SOAP NOTE FOR ELIZA
Subjective
Eliza is an 18 years old university student. She recently enrolled at the University. She has no friends since she has been there for a short time. Eliza has never been alone before in her life since she has been living with her parents and had some friends at the former school. She feels anxious, depressed, and stressed making her experience low self-esteem. She is not sure about how to cope with the new reality that she is an adult and must learn to do things on her own. Although she has been living comfortably well with her parents, she notes that her relationship with the mother is good and that with the father is okay. Eliza is an only child in her family. She has not had any problems in the past with stress neither has she been in any form of treatment or medication regarding the same. Moreover, she has not had any legal substance abuse in her past or anything related to addiction. Objective
Using the DSM IV manual directions, my primary contextual treatment goals for Eliza are as follows (DSM-IV, 1994):
Eliza notes that she is experiencing low esteem and does not how to cope with the new life that she has been exposed to in the university.
Therefore, Eliza id suffering from:
Anxiety
Depression
Stress
Has problems with coping.
Plan
In an attempt to alleviate the critical symptoms that Eliza is exhibiting, a contextual plan which is non-confrontational like dialogue and inclusive therapy is necessary.
The first line of action is to request Eliza to make a list of her key strengths and weaknesses that she believes are pertinent to her as an individual.
The second factor is to have a one on one therapy session about her upbringing and the general relationship with her parents.
Solution oriented therapy that is questions and answers oriented will also play a significant role in alleviating the situation facing Eliza.
Visualization strategy is also a technique suitable for a patient like Eliza since she will be required to imagine and visualize what a positive outcome of the therapy will mean for her and why she should be keen and positive pertaining the entire therapy session.
Eliza will also be required to talk to her professor regarding common anxiety triggers like exams to have an insight on how the professor perceives the situation.
Alternative approach
Although the therapy follows a typical structure that is common to many new students joining higher education, I would recommend that group counselling session with students facing the same predicament be conducted in an attempt to reassure them that the problem is not unique to them and further promote making of new friends (Meyer et al., 2016). Therefore, the documentation would follow both a group and an individual counselling structure and format.
References
Diagnostic and statistical manual of mental disorders: DSM-IV. (1994). Washington, DC: American Psychiatric Association. Mackenzie, K. R. (1991). Brief psychotherapies. Therefore, NJ: Slack.
Meyer, J. D., Koltyn, K. F., Stegner, A. J., Kim, J., & Cook, D. B. (2016). Influence of Exercise Intensity for Improving Depressed Mood in Depression: A Dose-Response Study. Behavior Therapy,47(4), 527-537. doi: 10.1016/j.beth.2016.04.003
