Theory to Practice: Person-Centered Progress Note

Last week for the series Theory to Practice, we reviewed an example solution-focused SOAP note. This week, we focus this week writing a person-centered/humanistic progress note. If you haven’t already, check out “Beginner’s Guide to Writing a SOAP Note (with SOAP note template)” and “Theory to Practice: Solution-Focused Progress Note”

The person-centered, or Rogerian, therapist believes that the client naturally strives towards growth and self-actualization. Carl Rogers, the founder of person-centered therapy, believed that there were three core conditions that needed to be present for effective therapy:

1. Unconditional positive regard 
2. Congruence 
3. Empathy

Person-centered therapy is relatively unstructured and is well-known for its lack of interventions. Rogers believed that therapists could be overly reliant on techniques which could ultimately hurt the therapeutic relationship.

Since this made-up note is written for a made-up behavioral health agency (should we give this agency that I keep using a name? Drop your suggestions in the comments below!), we have to integrate some type of intervention or technique. I really don’t know how ok Medicaid, or any insurance, would be with us not using any interventions and justifying our services. 

For this reason, I use a number of basic counseling skills for this note that promote the three core conditions of positive regard, congruence, and empathy. If you would like more ideas for person-centered interventions, check out this resource. Also be sure to review the following graphic to see some common goals for person-centered therapy:

From http://primarygoals.com/teams/models/rogers/

Some humanistic therapists also suggest completing progress notes concurrently. This means that the therapist completes the note with the client present and reviews the note with the client to communicate transparency and to involve the client in the treatment process. I use this method currently so that clients can sign off on notes for billing purposes. Avoiding technical jargon is also a hallmark of the person-centered note which, in turn, allows the client to understand their treatment process.

Keep reading to see how I integrated a person-centered approach in a progress note based off of a made-up case.

Sample:

S : Client reported her son had died due to an overdose since last meeting. Processed client’s grief and assessed risk of substance use for client due to history of substance use. Client stated she “didn’t do that now” and had already reached out to her sponsor. Praised client for actively seeking support, and thanked client for sharing. Reflected client’s feelings of panic and guilt. Client stated she found her feelings of guilt confusing since she knew she did not cause her son’s death. Assured client that feelings of guilt could be a normal part of the grieving process. Client stated she had plans to reach out to her brother for support after session. 

O : Client had stains on clothing. Client’s mood depressed, affect appropriate to context. Client tearful for majority of session. 

A : Client experiencing grief due to son’s recent death, experiencing incongruence between her experience and her emotions. Client seeking emotional support to meet safety and love/belonging needs.

P : Continue to process grief, explore feelings of guilt. 

Theory: 

1. Assessed client’s safety needs, as outlined in Maslow’s hierarchy of needs, specifically, client’s risk related to substance use.
2. Used affirmations to encourage client to continue sharing with therapist and continue seeking support.
3. Used basic skill of reflecting emotion.
4. Used psychoeducation skills to normalize feelings of guilt.
5. The objective portion of the note can also be a good place to note congruence or incongruence; is the client tapping their foot while stating they’re calm? Are they crying even when they say that an event did not bother them? Is mood congruent with affect?
6. Noted in assessment that client had unmet needs using the hierarchy of needs model; also noted any incongruent thoughts, emotions, or behaviors.
7. Made plans to continue processing based on client’s needs next week. A person-centered therapist might choose a less structured approach to address grief; for instance they might use open ended questions, reflecting, and paraphrasing instead of using specific interventions.

How do you use person-centered techniques in your practice?