❑ Only responsive ❑ Minimal ❑ Withdrawn

2. Participation quality: ❑ Expected ❑ Supportive ❑ Sharing ❑ Attentive ❑ Intrusive

❑ Monopolizing ❑ Resistant ❑ Other: _____________________________________

3. Mood: ❑ Normal ❑ Anxious ❑ Depressed ❑ Angry ❑ Euphoric ❑ Other: _______________

4. Affect: ❑ Normal ❑ Intense ❑ Blunted ❑ Inappropriate ❑ Labile ❑ Other:_______________

5. Mental status: ❑ Normal ❑ Lack awareness ❑ Memory problems ❑ Disoriented ❑ Confused

❑ Disorganized ❑ Vigilant ❑ Delusions ❑ Hallucinations ❑ Other:__________________

6. Suicide/violence risk: ❑ Almost none ❑ Ideation ❑ Threat ❑ Rehearsal ❑ Gesture ❑ Attempt

7. Change in stressors: ❑ Less severe/fewer ❑ Different stressors ❑ More/more severe ❑ Chronic

8. Change in coping ability/skills: ❑ No change ❑ Improved ❑ Less able ❑ Much less able

9. Change in symptoms: ❑ Same ❑ Less severe ❑ Resolved ❑ More severe ❑ Much worse

10. Other observations/evaluations:________________________________________________________

In-session procedures:  _______________________________________________________________________________

 _______________________________________________________________________________

 _______________________________________________________________________________

 _______________________________________________________________________________

 __________ _____________________________________________________________________

Homework: 1.

2.

3.

Other Comments: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Signatures Date

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