17

Seventeen
February 19 Imbolgen 25
Adrienne Venet
DOB 7-1-1982
Vanessa McClain, MA, LAPC
Psychotherapy Note
The client has failed to take her psychotropic medications consistently as prescribed. A review of the client’s medication indicates that she has not used the expected amounts. The client has verbalized her fears related to physical and emotional side effects of prescribed medications. A.V. states that she does “not like how they make me feel, all sluggish and mushy.” Client has indicated reluctance to take her prescribed medications. A.V. was asked to identify all her currently prescribed medications, including names, times administered, and dosage. The client was provided with feedback regarding the accuracy of her list of medications. Client was requested to provide honest, realistic description of her medication compliance. Her description of her medication usage was compared with information from her medical chart, information from her psychiatrist, and other objective data. An objective data review indicates poor medication compliance. Motivational interviewing techniques were used to help assess the client’s preparation for change. A. V. was requested to describe fears that she may experience regarding the use of her medications. Myths and misinformation regarding the client’s understanding and fears were corrected. The client’s fears were reviewed, discussed and processed to conclusion. A.V. was reinforced for positive reality based cognitive messages to enhance prescription medication compliance. Client was referred to psychiatrist for evaluation of psychotropic medication. Follow up session TBA.