DAP Note Example 1: Relationship stress (adjustment disorder)
Adult client in individual counseling for conflict with a spouse about parenting.
- Data
- Client attended scheduled 50-minute individual therapy session. Discussed ongoing conflict with spouse regarding parenting approaches. Client reported feeling "unheard and dismissed" during disagreements. Explored communication patterns using Gottman framework, identified criticism and defensiveness as recurring patterns. Practiced I-statement formulation during session. Client demonstrated improved ability to express needs without blame language by end of session. Appeared engaged and motivated throughout.
- Assessment
- Adjustment Disorder with Mixed Anxiety and Depressed Mood (F43.23). Client is making steady progress in identifying maladaptive communication patterns. Demonstrated ability to reframe criticism as specific requests during role-play exercises. Emotional regulation has improved since intake: fewer instances of escalation reported this week. Continued focus on communication skills is appropriate.
- Plan
- 1. Continue biweekly couples-informed individual sessions. 2. Homework: Practice I-statements during one disagreement this week and journal the outcome. 3. Provide psychoeducation handout on Gottman Four Horsemen. 4. Discuss possibility of joint session with spouse in 2-3 weeks. Next session: 2 weeks.