SOAP Notes
Subjective; Sonia was confronted with current changes in her life that involved being divorced by her husband whom they had married for a long time. Although she has accepted that the changes have affected when she says, “I have not slept, eaten or done any house chore properly for two weeks” and “I feel like leaving this place and start a new life somewhere else.”
Objective; Sonia was elegantly dressed and sat in a professional manner depicting good morals. She came on time and was ready for the session. Her mood was sad and matched with what she was feeling about the situation. His posture was upright and focused on my eyes as we discussed while his attitude was good for the session.
Plan;
She has to complete the treatment plan 1 that involves learning how to speak to others through appropriate language, tone, and attitude.
She would learn the disadvantages of committing suicide that will affect her life, children and her relatives negatively.
She would also go through a psychotherapy session with Sonia in order to lose her anger and make her smile again.
DAP Notes
Data; Sonia is an Asian-American woman who is 6 months divorced. Her marriage faced some difficulties and she was repeatedly abused by her husband. She often feels fatigue, unable to perform her role as the manager at her working place, she feels worthless and shameful (American Psychiatric Association, 2000). She also has some suicidal thoughts at some point. This was her first time to experience such emotions and feelings. Sonia reports to have been mistreated in the marriage when she said that “my husband used to come late in the night and beat me up”
Plan; during the time she had finished the first session and waiting for the second session, she was directed to engage in constructive talk verbally by being aware of the tone, language and attitude she will be using. This will help her to social well with other individuals; hence express her feelings to others, which is also a good step (Parker & Manicavasagar, 2005). In the psychotherapy session, she will have to express her emotions through crying and laughing if necessary despite her situation.
References
American Psychiatric Association. (2000). Major depressive disorder: A patient and family
guide. Washington, D.C: American Psychiatric Association.
Parker, G., & Manicavasagar, V. (2005). Modelling and managing the depressive disorders: A
clinical guide. Cambridge: Cambridge University Press.
