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the tapes: therapy session #1

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U of CB Counseling & Psychiatric Services  

2249 Williard Drive  

Building 302   

   Boulder, Colorado        

Date of Session: 10/28/2005  

Time of Session: 10:15:04 AM  

   

Patient Name: Clearwater, Leah Jacqueline  

Patient Number: 10000010659748  

Psychotherapy Progress Notes  

   

It has been a week since the initial intake interview with Miss. Clearwater and she seems to have had no major changes in behavior. Symptoms of PTSD, GAD, BDD, and gender dysphoria continue as described. Her symptoms are unchanged, they are just as frequent and intense as previously described (10/05/2006). Miss. Clearwater denies suicidal thoughts or ideations. Miss. Clearwater’s anxiety symptoms continue, she does not report feeling ‘sad’, but she is ‘tired.’ Miss. Clearwater has trouble sleeping at night, often waking from nightmares drenched in sweat. Miss. Clearwater is bereaved, but hypervigilant of her surroundings, fluxing her anxiety and stress.  

Behavior:  

Since Miss. Clearwater’s father’s death her self-care has been heavily reduced in comparison to how she previously describes her self-care. Miss. Clearwater is socially isolated, even with her enrolling in the university and taking in-person classes. Sleep problems are reported. Difficulty staying asleep is reported. Difficulty falling asleep is also reported.

Content of Therapy:  

The patient today mainly spoke of about having issues with grief and how she does not wish to drown in it. Problems in the family were also discussed by the patient; her mother dating her deceased father’s best friend, and her little brother joining the same gang her ex-fiancé is a leader of – of the former gang she ran away from. Feelings of loss were also expressed. Feelings of grief were also expressed. Miss. Clearwater described her anger over a former friend, but when asked to continue, she closed herself off. Session ended.  

Therapeutic Intervention:  

This session the therapeutic focus was on facilitating the communication of emotions and feelings. Miss Clearwater was urged to ask for help and support from staff members of the University if university work seems overloaded. Patient asked to go to U of CB’s Student Accessibility Resource Office to get accommodations for courses. Leah will use the session to deal with grief and anxiety over loss as demonstrated by the expression of painful feelings that were associated with affect. Patient was encouraged to ventilate her emotions. Ways to reduce stress were also discussed with patient.  

Diagnoses:  

Post-Traumatic Stress Disorder (PTSD), F43.1 (ICD-10) (Active)  

Generalized Anxiety Disorder (GAD), F41.1 (ICD-10) (Active)  

Gender Dysphoria, F64.9 (ICD-10) (Active)  

Body Dysmorphic Disorder (BDD), F45.22 (ICD-10) (Active)  

Instructions/Recommendations/Plan:  

The risks and benefits of prescribed medications of paroxetine and sertraline was explained to Miss. Clearwater, will start off with low dosage along introducing holistic therapy that will be independent work for patient.  

Writing, music, and gardening have been encouraged as holistic approaches for Miss. Clearwater. In the initial intake interview, she expressed how she has already began using a journal to make sense of her thoughts. Music and gardening can also be therapeutic and readily accessible should she need it/have an episode.  

Miss. Clearwater also encouraged to continue her visits to Mount Evans, as she says it helps her gain clarity and to reset her mind.  

Miss. Clearwater was also encouraged to take some time for self-care i.e., painting her nails, cooking, or ordering out her favorite meal, adopting a skin-care regime and exercise.  

Notes & Risk Factors:  

Acute Grief: Death of father and miscarriage (03/07/2006 & 09/01/2006)  

Dissociation  

Return 1 week, or earlier if needed.

87045: Psychotherapy 60 min  

Review session tape before next session.