Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 16

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 antisocial behavior 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 Identify Antisocial and Addictive Behavior as Self-Defeating (3)The client was asked to list the negative consequences that have accrued because of their antisocial behavior.The client was assigned the Step One exercise from The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client was asked to identify others who have been negatively affected by their antisocial behavior and to list the specific pain that these individuals have suffered.The client was asked to verbalize an acceptance of the powerlessness and unmanageability they have over antisocial behavior and addiction.The client was confronted with the fear, disappointment, loss of trust, and loss of respect that others experience as a consequence of self-centered behavior and lack of sensitivity.The client denied any negative or self-defeating consequences because of their antisocial/addictive behavior and was provided with tentative examples of how this occurs.The client has not completed the assigned Step One homework and was redirected to do so.

4 Recognize Reciprocity of Antisocial and Addictive Behavior (4)The client was presented with the concept of a reciprocal relationship between antisocial behavior and addiction.The client was asked to identify how substances have played a part in their choices regarding antisocial behavior.The client was asked to verbalize how antisocial behavior has encouraged their addiction.The client denied any connection between antisocial and addictive behaviors and was urged to remain open to this concept.

5 Administer Antisocial Behavior Rating Scales (5)The client was administered psychological instruments designed to objectively assess baseline levels of antisocial behavior, impulsivity, and/or aggression.The client was administered the Psychopathy Checklist–Revised (PCL-R).The client was administered the Aggressive Acts Questionnaire (AAQ).The client was administered the Barratt Impulsiveness Scale-11 (BIS-11).The client was provided feedback regarding the results of the assessment of antisocial behavior, impulsivity, and/or aggression.The client declined to participate in taking the instruments used to assess antisocial behavior, impulsivity, and/or aggression and was redirected to do so.

6 Recognize Insanity (6)The client was presented with the concept of how doing the same things over and over again but expecting different results is irrational.The client was presented with the concept that irrational behavior (e.g., doing the same thing over and over and expecting different results) is what 12-step recovery programs call insanity.The client was asked to identify their experience of insane and irrational behavior and how this concept applies to them.The client rejected the concept of their behavior being insane or irrational and was provided with remedial feedback in this area.

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 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 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.

9 Assess for Culturally Based Confounding Issues (9)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.

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 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.

11 Review the Rules and Consequences for Failure to Comply (11)The client was presented with a list of rules that must be kept by participants in the treatment program.The client was presented with a list of general societal rules/expectations.The client was presented with appropriate consequences for failing to follow the rules.The client was praised as they have been able to maintain the rules of the program.The client has failed to follow the presented rules, and appropriate consequences have been implemented.

12 Review Rule Breaking and Natural Consequences (12)The client was presented with several examples of rule/limit breaking that have led to negative consequences for self and others.The client was asked to identify several examples of rule/limit breaking that have led to negative consequences for self and others.The client was consistently reminded of the pain that others suffer as a result of their antisocial behavior.

13 Teach About Empathy (13)Role-playing and role reversal techniques were used to teach the client the value of being empathetic to the needs, rights, and feelings of others.The client was assigned “How I Have Hurt Others” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was asked to commit to acting more sensitively to the rights and feelings of others.The client has not completed the assigned “How I Have Hurt Others” homework and was redirected to do so.

14 Teach About Criminal Thinking (14)The client was taught that actions do not spontaneously occur but rather are preceded by a variety of decisions.The client was asked to review how their decisions are sometimes based in criminal thinking.The client was asked to list five times that antisocial behavior led to negative consequences and also to list the many decisions that were made along the way.The client was helped to see how many negative consequences are preceded by decisions based in criminal thinking.It was pointed out to the client that they justify their antisocial attitude as the way that they learned to live because of childhood or other socialization processes.

15 Teach About the Effects of Dishonesty (15)The client was asked to list the positive effects for others when they are honest and reliable.The client was taught that pain and disappointment result when honesty and reliability are not given the highest priority in one's life.The client was asked to identify situations in which they could be more honest and reliable.The client identified ways in which they are being more honest and reliable, and these were processed.The client was confronted for continuing to be dishonest and unreliable.

16 Connect Criminal Activity and Low Self-Esteem (16)The client was taught about how the emotional dynamics of criminal activity lead to feelings of low self-esteem.The client was asked to identify personal examples of how criminal activity has led to feelings of low self-esteem.The client displayed a clearer understanding of the connection between criminal activity and feelings of low self-esteem, and this insight was reinforced.The client had difficulty displaying an understanding of the connection between criminal activity and low self-esteem and was provided with additional information in this area.

17 Link Criminal Thinking to Antisocial Behavior and Addiction (17)The client was taught how criminal thinking (e.g., super-optimism, little empathy for others, power orientation, a sense of entitlement, self-centeredness) leads to antisocial behavior and addiction.Personal examples of how criminal thinking has led to antisocial behavior and addiction in the client's life were processed.The client denied engaging in criminal thinking leading to antisocial behavior and addiction and was provided with remedial feedback.

18 Identify How Blaming Results in Continued Mistakes (18)The client was asked to identify how blaming others results in a failure to learn from mistakes.The client was confronted with a pattern of behavior that demonstrates a failure to learn from mistakes.The client was asked to list incidents from the past that are examples of blaming others, resulting in a failure to learn from mistakes.The client was assigned “Taking Inventory of Destructive Behaviors” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).Active listening was provided as the client displayed an understanding of how blaming others results in a failure to learn from mistakes and described situations in which the client was changing that pattern.The client was confronted for continuing to blame others for their own mistakes.

19 Explore Reasons for Blaming (19)The client's history was explored, with a focus on causes for the avoidance of accepting responsibility for behavior.The client's history of physical and emotional abuse was explored, and an association with denying responsibility for behavior was made.The client's early history of lying was explored as to causes and consequences.Parental modeling of projection of responsibility for their behavior was examined.

20 Confront Projection (20)The client was consistently confronted for failing to take responsibility for their own actions and for placing the blame onto others for them.The client was assigned “Letter of Apology” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).As the client's pattern of projecting blame onto others began to weaken, the client was reinforced for taking personal responsibility for their actions.The importance of taking responsibility for one's own behavior and the positive implications for this as a way to motivate change were reviewed.

21 Teach the Difference Between Antisocial and Prosocial Behaviors (21)The specific criteria for identifying antisocial behaviors and the opposite prosocial behaviors were brainstormed with the client.A commitment to practicing prosocial behaviors was developed.The client was assigned “Benefits of Helping Others” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma) or “Three Acts of Kindness” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assisted in developing a list of prosocial behaviors (e.g., helping others) to practice each day.The client was helped to identify several instances in which they have been practicing prosocial behaviors.The client was confronted for persisting in antisocial behaviors.

22 Confront Disrespect (22)The client was confronted consistently and firmly when exhibiting an attitude of disrespect for the rights and feelings of others.It was firmly and consistently emphasized to the client that others have a right to boundaries, privacy, and respect for their feelings and property.Thoughtful attitudes and beliefs about the welfare of others, as well as respect for others, were modeled for the client.

23 List Typical Antisocial Thoughts and Alternative Thoughts (23)The client was assisted in identifying their typical antisocial thoughts.Positive feedback was provided as the client listed typical antisocial thoughts, as well as alternative, respectful, trusting, empathic, and prosocial thoughts.The client identified success in using alternate, respectful, trusting, empathic thoughts to replace antisocial thoughts; this progress was highlighted.The client acknowledged an ongoing pattern of antisocial thoughts, and a lack of the use of alternate, more prosocial thoughts; additional alternatives were provided.

24 Teach Recovery Group Involvement (24)The client was taught about how active involvement in a recovery group is a way to build trust in and respect for others as well as to develop self-confidence.The client was provided with examples of how recovery groups provide emotional support, social relationships, and guidance, as well as relieve anxiety and reinforce self-worth.The client was assigned the Step 3 exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client was referred to an appropriate recovery group.The client's involvement in an active recovery group was reinforced.The client acknowledged that they had not followed through with involvement in the recovery group and was redirected to do so.The client has not completed the assigned Step 3 homework and was redirected to do so.

25 Confront Rule Breaking (25)The client was firmly and consistently confronted when they broke the rules, blamed others, or made excuses.As the client's pattern of breaking rules, blaming others, or making excuses weakened, the client was reinforced for taking personal responsibility for their own behavior.The client maintained a pattern of breaking rules, blaming others, and making excuses and was redirected in this area.

26 Address Legal Problems (26)The client was supported, encouraged, and reinforced in addressing legal problems that have resulted from irresponsible behavior.The client was assigned “Accept Responsibility for Illegal Behavior” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce) or “What's Addiction Got to Do with My Problems” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).It was reflected that the client has taken increased responsibility in addressing legal problems honestly and directly.The client was confronted for continuing an inappropriate pattern of trying to escape the legal effects of their behavior.

27 Teach About Helping Others via Recovery Groups (27)The client was taught how helping others at recovery groups can increase empathy and build mutual trust and respect.The client reported attending a recovery group, situations in which they have been able to help others, and the positive effects they have had; these were reviewed.The client acknowledged a lack of recovery group attendance and failure to help others and was redirected to do so.

28 Practice Encouraging Others (28)Modeling, role-playing, and behavior rehearsal were used to practice with the client how to encourage others in recovery.The client was assigned “Benefits of Helping Others” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client's positive experiences with encouraging others in recovery were reviewed.The client acknowledged that they had not used techniques to encourage others in recovery and was redirected to do so.

29 List the Value of Trust in Others (29)The client was asked to list the benefits of trusting others and how these are important basic elements for any human relationship.The client was taught the absolute necessity of trust in others as an example of the different forms of relationships that are based in trust and honesty.The client was asked to list the positive effects for others when the client is trusting in others.The client rejected the concept of positive benefits of trusting others and has not focused in this area; the client was redirected to do so.

30 Identify Prosocial Replacement Behaviors (30)The client was assisted in identifying the benefits sought from their addictive behavior (i.e., affiliation with others or emotional balance).The client was reinforced that the goals that they were pursuing with addictive behavior were natural goals but were being met in unhealthy and counterproductive ways.The client was assisted in developing alternative ways to meet goals.The client was assigned the exercise “Alternatives to Addictive Behavior” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).

31 Confront Denial of Responsibility (31)The client was firmly and consistently confronted when attempting to deny responsibility for self-centered and impulsive behaviors.The client was directed to identify how their behavior discouraged others from placing trust in them.Positive reinforcement was provided as the client reported an understanding of how denial of responsibility has invoked the lack of trust from others.The client was assigned “Letter of Apology” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).It was noted that the client has made a commitment to accept responsibility for their own behavior, in order to increase others' trust in them.The client denied having any irresponsible, self-centered, or impulsive behaviors and was urged to monitor this dynamic.The client has not completed the assigned “Letter of Apology” homework and was redirected to do so.

32 Emphasize Keeping Commitments (32)The importance of keeping commitments and promises to others and finding ways to prove oneself as trustworthy in relationships were discussed with the client.The client was assisted in endorsing several ways in which they have attempted to prove trustworthy in relationships.The client reported a significant increase in keeping commitments, as well as other ways of proving trustworthy in relationships; this progress was highlighted.The client acknowledged an ongoing pattern of failure in keeping commitments and a continuing lack of trustworthiness in relationships; the client was urged to make some commitments in this area.

33 Establish Sponsor Relationship (33)The client was introduced to a 12-step recovery group sponsor.The client was encouraged to ask a stable person in recovery to be their sponsor.The client was taught about the many ways in which a sponsor can be helpful in recovery.The client has not asked someone to be their sponsor and was redirected to do so.

34 Develop an Aftercare Plan (34)The client was assisted in developing an aftercare plan, including regular attendance at Alcoholics Anonymous/Narcotics Anonymous (AA/NA) meetings, which will support recovery from antisocial issues.The client was assisted in listing several components of an aftercare plan that will support their sobriety (e.g., self-help groups and a sponsor, family activities, counseling with a specific psychotherapist).The client was assigned “Aftercare Plan Components” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce) or “Taking Daily Inventory” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was reinforced while describing active pursuit of the elements of the aftercare plan.The client has not followed through on the aftercare plan and was redirected to do so.The client has not completed the assigned “Taking Daily Inventory” homework and was redirected to do so.

35 Teach the Family About Criminal Thinking (35)Family members were taught about criminal thinking, and the client was assisted in identifying how this occurs for them.The client and family members were assigned “Crooked Thinking Leads to Crooked Behavior” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).Family members reported an understanding of what they were taught about how criminal thinking occurs for the client.Family members were taught about how to correct the client's inaccurate thoughts.Family members were reinforced for a willingness to confront and correct the client's inaccurate thoughts.

36 Encourage Family Recovery (36)The client's family members were encouraged to each work out their own program of recovery.The client's family members were encouraged as they reported an ongoing pattern of using their own program of recovery.Family members were taught the need to overcome the denial of and making excuses for the client's antisocial behavior.As the client has improved, the family has identified a decrease in reinforcing or being intimidated by the client's antisocial behavior; this progress was celebrated.The client reported that family members are not working out their own program of recovery, and they were confronted about this.Family members reported a continuing pattern of reinforcing and of being intimidated by the client's antisocial behavior, and additional interventions were brainstormed.

37 Teach Conflict Resolution Techniques (37)Family members were taught conflict resolution techniques through behavior rehearsal, modeling, and role-playing within the session.The client was assigned “Applying Problem Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).Family members were reinforced as they reported implementation of the conflict resolution techniques to settle issues reasonably between family members.Family members have not used conflict resolution techniques, and they were redirected to do so.

38 Direct Family Members to List Support for Recovery (38)Family members were assisted in identifying ways in which they could be supportive of the client's sobriety.The client reported family members assisting significantly in encouragement and other techniques to help recovery from antisocial behavior and addiction; this help was reinforced.The client's significant others were strongly encouraged to attend Al-Anon meetings on a regular basis to help support the client's recovery.

39 Develop 5-Year Plan (39)The client was asked to set goals for recovery from antisocial behavior 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 has outlined a recovery plan that includes concepts learned in treatment.The client was unable to set goals for recovery and roadblocks were assessed and managed.

40 Assess Satisfaction (40)A client satisfaction survey was administered.The client displayed a high level of satisfaction, which was reviewed with the client.The client displayed a medium level of satisfaction with services, which was reviewed with the client.The client displayed a low level of satisfaction with treatment, and the reasons for this were processed.The client declined to take the satisfaction survey and was redirected to do so.