COUPLE PROGRESS NOTE 1.24.23
AGENDA: [checkbox name="cb1" value="Review insights from previous session|Review assessments, screeners, and scoring|Assess relationship distress|Assess mood/functioning|Assess sexual relationship |Assess sexual functioning/concerns| Explore polyamory/open relationship concerns|Observe couple’s communication|Psychoeducation|Psychosexual education|Communication skills training|Sexual communication skill building|Explore relationship values |Emotion regulation skills training|Behavioral health interventions|Stress management|Safety planning|Review of Progress|Review diagnostic conclusions/recommendations|Treatment planning|Goal setting|Termination"] ASSESSSMENTS, SCREENERS, & SCORING [checkbox name="cb2" value="Self-report and Behavioral Observation|PHQ-9|GAD-7|DAS|DSCS"] SESSION SUMMARY [textarea name="sesssumm" default=" "] SESSION ISSUES/TOPICS DISCUSSED The following tropics/concerns were discussing in session: [checkbox name="cb3" value="Relationship distress|Loss of connection|Decreased emotional intimacy|Recent conflict|Recent argument|Attachment issues|Relationship dissatisfaction|Relationship argument or regrettable incident|Relationship intimacy concerns|-----INFIDELITY ISSUES------|Infidelity/affair concerns|Trust violation|Relationship trust issues|-----Polyamory Issues----|Polyamory concerns|Exploration of nonmonogamy|Exploring open relationship agreements|Time management concerns| ---POWER AND CONTROL-----|Intimate partner violence concerns|Power and control issues|----SEXUAL FUNCTIONING------|Discordant sexual interest| Differences in sexual interest|Low sexual interest|Sexual functioning concerns|Erectile difficulties|Painful sex|Sexual health concerns|Sexual behavior(s) of concern|Sexual Script Adjustment|Sexual relationship dissatisfaction|Sexual communication discomfort|Exploration of sexual interests (e.g., kink/BDSM)|----FERTILTY ISSUES------|Fertility concerns|IVF-related stress|Pregnancy concerns|Delivery/post-delivery concerns|Peri/post menopause issues|Hormone therapy issues|Cancer and sexuality concerns|Age and sexuality concerns|------STRESSORS----|Stressors|Stressor/coping mechanism(s)|Familial relationship distress|Work problems|Financial issues|Legal Issues|Housing issues|Parenting stress|----------|Medical/health concerns|Disease management|Medication concerns|Health anxiety|----------|Religious/spiritual concerns"]. THERAPEUTIC INVERVENTIONS The following tropics/concerns were discussing in session: [checkbox name="cb4" value="Gottman Method Couple Therapy Interventions|Discussed Gottman’s Sound Relationship House Concept|Gottman Love Maps|Psychoeducation on building fondness and admiration|Turning toward instead of away|Discussed allowing for a positive sentiment override|Managing conflict with a gentle approach|Psychoeducation about the Four Horsemen|Helped to identify the Four Horsemen|Encouraged a gentle approach|Practiced psychological soothing for flooding|Introduced Couple to the State of the Union Discussion|Reviewed the State of the Union Discussion|Introduced Couple to the Aftermath of an Argument or Regrettable Incident exercise|Processed the aftermath of an argument or regrettable incident|Utilized Gottman Repair Checklist statement(s)|Explored pattern of closeness and distance|Explored solvable and perpeptual problems|Introduced the Gottman Rapoport Intervention|Practiced a Gottman Rapoport Intervention|-----COMMUNICATION INTERVENTIONS------|Observed and provided feedback on Couple communication| Explore communication pattern|Practiced antidotes to the Gottman Four Horsemen|Practiced a Gottman Rapoport Intervention|-----INFIDELITY INTERVENTIONS-----|Assisted Couple in talking about infidelity|Strategies for coping with infidelity triggers/flashbacks|Explored factor that contributed to the infidelity|Discussed the impact of the infidelity|Explored the context of the affair|Instructions for Writing a Letter to the Participating Partner|Reviewing a letter to the participating partner|Setting boundaries with the outside affair partner|Trust building through emotonal risk taking|Exploration of forgiveness|Reviewing consequences of forgiving or not|Exlored blocks to forgiveness|------Sex Therapy-Interventions---|Provided psychosexual education|Utilized sex therapy interventions|Reviewed the Sexual Health Model|Explored meaning of sex|Explored meaning of touch|Discussed Sensate Focus exercise|Explored sexual response cycles|Processed a recent sexual encounter|------ASSESSMENT-----|Explored family of origin dynamics|Provided feedback on DAS scores|Provided feedback on assessment results|-----Polyamory-Issues---|Reviewed Ester Perel’s questionnaire|Discussed how to managing sharing information related to open relationships|Managing NRE (New Relationship Energy)|Explored fears of abandonment in open relationships"]. TREATMENT PROGRESS/PROGRESS TOWARDS TREATMENT GOALS Couple’s progress in achieving treatment goals is best assessed as - [checkbox name="cb5" value="responding well to interventions|unchanged|making some progress|slow/slight progress|fluctuating/intermittent progress|maintaining past gains|maintaining current goal focus|reprenting relapse|an increase in symptoms|a decrease in symptoms|a significant excalation in symptoms|minimal|improving|stable"] - as evidenced by Couple’s self-report, behavior, and engagement. PLAN/HOMEWORK [textarea name="Plan" default="sample text"] MENTAL STATUS EXAM Orientation: [select name="MSE_1" value="Alert and oriented X4|Alert, cooperative, and friendly"]; Affect: [select name="MSE_2" value="Both partner’s express full range|Flat|Tearful at times|Flat, tearful & congruent with depressed & anxious mood|Appropriate to mood and thoughts|Inapporpriate to mood and thoughtsRestricted in range and mood congruent"]; Observations: [select name="MSE_3" value="WNL|Crying|Mild agitation when discussing stressor|moderate agitation when discussing stressor|yawning|left room"]; Speech: [select name="MSE_4" value="WNL|Normal rate and rhythm, not pressured|Pressured at times|soft"]; Behavior: [select name="MSE_5" value="WNL|Left room to use bathroom"]; Thought process: [select name="MSE_6" value="WNL|Logical, linear, goal directed|circumstantial|Circumstantial but redirectable|Tangential"]; SI/HI: [select name="MSE_7" value="Not indicated|denied|SI endorsed/HI denied"] FOLLOW-UP PLAN: [checkbox name="cb6" value="RCT in 1 week to assess relationship distress, review homework, and goal setting|RTC in 1-2 weeks to assess relationship distress, review homework, and goal setting|RTC in 1 month to assess relationship distress, review homework, and goal setting|Couple will contact Provider to schedule next session.|Provider will contact Couple to schedule next session."]
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