Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 29

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 borderline 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 Behavior, Affect, and Cognitions (3)The client's experience of distress and disability was assessed to identify targets of therapy.The client's pattern of behaviors (e.g. parasuicidal acts, angry outbursts, overattachment) was assessed to help identify targets for therapy.The client's affect was assessed, including emotional overreactions and painful emptiness, in regard to targets for therapy.The client's cognitions were assessed, including biases such as dichotomous thinking, overgeneralization, and catastrophizing, to assist in identifying targets for therapy.Specific targets for therapy were identified.

4 Explore Childhood Abuse/Abandonment (4)Experiences of childhood physical or emotional abuse, neglect, or abandonment were explored.As the client identified instances of abuse and neglect, the feelings surrounding these experiences were processed.The client's experiences with perceived abandonment were highlighted and related to his/her/their current fears of this experience occurring in the present.As the client's experience of abuse and abandonment in his/her/their childhood was processed, he/she/they denied any emotional impact of these experiences on self.The client denied any experience of abuse and abandonment in his/her/their childhood, and he/she/they were urged to talk about these types of concerns as he/she/they deem it necessary in the future.

5 Assess Substance Use History (5)The client's use of alcohol and other mood-altering substances was assessed.The client's use of alcohol and other mood-altering substances can be treated as a self-harm behavior.The client's use of alcohol and other mood-altering substances can be treated as an impulsive behavior.The client was referred for a more in-depth substance use assessment.

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 Refer for Medication Evaluation (11)The client was assessed in regard to the need for psychotropic medication.The client was referred to a prescriber to be evaluated for psychotropic medications to stabilize his/her/their mood.The client has cooperated with a referral to a prescriber and has attended the evaluation for psychotropic medications.The client has refused to attend an evaluation for psychotropic medications and was redirected to do so.

12 Monitor Medication Adherence (12)The client's adherence with prescribed medications was monitored and effectiveness of the medication on his/her level of functioning was noted.The client reported that the medication has been beneficial in stabilizing his/her/their mood and he/she/they were encouraged to continue its use.The client reported that the medication has not been beneficial in stabilizing his/her/their mood; this was reflected to the prescribing clinician.The client reported side effects of the medication that he/she/they found intolerable; these side effects were relayed to the prescribing clinician.

13 Monitor Misuse (13)The client was informed of the risks of misusing medications.The client reported appropriate use of medication and was encouraged to continue its use.The client reported misusing medication and was redirected; this was reflected to the prescribing clinician.

14 Orient to DBT (14)The client was oriented to dialectical behavioral therapy (DBT).The multiple facets of DBT were highlighted, including support, collaboration, mindfulness, distress tolerance, coping, and skill building.The concept of dialectics was reviewed with the client.DBT topics were explained to the client, including the emphasis on exchange and negotiation, balancing the rational and emotional, and acceptance and change strategies.Information from Cognitive-Behavioral Treatment of Borderline Personality (Linehan) was reviewed with the client.

15 Teach Biosocial View (15)The biosocial view related to borderline personality disorder was emphasized with the client.Biological and environmental vulnerabilities were explored with the client.

16 Assign Reading on Borderline Personality Disorder (16)The client was asked to read selected sections of books or manuals that reinforce therapeutic interventions.Portions of DBT Skills Training Handouts and Worksheets (Linehan) were assigned to the client.Portions of The Dialectical Behavior Therapy Skills Workbook (McKay, Wood, and Brantley) were assigned to the client.The client has read assigned information from books or manuals and key concepts were reinforced.The client has not read assigned portions of books or manuals that reinforce therapeutic interventions and was redirected to do so.

17 Solicit Agreement for DBT (17)Using commitment strategies, an agreement was solicited from the client to work collaboratively within the parameters of the DBT approach.A written agreement was developed with the client to work collaboratively within the parameters of the DBT approach.An emphasis was placed on the agreement for DBT, including the expectation to stay in therapy for a specified time, attend scheduled therapy sessions, work toward reducing suicidal behaviors, and participating in skills training.The client has agreed to work within the DBT approach to address the behavioral, emotional, and cognitive vulnerabilities targeted in treatment.The client was reinforced for his/her/their commitment to working within the DBT program.The client has not agreed to work within the DBT program, and this resistance was processed.

18 Explore Self-Harm Behavior (18)The client's history and nature of self-harm behavior were explored thoroughly.The client helped to recall a pattern of self-harm behavior that has dated back several years.The client's self-harm behavior was identified as being associated with feelings of depression, fear, and anger, as well as a lack of self-identity.

19 Assess Suicidal Behavior (19)The client's history and current status regarding suicidal gestures were assessed.The secondary gain associated with suicidal gestures was identified.Triggers for suicidal thoughts were identified and alternative responses to these trigger situations were proposed.

20 Arrange Hospitalization (20)As the client was judged to be harmful of self, arrangements were made for a voluntary psychiatric hospitalization.As the client refused a necessary psychiatric hospitalization, the proper steps to involuntary hospitalization of the client were initiated.The client has been psychiatrically hospitalized.Ongoing contact with the psychiatric hospital has been maintained in order to coordinate the most helpful treatment while in the hospital.

21 Assign Self-Monitoring Forms (21)The client was informed of the usefulness of self-monitoring forms, such as DBT Diary Cards.The client was assigned self-monitoring forms to assess self-harm risk.The client completed assigned self-monitoring forms, and these were reviewed at the start of each session.The client did not complete assigned self-monitoring forms and was redirected to do so.

22 Refer to Emergency Helpline (22)The client was provided with an emergency helpline telephone number that is available 24 hours a day.Positive feedback was provided as the client promised to utilize the emergency helpline telephone number rather than engaging in any self-harm behaviors.The client has not used the emergency helpline telephone system in place of engaging in self-harm behaviors and was reminded about this useful resource.

23 Provide Therapist Contact Information (23)The client was provided with the therapist's telephone number for phone coaching of skills learned in therapy.The client was provided with clear instructions for proper use of phone contact, including establishing limits.The client used the provided telephone number and was appropriate in his/her/their use.The client used the provided telephone number but was inappropriate in his/her/their use and was redirected in this area.The client has not used the provided telephone number and was reminded of its usefulness.

24 Elicit Contact Contract (24)An agreement was elicited from the client that he/she/they will initiate contact with the therapist or an emergency helpline if the suicidal urge becomes strong and before any self-injurious behavior is enacted.The client completed “No Self-Harm Contract” in the Adult Psychotherapy Homework Planner (Jongsma).The client was reinforced as he/she/they promised to terminate self-mutilation behavior and to contact emergency personnel if urges for such behavior arise.The client has followed through on the non-self-harm contract by contacting emergency service personnel rather than enacting any suicidal gestures or self-mutilating behavior; he/she/they were reinforced for this healthy use of support.The client's potential for suicide was consistently assessed despite the suicide prevention contract.

25 Teach Distress Tolerance Skills (25)The client was taught about how to apply DBT distress tolerance skills and chain analysis.The client was reinforced for using distress tolerance skills and chain analysis to identify and intervene to reduce self-harm and suicidal behaviors.The client struggled to understand distress tolerance skills and chain analysis and was provided with remedial information.

26 Assign Self-Monitoring Homework (26)The client was assigned self-monitoring homework (e.g. DBT Diary Card) to help guide in-session chain analysis and problem solving.The client completed self-monitoring homework, and this was reviewed.The client did not complete self-monitoring homework and was redirected to do so.

27 Resolve Therapy-Interfering Behaviors (27)The client's pattern of therapy-interfering behavior (e.g. missing appointments, lateness, noncompliance, abruptly leaving therapy) was consistently monitored.The client was confronted for his/her/their therapy-interfering behaviors.The clinician took appropriate responsibility for the clinician's own therapy-interfering behaviors.Therapy-interfering behaviors were problem-solved.

28 Use Strategies to Manage Maladaptive Behaviors, Thoughts, and Feelings (28)Validation, dialectical strategies, and cognitive-behavioral strategies were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.Therapeutic techniques as described in Dialectical Behavior Therapy in Clinical Practice (Dimeff and Koerner) were used to help the client manage his/her/their symptoms.Validation was consistently used to help the client manage, reduce, and stabilize mal- adaptive behaviors, thoughts, and feelings.Dialectical strategies, such as metaphor or devil's advocacy, were used to help the client manage, reduce, or stabilize maladaptive behaviors, biases, and feelings.Cognitive-behavioral strategies, such as cost-benefit analysis, chain analysis, and problem solving, were used to help the client manage, reduce, or stabilize his/her/their maladaptive behaviors, biases, and feelings.It was noted that the client has decreased maladaptive behaviors, maladaptive thought patterns, and maladaptive feelings.

29 Conduct Skills Training (29)Group skills training was used to teach responses to identified personal vulnerabilities and skill deficits.Individual skills training was used to teach the client responses to identified behavioral personal vulnerabilities and skill deficits.The client was taught assertiveness for use in abusive relationships.The client was taught cognitive strategies for identifying and controlling financial, sexual, and other impulsivity.The client has participated in skills training for specific behavioral problems, and the benefit of this treatment was reviewed.The client has not participated in group skills training and was redirected to do so.

30 Teach Skills for Regular Use (30)Behavioral strategies were taught to the client via instruction, modeling, and advising.Role-playing and exposure exercises were used to strengthen the client's use of behavioral strategies.The client was provided with regular homework assignments to help incorporate the behavioral strategies into his/her/their everyday life.The client was reinforced for his/her/their regular use and understanding of behavioral strategies.The client has struggled to understand the behavioral strategies and was provided with remedial information in this area.

31 Conduct Trauma Work (31)As the client's adaptive behavior patterns have been evident, work on posttraumatic sequela was initiated.The client was assisted in using his/her/their new adaptive behavior patterns and emotional regulation skills to reduce denial and increase insight into the effects of previous trauma.The client was helped to reduce maladaptive emotional and/or behavioral responses to trauma-related stimuli through the regular use of adaptive behavioral patterns and emotional skills.The client was assisted in tolerating the distress of remembering and accepting the facts of previous trauma and in reducing self-blame.The client has been noted to be successful in using his/her/their adaptive behavioral patterns and emotional regulation skills in managing the effects of previous trauma.The client has become more emotionally disregulated due to the trauma work and was redirected to use behavioral and emotional regulation skills.

32 Explore Schema and Self-Talk (32)The client was assisted in exploring how his/her/their schema and self-talk mediate his/her/their trauma-related and other fears.The client's distorted schema and self-talk were reviewed.The client was reinforced for his/her/their insight into his/her/their self-talk and schema that support his/her/their trauma-related and other fears.The client struggled to develop insight into his/her/their own self-talk and schema and was gently offered examples of these concepts.

33 Assign Exercises on Self-Talk (33)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 “Journal and Replace Self-Defeating Thoughts” from the Adult Psychotherapy Homework Planner (Jongsma).The client was directed to complete the “Daily Record of Dysfunctional Thoughts” from Cognitive-Behavioral Therapy of Depression (Beck et al.).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.

34 Reinforce Positive Self-Talk (34)The client was reinforced for implementing positive, realistic self-talk that enhances self-confidence and increases adaptive action.The client noted several instances from his/her/their daily life that reflected the implementation of positive self-talk, and these successful experiences were reinforced.

35 Develop Hierarchy of Triggers (35)The client was directed to develop a hierarchy of feared and avoided trauma-related stimuli.The client was helped to list many of the feared and avoided trauma-related stimuli.The client was assisted in developing a hierarchy of feared and avoided trauma-related stimuli.The client's journaling was used to assist in developing a hierarchy of feared and avoided trauma-related stimuli.

36 Direct Imaginal Exposure (36)Imaginal exposure was directed by having the client describe a chosen traumatic experience at an increasing, but client-chosen, level of detail.Cognitive restructuring techniques were integrated and repeated until the associated anxiety regarding childhood trauma was reduced and stabilized.The session was recorded and provided to the client to listen to between sessions.“Share the Painful Memory” from the Adult Psychotherapy Homework Planner (Jongsma) was assigned to help direct the client's imaginal exposure.Techniques from Dialectical Behavior Therapy in Clinical Practice (Linehan, Dimeff, and Koerner) were used to direct the client's imaginal exposure.The client's progress was reviewed, reinforced, and problem-solved.

37 Assign Homework on Exposure (37)The client was assigned homework exercises to perform exposure to feared stimuli and record his/her/their experience.The client was directed to listen to the taped exposure session to consolidate his/her/their skills for exposure to feared stimuli.The client was assigned situational exposures homework from Dialectical Behavior Therapy in Clinical Practice (Linehan, Dimeff, and Koerner).The client's use of exposure techniques was reviewed and reinforced.The client has struggled in his/her/their implementations of exposure techniques and was provided with corrective feedback.The client has not attempted to use the exposure techniques and was redirected to do so.

38 Treat Posttraumatic Stress Disorder (PTSD) (38)The client was identified as having a comorbid PTSD diagnosis.The client was treated with prolonged exposure therapy.The client was treated with cognitive processing therapy.The client was treated with eye movement desensitization and reprocessing (EMDR).The client's PTSD symptoms have significantly decreased, and positive reinforcement was provided for this.The client's PTSD symptoms have not significantly decreased, and additional treatment in this area was coordinated.

39 Encourage Trust in Own Evaluations (39)The client was encouraged to value, believe, and trust in his/her/their evaluations of self, others, and situations.The client was encouraged to examine situations in a nondefensive manner, independent of others' opinions.The client was encouraged to build self-reliance through trusting his/her/their own evaluations.The client was reinforced for his/her/their value, belief, and trust in his/her/their own evaluations of self, others, and situations.The client was redirected when he/she/they tended to devalue, disbelieve, and distrust his/her/their own evaluations.

40 Encourage Positive Experiences (40)The client was encouraged to facilitate his/her/their personal growth by choosing experiences that strengthen self-awareness, personal values, and appreciation of life.The client was encouraged to use spiritual practices and other relative life experiences to help increase his/her/their positive experiences.

41 Teach Problem-Solving Skills (41)The client was taught specific techniques for problem-solving.The client was taught about defining the problem; brainstorming solutions; listing pros and cons; seeking input from others; and selecting, implementing, evaluating, and readjusting actions.Role-playing and modeling were used to apply problem-solving skills.The client was assigned the homework exercise “Plan Before Acting” from the Adult Psychotherapy Homework Planner (Jongsma).The client was reinforced for his/her/their positive use of problem-solving skills.The client has struggled to use problem-solving skills and was provided with remedial feedback in this area.

42 Conduct Transference-Focused Therapy (42)Transference-focused therapy was conducted using client-therapist communications.The client was assisted in understanding split representations of self and difficulties with self-control.The client was taught about how to integrate split representations of self and develop more effective means to self-control.

43 Conduct Schema-Focused Therapy (43)Schema-focused therapy was conducted with the client.The client was assisted in learning and changing entrenched, self-defeating patterns.The client was focused on the relationship with the therapist and daily life outside of therapy.The client was assisted in exploring early developmental experience that included trauma.

44 Conduct Mentalization Therapy (44)Mentalization therapy was conducted with the client.The client was assisted in learning to interpret the actions of self and others through meaningful and understanding examination of mental states such as desires, needs, feelings, beliefs, and reasons.