Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 14

1 Establish Rapport (1)²Caring was conveyed to the client through support, warmth and empathy.The client was provided with nonjudgmental support and a level of trust was developed.The client was urged to feel safe in expressing his/her antisocial behavior symptoms.The client began to express feelings more freely as rapport and trust level have increased.The client has continued to experience difficulty being open and direct about his/her expression of painful feelings; he/she was encouraged to use the safe haven of therapy to express these difficult issues.

2 Focus on Strengthening Therapeutic Relationship (2)The relationship with client was strengthened through the implementation of a collaborative approach, agreement on goals, demonstration of empathy, verbalization of positive regard, and collection of client feedback.The client reacted positively to the relationship-strengthening measures taken.The client verbalized feeling supported and understood during therapy sessions.Despite attempts to strengthen the therapeutic relationship, the client reports feeling distant and misunderstood.The client has indicated that sessions are not helpful and will be terminating therapy.

3 Take History/Confront Denial (3)The client's history of illegal activities was collected.The client was assigned the homework exercise “Crooked Thinking Leads to Crooked Behavior” from the Adult Psychotherapy Homework Planner (Jongsma).The client was assigned the homework exercise “Accept Responsibility for Illegal Behavior” from the Adult Psychotherapy Homework Planner (Jongsma).The client was confronted consistently on his/her/their attempts to utilize minimizations, denial, or projection of the blame onto others for which he/she/they were responsible.The client's history was explored for instances of unkind, insensitive behavior that trampled on the feelings and rights of others.

4 List Antisocial Consequences (4)The client was asked to list the negative consequences that have accrued to him/her/them due to his/her/their antisocial behavior.The client was assigned “How I Have Hurt Others” from the Adult Psychotherapy Homework Planner (Jongsma).The client was confronted with the fact that his/her/their antisocial behavior results in others losing respect for him/her/them, loss of freedom for him/her/them due to legal consequences, and loss of self-respect.The client was consistently reminded of the pain that others suffer as a result of his/her/their antisocial behavior.The client was asked to list others who have been negatively impacted by his/her/their antisocial behavior and the specific pain that they have suffered.The client was confronted with the fear, disappointment, loss of trust, and loss of respect that result in others as a consequence of his/her/their lack of sensitivity and self-centered behavior.The client was provided with positive feedback as he/she/they were able to accept the consequences of his/her/their antisocial behavior.

5 Arrange Substance Abuse Evaluation (5)The client's use of alcohol and other mood-altering substances was assessed.The client was assessed to have a pattern of mild substance use.The client was assessed to have a pattern of moderate substance use.The client was assessed to have a pattern of severe substance use.The client was referred for a substance use treatment.The client was found to not have any substance use concerns.

6 Assess Level of Insight (6)The client's level of insight toward the presenting problems was assessed.The client was assessed in regard to the syntonic versus dystonic nature of his/her/their insight about the presenting problems.The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.The client was noted to be in agreement with others' concerns and is motivated to work on change.The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.

7 Assess for Correlated Disorders (7)The client was assessed for evidence of research-based correlated disorders.The client was assessed in regard to his/her/their level of vulnerability to suicide.The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.The client has been assessed for any correlated disorders, but none were found.

8 Assess for Culturally Based Confounding Issues (8)The client was assessed for age-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for gender-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand his/her/their clinical presentation.Alternative factors have been identified as contributing to the client's currently defined “problem behavior,” and these were taken into account in regard to his/her/their treatment.Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.

9 Assess Severity of Impairment (9)The severity of the client's impairment was assessed to determine the appropriate level of care.The client was assessed in regard to his/her/their impairment in social, relational, vocational, and occupational endeavors.It was reflected to the client that his/her/their impairment appears to create mild to moderate effects on the client's functioning.It was reflected to the client that his/her/their impairment appears to create severe to very severe effects on the client's functioning.The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.

10 Enhance Motivation (10)Directive, client-centered, empathic, and motivation-enhancing treatment interventions were utilized.Rapport was established with the client through reflective listening and asking permission before providing information or advice.Motivational interviewing techniques were used to help develop greater rapport.

11 Use Open-Ended Questions to Explore Motivation (11)Open-ended questions were used to help the client explore his/her/their own motivation for change.The client was affirmed for his/her/their change-related statements and efforts.

12 Elicit Discrepancy (12)The client was asked about his/her/their level of dissatisfaction with the status quo.The client was assisted in identifying the pros and cons of potential changes.The client was assisted in identifying the discrepancy gap between his/her/their current behavior and his/her/their desired life goals.Care was taken to avoid direct confrontation or argumentation.

13 Identify Trust Loss (13)The client was reminded that his/her/their behavior of broken promises, insensitivity, and trampling on the rights of others results in broken relationships as others lose trust in him/her/them.The client was consistently reminded that any meaningful relationship is based on trust that the other person will treat one with kindness and respect.The client's behavior pattern was reviewed to understand how he/she/they treated others with a lack of respect and a lack of kindness and how these actions resulted in the loss of trust in the relationship.Support and encouragement were provided to the client as he/she/they identified how his/her/their behavior has caused a lack of trust in the relationship.The client denied any connection between his/her/their behavior and the loss of trust in the relationship and was gently offered examples in this area.

14 Teach the Need for Lawfulness (14)The client's pattern of unlawful behavior was reviewed and he/she/they were reminded that if everyone in society adopted his/her/their unlawful attitude, anarchy would result.The client was taught that respect for law and order and the rights of others is the only way that a civilized society can function.The client was reinforced as he/she/they acknowledged the need for lawfulness and how this will result in trust and a civilized society.The client denied any pattern of lawlessness to his/her/their behavior, despite facts to the contrary, and was confronted for this denial.

15 Solicit Commitment to Lawfulness (15)The client was asked to give his/her/their commitment to conforming to the laws of society.The client was asked to give a rationale for a prosocial, law-abiding lifestyle being adopted.The client was asked to list 10 reasons why he/she/they would commit self to a law-abiding lifestyle.Positive feedback was given to the client for his/her/their commitment to lawfulness.The client declined to commit to living in a lawful manner and was provided with additional feedback regarding the negative consequences for such refusal.

16 Inhibit Future Lawlessness (16)The client was firmly and consistently reminded of the negative legal consequences that would accrue to him/her/them if continued lawlessness was practiced.The client was asked to list six future negative consequences of continued antisocial behavior.The client's list of negative consequences of continued antisocial behavior was reviewed and processed.The client has not completed a list of negative consequences of antisocial behavior and was redirected to do so.

17 Review Broken Relationships (17)The client was asked to list any and all relationships that have been lost due to his/her/their pattern of antisocial behavior.As lost relationships were reviewed, the client was confronted with his/her/their responsibility for the actions that resulted in the broken relationships.As broken relationships were reviewed, the client was asked to identify what behavior of his/her/their own led to the broken relationship.The client was provided with support as he/she/they seemed to openly describe his/her/their broken relationships.

18 Confront Lack of Sensitivity (18)The client was firmly and consistently confronted with the reality of his/her/their own behavior that caused pain to others and resulted in their breaking off the relationship.The client was asked to identify how he/she/they were insensitive to the needs and feelings of others.Role-reversal techniques were used to attempt to get the client in touch with the pain he/she/they have caused in others due to disrespect, disloyalty, aggression, or dishonesty.The client was provided with positive feedback as he/she/they took responsibility for broken relationships.The client has not taken responsibility for broken relationships and was provided with confrontation for this denial.

19 Confront Self-Centeredness (19)The client was taught, through role-playing and role-reversal, the value of being empathetic to the needs, rights, and feelings of others.It was reflected to the client that he/she/they present his/her/their attitude of “look out for number one” as the only way to live.Active-listening skills were used as the client justified his/her/their self-focused attitude as the way that he/she/they learned to live because of the abuse and abandonment suffered as a child.Attempts were made to get the client to view his/her/their own behavior from another person's perspective.The client was provided with positive feedback and verbal reinforcement whenever he/she/they made comments that were less self-centered.

20 Teach the Value of Honesty (20)The client was asked to list the benefits of honesty and reliability for self and others.The client was taught the absolute necessity for honesty as the basis for trust in all forms of human relationships as examples of the different forms of relationships that are based in trust and honesty were reviewed.The client was asked to list the positive effects for others when he/she/they are honest and reliable.Positive feedback was provided as the client identified the positive effects for others when he/she/they are honest and reliable.It was reflected to the client that he/she/they continue to be dishonest in relationships.

21 List Honesty Consequences (21)The client was asked to list the positive effects for others when he/she/they are honest and reliable.The client was taught that pain and disappointment result when honesty and reliability are not given the highest priority in one's life.The client was provided with positive feedback for his/her/their understanding of the effects of honesty versus dishonesty.The client failed to identify the effects of honesty and dishonesty and was gently offered examples in this area.

22 Solicit a Commitment to Honesty (22)The client was asked to make a commitment to live a life based in honesty and reliability.The client was asked to sign a behavioral contract that focuses on keeping promises and being responsible to others.The client was asked to list five reasons why he/she/they should make a commitment to be honest and reliable.Positive feedback was provided as the client committed to living a life based in honesty and reliability.

23 Teach Empathy (23)The client was taught, through role-playing and role reversal, the value of being empathetic to the needs, rights, and feelings of others.The client was asked to commit self to acting more sensitively to the rights and feelings of others.The client was encouraged as he/she/they committed to acting more sensitively regarding the rights and feelings of others.

24 Use Role Reversal Techniques (24)The client was reminded of the consequences of his/her/their lack of empathy for others.The client was taught about his/her/their lack of empathy and the consequences of this behavior for others through the use of role reversal techniques.The client gained new insight into the consequences of his/her/their behavior for others and was provided with encouragement.

25 Confront Disrespect (25)The client was confronted consistently and firmly when he/she/they exhibited an attitude of disrespect and rudeness toward the rights and feelings of others.It was emphasized to the client firmly and consistently that others have a right to boundaries and privacy and respect for their feelings and property.

26 Solicit Kind Actions (26)The client was required, in an attempt to get him/her/them to focus on the needs and feelings of others, to list three actions that would be performed as acts of kindness toward someone else.The client and therapist signed a contract in which he/she/they committed to performing three acts of service toward the community or others that would not result in direct benefit to self.The client was assigned “Three Acts of Kindness” in the Adult Psychotherapy Homework Planner (Jongsma).The client's acts of kindness were reviewed and the feelings associated with performing this assignment were processed.The client has not completed acts of kindness and was redirected to do so.

27 Solicit an Apology (27)The client was asked to make a list of those people who deserve an apology because they were injured by the client's insensitive, impulsive, aggressive, or dishonest behavior.The client was assigned the homework exercise “How I Have Hurt Others” from the Adult Psychotherapy Homework Planner (Jongsma).The client was confronted when he/she/they attempted to project the blame for his/her/their aggressive or dishonest actions onto others.The client was supported as he/she/they identified those people who deserve an apology because they were injured by his/her/their insensitive, impulsive, aggressive, or dishonest behavior.Positive feedback was provided as the client reported that he/she/they have given an apology to those who were injured by his/her/their insensitive, impulsive, aggressive, or dishonest behavior.The client has not made an apology to those identified as being injured by his/her/their insensitive, impulsive, aggressive, or dishonest behavior and was redirected to do so.

28 Teach Acceptance of Responsibility (28)The value of taking full responsibility for one's own behavior and then apologizing for the pain caused to others because of that behavior was reviewed and emphasized.Role-playing and modeling were used to teach how to apologize.Positive feedback was provided to the client for his/her/their understanding and use of apologies.

29 Review Elements of Apology (29)The specific steps were laid out that would be necessary to begin to make amends to others who have been hurt by the client's behavior.The client was assigned the homework exercise “Letter of Apology” from the Adult Psychotherapy Homework Planner (Jongsma).The client was asked to make a commitment to carry out those necessary steps that would make restitution for the hurt caused to others.Behavioral rehearsal was used to teach how to make amends or give an apology to those who have been hurt by the client's behavior.The client's implementation of apologizing to others was reviewed and the feelings associated with this action were processed.The client was strongly reinforced for taking responsibility for causing pain to others and apologizing for this behavior.The client has not taken responsibility for the pain he/she/they have caused others, or apologized for this behavior, and was redirected to do so.

30 Review Work Authority Conflicts (30)The client was asked to list the most important rules that should govern his/her/their behavior within the work setting.The client was assisted in developing a specific list of rules and duties related to the client's employment behavior.The client reviewed the expectations regarding how he/she/they should respond to authority figures within the employment setting; his/her/their appropriate expectations were reinforced.Role-playing was used to teach respectful responses to directives from authority figures.

31 Reinforce Employment Attendance (31)The client's attendance at work and his/her/their respect for authority were reviewed and reinforced.The client was asked to keep a journal of work attendance and instances of acceptance of directives from authority figures.The client's work records and journal material were reviewed and successful prosocial behavior was reinforced.The client has not kept a record or journal of work attendance and acceptance of directives from authority figures and was redirected to do so.

32 Teach Prosocial Work Behavior (32)The client was asked to list those negative behaviors that have led to conflicts within the work setting with both coworkers and authority figures.The client was assisted in developing prosocial responses toward resolving conflicts with coworkers and acceptance of directives from authority figures.The client has implemented more prosocial responses at work, and the positive results of this attitude were reviewed.

33 Confront Irresponsible Parenting (33)The client was asked to acknowledge and accept responsibility for a history of avoiding the obligations of parenthood.The client was confronted with a pattern of his/her/their behavior that demonstrates a lack of acceptance of responsibility for being a nurturant parent.The client was asked to list incidences from his/her/their past that are examples of avoidance of the responsibilities of parenting.

34 Reinforce Responsible Parenting (34)The client was asked to list specific behaviors that would indicate that he/she/they were taking on the responsibilities of being a reliable, responsible, and nurturant parent.The client was asked to list potential consequences to self and the child(ren) of avoiding the responsibilities of parenting.The client's list of behaviors and consequences related to taking responsibility for parenting were reviewed and processed.The client has not made a list of behaviors and consequences of being a responsible versus irresponsible parent and was redirected to do so.

35 Solicit a Commitment to Responsible Parenting (35)The client was assisted in developing a list of concrete steps that could be taken to demonstrate reliable, responsible parenting behavior.The client was asked to make a commitment to implementation of specific steps that would demonstrate responsible parenting.The client has begun to implement specific steps toward demonstrating responsible parenting and he/she/they were reinforced for this change in behavior.The positive impact of the client's implementation of positive parenting behavior was reviewed.The client has not implemented steps to responsible parenting and was redirected to do so.

36 Confront Projection (36)The client was consistently confronted whenever he/she/they failed to take responsibility for his/her/their own actions and instead placed blame for them onto others.The client was assigned the homework exercise “Accept Responsibility for Illegal Behavior” from the Adult Psychotherapy Homework Planner (Jongsma).As the client's pattern of projecting blame for his/her/their actions onto others began to weaken, he/she/they were reinforced for taking personal responsibility.The importance of taking responsibility for one's own behavior and the positive implications of this for motivating change were reviewed.

37 Explore Reasons for Blaming (37)The client's history was explored with a focus on causes for the avoidance of acceptance of responsibility for behavior.The client's history of physical and emotional abuse was explored.The client's early history of lying was explored for causes and consequences.Parental modeling of projection of responsibility for their behavior was examined.The client was gently offered examples of reasons why he/she/they tend to blame others for his/her/their actions (e.g. history of physically abusive punishment, parental modeling, fear of rejection, shame, low self-esteem, avoidance of facing consequences).

38 Reinforce Taking Personal Responsibility (38)The client was verbally reinforced in a strong and consistent manner when he/she/they took responsibility for his/her/their own behavior.The client was taught how others develop respect for someone who takes responsibility for his/her/their actions and admits to mistakes.

39 Explore Childhood Abuse and Neglect (39)Active-listening skills were used as the client described instances from his/her/their own childhood of emotional, verbal, and physical abuse.The client was assigned the homework exercise “Describe the Trauma” from the Adult Psychotherapy Homework Planner (Jongsma).Support and empathy were provided as the client described feelings of hurt, depression, abandonment, and fear related to parental abuse or neglect.It was reflected to the client that he/she/they were rather matter-of-fact in his/her/their description and showed little affect while describing a history of violence within the family during his/her/their childhood.It was reflected to the client that he/she/they have tended to minimize the negative impact of physical abuse that he/she/they suffered and, at times, even excused the behavior as something that he/she/they deserved.The client was shown the cycle of abuse or neglect is repeating itself in his/her/their behavior.

40 Review Emotional Detachment (40)The client's pattern of emotional detachment from others was reviewed.It was pointed out to the client that his/her/their childhood history of abuse and neglect has led to a pattern of emotional detachment in current relationships.The client accepted that his/her/their emotional detachment is related to his/her/their childhood history of abuse and neglect and was supported for this insight.The client denied connection between any emotional detachment and any childhood abuse and was urged to consider this connection as he/she/they felt able to do so.

41 Assess Anger-Producing Stimuli (41)The client was asked to describe his/her/their history and nature of anger feelings and expression.A focus was placed on assessing the stimuli that have triggered the client's anger and thoughts, feelings, and aggressive actions.The client's responses to various stimuli (e.g. situations, people, and thoughts) were reviewed.The client was assigned the homework exercise “Anger Journal” from the Adult Psychotherapy Homework Planner (Jongsma).

42 Administer Psychological Testing (42)Psychological testing instruments were administered with a focus on objectively assessing anger expression.The client was assessed with the Anger, Irritability, and Assault Questionnaire (AIAQ).The client was assessed with the Buss-Durkee Hostility Inventory (BDHI).The client was assessed with the State-Trait Anger Expression Inventory (STAXI).The client was provided with feedback regarding the results of the assessment.

43 Teach Calming Techniques (43)The client was taught calming relaxation skills.The client was taught progressive muscle relaxation, breathing-induced relaxation, calming imagery, cue-controlled relaxation, and applied relaxation.The client was taught how to discriminate better between relaxation and chronic or acute physiological activation that accompanies his/her/their angry feelings.The client was taught relaxation skills and was provided with feedback about his/her/their use of relaxation skills.

44 Role-Play Relaxation and Cognitive Coping Skills (44)Role-play techniques were used to help the client use relaxation and cognitive coping skills in visualized anger-provoking scenes.The client was assisted in applying relaxation and cognitive coping skills to lower and then higher anger-inducing scenes.The client was assigned to implement calming techniques in his/her/their daily life when facing trigger situations.The client was assisted in processing his/her/their application of calming techniques in his/her/their daily life.

45 Explore Self-Talk (45)The client was assisted in identifying distorted schemas and related automatic thoughts that mediate his/her/their angry feelings and actions.The client was taught the role of distorted thinking in precipitating emotional responses.The client was provided with examples of distorted or automatic thoughts, typically relating to should, must, or have-to statements.The client was challenged on his/her/their negative biases and assisted with healthier self-talk.The client was assisted in relating his/her/their self-talk and calming skills as a package of coping skills for managing anger.

46 Assign Exercises on Self-Talk (46)The client was assigned homework exercises in which he/she/they identify anger-inducing self-talk and create reality-based alternatives, such as “Alternatives to Destructive Anger” from the Adult Psychotherapy Treatment Planner (Jongsma).The client's replacement of anxiety of anger-producing self-talk with reality-based alternatives was critiqued.The client was reinforced for his/her/their successes at replacing anger-based self-talk with reality-based alternatives.The client was provided with corrective feedback for his/her/their failure to replace anger-producing self-talk with reality-based alternatives.The client has not completed his/her/their assigned homework regarding replacing angry self-talk and was redirected to do so.

47 Review Alternatives (47)The client was assisted in reviewing alternatives to destructive anger in response to trigger situations.The client was taught about assertiveness, relaxation, diversion, and calming self-talk.

48 Teach Forgiveness (48)The client was taught the value of forgiveness as a means of overcoming pain and hurt, rather than holding on to it and acting out the anger that results from it.The client was asked to list those parental figures from his/her/their childhood that have caused him/her/them pain and suffering.The client was assisted in developing a list of benefits of beginning a process of forgiveness toward those perpetrators of pain in his/her/their childhood.

49 Process Distrust (49)The client was asked to verbalize what he/she/they could be afraid of in placing trust in others.The client's fear of being taken advantage of, being disappointed, being abandoned, or being abused when trust is placed in another person was processed.Positive feedback was provided to the client as he/she/they displayed insight into his/her/their pattern of distrust.

50 Encourage Trust (50)The client was assisted in identifying some personal thoughts and feelings that he/she/they could disclose to another person as a means of beginning the process of showing trust in others.The client was assisted in identifying one or two other people within his/her/their life that he/she/they could trust with personal information.The client was asked to commit to making a disclosure to a significant other that would demonstrate trust.Positive feedback was provided as the client identified that he/she/they have made trusting disclosures to others.The client did not make trusting disclosures to others, and the reasons behind this failure were processed.

51 Process Trust Exercise (51)The client's feelings of anxiety regarding trusting someone were explored.The client's experience with placing trust in another person was reviewed and the success was reinforced.