Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 17

1 Establishing 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/their anxiety 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/their expression of painful feelings; he/she/they were encouraged to use the safe haven of therapy to express these difficult issues.

2 Focus on Strengthening Therapeutic Relationship (2)The relationship with the client was strengthened using empirically supported factors.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 Assess Nature of Anxiety Symptoms (3)The client was asked about the frequency, intensity, duration, and history of his/her/their anxiety symptoms, fear, and avoidance.The Anxiety and Related Disorders Interview Schedule for DSM-5 (DiNardo, Brown, and Barlow) was used to assess the client's anxiety symptoms.The assessment of the client's anxiety symptoms indicated that his/her/their symptoms are extreme and severely interfere with his/her/their life.The assessment of the client's anxiety symptoms indicates that these symptoms are moderate and occasionally interfere with his/her/their daily functioning.The results of the assessment of the client's anxiety symptoms indicate that these symptoms are mild and rarely interfere with his/her/their daily functioning.The results of the assessment of the client's anxiety symptoms were reviewed with the client.

4 Administer Client-Report Measure (4)A client-report measure was used to further assess the depth and breadth of the client's anxiety responses.The Penn State Worry Questionnaire (Meyer, Miller, Metzger, and Borkevec) was used to assess the depth and breadth of the client's anxiety responses.OQ-45.2 (Lambert and Burlingame) was used to assess the depth and breadth of the client's anxiety responses at the outset of treatment.The Symptom Checklist-90-R (Derogatis) was used to assess the client's level of anxiety.The client-report measure indicated that the client's anxiety is extreme and severely interferes with his/her/their life.The client-report measure indicated that the client's anxiety is moderate and occasionally interferes with his/her/their daily life.The client-report measure indicated that the client's anxiety is mild and rarely interferes with his/her/their daily life.

5 Refer for Assessment Regarding Etiology (5)The client was referred for an assessment to rule out nonpsychiatric medical etiologies for his/her/their anxiety.The client was referred for an assessment to rule out substance-induced etiologies for his/her/their level of anxiety.The client has complied with the referral and the results of this evaluation were reviewed.The client has not complied with the referral for a medical evaluation and was redirected to do so.

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 Refer for Medication Evaluation (10)The client was referred to a prescribing clinician to evaluate him/her for psychotropic medication to reduce symptoms of anxiety.The client has completed an evaluation by the prescribing clinician and has begun taking antianxiety medications.The client has resisted the referral to a prescribing clinician and does not want to take any medication to reduce anxiety levels; his/her/their concerns were processed.

11 Monitor Medication Adherence (11)The client's adherence with the clinician's prescription for psychotropic medication was monitored for the medication's effectiveness and side effects.The client reported that the medication has been beneficial to him/her/them in reducing his/her/their experience of anxiety symptoms; the benefits of this progress were reviewed.The client reported that the medication does not seem to be helpful in reducing anxiety experiences; this was reflected to the prescribing physician.The therapist conferred with the prescribing clinician to discuss the client's reaction to the psychotropic medication and adjustments were made to the prescription by the clinician.

12 Discuss Anxiety Cycle (12)The client was taught about how anxious fears are maintained by a cycle of unwarranted fear and avoidance that precludes positive, corrective experiences with the feared object or situation.The client was taught about how treatment breaks the anxiety cycle by encouraging positive, corrective experiences.The client was taught information from Mastery of Your Anxiety and Worry—Therapist Guide (Craske, Barlow, and O'Leary) regarding the anxiety pattern.The client was taught information from the book Treating GAD (Rygh and Sanderson).The client was reinforced as he/she/they displayed a better understanding of the anxiety cycle of unwarranted fear and avoidance and how treatment breaks the cycle.The client displayed a poor understanding of the anxiety and was provided with remedial feedback in this area.

13 Discuss Target of Treatment (13)A discussion was held about how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively.The reduction of overarousal and unnecessary avoidance were emphasized as treatment targets.The client displayed a clear understanding of the target of treatment and was provided with positive feedback in this area.The client struggled to understand the target of treatment and was provided with specific examples in this area.

14 Assign Reading on Anxiety (14)The client was assigned to read psychoeducational chapters of books or treatment manuals on anxiety.The client was assigned information from Mastery of Your Anxiety and Worry—Client Manual (Zinbarg, Craske, Barlow, and O'Leary).The client was assigned to gather information from the book The Anxiety and Worry Workbook (Clark and Beck).The client has read the assigned information on anxiety and key points were reviewed.The client has not read the assigned information on anxiety and was redirected to do so.

15 Teach Calming/Relaxation/Mindfulness Skills (15)The client was taught calming, relaxation, and mindfulness skills.The client was taught techniques such as applied relaxation, progressive muscle relaxation, cue-controlled relaxation, mindful breathing, and biofeedbackThe client was taught how to discriminate better between relaxation and tension.The client was taught how to apply relaxation skills to his/her/their daily life.The client was taught relaxation skills as described in New Directions in Progressive Muscle Relaxation (Bernstein, Borkovec, and Hazlett-Stevens).The client was taught relaxation skills as described in The Relaxation and Stress Reduction Workbook (Davis et al.).The client was provided with feedback about his/her/their use of relaxation skills.

16 Assign Relaxation Homework (16)The client was assigned to do homework exercises in which he/she/they practice relaxation on a daily basis.The client was assigned “Deep Breathing Exercise” in the Adult Psychotherapy Homework Planner (Jongsma).The client has regularly used relaxation exercises, and the helpful benefits of these exercises were reviewed.The client has not regularly used relaxation exercises and was provided with corrective feedback in this area.The client has used some relaxation exercises but does not find these to be helpful; he/she/they were assisted in brainstorming how to modify these exercises to be more helpful.

17 Implement Worry Time (17)The client was taught to implement “worry time”—delaying the worry about various environmental settings until a designated “worry time.”The rationale for using a “worry time” was explained, focusing on trying to limit the association between various environmental settings and the experience of worry.The client and therapist agreed upon a specific “worry time” and the client was urged to implement this process.

18 Teach Techniques to Postpone Until Worry Time (18)The client was taught how to recognize, stop, and postpone worry until the agreed upon worry time.Skills were taught to the client, including thought stopping, relaxation, and redirection of attention.The “Making Use of the Thought-Stopping Technique” exercise from the Adult Psychotherapy Homework Planner (Jongsma) was assigned.The client was assigned the “Worry Time” homework exercise from the Adult Psychotherapy Homework Planner (Jongsma).The client was encouraged to use the techniques in his/her/their daily life.The client's use of recognizing, stopping, and postponing worry techniques was reviewed within the session with reinforcement for success and corrective feedback toward improvement.

19 Discuss Estimation Errors (19)In today's session, examples were discussed about how unrealistic worry typically overestimates a probability of threats.The client was assigned “Past Successful Anxiety Coping” from the Adult Psychotherapy Homework Planner (Jongsma).It was noted that unrealistic worry often underestimates the client's ability to manage realistic demands.The client was assisted in identifying specific examples of how his/her/their unrealistic worry involves estimation errors.The client was reinforced for his/her/their insightful identification of unrealistic worry and inappropriate estimation.The client has struggled to identify estimation errors in regard to his/her/their unrealistic worry and was gently offered examples in this area.

20 Analyze Fears Logically (20)The client's fears were analyzed by examining the probability of his/her/their negative expectation becoming a reality, the consequences of the expectation if it occurred, his/her/their ability to control the outcome, the worst possible result if the expectation occurred, and his/her/their ability to cope if the expectation occurred.The client was assigned “Analyze the Probability of a Feared Event” from the Adult Psychotherapy Homework Planner (Jongsma).The client's ability to control the outcome of circumstances was examined, and the effectiveness of his/her/their worry on that outcome was also examined.Cognitive therapy techniques have been effective at helping the client understand his/her/their beliefs and distorted messages that produce worry and anxiety.As the client has increased his/her/their understanding of distorted, anxiety-producing cognitions, his/her/their anxiety level has been noted to be decreasing.Despite the client's increased understanding of distorted messages that produce worry and anxiety, his/her/their anxiety level has not diminished.

21 Develop Insight into Worry as Avoidance (21)The client was assisted in gaining insight into how worry is a form of avoidance of a feared problem and how it creates chronic tension.The client was reinforced for his/her/their insightful understanding about how his/her/their worry creates avoidance and tension.The client struggled to understand the nature of worry as a form of avoidance and was provided with remedial information in this area.

22 Identify Distorted Thoughts (22)The client was assisted in identifying the distorted schemas and related automatic thoughts that mediate anxiety responses.The client was assisted in challenging and changing biases.The client was reinforced as he/she/they verbalized an understanding of the cognitive beliefs and messages that mediate his/her/their anxiety responses.The client was assisted in replacing distorted messages with positive, realistic cognitions.The client failed to identify his/her/their distorted thoughts and cognitions and was gently offered examples in this area.

23 Assign Exercises on Self-Talk (23)The client was assigned homework exercises in which he/she/they identify fearful self-talk and create reality-based alternatives.The client was assigned the homework exercise “Negative Thoughts Trigger Negative Feelings” from the Adult Psychotherapy Homework Planner (Jongsma).The client's replacement of fearful self-talk with reality-based alternatives was critiqued.The client was reinforced for his/her/their successes at replacing fearful self-talk with reality-based alternatives.The client was provided with corrective feedback for his/her/their failures to replace fearful self-talk with reality-based alternatives.The client has not completed his/her/their assigned homework regarding fearful self-talk and was redirected to do so.

24 Construct Anxiety Stimuli Hierarchy (24)The client was assisted in constructing a hierarchy of anxiety-producing situations associated with two or three spheres of worry.It was difficult for the client to develop a hierarchy of stimulus situations, as the causes of his/her/their anxiety remain quite vague; he/she/they were assisted in completing the hierarchy.The client was successful at creating a focused hierarchy of specific stimulus situations that provoke anxiety in a gradually increasing manner; this hierarchy was reviewed.

25 Select Initial Exposures (25)Initial exposures were selected from the hierarchy of anxiety-producing situations, with a bias toward likelihood of being successful.A plan was developed with the client for managing the symptoms that may occur during the initial exposure.The client was assisted in rehearsing the plan for managing the exposure-related symptoms within his/her/their imagination.Positive feedback was provided for the client's helpful use of symptom management techniques.The client was redirected for ways to improve his/her/their symptom management techniques.

26 Assign Imagination Exercises (26)The client was asked to vividly imagine worst-case consequences of worries, holding them in mind until the anxiety associated with them weakens.The client was asked to imagine consequences of his/her/their worries as described in Mastery of Your Anxiety and Worry—Therapist Guide (Craske, Barlow, and O'Leary).The client was supported as he/she/they have maintained a focus on the worst-case consequences of his/her/their worry until the anxiety weakened.The client was assisted in generating reality-based alternatives to the worst-case scenarios, and these were processed within the session.

27 Conduct Exposure In Vivo (27)The client was assisted in engaging in activities usually avoided due to unrealistic worry.The client was assisted in removing any unnecessary, anxiety-driven safety behaviors as described in Mastery of Your Anxiety and Worry—Therapist Guide (Craske, Barlow, and O'Leary).The client was supported as he/she/they engaged in difficulty activities until his/her/their anxiety weakened.

28 Assign Homework on Situational Exposures (28)The client was assigned homework exercises to perform worry exposures and record his/her/their experience.The client was assigned situational exposures homework from Mastery of Your Anxiety and Worry—Client Guide (Zinbarg, Craske, Barlow, and O'Leary).The client was assigned situational exposures homework from Generalized Anxiety Disorder (Brown, O'Leary, and Barlow).The client's use of worry exposure techniques was reviewed and reinforced.The client has struggled in his/her/their implementation of worry exposure techniques and was provided with corrective feedback.The client has not attempted to use the worry exposure techniques and was redirected to do so.

29 Teach Problem-Solving Strategies (29)The client was taught a specific problem-solving strategy.The client was taught problem-solving strategies including specifically defining a problem, generating options for addressing it, implementing a plan, evaluating options, and reevaluating and refining the plan.The client was assigned the homework exercise “Applying Problem Solving to Inter- personal Conflict” from the Adult Psychotherapy Homework Planner (Jongsma).The client was provided feedback on his/her/their use of the problem-solving strategies.

30 Assign Problem-Solving Exercise (30)The client was assigned a homework exercise in which he/she/they problem-solve a current problem.The client was assigned to solve a problem as described in Mastery of Your Anxiety and Worry: Workbook (Craske and Barlow).The client was provided with feedback about his/her/their use of the problem-solving assignment.

31 Engage in Behavioral Activation (31)The client was engaged in “behavioral activation” by scheduling activities that have a high likelihood for pleasure and mastery.The client was directed to complete tasks from the “Identify and Schedule Pleasant Events” assignment from the Adult Psychotherapy Homework Planner (Jongsma).Rehearsal, role-playing, role-reversal, and other techniques were used to engage the client in behavioral activation.The client was reinforced for his/her/their success in scheduling activities that have a high likelihood for pleasure and mastery.The client has not engaged in pleasurable activities and was redirected to do so.

32 Develop Interpersonal Skills and Relationships (32)As interpersonal deficits were identified as a primary factor in the client's anxiety, he/she/they were assisted in developing new interpersonal skills and relationships.The client displayed a clear understanding of the new interpersonal skills and relationships and was reinforced for this success.The client has struggled in regard to developing new interpersonal skills and relation- ships and was redirected in this area.

33 Assign Homework on Communication Skills (33)The client was assigned a homework exercise in which he/she/they implement communication skills and training into his/her/their everyday life.The client was assigned the homework exercise “Restoring Socialization Comfort” from the Adult Psychotherapy Homework Planner (Jongsma).The client's use of homework exercises in his/her/their daily life was reviewed, with reinforcement for success and corrective feedback toward improvement.

34 Provide Psychoeducation About Acceptance Approach (34)The client was taught about acceptance of worry.The client was taught about approaches such as mindfulness, cue detection, monitoring, and decentering.The client was assigned reading from An Acceptance-based Behavioral Therapy for Generalized Anxiety Disorder (Roemer and Orsillo).The client was given supplemental material from The Mindful Way Through Anxiety (Orsillo and Roemer).The client has read the assigned information on acceptance and key points were reviewed.The client has not read the assigned information and was redirected to do so.

35 Differentiate Between Lapse and Relapse (35)A discussion was held with the client regarding the distinction between a lapse and a relapse.A lapse was associated with an initial and reversible return of symptoms, fear, or urges to avoid.A relapse was associated with the decision to return to fearful and avoidant patterns.The client was provided with support and encouragement as he/she/they displayed an understanding of the difference between a lapse and a relapse.The client struggled to understand the difference between a lapse and a relapse and was provided with remedial feedback in this area.

36 Discuss Management of Lapse Risk Situations (36)The client was assisted in identifying future situations or circumstances in which lapses could occur.The session focused on rehearsing the management of future situations or circum- stances in which lapses could occur.The client was reinforced for his/her/their appropriate use of lapse management skills.The client was redirected in regard to his/her/their poor use of lapse management skills.

37 Encourage Routine Use of Strategies (37)The client was instructed to routinely use the strategies that he/she/they have learned in therapy (e.g. cognitive restructuring, exposure).The client was urged to find ways to build his/her/their new strategies into his/her/their life as much as possible.The client was reinforced as he/she/they reported ways in which he/she/they have incorporated coping strategies into his/her/their life and routine.The client was redirected about ways to incorporate his/her/their new strategies into his/her/their routine and life.

38 Develop a “Coping Card” (38)The client was provided with a “coping card” on which specific coping strategies were listed.The client was assisted in developing his/her/their “coping card” in order to list his/her/their helpful coping strategies.The client was encouraged to use his/her/their “coping card” when struggling with anxiety-producing situations.

39 Schedule a “Maintenance” Session (39)The client was scheduled for a “maintenance” session between 1 and 3 months after therapy ends.The client was advised to contact the therapist if he/she/they need to be seen prior to the “maintenance” session.The client's “maintenance” session was held and he/she/they were reinforced for his/her/their successful implementation of therapy techniques.The client's “maintenance” session was held and he/she/they were coordinated for further treatment, as his/her/their progress has not been sustained.

40 Use Motivational Interviewing (40)Techniques from motivational interviewing were used to help the client discuss ambivalence about changing current worry patterns.The client was assisted in deciding on whether to make changes.The client was assisted in identifying willingness to take action steps toward change.

41 Utilize Paradoxical Intervention (41)A paradoxical intervention was developed with the client in which he/she/they were encouraged to experience the anxiety at specific intervals each day for a defined length of time.The client has implemented the assigned paradoxical intervention and reported that it was difficult for him/her/them to maintain the anxiety as he/she/they were eager to get on with other activities.The client has experienced, in general, a reduction of his/her/their anxiety as he/she/they have developed an insight into his/her/their ability to control it; this insight was processed.The client has not used the paradoxical intervention and was redirected to do so.

42 Assign Cost-Benefit Analysis (42)The client was asked to complete a cost-benefit analysis as found in Ten Days to Self-Esteem! (Burns) in which he/she/they were asked to list the advantages and disadvantages of maintaining the anxiety.Completing the cost-benefit analysis exercise has been noted to be beneficial to the client as he/she/they developed more insight into the impact of anxiety on his/her/their daily life.The client has not followed through on completing the cost-benefit analysis of his/her/their anxiety and was encouraged to do so.

43 Identify Unresolved Conflicts (43)The client was assisted in becoming aware of unresolved life conflicts that contribute to his/her/their persistent fears.The client was assisted in clarifying his/her/their feelings of anxiety as they relate to unresolved life conflicts.The client was assisted in identifying steps that could be taken to begin resolving issues in his/her/their life that contribute to persistent fear and worry.As the client has been helped to resolve life conflicts, his/her/their feelings of anxiety have diminished.The client did not display insight into unresolved conflicts and how they contribute to his/her/their persistent fears and was gently offered examples in this area.

44 Develop Insight into Past Traumas (44)The client's past traumatic experiences that have become triggers for anxiety were examined.The client has been assisted in developing insight into how past traumatic experiences have led to anxiety in present unrelated circumstances.The client's insights into the role of past emotional pain and present anxiety were reinforced.The development of insight regarding past traumas has resulted in a reduction in the experience of anxiety.

45 List Life Conflicts (45)The client was asked to list his/her/their important past and present life conflicts that may contribute to his/her/their feelings of worry.The client's list of life conflicts that trigger anxiety was processed.The client was assisted in clarifying the causes for his/her/their worry and to put them into better perspective.The client was unable to make a connection between life conflicts and his/her/their anxiety/worry and was gently offered examples in this area, as well as ways to put them in better perspective.

46 Reinforce Responsibility Acceptance (46)The client was supported and reinforced for following through with the work, family, and social responsibilities rather than using escape and avoidance to focus on anxiety symptoms.The client reported performing responsibilities more consistently and being less preoccupied with the worry symptoms or fear that worry symptoms might occur; his/her/their progress was highlighted.

47 Teach Sleep Hygiene (47)The client was taught about sleep hygiene practices to help reestablish a consistent sleep-wake cycle.The client was taught to implement sleep hygiene practices.The client's use of sleep hygiene practices was reviewed, reinforcing for success and providing corrective feedback toward improvement.