Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 13

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 anger 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 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 Assess Anger Dynamics (3)The client was assessed for various stimuli that have triggered anger.The client was assisted in identifying situations, people, and thoughts that have triggered anger.The client was assisted in identifying the thoughts, feelings, and actions that have characterized anger responses.

4 Administer Anger Expression Assessment Instruments (4)The client was administered psychological instruments designed to objectively assess anger traits.The client was assessed with the Anger, Irritability, and Assault Questionnaire (AIAQ).The Buss-Durkee Hostility Inventory (BDHI) was used to assess the client's anger expression.The State-Trait Anger Expression Inventory (STAXI) was used to assess the client's anger expression.Feedback was provided to the client regarding the results of the anger expression assessment.The client declined to complete the psychological instruments designed to objectively assess anger expression, and the focus of treatment was changed to this resistance.

5 Refer for Medical/Physical Examination (5)The client was referred for a complete medical/physical examination to rule out organic contributors (e.g., brain damage, tumor, elevated testosterone levels) to anger.The client has complied with the medical/physical examination and the results were shared with the client.The medical/physical examination has identified organic contributors to poor anger control and treatment was suggested.The medical/physical examiner has not identified any organic contributors to poor anger control, and this was reflected to the client.The client has not complied with the medical/physical examination to assess organic contributors and was redirected to do so.

6 Assess Level of Insight (6)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 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.

7 Assess for Correlated Disorders (7)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.

8 Assess for Culturally Based Confounding Issues (8)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 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.

9 Assess Severity of Impairment (9)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.

10 Identify Positive Consequences of Anger Management (10)The client was asked to identify the positive consequences they have experienced in managing anger.The client was assigned the homework exercise “Alternatives to Destructive Anger” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assisted in identifying positive consequences of managing anger (e.g., respect from others and self, cooperation from others, improved physical health).The client was asked to agree to learn new ways to conceptualize and manage anger.

11 List Negative Anger Impact (11)The client was assisted in listing ways that explosive expression of anger has negatively affected their life.The client was supported while identifying many negative consequences that have resulted from poor anger management.It was reflected to the client that denial about the negative impact of anger has decreased, and the client has verbalized an increased awareness of the negative impact of their behavior.The client has been guarded about identifying the negative impact of anger and was provided with specific examples of how their anger has negatively affected their life and relationships (e.g., injuring others or self, legal conflicts, loss of respect from self or others, destruction of property).

12 Use Motivational Interviewing (12)Motivational interviewing techniques were used to help the client clarify their stage of motivation to change.Motivational interviewing techniques were used to help move the client to the action stage in which they agree to learn new ways to conceptualize and manage anger.The client was assisted in identifying dissatisfaction with the status quo and the benefits of making changes.The client was assisted in identifying level of optimism for making changes.

13 Educate About Addictive Behavior to Relieve Uncomfortable Feelings (13)The client was educated about the tendency to engage in addictive behavior as a means of relieving uncomfortable feelings.The client was able to develop a list of several incidences of how addictive behavior has been used as a means of relieving uncomfortable feelings.The client reported a decrease in the use of addictive behaviors as a means of relieving uncomfortable feelings; this success was highlighted.The client reported that they have not decreased the use of addictive behaviors as a means of relieving uncomfortable feelings and was provided with additional feedback in this area.

14 Teach About High-Risk Situations (14)The client was taught about high-risk situations (e.g., negative emotions, social pressure, interpersonal conflict, strong positive emotions, testing personal control).The client was taught about how anger, as a negative emotion, places them at a higher risk for addiction.Active listening skills were used as the client acknowledged the higher risk of addictive behaviors related to negative emotions, social pressure, interpersonal conflict, positive emotions, and testing personal control.The client was supported while acknowledging how anger places them at a higher risk for addiction.The client rejected the connections between anger and higher risk of substance abuse and was provided with additional feedback.

15 Engage in New Ways to Recognize and Manage Anger (15)The client was asked to learn new ways to recognize and manage anger.The client was reinforced for their agreement to learn new ways to recognize and manage anger.The client was uncertain about committing to any change about their anger pattern and was provided with additional feedback in this area.

16 Refer for Psychopharmacological Intervention (16)The client was referred to a prescribing clinician for the purpose of evaluation for a prescription for psychotropic medication to aid in reducing tension and improving anger control.The client has followed through on the referral to a prescribing clinician 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.

17 Monitor Medication Effectiveness and Side Effects (17)As the client has taken psychotropic medication prescribed by the prescribing clinician, the effectiveness and side effects of the medication have been monitored.The client reported that the psychotropic medication has been beneficial, and this was relayed to the prescribing clinician.The client reported that the psychotropic medication has not been beneficial, and this was relayed to the prescribing clinician.The client has not consistently taken the prescribed psychotropic medication and has been redirected to do so.The client identified side effects of the psychotropic medications and was directed to consult with the prescribing clinician if the side effects persist or worsen.

18 Assign an Anger Journal (18)The client was assigned to keep a daily journal in which to document persons or situations that cause anger, irritation, and disappointment and to record the depth of anger, rating on a scale of 1 to 100.The client was assigned “Anger Journal” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client has kept a journal of anger-producing situations and this material was processed within the session.It was noted that the client has become more aware of the causes for targets of their anger, as a result of journaling these experiences on a daily basis.The client has not kept an anger journal and was redirected to do so.

19 List Targets of/Causes for Anger (19)The client was assisted in listing as many of the causes for and targets of their anger that they are aware of.The client was assigned “Is This Anger Due to Feeling Threatened?” or “Is My Anger Due to Unmet Expectations?” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client's list of targets of and causes for anger was processed in order to increase awareness of anger management issues.The client has indicated a greater sensitivity to angry feelings and the causes for them as a result of the focus on these issues.The client has not been able to develop a comprehensive list of causes for and targets of anger and was provided with tentative examples in this area.

20 Convey Model of Anger (20)The client was assisted in understanding a model of anger as involving different components that go through predictable phases.The client was taught about the different components of anger, including cognitive, physiological, affective, and behavioral components.The client was taught how to better discriminate between relaxation and tension.The client was taught about the predictable phases of anger, including demanding expectations that are not met, leading to increased arousal and anger, which lead to acting out.The client displayed a clear understanding of this model of anger and was provided with positive reinforcement.The client has struggled to understand this model of anger and was provided with remedial feedback in this area.

21 Process Anger Triggers (21)The client was assisted in processing the list of anger triggers and other relevant journal information.The client was assisted in understanding how cognitive, physiological, and effective factors interplay to produce anger.The client was reinforced for their insight into anger triggers and the cognitive, physiological, and effective factors.The client struggled to connect anger triggers with cognitive, physiological, and effective factors and was provided with remedial information in this area.

22 Discuss Rationale for Treatment (22)The client was engaged in a discussion about the rationale for treatment.Emphasis was placed on how functioning can be improved through change in various dimensions of anger management.The concept of rationale for treatment and how functioning can be improved through change in the various dimensions of anger management was revisited.

23 Assign Reading Material (23)The client was assigned to read material that educates about anger and its management.The client was directed to read Overcoming Situational and General Anger: Client Manual (Deffenbacher & McKay).The client was directed to read Of Course You're Angry (Rosselini & Worden).The client was directed to read The Anger Control Workbook (McKay & Rogers).The client was assigned to read Anger Management for Everyone (Kassinove & Tafrate).The client has read the assigned material on anger management and key concepts were reviewed.The client has not read the assigned material on anger management and was redirected to do so.

24 Teach Calming Techniques (24)The client was taught deep-muscle relaxation, rhythmic breathing, and positive imagery as ways to reduce muscle tension when feelings of anger are experienced.The client has implemented the relaxation techniques and reported decreased reactivity when experiencing anger; the benefits of these techniques were underscored.The client has not implemented the relaxation techniques and continues to feel quite stressed in the face of anger; the client was encouraged to use the techniques.

25 Explore Self-Talk (25)The client's self-talk that mediates angry feelings was explored.The client was assessed for self-talk, such as demanding expectations reflected in “should,” “must,” or “have to” statements.The client was assisted in identifying and challenging biases and in generating alternative self-talk that corrects for the biases.The client was taught about how to use correcting self-talk to facilitate a more flexible and temperate response to frustration.

26 Assign Self-Talk Homework (26)The client was assigned a homework exercise in which they identify angry self-talk and generate alternatives that help moderate angry reactions.The client was assigned the exercise “Journal and Replace Self-Defeating Thoughts” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client's use of self-talk alternatives was reviewed within the session.The client was reinforced for success in changing angry self-talk to more moderate alternatives.The client was provided with corrective feedback to help improve use of alternative self-talk to moderate angry reactions.

27 Role-Play Relaxation and Cognitive Coping (27)The client was assisted in visualizing anger-provoking scenes and then using relaxation and cognitive coping skills.The client engaged in role-plays regarding the use of relaxation and cognitive coping in anger-provoking scenes.The client was gradually moved from low to high anger-inducing scenes.The client was assigned to implement calming techniques in daily life and when facing anger-triggering situations.The client's experience of using relaxation and cognitive coping in daily life was processed, with reinforcement for success and problem-solving for obstacles identified.

28 Assign Thought-Stopping Technique (28)The client was directed to implement a thought-stopping technique on a daily basis between sessions.The client was assigned “Making Use of the Thought-Stopping Technique” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client's use of the thought-stopping technique was reviewed.The client was provided with positive feedback for helpful use of the thought-stopping technique.The client was provided with corrective feedback to help improve use of the thought-stopping technique.

29 Teach Assertive Communication (29)The client was taught assertive communication through instruction, modeling, role-playing, rehearsal, and practice.The client was referred to an assertiveness training class.The client was assigned Your Perfect Right (Alberti & Emmons) or “Assertive Communication of Anger” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client displayed increased assertiveness and was provided with positive feedback in this area.The client has not increased level of assertiveness and was provided with additional feedback in this area.

30 Teach Problem-Solving Skills (30)The client was taught problem-solving skills through the use of instruction, modeling, role-playing, rehearsal, and practice.The client was taught about defining the problem clearly, brainstorming multiple solutions, listing the pros and cons of each solution, seeking input from others, selecting and implementing a plan of action, and evaluating and readjusting the outcome.The client was assigned “Problem Solving: An Alternative to Impulsive Action” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client displayed a clear understanding of the use of the problem-solving skills and displayed this through examples.The client struggled to understand the use of problem-solving skills and was provided with remedial feedback in this area.

31 Teach Conflict Resolution Skills (31)The client was taught conflict resolution skills through instruction, modeling, role-playing, rehearsal, and practice.The client was taught about empathy and active listening.The client was taught about “I messages,” respectful communication, assertiveness without aggression, and compromise.The client was reinforced for clear understanding of the conflict resolution skills.The client displayed a poor understanding of the conflict resolution skills and was provided with remedial feedback.

32 Conduct Conjoint Session for Skill Generalizations (32)The client was asked to invite their significant other for a conjoint session.The client and significant other were seen together in order to help implement assertiveness, problem-solving, and conflict resolution skills.The client was assigned “Applying Problem-Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was reinforced for increased use of assertiveness, problem-solving, and conflict resolution skills with the significant other.The client's significant other was urged to assist the client in use of assertiveness, problem-solving, and conflict resolution skills.The client has not regularly used assertiveness, problem-solving, and conflict resolution skills with the significant other and was assisted in identifying barriers to this success.

33 Construct Strategy for Managing Anger (33)The client was assisted in constructing a client-tailored strategy for managing anger.The client was encouraged to combine somatic, cognitive, communication, problem-solving, and conflict resolution skills relevant to their needs.The client was reinforced for their comprehensive anger management strategy.The client was redirected to develop a more comprehensive anger management strategy.

34 Select Challenging Situations for Managing Anger (34)The client was provided with situations in which they may be increasingly challenged to apply new strategies for managing anger.The client was asked to identify likely upcoming challenging situations for managing anger.The client was urged to use strategies for managing anger in successively more difficult situations.

35 Consolidate Anger Management Skills (35)Techniques were used to help the client consolidate new anger management skills.Techniques such as relaxation, imagery, behavioral rehearsal, modeling, role-playing, or in vivo exposure/behavioral experiences were used to help the client consolidate the use of new anger management skills.The client's use of techniques to consolidate anger management skills was reviewed and reinforced.

36 Monitor/Decrease Outbursts (36)The client's reports of angry outbursts were monitored, toward the goal of decreasing their frequency, intensity, and duration.The client was urged to use new anger management skills to decrease the frequency, intensity, and duration of anger outbursts.The client was assigned “Alternatives to Destructive Anger” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client's progress in decreasing angry outbursts was reviewed.The client was reinforced for success at decreasing the frequency, intensity, and duration of anger outbursts.The client has not decreased the frequency, intensity, or duration of anger outbursts and corrective feedback was provided.

37 Differentiate Between Lapse and Relapse (37)A discussion was held with the client regarding the distinction between a lapse and a relapse.A lapse was associated with an initial and reversible return of angry outbursts.A relapse was associated with the decision to return to the old pattern of anger.The client was provided with support and encouragement as they displayed an understanding of the difference between a lapse and a relapse.The client struggled to understand the difference between a lapse and a relapse and was provided with remedial feedback in this area.

38 Discuss Management of Lapse Risk Situations (38)The client was assisted in identifying future situations or circumstances in which lapses could occur.The session focused on rehearsing the management of future situations or circumstances in which lapses could occur.The client was reinforced for appropriate use of lapse management skills.The client was redirected in regard to poor use of lapse management skills.

39 Encourage Routine Use of Strategies (39)The client was instructed to routinely use the strategies learned in therapy (e.g., calming adaptive self-talk, assertion, and/or conflict resolution).The client was urged to find ways to build new strategies into daily life as much as possible.The client was reinforced while reporting ways in which they have incorporated coping strategies into their life and routine.The client was redirected about ways to incorporate new strategies into their routine and life.

40 Develop a “Coping Card” (40)The client was provided with a “coping card” on which specific coping strategies were listed.The client was assisted in developing the “coping card” in order to list helpful coping strategies.The client was encouraged to use the “coping card” when struggling with anger-producing situations.

41 Schedule “Maintenance” Sessions (41)The client was assisted in scheduling “maintenance” sessions to help maintain therapeutic gains and adjust to life without angry outbursts.Positive feedback was provided to the client for maintenance of therapeutic gains.The client has displayed an increase in anger symptoms and was provided with additional relapse prevention strategies.

42 Encourage Disclosure (42)The client was encouraged to discuss anger management goals with trusted persons who are likely to support the change.The client was assisted in identifying individuals who are likely to support the change.The client has reviewed anger management goals with trusted persons and their responses were processed.The client has not discussed anger management goals and was redirected to do so.

43 Use the ACT Approach (43)The use of acceptance and commitment therapy (ACT) was applied.The client was assisted in accepting and openly experiencing angry thoughts and feelings, without being overly affected by them.The client was assisted in committing time and efforts to activities that are consistent with identified personally meaningful values.The client has engaged well with the ACT approach and applied these concepts to their symptoms and lifestyle.The client has not engaged well with the ACT approach and remedial efforts were applied.

44 Teach Mindfulness Meditation (44)The client was taught mindfulness meditation techniques to help recognize negative thought processes associated with anger.The client was taught to focus on changing their relationship with the anger-related thoughts by accepting the thoughts, images, and impulses that are reality-based while noticing, but not reacting to, nonreality-based mental phenomenon.The client was assisted in differentiating between reality-based thoughts and nonreality-based thoughts.The client has used mindfulness meditation to help overcome negative thought processes that trigger anger and was reinforced for this.The client has struggled to apply mindfulness meditation and was provided with remedial assistance in this area.

45 Assign ACT Homework (45)The client was assigned homework situations in which the client practices lessons from mindfulness meditation and ACT.The client was assisted in consolidating mindfulness meditation and ACT approaches into everyday life.

46 Assign Reading on Mindfulness and ACT (46)The client was assigned reading material consistent with mindfulness and the ACT approach to supplement work done in session.The client has read assigned material and key concepts were processed.The client has not read assigned material and was redirected to do so.

47 Identify Anger Expression Models (47)The client was assisted in identifying key figures in their life who have provided examples of how to positively or negatively express anger.The client was reinforced in identifying several key figures who have been negative role models in expressing anger explosively and destructively.The client was supported and reinforced while acknowledging that they manage anger in the same way that an explosive parent figure had done when the client was growing up.The client was encouraged to identify positive role models throughout their life whom they could respect for their management of angry feelings.The client was supported while acknowledging that others have been influential in teaching destructive patterns of anger management.The client failed to identify key figures in their life who have provided examples as to how to positively express anger and was questioned more specifically in this area.

48 Teach Anger Effects (48)The client was educated regarding the ways in which anger blocks the awareness of pain, discharges uncomfortable feelings, erases guilt, and places the blame on others for problems.The client verbalized an understanding of how anger blocks the awareness of pain, discharges uncomfortable feelings, erases guilt, and places the blame for problems on others; this insight was reinforced.The client's understanding of the effects of anger has resulted in the client demonstrating improved anger management; this progress was highlighted.The client did not accept the relationship between how anger blocks the awareness of pain, discharges uncomfortable feelings, erases guilt, and places the blame on others for problems; the client was urged to continue to consider this relationship.

49 Develop Forgiveness (49)The client was assisted in identifying whom they need to forgive.The client was educated as to the long-term process that is involved in forgiveness versus it being a magical, single event.The client was encouraged to read Forgive and Forget (Smedes) to learn more about the process of forgiveness.The client identified a list of individuals whom they need to forgive.The client was reluctant to emphasize forgiveness and was provided with additional support in this area.

50 Turn Perpetrators Over to the Higher Power (50)The client was taught about the 12-step recovery program concept of a higher power.The client was taught about the choice to turn the perpetrators of pain over to a higher power for judgment.The client indicated understanding of the concept of a higher power and using the higher power for judgment of perpetrators of pain; this insight was processed.The client rejected the idea of a higher power as a way to provide judgment for perpetrators of pain and was urged to consider this further.

51 Focus on Exercise Program (51)The client was taught the importance of regular exercise in improving anger control and reducing addictive behavior.The client was referred for assistance in developing an individually tailored exercise program that is approved by their personal physician.The client was reinforced while accepting the need for regular exercise and has developed a program of implementation.The client reported implementing an exercise program, and level of relaxation was reviewed.The client has resisted implementation of an exercise regimen and was redirected to do so.

52 Teach the Importance of a 12-Step Recovery Program (52)The client was taught the importance of actively attending a 12-step recovery program, getting a sponsor, reinforcing people around them, and sharing feelings.The client has verbalized an acceptance of the need for a 12-step recovery program, getting a sponsor, reinforcing people around them, and sharing feelings; this progress was reinforced.The client was resistive to acceptance of a 12-step recovery program, and additional examples of how helpful this can be were provided.

53 Develop 5-Year Plan (53)The client was asked to set goals for recovery from anger 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.

54 Assess Satisfaction (54)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.