Constructing A Psychotherapy SOAP Note

Constructing A Psychotherapy SOAP Note

Constructing A Psychotherapy SOAP Note

Case Study

Sally contact you as a referral from a colleague who felt Sally needed psychotherapy to address her problematic substance use. An overdose on prescription opioids was the precipitating event that pushed Sally to seek professional care although she had been in denial about her problem for many years. Sally was a high-functioning client with a bachelor’s degree in psychology working as an executive producer of a well-known real-life television series on addictions. She had just moved to New York City from the West Coast after a failed marriage in which she and her husband had engaged in infidelity. Sally had no children and felt relatively isolated given that her only living relatives were her mother and father—both of whom had mental illness—living 2,000 miles away. Sally had many resentments from her childhood as her father had untreated bipolar disorder and “put us through hell.” Throughout the course of treatment, Sally came to share with you that much of her adolescence was spent moving around the country with her depressed mother in an attempt to escape her father. She developed rather superficial relationships with people and had very few friends; that pattern followed Sally to New York.Constructing A Psychotherapy SOAP Note

At the time you meet Sally, she is 38 years old and identifies herself as an “existential thinker” who questioned “the purpose” of her life. She had no higher power and did not believe in God, nor did she suspect that the universe had any sort of energy that influenced her existence. Sally had an overwhelming sense of guilt and shame about being addicted to prescription opioids, which she had started using about a decade prior to treat her migraine headaches. She would commonly refer to herself as an “undercover addict.” There was a degree of paranoia that she would be “found out for a fraud” and had even requested that the initial screening be performed via a private, untraceable application on a smartphone.

At the beginning of treatment, it was clear that Sally did not like who she was at her core. Although her mother was physically present, she was overly anxious and controlling during her childhood. Sally often assumed the parental role given that her mother had frequent decompensations for which her mother was hospitalized. Sally developed poor patterns of self-regulation yet wanted to control her life without any assistance. She was a lonely person with a tough exterior facade. Sally felt guilty about her infidelity and more guilty about not being able to control the substances she consumed. In fact, during her course of treatment, she would try to manage her own medication regimen by changing her doses and had poor boundaries, often approaching me as her coworker rather than her therapist.

Sally reports having difficulty with self-control, has made attempts to abstain-believing that abstinence is the ultimate self-control, experienced relapse, struggled with further guilt and shame, and suffered the consequences of subsequent use. Throughout the course of treatment, the door was never closed and Sally has left treatment with you and returned about five times.


Construct a Psychotherapy Note based on one hypothetical session with this client.


The SOAP note is a problem focused method to document patient care.


·  Use facts, not opinions.

·  When quoting the patient, use quotation marks.

·  The note should be concise and clearly written.

·  Be as thorough as possible.

·  Before you write, consider what you want to say.  The record may be

·  Use professional language and only approved standard abbreviations.

Subjective (S)

(What did the patient say?  It should be quoted verbatim.)



(What did you observe?  You will include laboratory values, vital signs and diagnostic tests pertinent to your problem.) Including abnormal labs.



– 2 pages

no plagiarism

include references 2-3 no older than 5 years

– due date MARCH 24, 2023

Constructing A Psychotherapy SOAP Note