LCSW progress note
Subjective [textarea] continues to endorse indicated explored shared engaged in reports feeling discussed pros & cons of continues to struggle w/ admits agrees commented stated denied expressed fears of added asked [/textarea] Response to Intervention: [textarea] copes w responsive to CBT interventions; DBT skill of "check the facts" chain analysis DEARMAN WiseMind Practiced grounding Used Internal Family Systems to explore exiled parts and managers Addressed executive dysfunction tearful throughout session; incongruent affect smiled/ nervous laughter as we discussed difficult topics. Reported an increase/decrease/ no change in trauma responses. CLient stated that they most often react with figh/flight/freeze/appease response disclosed increase in irritability; decrease in self care; increase in dissociative symptoms decrease in social activities; increase in negative thinking frequently reports that although... it is insufficient[/textarea] [textarea] responsive to attentive listening, empathic responses & cognitive restructuring techniques responsive to open-ended questions negative self-talk & self-critical internal dialogue continue to ruminate & promote depressive sx & anxiety sx[/textarea] [textarea] Denied SI, HI, NSSIB, or AVH. Appearance: Judgment: Insight: Speech: Memory Impairment: None/ Intact Thought Process: Cohesive /Goal Oriented Mood: Eye contact Motor Activity Affect: [/textarea] [textarea] Continues to struggle w/ strongly held schemas/interpersonal conflicts Acknowledges intellectual understanding and is still in the process of embodying Receptive to intervention Shows motivation to change [/textarea] [textarea] Demonstrated psychological flexibility; made comments indicating rigid thinking engaged throughout session answered questions w/ one word answers appeared began having great deal of expressed commitment around verbalizes feeling some relief in discussing identified own triggers [/textarea]
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