Case Notes
Adam
Walden University

Case Notes There are many factors that go into why it is important for a mental health counselor to document what they have done in a counseling session or relationship. Case notes help counselors to better understand and conceptualize their clients and information in a counseling relationship (Prieto & Scheel, 2002). This paper presents case notes that I constructed for a counseling session with Aaron, Robyn, and Michelle.
S.O.A.P. Notes
Subjective-Aaron stated that he is upset at his daughter (Michelle) for getting sick and drinking alcohol in his home. He also said that he is disappointed in his wife (Robyn), because she was encouraging and comforting their daughter, instead of being a parent and not alloying her to drink alcohol. Aaron shared that he does not understand why his wife considers herself as a “friend” to their daughter. Robyn and Michelle both stated that Aaron only cares about what other people in their community think. They also talked about how they feel pressured by Aaron to act like their family is perfect and there are no internal problems going on between them. Michelle shared that she feels that her father wants her to live the life that he wants her to live, and has no idea who she really is as a person. Robyn discussed how she feels that Aaron looks at her and her daughter as a trophy, so he can show them to everyone. Robyn stated, that even though she feels the disconnect between Aaron, she does not want her family to be broken up (Laureate Education, Inc., 2010f).
Objective- Each client made excellent eye contact when talking to me or others in the room. Aaron sat away from both Robyn and Michelle, while Robyn and Michelle sat close together. When Michelle and Robyn were talking to me, they would constantly look at each other. When Robyn was talking directly to Aaron, the volume of her voice increased. Whenever, Robyn or Michelle would talk about actions or behavior that Aaron would do, Aaron kept shaking his head (Laureate Education, Inc., 2010h).
Assessment-Aaron seemed really angry on the fact that alcohol was brought in his home. It seems as though Aaron is more worried about how his family’s appearance is presented outside of their home, which is causing internal conflicts between him, his wife, and his daughter. Robyn feels as though she needs to put on a fake image of herself when they go out with each other. It is apparent that Aaron’s definition of showing love to his family is by working all the time and giving them what they want or need, instead of spending time with each other. Although, all parties have issues with one another, they are willing to change in order to make their relationship better between each other (Laureate Education, Inc., 2010h).
Plan-The client’s have agreed to meet with me next week. I will provide psychoeducation when it comes to Michelle’s drinking, especially since she will be going away soon to college. In the next session, I want to focus on what they want out of this counseling relationship and what they want from each other. I want to follow-up to see how their interactions was during the week, to see if any new issues or concerns have arise. My plan is to use rational emotive behavioral theory to help Aaron think more rational about how his definition of family. I will continue to create goals.
Goal that might be established based on what the family expressed It is apparent that Aaron does not spend enough time with Robyn and Michelle. Robyn stated, that on his free time, he goes golfing instead spending quality time with his family (Laureate Education, Inc., 2010h). This could be a reason on why both Robyn and Michelle are distant from Aaron. A goal that might be established would be to help Aaron spend more time with his family. This goal can be achieved by helping the unit discuss activities or events that they feel they would enjoy together as a family.
Techniques that will work to achieve the goal An effective technique that I suggest is the WDEP technique. This techniques as to do with client’s knowing what they want, what they are currently doing, evaluating themselves to see if what they are doing is working, and developing a plan to help them fulfill their wants (Jacobs & Schimmel, 2013). This technique will work towards the goal of spending more time together by helping the family develop a plan that will be beneficial for them to spend time together. For instance, instead of Aaron always playing gold on the weekends, he could make a plan to go golfing once or twice a month, so that would allow him to be free to spend time with his wife and daughter.
Counseling theory informs my technique The counseling theory that informs my technique is reality therapy. This approach has to do with the present behavior, thoughts, or actions of the unit. This therapy helps clients identify their wants and helps them make changes in order to satisfy their wants (Wubbolding, 2011).
How did the experience writing influence what I thought about the case The experience that I got from writing about the case influenced my conceptualization of the case. I was able to connect the behavior, thoughts, and feelings that each individual had, which helped me come up with a clear assessment of the unit. The experience also influenced my feelings on writing case notes, for instance, I noticed how easily it was to identify techniques that could be effective.

References
Jacobs, E., & Schimmel, C. (2013). Impact therapy: The courage to counsel.
Laureate Education, Inc. (Executive Producer). (2010h). Counseling techniques — micro-skills and techniques I. Baltimore, MD: Author.
Laureate Education, Inc. (Executive Producer). (2010f). Counseling techniques — micro-skills III. Baltimore, MD: Author.
Prieto, L. R., & Scheel, K. R. (2002). Using case documentation to strengthen counselor trainees' case conceptualization skills. Journal of Counseling & Development, 80(1), 11. Retrieved from the Walden Library databases.
Wubbolding, R.E. (2011). Reality Therapy/Choice Theory. In D. Capuzzi and D. Gross (Eds.). Counseling and psychotherapy: Theories and interventions. (pp. 263-285). Alexandria, VA: American Counseling Association.