Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 10

1 Build Trust and Establish Rapport (1)*Caring 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 experiences as an ACA.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 the expression of painful feelings; the client 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 Explore Feelings of Powerlessness (3)The client was probed for childhood experiences of powerlessness while growing up in an alcoholic home.The client was asked to explore similarities between feelings of childhood powerlessness and feelings when abusing chemicals.The client was assigned to complete the Step 1 exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client was assisted in comparing and contrasting adult feelings of powerlessness connected to substance abuse with historical feelings of powerlessness associated with growing up in an alcoholic home.The client was probed for childhood experiences of powerlessness but denied any concerns in this area.

4 Teach Connection Between Childhood and Addiction (4)The client was taught about the increased likelihood to repeat addictive behavior because of growing up in an addictive family.The client was taught specific syndromes of thought and behavior that often repeat from one addictive generation to another.The client was provided with specific examples of the repetition of addiction from one generation to another.The client was encouraged to identify the connection between childhood experiences and the likelihood of repeating behavior.The client denied any connection between childhood experiences and the likelihood of repeating those types of behaviors; the client was reminded to be aware of this connection.

5 Administer Assessment for ACA Traits (5)The client was administered psychological instruments designed to objectively assess the strength of traits associated with being an adult child of an alcoholic.The Children of Alcoholics Screening Test was administered to the client.The client has completed the assessment of adult-child-of-an-alcoholic traits, but minimal traits were identified; these results were reported to the client.The client has completed the assessment of adult-child-of-an-alcoholic traits, and significant traits were identified; these results were reported to the client.The client refused to participate in psychological assessment of adult-child-of-an- alcoholic traits, and the focus of treatment was turned toward this defensiveness.

6 Explore Dysfunctional Family Rules (6)The client explored the pattern of dysfunctional family rules from childhood.The client was asked to explore how dysfunctional family rules lead to chronic fear and an escape into addiction.The client was given support and affirmation regarding the chronic fear related to dysfunctional family rules.It was reflected to the client that they are continuing to exhibit emotional distress and a desire to escape into addiction.

7 Educate About ACA Rules (5)The client was taught the ACA rules for living (i.e., “don't talk, don't trust, don't feel”).The client was taught the connection between dysfunctional ACA rules and the impossibility of healthy relationships occurring.The client was reinforced for verbalizing an understanding of dysfunctional ACA rules and how these have affected relationships.The client denied any pattern of ACA rules or dysfunctional current relationships and was urged to monitor these patterns.

8 Develop Connection Between ACA Traits and Addiction (8)The client was directed to list five ways in which ACA traits have led to addiction.The client was assigned “Addressing ACA Traits in Recovery” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was assisted in identifying how their ACA traits have led to addiction.The client has displayed greater insight into the connection between their ACA traits and addiction and was reinforced for this growth.The client has not completed assignments regarding understanding codependent behaviors and was redirected to do so.

9 Identify ACA Traits (9)The client was assisted in clarifying ACA traits and the relationship between ACA traits and addiction.The client clearly understood the role that ACA traits have played within their functioning and how that has contributed to the dynamics of their addiction; this insight was reinforced.The client verbalized an understanding of ACA traits and how they have an impact on current functioning in relationships; this insight was reinforced.The client denied the connection between ACA traits and addictive behavior or relationship conflicts and was urged to monitor for this dynamic.

10 Assess Level of Insight (10)The client's level of insight toward the presenting problems was assessed.The client was assessed in regard to the syntonic vs. dystonic nature of 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.

11 Assess for Correlated Disorders (11)The client was assessed for evidence of research-based correlated disorders.The client was assessed in regard to the 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.

12 Assess for Culturally Based Confounding Issues (12)The client was assessed for age-related issues that could help to better understand their clinical presentation.The client was assessed for gender-related issues that could help to better understand 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 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 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.

13 Assess Severity of Impairment (13)The severity of the client's impairment was assessed to determine the appropriate level of care.The client was assessed in regard to impairment in social, relational, vocational, and occupational endeavors.It was reflected to the client that their impairment appears to create mild to moderate effects on the client's functioning.It was reflected to the client that 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.

14 Explore Reaction to Parent's Chemical Abuse (14)The client described experiences of parental chemical abuse and was assisted in relating how these experiences had a negative impact, including the fear of violence, abandonment, unpredictability, and embarrassment.The client was supported while expressing increased insight into how parental chemical abuse has affected their emotional functioning.The client was reinforced for beginning to identify the inappropriateness of parental abuse of chemicals.The client was noted to be in denial regarding the negative impact of parental substance abuse.

15 Probe Abandonment/Rejection Fears (15)The client was asked to identify specific childhood situations in which they experienced a fear of abandonment, mental or physical abuse, and/or feelings of rejection.Active listening skills were used as the client explained what it was like to grow up in the alcoholic home environment, focusing on situations in which fear of abandonment, mental or physical abuse, and/or feelings of rejection occurred.The client has begun to be more open about childhood experiences but was noted to remain rather guarded.The client was supported while describing, in detail, the facts and feelings associated with painful childhood experiences.The client denied any fears of abandonment, mental or physical abuse, and/or rejection, and this was accepted at face value.

16 Explore Childhood Experience's Effect on Intimate Relationships (16)The client was assisted in becoming more aware of fears of abandonment, rejection, neglect, and the assumption of the caretaker role and how these fears are connected to past experiences of being raised in an alcoholic family.The client was assisted in expressing insight into the historical and current sources of fears of abandonment, rejection, neglect, and the assumption of the caretaker role.The client was helped to identify ways in which growing up in an alcoholic family have led to detrimental intimate relationships.The client denied any connection between childhood experiences and problems in intimate relationships and was urged to monitor this area.

17 Identify Parental Role of Caretaker (17)The client was assisted in identifying ways in which the client takes on the parental role of caretaker.The client was assisted in developing a plan for meeting emotional needs without adopting the parental/caretaker role.The client was noted to have begun to reduce the adoption of the parental/caretaker role and to increase healthy relationship skills.The client denied taking on the parental role but has continued in the role of caretaker; additional feedback was provided.

18 Explore Feelings of Worthlessness and Shame (18)The client was probed to describe feelings of worthlessness/shame and level of functioning when compared with others.The client was supported while acknowledging feelings of worthlessness/shame and feeling less competent than others.The client was assisted in identifying parental substance abuse as a factor in low self-esteem issues.The client denied feelings of worthlessness or shame; this was accepted at face value.

19 Teach Low Self-Esteem Precursors (19)The client was taught about the connection between low self-esteem and how the alcoholic home causes experiences of emotional rejection, broken promises, abuse, neglect, poverty, and loss of social status.The client acknowledged a connection between low self-esteem and experiences of emotional rejection, broken promises, abuse, neglect, poverty, and loss of social status because of parental chemical dependence; this insight was reinforced.The client reported beginning to increase self-esteem by moving beyond the effects of being raised in an alcoholic home; this progress was highlighted.

20 List Positive Traits (20)The client was asked to list their positive traits and accomplishments.The client has identified several positive traits and accomplishments; these were reinforced as a foundation for building self-esteem.The client struggled to identify their own positive traits and accomplishments and was provided with tentative examples.The client was assigned “Acknowledging My Strengths” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client has not listed positive traits and accomplishments and was redirected to do so.

21 Emphasize Self-Worth (21)An emphasis was placed on the client's inherent self-worth as a human being.The connection between the client's inherent self-worth and acceptance of a higher power was emphasized.The client was reinforced as they displayed an understanding of self-worth and how this is related to the acceptance of a higher power.The client continues to display poor self-worth; positive self-worth was reemphasized.

22 Explore Family Response to Sharing Feelings (22)The client was asked to identify how the family responded to expressions of feelings, wishes, and wants.The client was assigned “Understanding Family History” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).It was noted that the client identified negative responses from family members during childhood regarding the expression of feelings.It was noted that the client identified a connection between learning in childhood that it was dangerous to share feelings with others and current problems with sharing feelings with peers.The client did not complete the assignment to help understand family history and was redirected to do so.The client denied the family's history of negative responses to sharing feelings; this was accepted.

23 Identify Trustworthiness Traits (23)The client was asked to list a set of character traits in others that qualify them as trustworthy.The client was assisted in identifying several traits that they would expect from others that would identify them as trustworthy (e.g., honesty, sensitivity, open-mindedness, kindness).The client was reinforced as they identified situations in which they saw others being trustworthy.The client was unable to list a set of character traits in others that qualify them as trustworthy and was redirected to do so.

24 Teach Honest Communication Skills (24)The client was taught that the tendency to tell others what we think they want to hear is based on fear of rejection, commonly learned in an alcoholic home.The client was provided with modeling, role playing, and behavior rehearsal to teach more honest communication skills.The client was reinforced for more honest communication in place of telling others what the client thinks they want to hear.The client struggled to understand the techniques or usefulness for honest communication skills; remedial feedback was provided in this area.

25 Assign a Journal of Honest Communication (25)The client was asked to keep a journal to record incidents in which they told the truth rather than saying only what others want to hear.The client presented a journal of situations in which they told the truth rather than saying only what others want to hear; these situations were processed.The client was reinforced in acknowledging a healthier pattern of communication through reviewing journal entries regarding honest communication rather than saying what others want to hear.The client did not journal honest communication and was redirected to do so.

26 Teach Problem-Solving Skills (26)The client was presented a specific problem-solving technique (i.e., identify the problem, brainstorm alternate solutions, examine the advantages and disadvantages of each solution, select an option, implement a course of action, evaluate the results).The client was assigned “Applying Problem-Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client and therapist role-played examples of implementing problem-solving techniques.The client was helped to recount instances of using problem-solving techniques in day-to-day situations.The client has completed the assignment regarding how to resolve interpersonal conflict, and the answers were reviewed.The client has not completed the assignments regarding applying problem-solving to personal conflict, and this resistance was processed.

27 Explore Family Response to Sharing Feelings (27)The client was asked to identify how the family responded to expressions of feelings, wishes, and wants.It was noted that the client identified negative responses from family members during childhood regarding the expression of feelings.It was noted that the client identified a connection between learning in childhood that it was dangerous to share feelings with others and current problems with sharing feelings with peers.The client did not complete the assignment to help understand family history and was redirected to do so.The client denied the family's history of negative responses to sharing feelings; this was accepted.

28 Educate About Healthy Relationships (28)The client was presented with information about building healthy interpersonal relationships through openness, respect, and honesty, including the sharing of feelings to build trust and mutual understanding.The client was assigned the honesty exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client has completed the honesty exercise and the responses were processed.The client has not completed the honesty exercise from The Alcoholism and Drug Abuse Client Workbook (Perkinson) and was redirected to do so.The client acknowledged situations in which they could increase sharing of feelings in order to build trust and mutual understanding; the client was directed to do so.The client was supported while recounting situations in which they used openness and honesty in order to increase trust and mutual understanding.

29 Explore the Client's Focus on Others (29)The client was assisted in comparing reluctance to share personal problems with their pattern of focusing on helping others with their problems.Active listening skills were used as the client expressed an understanding of how childhood experiences have prompted the client to focus on helping others as a way to resist sharing personal problems.The client struggled to identify a pattern of resistance to sharing personal problems and was provided with examples of this pattern.

30 Connect Overhelping Others With Low Self-Esteem (30)The client was presented with the concept that overemphasis on helping others is based on low self-esteem and a need for acceptance, which was learned in the alcoholic family of origin.The client was presented with the concept that caretaking behavior often results from choosing friends and partners who are chemically dependent or psychologically disturbed.The client rejected the concept that helping others is based on low self-esteem and relates to choosing friends who are chemically dependent or psychologically disturbed; the client was urged to review this pattern.The client was reinforced in accepting the concept that they have a strong need to help others because of low self-esteem.The client was able to connect caretaking behavior to the choice of friends who are chemically dependent or psychologically disturbed; this insight was reinforced.

31 Teach Recovery Group Involvement (31)The client was taught about how active involvement in a 12-step recovery group is a way to build trust in others and self-confidence.The client was referred to an appropriate 12-step recovery group.Active listening was provided as the client described involvement in an active 12-step recovery group.The client reported that they had not followed through with involvement in a 12-step recovery group and was redirected to do so.The client reported that they had not followed through with involvement in a 12-step recovery group and was instead assigned the Step 12 exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson).

32 Develop an Aftercare Plan (32)The client was assisted in developing an aftercare plan that will support recovery from ACA issues, including regular attendance at Alcoholics Anonymous/Narcotics Anonymous (AA/NA) meetings.The client's aftercare plan that will support sobriety (e.g., self-help groups and sponsors, family activities, counseling) was reviewed.The client described active pursuit of the elements of the aftercare plan.The client has not followed through on an aftercare plan and was redirected to do so.

33 List Reasons for Recovery Group Attendance (33)The client was assigned to list 10 reasons why 12-step recovery group attendance is helpful in overcoming ACA traits.The client was assisted in developing a list of 10 reasons why 12-step recovery group attendance is helpful in overcoming ACA traits.The client has not followed through in developing a list of reasons why 12-step recovery group attendance is helpful and was redirected to do so.

34 Identify ACA Traits’ Effect on Recovery Groups (34)The client was urged to identify the relationship between ACA traits and the fear of attending recovery group meetings.The client was provided with feedback about common ways in which ACA traits cause fear of attending recovery group meetings.The client was assisted in brainstorming ways to help cope with fear of attending recovery group meetings.The client was assigned “Safe and Peaceful Place Meditation” from Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma) or “Progressive Muscle Relaxation” from Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The client was taught about how to give self positive messages regarding self-worth in order to overcome the fear of attending recovery group meetings.The client was taught how to use relaxation techniques to reduce tension when attending recovery group meetings.The client was taught how to use meditation to induce calm and support from a higher power in order to be more comfortable attending recovery group meetings.The client's fear of openness with others was noted to cause them to continue to avoid recovery group meetings.

35 Teach ACA/AA/NA Group as Trust Builder (35)The client was presented with the idea that an ACA/AA/NA home recovery group can aid in building trust with others and self-confidence.The client was assisted in understanding the need to gain trust and confidence.The client was reinforced for accepting the idea that an ACA/AA/NA group can help build trust and confidence.The client was resistant to acknowledging the need for gaining trust and confidence; additional support and encouragement were provided.

36 Emphasize Family Atmosphere in Home Recovery Group (36)An emphasis was placed on the opportunity to engage in a home recovery group as a way to develop a healthy family atmosphere.The client was urged to help others in the home recovery group.The client was asked about how their self-concept is boosted through helping others in a healthy manner.

37 Teach ACA/AA/NA Group as a Promoter of Self-Worth (37)The client was presented with the idea of an ACA/AA/NA home recovery group functioning as the healthy family they never had.The client was advised about how helping others can aid in recovery and establish a feeling of worth.The client was reinforced while verbalizing acceptance of the family atmosphere in ACA/AA/NA.The client identified ways in which they specifically use the ACA/AA/NA group as a healthy family; these examples were processed.The client was resistant to acknowledging the ACA/AA/NA group as a promoter of self-worth and was urged to review this on a daily basis.

38 Teach About a Higher Power (38)The client was presented with information about how faith in a higher power can aid in recovery from ACA traits and addiction.The client was assigned the Step 2 exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client has completed the Step 2 exercise and responses were reviewed and processed.The client has not completed the Step 2 exercise from The Alcoholism and Drug Abuse Client Workbook (Perkinson) and was redirected to do so.The client was assisted in processing and clarifying ideas and feelings regarding the existence of a higher power.The client was encouraged to describe beliefs about the idea of a higher power.The client rejected the concept of a higher power but was encouraged to review this at a later time.

39 Read About Spirituality in AA's Big Book (39)The client was assigned to read about spirituality and the role of a higher power in portions of Adult Children of Alcoholics's Red Book and AA's Big Book.The client reported reading Adult Children of Alcoholics's Red Book and AA's Big Book on the topic of spirituality and the role of a higher power, and this topic was discussed.The client was helped to process the material related to spirituality from Adult Children of Alcoholics's Red Book and AA's Big Book and identified ways in which this related to their situation.The client did not read the portions of Adult Children of Alcoholics's Red Book and AA's Big Book on the topic of spirituality, and this was reassigned.

40 Identify Issues for a Higher Power (40)The client was asked to identify circumstances in their life that could benefit from being turned over to a higher power.The client was assigned “Understanding Spirituality” or “Finding a Higher Power That Makes Sense” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was assisted in identifying specific issues that need to be turned over to a higher power.The client was reinforced in identifying specific steps that they are taking to turn specific issues over to a higher power.The client denied any need for turning any issues over to a higher power and was urged to remain open to this concept.

41 Teach Assertiveness Skills (41)The client was taught assertiveness skills through the use of modeling, behavior rehearsal, and role-playing.The client was assigned the “Becoming Assertive” exercise from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client displayed an understanding of assertiveness skills that they have been taught.The client's journal of assertiveness experiences was reviewed.The client listed several different situations in which they have been able to be assertive; this success was celebrated.The client reported finding it very difficult to implement assertiveness skills, and remedial assistance was provided.

42 Teach Assertiveness Formula (42)The client was taught the “I feel … when you…. I would prefer it if…” assertiveness formula.The client and the therapist role-played several applications of the assertiveness formula in the client's life.The client was reinforced while displaying an understanding and mastery of assertiveness techniques.The client was assigned to use the assertiveness formula three times per day.The client struggled to understand the techniques and usefulness of the assertiveness formula and was provided with remedial assistance in this area.

43 Teach the Share Check Method (43)The client was taught the share check method of building trust in relationships.The therapist and client role-played several applications of the share check method in the client's life.The client was noted to have indicated a desire to increase their level of trust in others and has implemented the share check method to do so.The client continues to be distrustful of others and has not implemented the share check method to increase trust in others; the client was redirected to do so.

44 Reinforce Honest Sharing (44)The client was encouraged and reinforced to share honestly and openly with a trusted person.As the client identified situations in which they have shared honestly and openly with a trusted person, strong reinforcement was given.It was reflected that the client continues to struggle with sharing openly and honestly with a trusted person.

45 Refer for Psychopharmacological Intervention (45)A referral to a physician was made to evaluate the client for a prescription for psychotropic medication.The client has followed through on the referral to a physician and has been assessed for a prescription of psychotropic medication, but none were prescribed.The client has been prescribed psychotropic medications.The client has refused a prescription of psychotropic medication provided by the physician.

46 Administer Medications (46)The medical staff administered medications as prescribed.The medical staff assisted the client in administering their own medications.The client refused to accept medication as prescribed.

47 Monitor Medication Effectiveness and Side Effects (47)As the client has taken psychotropic medication prescribed by a physician, the effectiveness and side effects of the medication were monitored.It was noted that the client has reported that the psychotropic medication has been beneficial.The client reported that the psychotropic medication has not been beneficial; this was relayed to the prescribing clinician.The client identified side effects of the medications; this was relayed to the prescribing clinician.The client has not consistently taken the prescribed medication and has been redirected to do so.

48 Develop 5-Year Plan (48)The client was asked to set goals for recovery from ACA traits at 6 months, 12 months, and 5 years.The identification of specific steps toward recovery was emphasized.The client was assigned the “Personal Recovery Plan” exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client was unable to set goals for recovery, and roadblocks were assessed and managed.

49 Assess Satisfaction (49)A treatment satisfaction survey was administered to the client.The client's survey responses indicated a high level of satisfaction with treatment services; these results were processed.The client's survey responses indicated a medium level of satisfaction with treatment services; these results were processed.The client's survey responses indicated a low level of satisfaction with treatment services; these results were processed.Although the client was encouraged to complete a treatment satisfaction survey, it was refused.