MH – Generic SOAPNOTE with defenses II

PRESENTING CONCERN

Pt reported feeling [textarea default=" emotion"] about [textarea default=" situation"], stating: [textarea default=""].

OBSERVATIONS

The Pt was a [text default="X year old"] [text default="fe|male"] who looked [checkbox value="older than|younger than|his|her"] chronological age. Overall grooming was [select value="unremarkable|neglected|immaculate"], [checkbox value="average weight|overweight|underweight"][checkbox value="+|++|+++"]
Posture was [checkbox value="relaxed|rigid|stooped|confident|aggressive|tense|slumped"][checkbox value="+|++|+++"]
Movement was [checkbox value="unremarkable|odd / peculiar|slowed|repetitive|restless|agitated|tremorous"][checkbox value="+|++|+++"]

Attention: [checkbox value="no concerns - attended well|seemed unaware|inattentive|distractible|hyper-vigilant|scattered concentration|preoccupied|confused|focused on irrelevancies"][checkbox value="+|++|+++"]

Engagement: [checkbox value="no concerns - engaged well|avoided eye contact|fixed staring|glaring at author|tense facial expression|dependent and needy|dramatic and exaggerating concerns|passive and difficult to engage|uninterested|silly and joking around|resistant|critical and verbally combative|hostile and threatening|sarcastic and taunting|irritable|fatuous|flirtatious|demanding|threatening|guarded|paranoid|defensive and resistant|manipulative|argumentative"][checkbox value="+|++|+++"]

Mood & Affect: [checkbox value="emotionally expressive|tearful|labile affect|restricted affect|blunted affect|flat affect|dysphoric|anxious|angry |apathetic|ashamed|prideful|sad|irritable|hostile|pessimistic|depressed|manic|euphoric|neutral"][checkbox value="+|++|+++"]

Speech was: [checkbox value="clear and articulate|selectively mute|completely mute|loud|laconic|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances"][checkbox value="+|++|+++"]

Thinking: [checkbox value="logical and reality-based|rigid and concrete|tended to personalize|persecutory|indecisive and ambivalent|deluded and unrealistic|impaired by difficulties of reference|assumed magical ideas of influence and control|distorted|prone to pseudologica fantastica|memory difficulties|provided unnecessary detail (circumstantial)|wandered between many topics (tangential)|jumped from one idea to another (loose associations)|racing thoughts (flight of ideas)|abruptly changed topic or stopped mid-sentence (thought blocking)|tended to loop or repeat themes (obsessive)|stuck on over-valued ideas (preoccupations)"][checkbox value="+|++|+++"]

Orientation: [checkbox value="no concerns|AH reported|VH reported|poor judgement|poor reality testing|poor insight|complete denial"][checkbox value="+|++|+++"]

Stressors disclosed without prompting: [checkbox value="nil|self-esteem|parenting|money|school|physical health|energy|sleep|housing|employment|mood|family|work|grief and loss|illness|transitions|legal|peers|relationship"][checkbox value="+|++|+++"]

Suicide risk: [select value="denied active suicidal ideation when asked|vague suicidal ideation|intense suicidal ideation|has a suicide plan without strong intent|has strong intent to suicide without a plan|has strong intent and a plan to complete suicide"].

ASSESSMENT

Dx features: [checkbox value="Developmental Disorder|Schizophrenia Spectrum Disorder|Bipolar Disorder|Depressive Disorder|Anxiety Disorder|OCD|Trauma, Stress and Adjustment related Disorders|Dissociative Disorder|Somatic Symptom related|Feeding and Eating related|Elimination related|Sleep-Wake Disorder|Sexual Dysfunction|Gender Dysphoria|Impulse Control related disorder|Substance related disorder|Neurocognitive Disorder|emerging personality disorder"], [checkbox value="but would not meet criteria for a diagnosis at this time|and meets criteria for a clinical diagnosis"].
Progress: [checkbox value="good|fair|static"]
Sx: [checkbox value="stable|improved|worsening|nil reported"]
Impression: [checkbox value="functioning well, uses mature defenses to cope with daily stresses, particularly:|generally functions well, however, occasionally prone to maladaptive defenses, particularly:|functioning poorly, uses regressive defenses against reality, particularly:"] 

[comment memo="I. (mature) Adaptive defenses:"]

[checkbox value="affiliation - the drive to socialize with others so as to benefit from their company and counsel.|aim inhibition - accepting a modified form of one's original goal.|altruism - satisfying internal needs through helping others.|anticipation - The devotion of one's effort to solving problems before they arise.|compensation - overachieving in one area to compensate for failures in another.|humor - managing emotional conflict by identifying the amusing or ironic qualities of the situation.|self-assertion - expressing one's own opinions and needs in a respectful and firm way.|self-observation - dealing with stress by reflection on one's thoughts, feelings, motivation, and behaviors, then responding appropriately.|sublimation - dealing with internal conflict by channeling potentially inappropriate feelings or impulses into socially acceptable activities.|suppression - intentionally avoiding difficult inner thoughts, feelings, and desires.|distraction - a means of consciously deciding to put off thinking or feeling distressing thoughts or feelings by temporarily focusing your attention towards something less threatening.|imitation - emulating the positive behaviours of an idealized other|sexualization - allows attributing the erotic component to negative events in order to make them positive."]

[comment memo="II. (mature) Obsessional defenses:"]

[checkbox value="isolation of affect - separating the event from the emotions that accompany it. Thus, there is a failure of expression of any emotion with the event.|intellectualization - using reason and logic to avoid uncomfortable or anxiety-provoking emotions.|undoing - trying to 'undo' an unhealthy, destructive or otherwise threatening thought by acting out the reverse of the unacceptable. Involves symbolically nullifying an unacceptable or guilt provoking thought, idea, or feeling by confession or atonement."]

[comment memo="III. (Maladaptive) Neurotic defenses:"]

[checkbox value="withdrawal - entails removing oneself from events, stimuli, and interactions under the threat of being reminded of painful thoughts and feelings.|repression - repressing unacceptable desires, thoughts, or experiences from conscious awareness to the extent that the Pt is unaware of the inner conflict.|reaction-formation - dealing with difficult inner conflict by engaging in actions that are diametrically opposed to the denied thought, feelings, and behaviors.|displacement - shifting feelings about one person (or situation) to another, less threatening substitute object.|Controlling - trying to excessively manage or regulate the external environment to avoid the underlying feeling of anxiety.|Upward and downward social comparisons: A defensive tendency that is used as a means of self-evaluation. Individuals will look to another individual or comparison group who are considered to be worse off in order to dissociate themselves from perceived similarities and to make themselves feel better about themselves or their personal situation."]

[comment memo="IV. (Maladaptive) Minor narcissistic defenses:"]

[checkbox value="avoidance - refusing to deal with or encounter unpleasant objects or situations.|devaluation - attributes themselves, an object, or another person as completely flawed, worthless, or as having exaggerated negative qualities.|minimization - denial coupled with rationalisation/rationalization in situations where complete denial is implausible.|Idealization - tending to perceive another individual as having more desirable qualities than they may actually have.|omnipotence - treating another as an extension of oneself, with little recognition that the other person is a separate human being."]

[comment memo="V. (Maladaptive) Disavowal defenses:"]

[checkbox value="denial - refusing to acknowledge a painful truth that is readily apparent to others.|projection - falsely attributing their own unacceptable feelings, impulses, or wishes onto another.|rationalization - dealing with emotional conflict by developing elaborate reassuring but incorrect explanations for thoughts, feelings, and emotions.|autistic fantasy - tendency to retreat into fantasy in order to resolve inner and outer conflicts|hypochondria - uses the body to displace anxiety away from something even more anxiety-provoking."] 

[comment memo="VI. (regressive) Major image-distorting (borderline) defenses:"]

[checkbox value="splitting - the inability to see an individual as having both positive and negative qualities.|passive-aggression - covertly resisting, resenting, procrastinating, forgetting, or undermining.|introjection - emulating behaviors of someone who is perceived to be more powerful. The patterned behavior can be either positive or negative and occurs at a subconscious level.|wishful thinking - making decisions according to what might be pleasing to imagine instead of by appealing to evidence, rationality, or reality.|primitive devaluation - seeing another as completely worthless, with no redeeming qualities whatever."]

[comment memo="VII. (regressive) action defenses:"]

[checkbox value="acting out - deals with inner emotional conflict through action such as 'bad behavior' or 'bad habit' rather than reflecting on feelings.|help-rejecting complaining - dealing with stress by complaining but invariably rejects suggestions, advice, or help that others offer.|projective identification - falsely attributing their own unacceptable feelings to another and then acting in such a way as to confirm the projection.|dissociation - becoming separated or removed from one's experience.|regression - reverting to patterns of behaviour used earlier in development.|somatization - The transformation of uncomfortable feelings towards others into uncomfortable feelings toward oneself - pain, illness, and anxiety."]

[comment memo="VIII. (regressive) Psychotic defenses:"]

[checkbox value="psychotic denial - refusal to accept external reality because it is too threatening. Pt argues against an anxiety-provoking stimulus by stating it does not exist.|conversion - the expression of an intrapsychic conflict as a physical symptom; examples include blindness, deafness, paralysis, or numbness. This phenomenon is sometimes called hysteria.|Severe autistic withdrawal - retreating from the world and focusing inwardly. Perhaps inner fantasies, or maybe a blank nothingness|distortion - a gross reshaping of perceived external reality in order to meet internal needs.|delusional projection - falsely attributing their own unacceptable feelings, impulses, fantasies or wishes onto another that bears no relationship to reality.|fragmentation - a person’s representations of self and others (and their connections) are fragmented in multiple ways, leading to an active and pervasive division of various aspects of the experience. It can be considered active disorganization, leading to a confused and disorganized narrative.|concretization - refers to the transformation of a mental representation into a concrete object, situation, or action. The choice of the concrete form into which a certain mental representation is transformed is not at all random but symbolically connected to its internal and abstract representation."]

[textarea default="Although reporting problems with XXXX, Pt poorly tolerates affects around XXXX"]

ACTION

Worked with Pt to better cope with the reality of 
[textarea default="situation"] with [checkbox name="variable_47" value="Medication|Psychosocial supports|CBT|DBT|BT|Relaxation|Mindfulness |Narrative Therapy|FBT|EFT|Group Therapy|Skills training|Psychoeducation|Insight oriented counselling|Emotional regulation skills training|Psychodynamic Counselling Techniques|enhancing Psychosocial supports"], [comment memo="add a specific technique, using the format provided"] [textarea name="variable_7" default=""]

Risk assessment: [checkbox name="variable_30" value="No need for further action today|I reminded the patient of their calling MHAL 1800011511 if needed, and urged them to present to the ED or call 000 in a crisis|Pt and I agreed to a harm minimization approach by removing access to lethal means|and I further discussed their risks with their parent|I called emergency services and reported my concerns|I called the MHAL and reported my concerns|I made a notification of suspected abuse to FACS"]

PLAN

Focus of next session: [checkbox value="enhancing mood|reducing and tolerating psychotic Sx|learning relaxation skills|learning mindfulness and meta-cognitive skills|developing greater insight|decreasing over-eating behaviours|increasing eating and calorie intake|decreasing ETOH misuse|enduring withdrawal of substances|enhancing distress tolerance skills|feeling more hopeful about the future|reducing symptom severity|improving sleep|enhancing a sense of self-efficacy|reducing physical pain|increasing psychological knowledge|becoming more assertive|adhering to recommended medical treatment|enhancing problem-solving skills|increasing resilience|modifying distorted cognitions and beliefs|becoming motivated to treat medical concerns|improving medication adherence and compliance|feeling enhanced self-agency|strengthening ego functioning"]
Homework: [checkbox value="none|create a SUDS hierarchy|exposure to feared stimulus|relaxation practice|practice cognitive distancing|reflect on content of session|practice skills form today|notice patterns of dysfunction as they arise|keep a diary of emotions|keep a food diary of meals and feelings"].

Next apt: [textarea default="Wed / Thur"]