Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 23

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 bipolar depression 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 Mood Episodes (3)An assessment was conducted of the client's current and past mood episodes, including the features, frequency, intensity, and duration of the mood episodes.The Inventory to Diagnose Depression (Zimmerman, Coryell, Corenthal, and Wilson) was used to assess the client's current and past mood episodes.The results of the mood episode assessment reflected severe mood concerns, and this was presented to the client.The results of the mood episode assessment reflected moderate mood concerns, and this was presented to the client.The results of the mood episode assessment reflected mild mood concerns, and this was presented to the client.

4 Administer Psychological Tests for Depression (4)Psychological testing was arranged to objectively assess the client's depression and suicide risk.The Beck Depression Inventory–II was used to assess the client's depression and suicide risk.The Beck Hopelessness Scale was used to assess the client's depression and suicide risk.The Perceived Criticism Scale (Hooley and Teasdale) was used to assess the client's depression.The results of the testing indicated severe concerns related to the client's depression and suicide risk, and this was reflected to the client.The results of the testing indicated moderate concerns related to the client's depression and suicide risk, and this was reflected to the client.The results of the testing indicated mild concerns related to the client's depression and suicide risk, and this was reflected to the client.

5 Refer for Physician Assessment Regarding Etiology (5)The client was referred to a physician to rule out nonpsychiatric medical etiologies (e.g. thyroid dysregulation, sedative use) for his/her/their bipolar disorder.The client was referred to a physician to rule out substance-induced etiologies for his/her/their bipolar disorder.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 Arrange Substance Abuse Evaluation (6)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.

7 Assess Level of Insight (7)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.

8 Assess for Correlated Disorders (8)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.

9 Assess for Culturally Based Confounding Issues (9)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.

10 Assess Severity of Impairment (10)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.

11 Explore Suicide Potential (11)The client's experience of suicidal urges and his/her/their history of suicidal behavior were explored.It was noted that the client has stated that he/she/they do experience suicidal urges but feel that they are clearly under his/her/their control and that there is no risk of engagement in suicidal behavior.The client identified suicidal urges as being present but contracted to contact others if the urges became strong.Because the client's suicidal urges were assessed to be very serious, immediate referral to a more intensive supervised level of care was made.Due to the client's suicidal urges, and his/her/their unwillingness to voluntarily self-admit to a more intensive, supervised level of care, involuntary commitment procedures were begun.

12 Monitor Ongoing Suicide Potential (12)The client was asked to report any suicidal urges or increase in the strength of these urges.The client stated that suicidal urges are diminishing and that they are under his/her/their control; he/she/they were praised for this progress.The client stated that he/she/they have no longer experienced thoughts of self-harm; he/she/they will continue to be monitored.The client stated that his/her/their suicide urges are strong and present a threat; a transfer to a more supervised setting was coordinated.

13 Refer for Hospitalization (13)Because the client was judged to be harmful to self, a referral was made for immediate hospitalization.The client was resistive to hospitalization for treatment of his/her/their suicide potential, so a commitment procedure was utilized.The client cooperated with hospitalization to treat the serious suicidal urges.

14 Refer to Medication Prescriber (14)A referral to a medication prescriber was made for the purpose of evaluating the client for a prescription for psychotropic medication.The client has followed through on a referral to a physician and has been assessed for a prescription of psychotropic medication.The client has been prescribed antidepressant medication.The client has refused the prescription of psychotropic medication prescribed by the physician.

15 Monitor Medication Adherence (15)As the client has taken the antidepressant medication prescribed by his/her/their prescriber, the effectiveness and side effects of the medication were monitored.The client reported that the antidepressant medication has been beneficial in reducing sleep interference and in stabilizing mood; the benefits of this progress were reviewed.The client reported that the antidepressant medication has not been beneficial; this was relayed to the prescribing clinician.The client was assessed for side effects from his/her/their medication.The client has not consistently taken the prescribed antidepressant medication and was redirected to do so.

16 Monitor Ability to Participate in Psychotherapy (16)The client's pattern of symptom improvement was monitored, with a focus on how stable he/she/they are in regard to participation in psychotherapy.The client was judged to be significantly improved and capable of participating in psychotherapy.The client was judged to still be too depressed to allow helpful participation in psychotherapy.

17 Educate About Mood Episodes (17)A variety of modalities were used to teach the family about signs and symptoms of the client's mood episodes.The phasic relapsing nature of the client's mood episodes was emphasized.The client's mood episode concerns were normalized.The client's mood episodes were destigmatized.

18 Teach Stress Diathesis Model (18)The client was taught a stress diathesis model of bipolar disorder.The biological predisposition to mood episodes was emphasized.The client was taught about how stress can make him/her/them more vulnerable to mood episodes.The manageability of mood episodes was emphasized.The client was reinforced for his/her/their clear understanding of the stress diathesis model of bipolar disorder.The client struggled to display a clear understanding of the stress diathesis model of bipolar disorder and was provided with additional remedial information in this area.

19 Provide Rationale for Treatment (19)The client was provided with a rationale for treatment involving ongoing medication and psychosocial treatment.The focus of treatment was emphasized, including recognizing, managing, and reducing biological psychological vulnerabilities that could precipitate relapse.A discussion was held about the rationale for treatment.The client was reinforced for his/her/their understanding of the appropriate rationale for treatment.The client was redirected when he/she/they displayed a poor understanding of the rationale for treatment.

20 Educate About Medication Adherence (20)The client was educated about the importance of medication adherence.The client was taught about the risk for relapse that occurs when medication is dis- continued.The client was asked to make a commitment to prescription adherence.The client was reinforced for his/her/their understanding and commitment to prescription adherence.The client was redirected when he/she/they displayed poor understanding or commitment to prescription adherence.

21 Assess Prescription Nonadherence Factors (21)Factors that have precipitated the client's prescription nonadherence were assessed.The client was checked for specific thoughts, feelings, and stressors that might con- tribute to his/her/their prescription nonadherence.The client was assigned “Why I Dislike Taking My Medication” from the Adult Psychotherapy Homework Planner (Jongsma).A plan was developed for recognizing and addressing the factors that have precipitated the client's prescription nonadherence.

22 Coordinate Group Psychoeducational Program (22)The client was admitted to a group psychoeducational program that teaches clients the psychological, biological, and social influences in the development of bipolar disorder.The client's involvement in the group psychoeducational program focused on the biological and psychological treatment of his/her/their disorder.The client has followed through on his/her/their involvement in a group psychoeducational program and key topics were reviewed.The client has not followed through on his/her/their involvement in a group psychoeducational program and was redirected to do so.

23 Teach Illness Management Skills (23)The client was taught about illness management skills.The client was taught about identifying early warning signs, common triggers, and copying strategies.The client was taught about problem solving regarding life goals, and development of a personal care plan.The client was provided with “Early Warning Signs of Depression” and “Identifying and Handling Triggers” from the Adult Psychotherapy Homework Planner (Jongsma).

24 Conduct Family-Focused Treatment (24)The client and significant others were included in the treatment model.Family-focused treatment was used as an approach with the client and significant others as indicated in Bipolar Disorder: A Family-Focused Approach (Miklowitz and Goldstein).As family members were not available to participate in therapy, the family-focused treatment model was adapted to individual therapy.

25 Assess and Educate About Aversive Communication (25)The family was assessed for the role of aversive communication and family distress and in the risk for the client's manic relapse.The family was educated about the role of aversive communication (e.g. highly expressed emotion) in developing greater family stress and an increase in the client's risk for manic relapse.The family displayed a clear understanding of the effects of aversive communication and this was reinforced.The family was provided with remedial feedback as they did not display a clear understanding of the risk for relapse due to aversive communication.

26 Teach Communication Skills (26)Behavioral techniques were used to teach communication skills.Communication skills such as offering positive feedback, active listening, making positive requests for behavioral change, and giving negative feedback in an honest, respectful manner were taught to the client and family.Behavioral techniques were used to teach the family healthy communication skills.Education modeling, role-playing, and corrective feedback and positive reinforcement were used to teach communication skills.

27 Address Problem Solving (27)The client was asked to identify conflicts that can be addressed through problem-solving techniques.The family members were asked to give input about conflicts that could be addressed with problem-solving techniques.The client and family arrived at a list of conflicts that could be addressed with problem-solving techniques.

28 Teach Problem-Solving Skills (28)Behavioral techniques such as education, modeling, role-playing, corrective feedback, and positive reinforcement were used to teach the client and family problem-solving skills.Specific problem-solving skills were taught to the family, including defining the problem constructively and specifically, brainstorming options, evaluating options, choosing options, implementing a plan, evaluating the results, and reevaluating the plan.Family members were asked to use the problem-solving skills on specific situations.The family was reinforced for positive use of problem-solving skills.The family was redirected for failures to properly use problem-solving skills.

29 Assign Problem-Solving Homework (29)The client and family were assigned to use newly learned problem-solving skills and record their use.The client and family were assigned “Plan Before Acting” in the Adult Psychotherapy Homework Planner (Jongsma).The client and family were assigned “Problem Solving: An Alternative to Impulsive Action” in the Adult Psychotherapy Homework Planner (Jongsma).The results of the family members' use of problem-solving skills were reviewed within the session.

30 Develop Relapse Drill (30)The client and family were assisted in drawing up a “relapse drill,” detailing roles and responsibilities.Family members were asked to take responsibility for specific roles (e.g. who will call a meeting of the family to problem-solve potential relapse; who will call the physician, schedule a serum level, or contact emergency services, if needed).Obstacles to providing family support to the client's potential relapse were reviewed and problem-solved.The family was asked to make a commitment to adherence to the plan.The family was reinforced for their commitment to adherence to the plan.The family has not developed a clear commitment to the relapse prevention plan and was redirected in this area.

31 Use Cognitive Therapy Techniques (31)Cognitive therapy techniques were used to assess, challenge, and change cognitive biases that trigger his/her/their elevated or depressive mood.The client was reinforced for his/her/their greater insight into his/her/their cognitive biases.

32 Assign Homework on Cognitive Biases (32)The client was assigned homework exercises in which he/she/they identified cognitive biases in appraising self, others, and the environment.The client was assigned “Journal and Replace Self-Defeating Thoughts” in the Adult Psychotherapy Homework Planner (Jongsma).The client was assisted in reviewing his/her/their insight regarding cognitive biases, and his/her/their successes were reinforced.The client was provided with corrective feedback toward improvement of his/her/their understanding of cognitive biases and alternatives.

33 Teach Coping and Relapse Prevention Skills (33)The client was taught coping and relapse prevention skills via cognitive-behavioral techniques.The client was taught about delaying impulsive actions, structuring and scheduling daily activities, keeping a regular sleep routine, avoiding unrealistic goals striving, and using relaxation procedures.The client was taught about identifying and avoiding episode triggers.

34 Conduct Interpersonal and Social Rhythm Therapy (34)An assessment was conducted of the client's daily activities using an interview and the social rhythm metric.Information from the interview and social rhythm metric helped to conduct interpersonal and social rhythm therapy.

35 Establish Routine Daily Activities (35)The client was assisted in establishing a more routine pattern of daily activities.The client was assigned “Identify and Schedule Pleasant Activities” in the Adult Psychotherapy Homework Planner (Jongsma).The client was assisted in identifying a routine pattern of sleeping, eating, solitary and social activities, and exercise.A form was developed to help review and schedule activities.An emphasis was placed on creating a predictable rhythm for each day.

36 Teach About Sleep Hygiene Importance (36)The client was taught about the importance of good sleep hygiene.The client was assigned the “Sleep Pattern Record” from the Adult Psychotherapy Homework Planner (Jongsma).The client's sleep pattern was routinely assessed.Interventions for the client's sleep pattern were provided, as he/she/they have been noted to have a dysfunctional sleep pattern.

37 Engage in Behavioral Activation (37)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 successes 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.

38 Conduct Interpersonal Portion of Therapy (38)The interpersonal component of the interpersonal and social rhythm therapy techniques was initiated.An assessment was completed of the client's current past significant relationships, including themes related to grief, interpersonal role disputes, role transitions, and skill deficits.The client was supported as he/she/they reviewed concerns related to interpersonal relationships.

39 Use Interpersonal Therapy Techniques to Resolve Interpersonal Problems (39)Interpersonal therapy techniques were used to explore and resolve issues surrounding grief, role disputes, and role transitions.The client was provided with direction and training in regard to skill deficits.Support and strategies for resolving identified interpersonal issues were provided.

40 Establish a Rescue Protocol (40)A rescue protocol was developed, in order to identify and manage clinical deterioration.Specific factors that would trigger the rescue protocol were identified.Specific factors of the rescue protocol were developed, including medication use, sleep pattern restoration, daily routine, and conflict-free social support.The client was provided with “Keeping a Daily Rhythm” in the Adult Psychotherapy Homework Planner (Jongsma).The client and significant others were reinforced for their use of the rescue protocol.The client and significant others were redirected in regard to the use of the rescue protocol.

41 Schedule “Maintenance Sessions” (41)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.

42 Assign Reading on Bipolar Disorder (42)The client was assigned to read a book on bipolar disorder.The client was assigned to read The Bipolar Disorder Survival Guide (Miklowitz).The client was assigned to read The Bipolar Disorder Workbook (Forester and Gregory).The client was assigned to read Bipolar 101 (White and Preston).The client has read the assigned information on bipolar disorder and key concepts were reviewed.The client has not read the assigned information on bipolar disorder and was redirected to do so.

43 Pledge Support (43)The client was reassured on a regular basis that the therapist would be available to consistently listen to and support him/her/them.The client reacted favorably to the therapist's pledge of support and has begun to show trust in the relationship by sharing thoughts and feelings.

44 Explore Abandonment Fears (44)The client's fear of abandonment by sources of love and nurturance was explored.Active listening skills were used as the client confirmed that he/she/they struggle with the fear that those who have provided love and nurturance to him/her/them will eventually abandon him/her/them.The client denied any fear of abandonment by sources of love and nurturance; he/she/they were urged to monitor this on an as-needed basis.

45 Differentiate Losses (45)The client was helped to differentiate between real and imagined, as well as actual and exaggerated, losses.The client was supported as he/she/they verbalized grief, fear, and anger regarding real or imagined losses in life.The client was helped to make a differentiation between his/her/their real and imagined losses, rejections, and abandonment.The client was quite guarded and unrealistic about his/her/their pattern of losses and was provided with feedback in this area.

46 Probe Losses (46)Real or perceived losses in the client's life were explored.Active listening was used as the client confirmed that he/she/they have unresolved feelings regarding losses that have been experienced.It was interpreted to the client that his/her/their experience of loss has precipitated fears of abandonment in other relationships.The client denied any significant losses in his/her/their life, and this was accepted.

47 Process Losses (47)The client's experiences of loss were processed in an attempt to help him/her/them put them into proper perspective.The client was helped to identify adaptive ways to replace the losses that were experienced.The client failed to process and develops adaptive ways to replace losses that have been experienced and was gently offered examples of how to do this.

48 Explore Family-of-Origin History (48)The client was supported as he/she/they shared experiences from his/her/their family-of-origin history that have caused feelings of low self-esteem and fear of abandonment.The client was supported as he/she/they revealed experiences with critical and rejecting parents that led to feelings of low self-esteem.The client disclosed experiences of childhood abandonment by parent figures; these have been noted to lead to the fear of abandonment in current relationships.The client was quite guarded about his/her/their family-of-origin history and was urged to be more open in this area, as he/she/they feel capable of doing so.

49 Use ACT Approach (49)Acceptance and commitment therapy (ACT) was applied.The client was assisted in accepting and openly experiencing depressive thoughts and feelings, without being overly impacted by them.The client was assisted in committing his/her/their time and efforts to activities that are consistent with identified personally meaningful values.The client has engaged well in the ACT approach and applied these concepts to his/her/their symptoms and lifestyle.The client has not engaged well in the ACT approach and remedial efforts were applied.

50 Assign Positive Affirmations (50)The client was assigned to write at least one positive affirmation statement on a daily basis regarding oneself and the future.The client was assigned “Positive Self-Talk” exercise from the Adult Psychotherapy Homework Planner (Jongsma).The client has followed through on the assignment of writing positive affirmation statements and reported that he/she/they are feeling more positive about the future.The client was reinforced for making positive statements regarding oneself and his/her/their ability to cope with the stresses of life.The client has not followed through on the assignment of writing positive affirmation statements and was encouraged to do so.

51 Teach Normalization of Sadness (51)The client was taught about the variation in mood that is within the normal sphere.The client reported that he/she/they are developing an increased tolerance to mood swings and is not attributing them to significant depression; this progress was reinforced.The client is verbalizing more hopeful and positive statements regarding the future and accepting some sadness as a normal variation and feeling; the benefits of this progress were highlighted.