MH Generic SOAPNOTE with Defenses – I

PRESENTING CONCERN

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

OBSERVATIONS

Pt is a [checkbox value="young adult|mid-aged adult|older adult|young teen|older teen|child"] [checkbox value="male|female"]. [checkbox value="Reasonably|Not well|Meticiulously"] kempt [checkbox value="+|++|+++"], [checkbox value="average weight|overweight|underweight"][checkbox value="+|++|+++"].
Posture [checkbox value="relaxed|rigid|stooped|confident|aggressive|tense|slumped"][checkbox value="+|++|+++"]
Movement [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 reported & affect observed: [checkbox value="euthymic|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: [checkbox value="spontaneous|normal RTV|abnormal RTV|clear and articulate|selectively mute|mute|loud|laconic|verbose|quiet|pressured|rambling|babbling|incongruent with mood and current circumstances"][checkbox value="+|++|+++"]
Thinking: [checkbox value="logical|linear|rigid and concrete|personalizing|persecutory|indecisive|unrealistic|difficulties of reference|magical ideas of influence|distorted|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|spouse|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"].
Sx: [checkbox value="stable|improved|worsening|nil reported"]
Impression: [checkbox value="functioning well, mature defenses, particularly:|generally functions well, occasionally prone to maladaptive defenses, particularly:|functioning poorly, overreliance on regressive defenses, particularly:"] 

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

[checkbox value="affiliation - regulates mood through social contact.|aim inhibition - accepts realistic ambitions.|altruism - derives satisfaction through helping others.|anticipation - solving problems before they arise.|compensation - overachieving in one area to compensate for struggles in another.|humour - sees amusing or ironic qualities of the situation.|self-assertion - expresses opinions and needs in a respectful and firm way.|self-observation - reflects on one's thoughts, feelings, motivation, and behaviours.|sublimation - channels difficult feelings into socially acceptable activities.|suppression - puts aside difficult inner thoughts, feelings, and desires to get through the day.|distraction - puts off internal distress by focusing on something less threatening.|imitation - emulates the positive behaviours of idealized others."]

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

[checkbox value="isolates affect - separates the event from the emotions that accompany it.|intellectualization - using reason and logic to avoid uncomfortable or anxiety-provoking emotions.|undoing - trying to 'undo' an unhealthy, destructive or otherwise threatening thought by some form of atonement."]

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

[checkbox value="withdraws - removing oneself from distressing stimuli.|repression - is unaware of unacceptable desires, thoughts, or experiences.|reaction formation - deals with inner conflict by behaving in diametric opposition to the denied thought, feelings, and behaviours.|displacement - shifts feelings about one person (or situation) to another, less threatening substitute object.|controlling - tries to excessively manage or regulate the external environment to avoid the underlying feeling of anxiety.|downward comparisons - looks to another individual or comparison group who are considered to be worse off in order to feel better"]

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

[checkbox value="avoidance - refuses to deal with or encounter unpleasant objects or situations.|devaluation - attributes themselves, an object, or another person as having exaggerated negative qualities.|minimization - denial coupled with rationalisation where complete denial is implausible.|idealization - perceives others as having more desirable qualities than is feasible.|omnipotence - treating another as an extension of oneself."]

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

[checkbox value="denial - refuses to acknowledge a painful truth that is readily apparent to others.|projection - falsely attributes feelings, impulses, or wishes onto others.|rationalization - deals 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 - unconsciously emulating behaviors of someone else.|wishful thinking - making decisions according to what might be pleasing to imagine instead of 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 - deals with stress by complaining but invariably rejects suggestions, advice, or help that others offer.|projective identification - falsely attributing unacceptable feelings to another and then acts 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.|conversion - the expression of an intrapsychic conflict as a physical symptom.|Severe autistic withdrawal - retreating from the world and focusing inwardly.|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."]

Formulation: [textarea default="Although reporting problems with XXXX, Pt poorly copes with the reality of 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|thought challenging|behavioural experiments|DBT|BT|Relaxation|Mindfulness |Narrative Therapy|FBT|EFT|group therapy|skills training|psychoeducation|insight oriented counselling|emotional regulation skills training|psychodynamic counselling|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: [textarea default=""]

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