Читать книгу The Adult Psychotherapy Progress Notes Planner - Berghuis David J., Arthur E. Jongsma Jr., David J. Berghuis - Страница 32

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 childhood trauma.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 Develop Family Symptom Line (3)A genogram was developed for the client's family, along with a list of symptoms and characteristics of each family member.As the client described what it was like to grow up in his/her/their home, he/she/they were helped to describe the dysfunction present within each family member that contributed to the chaotic atmosphere of abuse and neglect.Active listening was used as the client described his/her/their feelings toward each family member as they were experienced in the past and in the present.The client was resistive to describing the dysfunction of each family member and became defensive out of a sense of loyalty to them; this defensiveness was reflected to him/her/them.

4 Explore Dissociative Experiences (4)The client's history of experiencing dissociative phenomena to protect oneself from the pain of childhood abusive experiences was explored.The client was assisted in understanding the role of dissociation in protecting oneself from emotional pain.The client reported the experience of dissociative phenomena to such an extent that this problem was made a focus of treatment.The client denied that there was any significant and consistent pattern of dissociative experiences; he/she/they were reminded to be vigilant for these symptoms.

5 Assess Dissociation Severity (5)The severity of the client's dissociative phenomena was assessed.Because the client's dissociative phenomena were significantly severe, hospitalization was recommended to stabilize his/her/their condition.The client's dissociative phenomena were not found to be severe or persistent.

6 Assess Substance Abuse (6)A complete drug and alcohol history of the client was gathered to assess whether substance abuse has been a means of coping with feelings regarding the childhood trauma.Chemical dependence was found within the client's behavior pattern and referral to substance abuse treatment was made.The assessment of the client's substance abuse determined that there is not a chemical dependence problem.The client acknowledged that he/she/they have abused substances as a means of coping with the pain resulting from childhood abuse and neglect, and the focus of treatment was modified to cover this issue.

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.

11 Clarify Family Role (11)The client was assisted in clarifying his/her/their role within the family and the feelings associated with that role assignment.It was noted that the client clearly understood the role that he/she/they played within the family and how that contributed to the dynamics of dysfunction.Active listening was provided as the client verbalized an understanding of how his/her/their role within the family as a child has had an impact on his/her/their current feelings toward self and others.The client failed to display an understanding of his/her/their role in the family and was gently offered examples in this area.

12 Research Family Dysfunction (12)The client was assigned to ask his/her/their parents about their family backgrounds and develop insight into patterns of behavior and causes for his/her/their parents' dysfunction.The client has identified patterns of abuse, neglect, and abandonment within the parents' families-of-origin and within the extended family also; these patterns were processed.The client was reinforced as he/she/they verbalized a recognition that his/her/their parents have followed a pattern that has been long established within the family of abuse and neglect of the children.Recognizing that his/her/their parents were following an extended family pattern of abuse and neglect has been noted to help the client begin the process of forgiving them.Recognition of the extended family pattern of abuse and neglect has been noted to alert the client to be vigilant against continuing this cycle of abuse and neglect within his/her/their own family.

13 Explore Childhood Experiences (13)The client's painful childhood experiences were explored.The client was assigned “Share the Painful Memory” in the Adult Psychotherapy Homework Planner (Jongsma).Active listening was used as the client explained what it was like to grow up in the home environment, focusing on the abusive/neglectful experiences that he/she/they endured.The client has begun to open up about his/her/their childhood experiences but still remains rather guarded; he/she/they were urged to continue this progress.The client described, in detail, the facts and feelings associated with his/her/their painful childhood experiences; he/she/they were supported through these difficult disclosures.

14 Encourage Feelings Expression (14)The client was supported and encouraged when he/she/they began to express feelings of rage, fear, and rejection relating to family abuse or neglect.The client was supported as he/she/they have continued to clarify his/her/their understanding of feelings associated with major traumatic incidents in childhood.As the client has clarified his/her/their feelings and shared them within the session, his/her/their feelings of emotional turmoil have diminished.The client continues to be very guarded about his/her/their feelings of rage, fear, and rejection related to the family abuse or neglect and was encouraged to get in touch with these feelings as he/she/they are capable of doing so.

15 Assign Feelings Journal (15)The client was assigned to record his/her/their feelings in a journal that describes memories, behavior, and emotions tied to traumatic childhood experiences.The client was assigned “How the Trauma Affects Me” from the Adult Psychotherapy Homework Planner (Jongsma).The client has followed through on the journaling assignment and has developed an increased awareness of the impact that his/her/their childhood experiences have had on present feelings and behaviors; this progress was reviewed.The client was assisted in identifying how his/her/their childhood experiences have influenced how he/she/they parent his/her/their own children today.The client has not completed the assigned feelings journal and was redirected to do so.

16 Assign Books on Childhood Trauma (16)Reading materials relating to traumatic childhood experiences were recommended to the client to assist him/her/them in developing insight.The client was advised to read It Will Never Happen to Me (Black), Outgrowing the Pain (Gil), or Healing the Child Within (Whitfield).The client has followed through on reading the recommended childhood trauma material, and insights related to that reading were processed.The client has not followed through on reading the recommended material and was redirected to do so.

17 Explore Client's Parenting (17)The client was assisted in comparing his/her/their own parenting behavior to that of parental figures of his/her/their childhood.The client's understanding of how his/her/their own parenting patterns have been influenced by the negative patterns of his/her/their own parents was processed.The client was resistive to drawing any parallels between his/her/their own parenting style and that of his/her/their abusive and neglectful parents; these parallels were offered in a tentative manner.

18 Refer for Dialectical Behavioral Therapy (DBT) (18)The client was identified as experiencing distress or disability due to borderline personality disorder concerns.The client was provided with DBT.The client was referred to a therapist specializing in DBT.The client was reinforced for his/her/their involvement in DBT.The client has not utilized DBT and was redirected to do so.

19 Refer for Posttraumatic Stress Disorder (PTSD) Treatment (19)The client was identified as manifesting PTSD symptoms.The client was provided with therapy for PTSD.The client was coordinated for prolonged exposure therapy.The client was coordinated for cognitive processing therapy.The client was coordinated for eye movement desensitization and reprocessing therapy.The client has followed through on treatment for PTSD and was reinforced for this.The client has not followed through on treatment for PTSD and was reminded to do so.

20 Train Relaxation Techniques (20)The client was trained in the use of deep muscle relaxation to offset tension associated with recalling trauma.The client was trained with deep breathing techniques to offset tension associated with recalling trauma.The client was assigned “Deep Breathing Exercise” from the Adult Psychotherapy Homework Planner (Jongsma).The client used relaxation techniques and was reinforced for doing so.The client struggled to use relaxation techniques and was given remedial feedback.

21 Assign Feelings Letter (21)The client was assigned the task of writing a letter to his/her/their parents regarding his/her/their feelings associated with the experience of childhood neglect or abuse.The client has followed through with writing a feelings letter to his/her/their parents regarding his/her/their childhood abuse/neglect and this letter was processed.It was reflected to the client that writing the letter regarding his/her/their childhood abuse experiences has helped him/her/them decrease feelings of shame and self-affirm as not being responsible for the abuse.The client has not followed through with writing the letter to his/her/their parents regarding the childhood abuse or neglect experiences and was redirected to do so.

22 Support Confrontation of Perpetrator (22)A conjoint session was held where the client confronted the perpetrator of his/her/their childhood abusive experiences.The client was supported in his/her/their confrontation of the perpetrator of abuse and neglect while responsibility for that neglect was placed clearly on the perpetrator.The client found it very difficult to be direct in his/her/their confrontation of the perpetrator of childhood abuse/neglect; he/she/they were urged to be more direct.The perpetrator responded with defensive statements and denial in reaction to the client's confrontation of him/her/them regarding childhood abuse and neglect; the client was supported in rejecting this blame and denial.Since the confrontation of the perpetrator, the client has reported decreased feelings of shame and more clarity regarding not being responsible for the abuse that occurred to him/her/them; the benefits of this progress were reviewed.The client has declined confrontation of the perpetrator; he/she/they were accepted for this decision and urged to consider confrontation at a later date.

23 Utilize Empty-Chair Exercise (23)The client was guided in an empty-chair exercise with the perpetrator of the abuse as the imagined person in the empty chair.The client was guided in an empty-chair exercise in which the nonperpetrating parent was imagined to be in the empty chair.The client was assisted in expressing his/her/their feelings and clarifying the impact that the childhood experiences of abuse had on him/her/them.The client was supported in confronting the nonperpetrating parent for not protecting him/her/them from the abusive experiences in childhood.The client was reinforced as he/she/they self-affirmed as not being responsible for the abuse and placed responsibility clearly on the perpetrator.

24 Reinforce Holding Perpetrator Responsible (24)Any and all statements that the client made that reflected placing blame on the perpetrators and nonprotective, nonnurturant adults for his/her/their painful childhood experiences were reinforced.The client was consistently reminded that he/she/they were not responsible for the abuse and neglect that occurred in his/her/their childhood but that it was the responsibility of his/her/their childhood parents or caretakers.The client continues to struggle with blaming self for the abusive experiences of his/her/their childhood; statements indicating self-blame were confronted and reframed.

25 Assign Forgiveness Letter (25)The client was assigned to write a letter of forgiveness to the perpetrator of the childhood hurt.The client was assigned “Feelings and Forgiveness Letter” from the Adult Psychotherapy Homework Planner (Jongsma).The client has followed through with writing his/her/their forgiveness letter to the perpetrator of the childhood hurt; as this letter was processed, he/she/they reported experiencing a sense of putting the issue in the past.The client reported that he/she/they have begun the process of forgiving the perpetrator of his/her/their childhood pain and others who may have been passive collaborators; the benefits of this progress were highlighted.The client has not followed through on writing the forgiveness letter to the perpetrator of his/her/their childhood pain and was redirected to do so.

26 Teach Forgiveness Benefits (26)The client was taught the benefits of beginning the process of forgiving those adults who perpetrated abuse and neglect on him/her/them during childhood.The client was supported as he/she/they have begun the process of forgiving the perpetrators of his/her/their childhood abuse and neglect.As the client has begun to forgive the perpetrators of his/her/their painful childhood experiences, it was noted that he/she/they have also begun to release feelings of hurt and anger and put the issue in the past.It was reflected that as the client has begun forgiveness, he/she/they have been able to experience feelings of trust in others.

27 Recommend Forgiveness Books (27)Reading books on forgiveness was recommended to the client to increase his/her/their understanding of the process and benefits of forgiveness.The client was advised to read Forgive and Forget (Smedes) or When Bad Things Happen to Good People (Kushner).The client has followed through with reading the recommended material on forgive- ness and key concepts were reviewed and processed.Since the client has read the forgiveness material, he/she/they have been able to identify the positive aspects for oneself of being able to forgive all those involved with the abuse; this insight was processed.The client has not followed through on reading the recommended material on forgiveness and was redirected to do so.

28 Explore Victim Versus Survivor (28)The client was asked to consider the positive and negative consequences of considering oneself as a victim versus being a survivor of childhood trauma.The client's understanding of the advantages of perceiving oneself as a survivor of abuse and neglect rather than a victim was processed.The client has continued to view self as a victim of painful childhood experiences and has not moved forward toward feeling empowered as a survivor; this stagnation was reflected to him/her/them.

29 Reinforce Survivor Self-Perception (29)The client was encouraged and reinforced to perceive self as a survivor rather than a victim of childhood abuse or neglect.The client was assigned “Changing from Victim to Survivor” from the Adult Psychotherapy Homework Planner (Jongsma).As the client increased his/her/their statements that reflected a self-perception of survivorship rather than victimization, strong reinforcement was given.The client has continued to make statements of being a victim rather than statements of personal empowerment that reflect survivorship; he/she/they were helped to reframe these statements into survivor statements.

30 Teach Share-Check Technique (30)The client was taught to build trust in relationships through the use of the share-check technique.The client reported that he/she/they have begun to share personal thoughts and feelings with others on a minimal basis in order to see if those feelings are dealt with respectfully and supportively; the results of this sharing were reviewed.The client expressed difficulty with building trust and intimacy with others; he/she/they were reminded to do this in small steps.The client was reinforced as he/she/they expressed insight into his/her/their difficulty with building trust as related to childhood experiences of abuse and neglect.

31 Teach Trust in Others (31)The client was encouraged and taught the advantages of treating others as trustworthy while continuing to assess their character.Positive feedback was provided as the client reported that he/she/they are beginning to increase trust and interaction with others.The client continues to struggle with issues of trust and to be withdrawn in social relationships; he/she/they were reminded to increase trust in small steps.