Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 20

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/their ADHD 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 Conduct Psychosocial Assessment (3)A thorough psychosocial assessment was conducted, including the past and present symptoms of ADHD and their effects on educational, occupational, and social functioning.The psychosocial assessment reflects significant concerns related to ADHD, and this was communicated to the client.The psychosocial assessment reflects minimal concerns related to ADHD, and this was reflected to the client.

4 Conduct/Refer for Psychological Testing (4)The client was administered psychological testing in order to establish or rule out the presence of an ADHD problem.Psychological testing has established the presence of an ADHD problem.The psychological testing failed to confirm the presence of ADHD.The psychological testing results were processed with the client to assist him/her/them in understanding his/her/their condition and to answer any questions that he/she/they might have.The client understood the explanation of the psychological testing and has accepted the presence of an ADHD problem.The client has denied the presence of ADHD and refused to accept the confirming results of the psychological testing; he/she/they were urged to be more open about this diagnosis.

5 Refer for Physician Assessment Regarding Etiology (5)The client was referred to a physician to rule out nonpsychiatric medical etiologies for his/her/their ADHD.The client was referred to a physician to rule out substance-induced etiologies for his/her/their level of ADHD.The client has complied with the referral to a physician 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 Process Medical and Psychological Evaluation (6)Results and recommendations of the medical evaluation were processed with the client and all questions were answered.The results and recommendations of the psychological evaluation were processed with the client and all questions were answered.As a result of the physician's evaluation, the client was prescribed medication to assist in the control of ADHD symptomatology.As a result of the psychological evaluation, the client was provided with several different techniques to assist in the control of ADHD symptomatology.

7 Hold a Conjoint Session to Give Evaluation Feedback (7)A conjoint session was held with the client and his/her/their significant others in order to present the results of the psychological and medical evaluations.All questions regarding the evaluation results were processed.The client's family members were solicited for support regarding his/her/their compliance with treatment for his/her/their ADHD symptoms.The client's family members were verbally reinforced as they gave strong support to the client regarding medical and psychological treatment for his/her/their ADHD symptoms.

8 Refer for Medication Evaluation (8)The client was referred to a prescribing clinician to evaluate him/her/them for psychotropic medication to reduce symptoms of ADHD.The client has completed an evaluation by the prescribing clinician and has begun taking ADHD medications.The client has resisted the referral to a prescribing clinician and does not want to take any medication to reduce ADHD levels; his/her/their concerns were processed.

9 Monitor Medication Adherence (9)The client has begun taking medications for ADHD symptoms and the side effects and effectiveness were processed.The client has struggled to adhere to regularly taking medication for ADHD symptoms and his/her/their concerns were processed.The client has not begun taking medications for ADHD symptoms and was redirected to do so.

10 Arrange Substance Abuse Evaluation (10)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.

11 Assess Level of Insight (11)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.

12 Assess for Correlated Disorders (12)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.

13 Assess for Culturally Based Confounding Issues (13)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.

14 Assess Severity of Impairment (14)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.

15 Identify Difficult ADHD Behaviors (15)The client was assisted in identifying the specific ADHD behaviors that have caused him/her/them the most difficulty.The client was supported as he/she/they listed such things as distractibility, lack of concentration, impulsivity, restlessness, and disorganization as the most difficult for him/her/them.The client was assisted in identifying specific behaviors that will be treatment targets.The client was resistive to becoming specific about identifying ADHD behaviors that cause him/her/them the most difficulty; he/she/they were encouraged to do this as he/she/they feel capable.

16 Review Evaluation Results (16)The results of the psychological testing and physician's evaluation were reviewed again with the client in order to assist him/her/them in the choice of his/her/their most difficult, problematic behaviors to address in counseling.The client was assisted in selecting those behaviors that are most difficult as focal points for treatment.The client was supported as he/she/they agreed to concentrate his/her/their efforts to change on these most difficult behavior areas.

17 Direct Family to Rank Client's Behaviors (17)The client was asked to request family members to complete a ranking of the three behaviors that they perceive as those that interfere the most with the client's daily functioning.Family members have ranked the client's behavior and have identified those three behaviors that they perceive to be the most problematic for the client; these were processed with the client.It was noted that the client's family has refused to cooperate with ranking his/her/their behaviors and would not provide such a list for him/her/them.The client has failed to ask for the family's participation in his/her/their treatment and has not asked them to rank his/her/their problematic behaviors; he/she/they were asked to get this feedback.

18 List Negative ADHD Consequences (18)The client was asked to make a list of the negative consequences that result from his/her/their problematic ADHD behaviors.The client was assigned “Impulsive Behavior Journal” in the Adult Psychotherapy Homework Planner (Jongsma).The list of the negative consequences that result from ADHD behaviors was processed to increase the client's awareness of the impact of his/her/their behavior on self and others.Coping strategies were reviewed that could be implemented as alternatives to the problematic ADHD behaviors that produce negative consequences.The client was guarded about making a list of the negative consequences that result from his/her/their problematic ADHD behaviors and was gently offered examples in this area.

19 Engage Significant Other (19)The client was directed to invite a significant other to participate in the therapy.The significant other was trained to help support the change and reduce friction in the relationship introduced by the ADHD.It was reflected that the significant other has been helpful in supporting the client's changes and reducing friction in the relationship.The significant other has struggled to be helpful to the client's change process and was provided with remedial feedback in this area.

20 Train the Coach in HOPE Technique (20)The person selected by the client to act as his/her/their coach was trained in the Help, Obligations, Plans, and Encouragement (HOPE) technique as described in the book Driven to Distraction (Hallowell and Ratey).The coach was trained in how to assist the client with Help, Obligations, Plans, and Encouragement as part of the HOPE procedure.The coach technique has been implemented and the client reported that it has been helpful in increasing his/her/their organization and task focus.The client and the coach have failed to implement the HOPE technique, and the client was encouraged to initiate this procedure.

21 Educate About Symptoms of ADHD (21)The client was taught about the signs and symptoms of ADHD.Emphasis was placed on how symptoms of ADHD disrupt functioning through the influence of distractibility, poor planning and organization, maladaptive thinking, frustration, impulsivity, and procrastination.The client was reinforced for his/her/their clear understanding of the signs and symptoms of ADHD.The client has struggled with understanding the signs and symptoms of his/her/their ADHD and was provided with remedial feedback in this area.

22 Discuss Rationale for Treatment (22)A rationale for treatment was discussed where the focus will be on improvement in organizational and planning skills, management of distractibility, cognitive restructuring, and overcoming procrastination.The client had a clear understanding of the rationale for treatment, and this was reinforced.The client seemed to struggle with understanding the rationale for treatment and was provided with additional information in this area.

23 Assign Books on ADHD (23)The client was referred to specific reading material designed to increase his/her/their knowledge about ADHD.The client was assigned Mastery of Your Adult ADHD—Client Workbook (Safren et al.).The client was assigned The Attention-Deficit Disorder in Adults Workbook (Weis).The client has followed through on reading the recommended books, and key concepts were processed within the session.The client has not followed through on reading the assigned material on ADHD and was encouraged to do so.

24 Assign Self-Help Readings on ADHD (24)The client was assigned self-help reading to facilitate his/her/their understanding of ADHD.The client was assigned Driven to Distraction (Hallowell and Ratey).The client was assigned Hyperactive Child, Adolescent, and Adult (Wonder).The client was assigned to read Putting on the Brakes (Quinn and Stern).The client was assigned to read You Mean I'm Not Lazy, Stupid, or Crazy!? (Kelly and Ramundo).The client was assisted in processing the material that he/she/they have read.The client was not read the assigned information on ADHD and was redirected to do so.

25 Teach Organization and Planning Skills (25)The client was taught organizational and planning skills.The client was taught about tasks such as using a calendar and a daily task list.The client was reinforced for his/her/their regular use of organizational and planning tools.The client has not used the organizational planning techniques and was redirected to do so.

26 Develop Document Management System (26)The client was assisted in developing a procedure for classifying and managing mail and other papers.The client was taught about taking care of mail and other important document tasks in the least amount of steps.The client was taught to organize his/her/their mail and documents in one place.

27 Teach Problem-Solving Skills (27)The client was taught problem-solving skills that involve identifying the problem, brainstorming solutions, evaluating options, implementing action, and evaluating results.The client was reinforced as he/she/they verbalized an understanding of the problem-solving skill techniques.Role-playing was used to help the client apply problem-solving techniques to daily problems in his/her/their life.The client has not internalized the problem-solving skills and was provided with remedial assistance in this area.

28 Assign Problem-Solving Homework (28)The client was assigned the homework of applying the problem-solving techniques previously learned to specific, identified ADHD behaviors.The client was assigned “Problem-Solving: An Alternative to Impulsive Action” in the Adult Psychotherapy Homework Planner (Jongsma).The client has followed through with the problem-solving homework and the results of that effort were processed.The client reported success at implementing the problem-solving techniques and he/she/they were reinforced for this success.The client has had difficulty applying problem-solving techniques and he/she/they were redirected regarding implementation of these techniques.

29 Assess Typical Attention Span (29)The client's typical attention span was assessed by having him/her/them do a few “boring” tasks.The client was asked to complete an uninteresting task until the point that they report distraction.The client's level of attention during this task was used as an approximate measure of his/her/their typical attention span.

30 Break Down Tasks (30)The client was taught about breaking down tasks into meaningful smaller units.An emphasis was placed on being able to complete small tasks without being distracted, based on his/her/their demonstrated attention span.The client was reinforced for breaking down tasks into meaningful smaller units.The client has struggled to apply the use of the smaller tasks technique and was pro- vided with additional examples in this area.

31 Teach Use of Timers (31)The client was taught to use timers or other cues to remind him/her/them to stop a task before he/she/they get distracted.The client was taught about reducing the time that he/she/they may be distracted and off task through the use of timers.The client was taught the regular use of timers and other cues to remind him/her/them to stop a task before he/she/they get distracted.The client has failed to regularly use the timer technique, and was redirected to do so.

32 Teach Stimulus Control Techniques (32)The client was taught techniques that use external structure such as lists, files, and daily rituals to improve on-task behavior.The client was taught to remove distracting stimuli from his environment when per- forming a task requiring focus.The client was urged to self-reward for successful focus and follow through with on-task behavior.The client followed through with implementing techniques to increase on-task behavior and he/she/they were reinforced for doing so.The client did not follow through with implementing on-task behavior and was encouraged to do so.

33 Modify Maladaptive Self-Talk (33)The client was taught about using cognitive therapy techniques to help identify maladaptive self-talk.The client was assisted in challenging biases and generating alternatives to his/her/their maladaptive self-talk.The client struggled to identify maladaptive self-talk and was provided with specific examples (e.g. “I must do this perfectly,” “I can do this later,” “I can't organize all these things”).

34 Discuss Metacognitive Therapy Approach (34)The client was taught about using a metacognitive approach to examine his/her thinking.The client was assisted in developing a more adaptive plan based on new, less-threatening metacognitive appraisals.The client was provided with positive reinforcement for his/her use of a metacognitive approach to examining his/her thinking.The client was provided with corrective feedback toward improving his/her ability to examine thinking.

35 Assign New Cognitive Appraisal Homework (35)The client was assigned to implement new cognitive appraisal skills while doing tasks in which maladaptive thinking has occurred previously.The client was assisted in reviewing his/her/their use of new cognitive appraisal skills in his/her/their real-life situations.The client was provided with positive reinforcement for his/her/their use of cognitive appraisal skills.The client was provided with corrective feedback toward improving his/her/their cognitive appraisal skills.

36 Discuss Procrastination (36)The client was assisted in identifying both the positive and negative effects of procrastinating.The client was assisted in moving toward the goal of being more engaged and staying focused.The client was reinforced for identifying the positives and negatives associated with procrastination.

37 Apply Problem-Solving Skills to Procrastination (37)The client was taught about applying new problem-solving skills to planning as a first step in overcoming procrastination.The client was taught that for each plan, he/she/they must break it down into manageable, time-limited steps to reduce the influence of distractibility.

38 Apply Cognitive Restructuring Skills to Procrastination (38)The client was taught to apply new cognitive restructuring to challenge thoughts that encourage the use of procrastination.The client was encouraged to embrace thoughts that encourage action.The client was provided with examples of cognitive restructuring to change thoughts from procrastination to action (e.g. “I can do this later” becomes “I am going to do this right away”).

39 Assign Homework on Procrastination (39)The client was assigned homework to accomplish identified tasks without procrastination.The client was assigned “Self-Monitoring Self-Reward Program” in the Adult Psychotherapy Homework Planner (Jongsma) to assist in reducing procrastination.The client was urged to use techniques learned in therapy to address procrastination.The client's use of new techniques was reviewed, with encouragement for successes and corrective feedback toward improving the skill and decreasing procrastination.

40 Teach Self-Control Strategies (40)The client was taught the self-control strategy of “stop, listen, think, and act” to assist him/her/them in curbing impulsive behavior.The client was taught problem-solving self-talk as a means of reducing impulsivity.Role-playing was used to help the client apply self-control strategies to daily life situations that are affected by his/her/their ADHD symptoms.The client reported success at applying self-control strategies and indicated that his/her/their impulsivity has been diminished; this progress was reinforced.The client has not learned the self-control strategies and was provided with remedial feedback in this area.

41 Select Situations to Apply Skills (41)The client was directed to identify situations in which he/she/they will be challenged to apply his/her/their new strategies for managing ADHD.The client was urged to start the application of new strategies with a situation that was highly likely to be successful.The client was assisted in identifying a hierarchy of gradually more challenging situations to apply his/her/their new techniques.

42 Consolidate New Skills (42)The client was assisted in consolidating the use of his/her/their new ADHD management skills.Techniques such as imagery were used to help the client consolidate his/her/their new ADHD management skills.Techniques such as behavioral rehearsal, modeling, role-playing, and in vivo expo- sure/behavioral experiments were introduced to help the client consolidate the use of his/her/their new ADHD management skills.

43 Teach Relaxation Techniques (43)The client was taught various relaxation techniques including deep muscle relaxation, rhythmic breathing, meditation, and guided imagery to be used when stress levels increase.The client was advised to use techniques from The Relaxation and Stress Reduction Workbook (Davis et al.).The client was advised to use techniques from “Deep Breathing Exercise” in the Adult Psychotherapy Homework Planner (Jongsma).It was noted that the client has implemented relaxation procedures to reduce tension and physical restlessness and reported that this technique is beneficial.The client has not followed through on implementation of relaxation techniques to reduce restlessness and tension and was encouraged to do so.

44 Review Symptoms and Fixes (44)The client was assisted in reviewing the symptoms that have been problematic and the newly learned coping skills that he/she/they will use to manage the symptoms.The client was assigned “Symptoms and Fixes for ADHD” in the Adult Psychotherapy Homework Planner (Jongsma).

45 Teach Mindful Meditation (45)The client was explained the rational for mindful meditation to enhance attention regulation.The client was taught the skills of mindful meditation.The client was asked to apply mindful meditation to tasks that require attentional focus.Positive feedback was provided as the client reported that he/she was able to use mindful meditation during tasks.The client reported difficulties with applying mindful meditation with appropriate tasks and was provided with remedial feedback in this area.

46 Refer to ADHD Group (46)The client was referred to group therapy for adults with ADHD to help increase his/her/their understanding of ADHD, boost self-esteem, and to receive feedback from others.It was noted that the client has followed through on attendance at the ADHD group therapy sessions and reported that they have been beneficial.The client has not followed through on consistent attendance at the ADHD group therapy sessions and was encouraged to do so.

47 Teach Listening Skills (47)Role-playing and modeling were used to teach the client how to listen to others and to accept their feedback regarding his/her/their behavior.Positive feedback was provided as the client reported that, on several occasions, he/she/they were able to use the new listening skills to accept direction and feedback from others.The client continued to report difficulties with listening as he/she/they become defensive whenever feedback or direction is given to him/her/them and he/she/they were provided with remedial feedback in this area.