Note Examples
Example SOAP

Example SOAP

SUBJECTIVE
Presentation

  • Chief Complaint: Couple presented for their fifth therapy session, continuing to report issues related to communication, trust and rebuilding intimacy in the marriage.
    • Quote (Chief Complaint): "We still struggle sometimes to communicate openly." - Wife
  • Impairments And Challenges: Despite recent progress, clients continue to experience relationship tension, arguments, and difficulty maintaining emotional intimacy. Lack of trust and resentment remain problematic.
    • Quote (Impairments And Challenges): "I can't fully open up when I know she's still holding onto resentment." - Husband
  • Communication Patterns: Communication has improved with more empathy and validation. However, some key issues remain unresolved, leading to avoidance of discussing certain topics.
    • Quote (Communication Patterns): "We communicate better in general but avoid the deeper issues." - Wife
  • Conflict Resolution: Clients report using skills to de-escalate conflicts when they arise. However, core relationship wounds have not been healed, leading to unresolved arguments at times.
    • Quote (Conflict Resolution): "We can calm things down when we fight but still feel hurt afterwards." -Husband

Psychological Factors:

  • Symptom 1:
    • Symptom Description: Trust issues, insecurity, and jealousy continue in the relationship.
    • Onset: 1 year ago
    • Frequency: 2-3 times per week
    • Ascendance: Minimal improvement in trust and jealousy.
    • Intensity: Moderate intensity expressed
    • Duration: Persistent over past year
    • Quote (Symptom): "I still sometimes worry he's not telling me everything." -Wife
  • Symptom 2:
    • Symptom Description: Rebuilding emotional and sexual intimacy remains a challenge.
    • Onset: 8 months ago
    • Frequency: Ongoing issue
    • Ascendance: Some minor improvement in emotional intimacy.
    • Intensity: Significant severity reported.
    • Duration: 8 months
    • Quote (Symptom): "It's hard for us to reconnect physically when we still feel distant." -Husband

OBJECTIVEClinical Assessment:

  • Assessment Tool: No new assessments administered
  • Results: NA
  • Status: Initial clinical interview and assessment remain sufficient currently. Additional tools may be considered if progress stalls.

Risk Assessment:

  • Risks Or Safety Concerns: No risks or safety concerns expressed during the session by either party.

Interventions:

  • Therapeutic Approach Or Modality: Continued use of CBT and Gottman techniques focused on improving communication, empathy and conflict resolution.
  • Psychological Interventions:
    -Practiced speaker/listener technique.
    -Discussed identifying negative sentiment override.
    -Assigned reading on rebuilding trust after conflicts.
  • Rationale: Interventions targeted at improving emotional attunement, empathy, and progressing through relationship injury impasses.

ASSESSMENT
Progress And Response:

  • Response To Treatment: Clients report some progress with communication and conflict resolution skills. However, core relationship intimacy issues remain. Resistance to vulnerability present at times.
  • Specific Examples Or Instances: Each partner took turns speaking and listening during exercise. Wife had difficulty accepting husband's perspective.
  • Quote (Progress): "I think we communicate better, but we need to keep working on fully reconnecting." -Husband
  • Challenges To Progress: Lingering resentment, lack of trust, and avoidance of emotional intimacy remain barriers. Resistance to vulnerability is impeding progress.
  • Therapist Observations And Reflections: Despite skills practice, core wounds remain unaddressed. Therapist observed lingering hostility from wife towards husband. Individual work may be needed to complement couples treatment.
  • Therapeutic Alliance: Alliance remains strong with both clients, who are engaged in the therapeutic process.

PLAN
Follow Up Actions And Plans:

  • Homework: Practice speaker/listener technique at home. Complete assigned reading.
  • Plan For Future Session: Process lingering relationship injuries. Assess need for individual sessions to complement couples work.
  • Plans For Continued Treatment: Continue weekly couples joint sessions. Consider adding periodic individual sessions as needed.
  • Coordination Of Care: No coordination of care needs at this time.