Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 13

1 Adolescent Antisocial History (1)¹The client confirmed that his/her/their history of rule breaking, lying, physical aggression, and/or disrespect for others and the law began when he/she/they were a teenager.The client reported that he/she/they were often incarcerated within the juvenile justice system for illegal activities.The client acknowledged that his/her/their substance abuse paralleled his/her/their antisocial behavior dating back to adolescence.

2 Dysfunctional Childhood History (1)The client described instances from his/her/their childhood in which severe and abusive punishment resulted whenever a parent laid blame on him/her/them for some perceived negative behavior.The client described a history of experiences in which he/she/they were unfairly blamed for others' behavior, leading to feelings of resentment of authority and a pattern of lying to avoid punishment.The client provided examples from his/her/their own childhood of instances when parental figures consistently projected blame for their behavior onto others, causing the client to learn and practice this same behavior.The client began to verbalize some insight into how previous instances of pain in child- hood are causing current attitudes of detachment from the concerns of others and a focus on self-protection and self-interest.The client began to understand how his/her/their attitudes of aggression are the result of having learned to accept and normalize aggression during childhood abusive experiences.

3 Legal Conflicts (2)The client maintained a disregard for laws, rules, and authority figures.The client reported engaging in illegal activities in his/her/their current situation.The client has repeatedly engaged in illegal activities in the past.The client often minimized the seriousness of his/her/their offenses against the law and other people's rights.The client acknowledged that his/her/their disregard for the law has resulted in serious problems and has pledged to live within the rules of society.

4 Aggressive/Argumentative (3)The client presented in a hostile, angry, and uncooperative manner.The client was intimidating in his/her/their style of interaction.The client is trying to interact in a more cooperative manner within social and employment settings.The client is showing less irritability and argumentativeness within therapy sessions.

5 Authority Conflicts (3)The client acknowledged a history of irritability, aggression, and argumentativeness when interacting with authority figures.The client's history of conflict with acceptance of authority has led to employment instability and legal problems.The client is beginning to accept direction from authority figures, recognizing his/her/their need to resist challenging such directives.

6 Consistent Use of Substances (4)The client described a history of alcohol and other mood-altering drug use on a frequent basis and, often, until intoxicated or passed out.Family members confirmed a pattern of chronic substance abuse by the client.The client acknowledged that his/her/their substance abuse began in adolescence and continued into adulthood.The client has committed self to a plan of abstinence from substance abuse and participation in a recovery program.The client has maintained total abstinence, which was confirmed by his/her/their family.

7 Lack of Remorse (5)The client, after describing his/her/their pattern of aggression or disrespect for others' feelings, showed no remorse for his/her/their behavior.The client projected blame for his/her/their hurtful behavior onto others, saying there was no alternative.The client is beginning to develop some sensitivity to the feelings of others and to recognize that he/she/they have hurt others.The client reported feelings of remorse and guilt over previous behaviors that were hurtful to others.

8 Blaming/Projecting (6)The client showed an attitude of blaming others for his/her/their problems.The client refused to take responsibility for his/her/their own behavior and decisions; instead, he/she/they pointed at the behavior of others as the cause for his/her/their decisions and actions.Interpersonal conflicts were blamed on others without taking any responsibility for the problem.The client is beginning to accept responsibility for his/her/their own behavior and to make fewer statements of projection of responsibility for his/her/their actions onto others.The client is gradually accepting more responsibility for his/her/their behavior and increasing the frequency of such statements.

9 Lying (7)The client reported a pattern of lying to cover up his/her/their responsibility for actions with little shame or anxiety attached to this pattern of lying.The client seemed to be lying within the session.The client acknowledged that his/her/their lying produced conflicts within relationships and distrust from others.The client has committed self to attempting to be more honest in his/her/their interpersonal relationships.

10 Verbal/Physical Aggression (8)The client reported physical encounters that have injured others or have threatened serious injury to others.The client showed little or no remorse for causing pain to others.The client projected blame for his/her/their aggressive encounters onto others.The client has a violent history and continues to interact with others in a very intimidating, aggressive style.The client has shown progress in controlling his/her/their aggressive patterns and seems to be trying to interact with more assertiveness than aggression.

11 Recklessness/Thrill Seeking (9)The client reported having engaged in reckless, adventure-seeking behaviors, showing a high need for excitement, having fun, and living on the edge.The client described a series of reckless actions but showed no consideration for the consequences of such actions.The client has begun to control his/her/their reckless impulses and reported that he/she/they are trying to think of the consequences before acting recklessly.

12 Sexual Promiscuity (10)The client reported a history of repeated sexual encounters with partners with whom there is little or no emotional attachment.The client's described sexual behaviors are focused on self-gratification only and reflect no interest in the needs or welfare of the partner.The client acknowledged that his/her/their sexual behavior has no basis in respect or expression of commitment to a long-term relationship.The client reported that he/she/they would like to develop a relationship in which sexual intimacy was a reflection of commitment and caring, rather than merely sexual release.

13 Impulsivity (11)The client has a pattern of impulsive behavior, which is demonstrated in his/her/their frequent geographical moves, traveling with little or no goals, and quitting one job after another.The client's impulsivity has resulted in a life of instability and negative consequences for him/her/them and others.The client has acknowledged that his/her/their life of impulsive reactivity has had many negative consequences, and he/she/they have committed to an effort of control over these impulses.The client has shown progress in controlling impulsive reactivity and now considers consequences of actions before quickly reacting.

14 Employment Conflicts (12)The client reported that authority conflicts have erupted in the employment situation.The client described coworker conflicts where he/she/they do not trust others and do not work as part of a team.The client's work history is very unstable, in that he/she/they have held many different jobs with little or no longevity to them.The client acknowledged a need to develop a tolerance for frustration within the work situation and accept authority that will give him/her/them direction within that setting.The client has maintained employment for the longest period of time in his/her/their life.

15 Irresponsible Parenting (13)As the client began to acknowledge a history of irresponsible parenting, he/she/they also tried to minimize the consequences and project blame for these actions onto others.The client described a feeling of love and devotion to his/her/their child(ren), but, behaviorally, there is little evidence of it.The client has not paid child support on a regular basis or shown consistent interest in the welfare of his/her/their child(ren).The client acknowledged some guilt over his/her/their lack of responsible parenting and has committed to behaving in a more responsible and consistent manner to support his/her/their child(ren).The client has initiated responsible behavior toward his/her/their child(ren) in terms of financial support and consistent contact.