370 Case Portfolio

Session 1 Soap Notes

Session 1: Soap Notes

Subjective –

Keana's feelings are frustration, sadness, and confusion about what’s going on and why its happening in their life. Unsure of how to support or what to do with the situation. These feelings stem from her mothers drinking and the trauma that it has caused in her and her families life. Keanas plans and goals are to create a way to better support her mother and have a better relationship with her mother along with better communication which doesn’t lead to conflict and anger. Some comments Keana makes are “my grandma in a way supports her drinking”, and “I avoid talking to her at night because I know she is drunk”.

Objective –

Keana appears genuinely upset the whole session, could tell that this is a emotional topic that the client has been dealing with for their whole life. Keana however is optimistic and has a good support system to lean on. Keana wants to change and support herself along with support her mother and is willing to put in the time.

Assessment –

Keana's behaviour seems to be ok and seems to be able to cope with life and continue on with regular daily activities. There may be sometimes when the mothers drinking effects her life at night and when she feels she has to distance herself. Moving away from home seems to be a positive thing in Keana's life.

Plan –

The plan going forward is to continue to talk about goals for Keana that we are working towards. Coming back into the next session we will talk about what the more specific goals are and the steps we are taking to get there. The date for the next contact is in 2 weeks.

Session #2 Soap Notes

Subjective -

- Keana still is feeling upset and hurt by her mothers drinking and the negative effects that it is having on her life because of the way her mother acts while she is drinking

- Keana shared about her father and how her and her father have become close because of her mothers drinking

- Keana also shares that her father has some emotional diffficulites and can tend to keep it all in and then explode – keana finds this frustrating and difficult to deal with as well

- Keana however did share that her father makes more of an effort to come and see her and that he flew from Ottawa to come see her and her mother didn’t come

- Keana shares that her biggest dream is to have her mother stop drinking

- Keana also states that she found the hand control exercise helpful to more fully understand what is actually in her control

- Keana states that she knows that distancing herself from her mother could benefit her

Objective -

- Keana appears upset throughout the session and it is clearly evidenced by her body language, ton of voice and where she is constantly looking / fidgeting

- Keana shows strength by the way she lives her life, client sees what she can control and understands her mothers drinking is out of her control

Assessment -

-Keanas behaviours stemming from her mothers drinking and the negatives that it brings into her life / the way that her mother makes her feel when she is drinkg

- Current issue is trying to deal with how to not let mothers drinking effect her so much – try to find some supports to help process through it

- Understand that it is out of Keana’s control and she needs to focus on what she can control (herself)

Plan -

To start planning the goal to help bring positives into Keana’s life

- Will meet again in two weeks to discuss

Session #3 Soap Notes

Subjective -

- client states that she is great

- Keana states that after the assessment of the last session they felt emotional and wanted to cry

- Talking about mom is a touchy topic

- A lot all at once, understanding that what she does is out of control

- What mom does hurts the client

- Call between Dad and Grandma didn’t go too well

- Mom and Dad don’t get along

- Keana wants them to separate so they can be happy

- “tricky question”, tricky situation

- Keana doesn’t agree with mothers drinking as a solution in life

- Keana doesn’t want to talk about what dad does that makes mom upset

-Mother however sends money and tries to care for daughter

Objective-

- Keana seemed okay in this session, wasn’t so emotional

- Keana appeared happier but still obviously has concerns and worries about mothers drinking and fathers actions

- Keana shows strengths through the way that she walks through life understanding that it isn’t her fault and that she knows that it is out of her control

- By moving across the country and starting her own life to get away from the negatives at home

- Stuck in way of feeling guilty and like she needs to do something but can’t do anything

Assessment-

- Keana is sad and upset because of mothers drinking and her not being able to do anything to change it. Client also has a rough relationship with mother and finds it hard because they butt heads and her mother makes her feel like she isn’t enough

- Keana to rebuild some sort of relationship with mother, to start off on a new foot and see what can happen going forward

- Keana states that her parents need to separate – what can she do? Is there anything?

- Keana also going home to visit her family – what will this look like?

- Obstacle is that client doesn’t seem to thrilled to want to talk to mother – why

Plan -

- To call mom once a week before dinner time in Ottawa and talk about life on the phone to hopefully build a better relationship / repair relationship

Activity: Balloons / Emotions

Activity #1

Session Rating Scale Activity

Activity #2

Subjective -

-Keanst states she is great

- Keana says that keeping / re-builidng relationship with mother does not benefit her

- Feels discouraged when talking to her mother and feels like after she gets off the phone with her she has negative feelings towards herself or towards other people

- Keana says that after talking on the phone with mother she needs time by herself / distraction and that no one around her makes her feel better

- Wants to change goal to something for herself

- Says that talking to dad and sister is a positive in her life because they understand

- Talks about how boyfriend isn’t the most supportive because his dad is an alcoholic and views his dad as someone that isn’t in his life and shouldn’t be given the chance

Objective-

- Keana's strengths is that she continues to see her mother as a person that she wants around and is a person that still supports her, however the majority of the relationship is negative

- Wants to leave the relationship with mother where it is – seemed happier with that than trying to rebuild or make it better

- Keana is generally happy with life and knows that what her mother thinks and what her mother says doesn’t actually matter

- Knows that what mother wants from her or wants for her isn’t the life that she wants to live

- Appeared down on herself while talking about comments that mother makes to her – but also understands that the majority of the time it’s the alcohol speaking

- Keana appeared and sounded worried and anxious about whats to come in the next two weeks as she leaves her boyfriend to go home and visit with her family

- Keana gets anxious when she can’t get ahold of boyfriend when they are separated for long periods of time

- Boyfriend is a comfort in life

Assessment -

- An issue to be addressed is the client as they have now gone home to visit with family for the next two weeks. What is this going to bring? What is it going to do positive / negative in life

- Assessment is that client needs to dig deeper / find more ways of making herself happy when mother brings her down

- Challenge herself to find these

- Talking to dad and sister make her happy and make her feel good – what else

- Motivated to make positive change her life by talking more to dad and sister

Plan -

- While visiting family back home to spend as much time with dad and sister and relax during holiday

Session #4 Soap Notes

Subjective -

- Keana is very happy today in session #5 – she is in Ottawa visiting her family and feels positive and is enjoying her time other there

- Keana feels a little sad about the fact that her mother didn’t come to the aiport to pick her up

- She feels disappointed because she thought maybe her mother would

- She continues to express her mothers interesting way of trying to bond / build a relationship with her

- She says her sister was there to get her mother to leave her alone when her mother was continuing to come into her room about 20 times throughout the night

- Her mother made a weird comment to her about her freckles which Keana says “I have nothing to say about that, it is just weird, and she says weird things like that”

Objective -

- Seemed very happy this session and very happy with continuing her goal and what is happening at home

- By what Keana shared it is clear she is enjoying her time at home and her dad and sister have been brining continual positives into her life

- I feel like this is the happiest I have seen Keana throughout our sessions and she had a lot of positives to say

- Client continues to be strong through the challenges with her mother and understanding that her behaviour is out of her control

- Continues to focus on the positives in her life

- Only weakness seen is not being able to stand up to her mother and claims it is because “she is too shy”

Assessment -

- My assessment is that Keana has found a goal that makes her happy and continues to have support through her dad and sister. Her time in Ottawa has been going and busy because of the time that she has been able to spend with them

- Continued issue is with her mother and how her mother doeens’t leave the house or want to go out and do things with keana, her dad and sister

- However, Keana did say they bond over puzzles and they brought a puzzle to the cottage that they can do together

- Keana is very motivated to continue to talk to her dad and sister and shows that by the time she spends with them currently, but also the time she takes aside in life to call them when she is in Victoria

Plan -

- Find time and space to call dad and sister along with coordinate with them how that is going to work and what is going on in their lives. Keana also says she wants to continue to be in the right mindset to call with one of them. We will check in again next week to see what is happening.

Session #5 Soap Notes

Subjective -

- Keana is feeling happy and is still glad to be in Ottawa with her family

- She feels that the supports from her dad and sister still really help her and that her goal is doing what she wants / what she needs

- Mother is still being difficult – finds it hard to hangout with her mother because she doesn’t have much in common and mother doesn’t seem to want to do anything that Keana and her dad and sister are doing

- Keana highlighted how throughout our time together she has enjoyed the activities we have done, specifically the hand activity about control

Objective -

– Keana appeared very happy this session and seemed to be enjoying her time with her family

- Keana continues to now have more posititve things to say about her mother – but is still appearing to be struggling with how her mother doesn’t want to do the same things as her so they don’t have a lot of opportunity to hangout

Assessment -

– Keana continues to see her dad and sister as positives supports in her life which have been experiencing the same challenges with her mother throughout the years

- Keanas behaviour is currently positive however she still feels that how her mother acts and the drinking is somehow on her and that it effects her negatively

- The way that Keana’s mother speaks to her also effects her negatively which changes her behaviour and the way she thinks / functions

- The goal of continuing to talk to her dad and sister and be able to relate is a goal that Keana likes and is something that she says shes going to continue to do

- Keana also highlighted how she understands now what is out of her control / in her control and will remember that going forward

- Keana also highlights how she knows she cannot change her mothers drinking and thinks it will be best to keep distance between them

Plan -

- Going forward Keana is going to continue to work on her goal and for right now she does not want to seek other counselling. In 6 months we are going to have a follow up session to see how the goal is going and to see what next steps need to be taken, if any.

Session #6 Soap Notes

Session 1

Session 2

Session 3

Session 4

Session 5

Session 6