Psychology Progress Note

General Session Information

• Type of session: Individual therapy and family session
• Attendees: Client (Lucas Vance), mother (Sarah Vance), CCS Facilitator (Marcus Vance, BSW), school counselor (Elena Rostova, M.Ed.)
• Place of service: Office
• Services delivered: Individual therapy, family psychoeducation, service planning
• Service timing: Individual therapy: 14:00 to 14:30, 30 minutes; family psychoeducation: 14:30 to 14:45, 15 minutes; service planning: 14:45 to 15:00, 15 minutes
• Client needs addressed: "Lucas needs to develop healthy coping mechanisms to manage severe emotional dysregulation and reduce self-harm urges."
• CCS goals and objectives addressed during the session: Goal: "Lucas will improve emotional regulation to maintain safety at home and school." Objective: "Lucas will utilize at least two DBT distress tolerance skills per week when experiencing urges to self-harm, reducing self-injurious incidents to zero over the next 90 days."

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Presenting Concerns

• Worsening depressive mood, persistent irritability, and increased frequency of non-suicidal self-injury (NSSI) urges triggered by academic performance pressures and peer exclusion.
• Difficulty initiating sleep and frequent nighttime awakenings averaging 3 hours of sleep per night over the past week.

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Medications

• Escitalopram (Lexapro) 10 mg PO QAM: partial efficacy for baseline anxiety, mild daytime somnolence reported; Melatonin 3 mg PO QHS: minimal efficacy for sleep initiation.

Medical Updates

• Medical problems: Mild iron-deficiency anemia diagnosed by PCP on 12/05/2026, contributing to baseline fatigue.
• Medical interventions: Initiated ferrous sulfate 325 mg PO QOD per PCP recommendation; repeat CBC scheduled in 8 weeks.

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Functioning and Updates Since Last Session

• Progress since the previous session: Successfully utilized ice-diving TIPP skill twice on 14/05/2026 when experiencing acute distress (rated 8/10), effectively averting NSSI.
• Treatment-related setbacks: Engaged in superficial cutting on left forearm on 16/05/2026 following a conflict with a peer at school, rating urge intensity at 9/10 prior to the act.
• Homework from the prior session: Completed 4 of 7 days on the DBT diary card, omitting entries over the weekend due to reported forgetfulness and low motivation.
• Continuing challenges or concerns: Persistent ruminative thoughts regarding upcoming final exams, ongoing social isolation during lunch periods, chronic sleep deprivation exacerbating emotional lability.
• Other relevant updates: Attended one after-school art club meeting on 13/05/2026, noting a temporary improvement in mood (rated 6/10).
• Parent reports regarding insight and judgment: Mother reports client demonstrates improved insight into emotional triggers retrospectivly, but exhibits impaired judgment in the moment by isolating in his bedroom and refusing parental support during high-distress episodes.
• Between-session behaviors that interfere with therapy: Incomplete DBT diary card monitoring, inconsistent utilization of distress tolerance skills during weekend periods, hiding emotional distress from parents until urges become overwhelming.

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Mental Status Examination

• Appearance, speech, affect, thought process or content, perceptions, and cognition: Casual dress with long sleeves covering forearms, fair grooming; speech normal in rate and volume, occasionally halting when discussing peer conflict; thought process linear and goal-directed; thought content notable for passive suicidal ideation and self-deprecating cognitions, devoid of delusions or hallucinations; cognition intact with full orientation, normal attention, and intact immediate and recent memory.

• Behavioral observations: Cooperative but guarded initially, maintained intermittent eye contact, exhibited psychomotor restlessness (fidgeting with sweatshirt strings), posture relaxed slightly during skills review.

• Affect and mood assessment: Mood reported as depressed and overwhelmed; affect constricted and dysphoric, congruent with stated mood.

• Insight: Fair; recognizes connection between academic stress and self-harm urges but underestimates the impact of sleep deprivation on emotional vulnerability.

• Judgment: Impaired; evidenced by recent NSSI episode instead of accessing adult support or safety plan resources.

• In-session behaviors that interfere with therapy: Initial avoidance of therapeutic tasks demonstrated by minimizing the severity of the recent cutting episode, brief emotional withdrawal when mother joined the session.

Past Medical and Psychiatric History

History of Major Depressive Disorder and Generalized Anxiety Disorder diagnosed in 2024; one prior inpatient psychiatric hospitalization in October 2025 for acute suicidal ideation; history of superficial NSSI (cutting) since age 14; childhood history of mild intermittent asthma.

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Risk Assessment

• Passive suicidal ideation reported (wishing to go to sleep and not wake up) occurring 3 times this week without active intent, method, or plan; NSSI occurred once this past week (2 superficial lacerations to left volar forearm using a disassembled pencil sharpener blade, wounds clean and healing without signs of infection); denies homicidal urges, aggressive behaviors, or substance use/addictive behaviors.

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Clinical Formulation

• Recent triggers and precipitating events: Exclusion from a peer group project at school on 16/05/2026 and receipt of a failing grade on a chemistry midterm.
• Long-standing and chronic vulnerabilities, including predisposing factors: Family history of mood disorders (maternal major depression), perfectionistic temperament, history of middle school bullying.
• Current dynamic and short-term risk factors: Acute sleep deprivation, active NSSI urges, high academic workload, social withdrawal at school.
• Perpetuating factors: Maladaptive avoidance of social interactions, irregular sleep-wake cycle, negative reinforcement of NSSI via temporary relief from emotional numbness and acute distress.
• Protective factors: Strong therapeutic alliance, supportive and engaged mother, active CCS wraparound team, engagement in creative arts, stated desire to attend college for graphic design.

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Risk Management

• Client verbalized commitment to safety for the upcoming week and agreed to utilize his written safety plan prior to acting on any self-harm urges.
• Reviewed and updated safety plan: client will use TIPP skills (cold water, paced breathing) and distraction (drawing, listening to music) at urge onset; mother agreed to conduct a room sweep today to remove sharp objects and lock all medications and razors in a combination safe; identified outside supports include mother (Sarah), school counselor (Elena Rostova) during school hours, mobile crisis team, and the 988 Suicide & Crisis Lifeline.

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Interventions

• New strategies or techniques taught: Taught the DBT PLEASE skill for emotion regulation, focusing specifically on addressing physical vulnerability through consistent sleep hygiene and adherence to iron supplementation.
• Psychoeducation: Provided education to client and mother regarding the bidirectional relationship between REM sleep deprivation, amygdala hyper-reactivity, and decreased distress tolerance.
• Validation: Validated client's feelings of rejection and disappointment regarding the peer group exclusion and chemistry grade, normalizing the difficulty of balancing recovery with academic demands.
• Behavior chain analysis: Conducted a detailed behavior chain analysis of the 16/05/2026 NSSI episode: identified vulnerability factors (4 hours of sleep, skipped lunch), prompting event (peer exclusion in class), links in the chain (catastrophic thoughts of being permanently alone, intense shame, isolating in bedroom after school), problem behavior (superficial cutting), and short-term/long-term consequences (immediate autonomic relief followed by guilt and parental restriction).
• Solution analysis: Generated alternative adaptive behaviors to insert into the behavior chain, including texting mother immediately upon arriving home, utilizing the ice dive skill before entering his bedroom, and practicing opposite action by remaining in the common living area.
• Missing links: Identified the missing link in homework completion and skill use on 16/05/2026 as the client leaving his DBT binder in his school locker and failing to set a daily phone alarm for diary card completion.
• Assessment: Administered the PHQ-9 (score: 16, indicating moderately severe depression, unchanged from two weeks ago).
• Problem solving: Collaborated with client, mother, and school counselor during the service planning portion to establish a protocol allowing client to access the counseling office for 10-minute cool-down periods during the school day.
• Continued treatment strategies: Reviewed TIPP skills (specifically temperature and paced breathing) to reinforce autonomous utilization prior to escalation of emotional distress.
• Troubleshooting strategy implementation: Addressed barriers to diary card completion by transitioning from a paper worksheet to a digital notes application on the client's smartphone, setting a recurring daily reminder for 20:00.

Relevance to CCS Goals and Objectives

The behavior chain analysis, solution analysis, and review of TIPP skills directly supported the CCS Goal: "Lucas will improve emotional regulation to maintain safety at home and school" and the CCS Objective: "Lucas will utilize at least two DBT distress tolerance skills per week when experiencing urges to self-harm, reducing self-injurious incidents to zero over the next 90 days."

Recommendations Made

Recommended that mother coordinate with the school 504 coordinator to request extended time on upcoming final exams to mitigate acute academic stress; recommended client discontinue screen use 60 minutes prior to bedtime to support sleep initiation.

Response to Interventions

Client was initially guarded during the behavior chain analysis but became increasingly collaborative once validated, demonstrating openness to transitioning his diary card to his phone; mother and CCS team were highly receptive to psychoeducation and actively engaged in safety planning and school accommodation coordination.

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Session Summary

• Conducting a behavior chain analysis of a recent NSSI incident, introducing the DBT PLEASE skill, updating the home safety plan, and coordinating school-based support strategies with the CCS team.

Session Content

• During the final 15 minutes with the CCS Facilitator and school counselor, discussed upcoming transition to summer schedule and potential enrollment in a therapeutic summer art program funded through CCS; client expressed moderate interest in the program provided he does not have to attend prior to 10:00.

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Treatment Plan

• Changes to treatment schedule: Increase individual therapy frequency from biweekly to weekly for the next 4 weeks to closely monitor safety and support skill acquisition during final exams.
• Treatment goals:
  • Eliminate non-suicidal self-injury behaviors through consistent application of DBT distress tolerance skills.
  • Improve sleep hygiene to achieve an average of 7 hours of restful sleep per night.
  • Increase adaptive communication of emotional needs to parents and school support staff.

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Next Steps

• Next session: 26/05/2026 at 14:00 (America/Chicago).
• Client decisions or agreement about treatment: Client agreed to weekly sessions, digital diary card tracking, and keeping his bedroom door ajar when experiencing distress rated 6/10 or higher.
• Client homework: Complete digital DBT diary card daily at 20:00 for 7 days; practice the PLEASE skill by turning off electronics at 22:00 nightly and taking prescribed iron supplement every other morning; Mother to complete bedroom safety sweep by 19:00 tonight.
• Continued skill practice and self-care: Continue utilizing TIPP skills (cold water, paced breathing) whenever self-harm urges exceed 5/10; engage in 20 minutes of sketching daily for self-soothing.
• Psychologist follow-up tasks: Send updated crisis safety plan PDF to mother, CCS Facilitator, and school counselor via secure portal by 20/05/2026; consult with prescribing psychiatrist regarding persistent insomnia and current Lexapro dosage.
• Plan for the next session: Review digital diary card compliance, assess sleep duration and NSSI urge frequency, and introduce DBT Check the Facts skill to address catastrophic academic cognitions.
• Future-session considerations: Explore Internal Family Systems (IFS) parts work regarding the inner critic driving academic perfectionism once acute NSSI urges are stabilized.