Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 26

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 bipolar mania 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 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 Mania Intensity (3)The client was assessed for whether he/she/they were or have been hypomanic, manic, or manic with psychotic features.The client was assessed with the Young Mania Rating Scale (Young et al.).The client was assessed with the Clinical Monitoring Form (Sachs et al.).The client was assessed to be hypomanic.The client was assessed to be manic.The client's mania was noted to be so severe as to evolve into periods of psychosis.

4 Assess Family Communication Patterns (4)Objective instruments were used to assess the family communication patterns.The level of expressed emotions within the family was specifically assessed.The Perceived Criticism Scale (Hooley and Teasdale) was used to assess family communication problems.The family was provided with feedback about their pattern of communication.The family has not been involved in the assessment of communication patterns, and the focus of treatment was diverted to this resistance.

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 history of suicidal behavior were explored.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.The client identified suicidal urges as being present but contracted to contact others if the urges became strong.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.

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 Arrange Hospitalization (13)Arrangements were made for the client to be hospitalized in a psychiatric setting based on the fact that his/her/their mania is so intense that he/she/they could be harmful to self or others or unable to care for his/her/their own basic needs.The client acknowledged the need for the recommended hospitalization and voluntarily self-admitted to the psychiatric facility.The client was not willing to voluntarily submit to hospitalization; therefore, commitment procedures were initiated.

14 Refer for Medication Evaluation (14)The client was referred for a medication evaluation to consider psychotropic medication to control the manic state.The client has followed through with the medication evaluation and pharmacotherapy has begun.The client has been resistive to cooperating with a medication evaluation and was encouraged to follow through on this recommendation.

15 Refer to Outpatient Systematic Care Team (15)The client was referred to an outpatient Systematic Care team to help manage medications and provide support services.The client has followed through with the referral to an outpatient Systematic Care team and support services have begun.The client has not engaged with the outpatient Systematic Care team and was redirected to follow through on this recommendation.

16 Monitor Medication Reaction (16)The client's reaction to the medication in terms of side effects and effectiveness were monitored.The client reported that the medication has been effective at reducing energy levels, flight of ideas, and the decreased need for sleep; he/she/they were urged to continue this medication regimen.The client has been reluctant to take the prescribed medication for his/her/their manic state, but was urged to follow through on the prescription.As the client has taken his/her/their medication, which has been successful in reducing the intensity of the mania, he/she/they have begun to feel that it is no longer necessary and have indicated a desire to stop taking it; he/she/they were urged to continue the medication as prescribed.

17 Monitor Ability to Participate in Psychotherapy (17)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 manic to allow helpful participation in psychotherapy.

18 Educate About Mood Episodes (18)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.

19 Teach Stress Diathesis Model (19)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.

20 Provide Rationale for Treatment (20)The client was provided with the rationale for treatment involving ongoing medication and psychosocial treatment.The focus of treatment was emphasized, including recognizing, managing, and reducing biological and 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.

21 Educate About Medication Adherence (21)The client was educated about the importance of medication adherence.The client was taught about the risk for relapse that occurs when medication is discontinued.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.

22 Assess Prescription Nonadherence Factors (22)Factors that have precipitated the client's prescription nonadherence were assessed.The client was checked for specific thoughts, feelings, and stressors that might contribute 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.

23 Coordinate Group Psychoeducational Program (23)The client was admitted to a group psychoeducational program that teaches clients the psychological, biological, and social influences in the development of BPD.The client's involvement in the group psychoeducational program focused on the bio- logical 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.

24 Teach Illness Management Skills (24)The client was taught about illness management skills.The client was taught about identifying early warning signs, common triggers, and coping strategies.The client was taught about problem solving regarding life goals, and development of a personal care plan.The client was assigned “Identifying and Handling Triggers” in the Adult Psychotherapy Homework Planner (Jongsma).The client was assigned “Recognizing the Negative Consequence of Impulsive Behavior” in the Adult Psychotherapy Homework Planner (Jongsma).

25 Use Cognitive Therapy Techniques (25)Cognitive therapy techniques were used to identify, challenge and, change cognitive appraisals that may trigger his/her/their elevated or depressive mood.The client was reinforced for his/her/their greater insight into his/her/their cognitive appraisals.

26 Assign Homework on Cognitive Biases (26)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.

27 Teach Coping and Relapse Prevention Skills (27)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.

28 Conduct Family-Focused Treatment (28)The client and significant others were included in the treatment model.Family-Focused Treatment was used 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.

29 Assess and Educate About Aversive Communication (29)The family was assessed for the role of aversive communication in 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 in increasing 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 under- standing of the risk for relapse due to aversive communication.

30 Teach Communication Skills (30)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, corrective feedback, and positive reinforcement were used to teach communication skills.

31 Teach Problem-Solving Skills (31)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.

32 Assign Problem-Solving Homework (32)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” or “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.The successful use of problem-solving skills by the client and family members was strongly reinforced.

33 Develop Relapse Drill (33)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.

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 “Keeping a Daily Rhythm” 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 Practices (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 Promote Behavioral Activation (37)The client was assisted in listing activities that he/she/they have previously enjoyed but not engaged in since experiencing the loss.The client was encouraged to re-engage in enjoyable activities.The client was assigned “Identify and Schedule Pleasant Activities” from the Adult Psychotherapy Homework Planner (Jongsma).The client's experience of reactivating previously enjoyed activities was processed.Care was taken to be certain not to overstimulate the client.The client was reinforced for initiating and maintaining a balanced level of activity and rest.

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.Encouragement and reinforcement were provided to the client for successful resolution of interpersonal problems.

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 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 or view material 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 place losses in perspective.The client was helped to identify adaptive ways to replace the losses that were experienced.The client failed to process and develop 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 Confront Grandiosity (49)The client's grandiosity and demandingness were gradually, but firmly, confronted.The client was assigned “What Are My Good Qualities?” from the Adult Psychotherapy Homework Planner (Jongsma).The client was assigned “Acknowledging My Strengths” from the Adult Psychotherapy Homework Planner (Jongsma).The client has become less expansive and more socially appropriate with the consistent confrontation of his/her/their grandiosity and demandingness.The client has reacted with anger and irritability when his/her/their grandiosity was confronted.