Treatment modality used and efficacy of approach

Title
Your Name:
Subject and Section:
Professor’s Name:
Date Submitted:
Part 1.
Treatment modality used and efficacy of approach
The treatment modality used for NM is cognitive-behavioral therapy catered to her role as a woman and as a client/patient. An increase in awareness of the triggers such as finances, children, relationships, etc. The treatment approach is effective and is showing progress with regards to more conscious control of thoughts which results in relaxation and better function.
Progress and/or lack of progress toward the mutually agreed-upon client goals (reference the Treatment plan—progress toward goals)
NM is showing progress with the goals that were set during the initial session. NM is now able to verbalize and process her thoughts and feelings, including past experiences which caused either positive or even negative emotions. There is also progress with processing and connecting certain events or situations, resulting in the ability to rationalize feelings and reactions regarding the said event during sessions. But, NM states difficulty in processing thoughts and emotions when alone at home, or when NM is experiencing sleep disturbances. NM also reports successful tracking and practice of relaxation techniques, except during the first few days after the initial session, which led to NM’s appreciation of the benefits of the relaxation techniques in her daily life and overall wellbeing. NM notes better focus and performance at work in comparison to her state during the initial evaluation, but still with the slight occurrence of worry and panic when the workload is heavy.
Modification(s) of the treatment plan that were made based on progress/lack of progress
The continuous building of trust is developed to further promote healthy self-expression and the processing of past trauma during therapy sessions. Psychosocial changes are encouraged such as reconnecting with acquaintances, friends, or coworkers to facilitate building a healthy support system. Physical activity is recommended for a holistic treatment approach, also providing mental clarity and improved mood.
Clinical impressions regarding diagnosis and/or symptoms
NM experiences evident anxiety attributed to the recent separation from her husband because of infidelity, resulting in concerns regarding NM’s two daughters and finances, aside from the significant emotional pain that is caused by the event.
Relevant psychosocial information or changes from original assessment (i.e., marriage, separation/divorce, new relationships, move to a new house/apartment, change of job, etc.)
No significant psychosocial changes from the initial assessment.
Safety issues
NM has a history of substance use, and a family history of alcoholism, both presenting as a possible safety concern.
Clinical emergencies/actions taken
A general health assessment was done to rule out and identify the causes of symptoms. No medical emergencies were reported.
Medications used by the patient (even if the nurse psychotherapist was not the one prescribing them)
NM reports taking Aleve (naproxen) whenever necessary, now she is more conscious of muscle tension and spasm.
Treatment compliance/lack of compliance