Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 22

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 ADHD 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 Targets (3)The various stimuli that have triggered the client's ADHD behavior were assessed, including situations, people, and thoughts.The thoughts, feelings, and actions that have characterized the client's ADHD behavior and their consequences were reviewed.The client was assisted in identifying target behaviors, antecedents, consequences, and the appropriate placement of interventions.Placement of interventions was prioritized in school-based situations and, to a lesser extent, home-based and peer-based situations.Placement of interventions was prioritized in home-based situations and, to a lesser extent, school-based and peer-based situations.Placement of interventions was prioritized in peer-based situations and, to a lesser extent, home-based and school-based situations.

4 Rule Out Alternative Conditions (4)Alternative conditions that could cause inattention, hyperactivity, and impulsivity were reviewed.Behavioral, physical, and emotional problems were reviewed in regard to the effect on the client's inattention, hyperactivity, and impulsivity.The client's level of normal developmental behavior was reviewed.

5 Coordinate Psychological Testing (5)The client was administered psychological testing in order to establish or rule out the presence of ADHD problems.The Connors ADHD Rating Scale (CARS) was administered to the client.The Substance Abuse Subtle Screening Inventory–3 (SASSI-3) was administered to the client.Psychological testing has established the presence of an ADHD problem.The psychological testing failed to confirm the presence of ADHD.

6 Monitor and Rate ADHD Symptoms (6)The client was taught techniques to monitor their ADHD symptoms.The client was asked to rate the severity of their ADHD symptoms on a daily basis, on a scale from 1 to 100.The client was assisted in rating their ADHD symptoms.The client has not monitored their ADHD symptoms and was redirected to do so.

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 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 their 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 Accept Powerlessness and Unmanageability Over ADHD Symptoms (11)The client was taught about the use of a 12-step recovery program's Step 1 exercise to acknowledge unmanageability of ADHD symptoms and addiction.The client was assigned the Step 1 exercise from The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client was noted to accept the concept of being powerless and unable to manage ADHD symptoms and addiction problems.It was noted that the client has had increased serenity after accepting powerlessness and inability to manage ADHD symptoms and addiction.The client rejected the concept of powerlessness and unmanageability over ADHD and addiction symptoms and was urged to monitor this dynamic.

12 Teach About the Relationship Between ADHD and Addiction (12)The client was taught, through the use of a biopsychosocial approach, about the relationship between ADHD symptoms and addictive behavior.The client was assisted in acknowledging several instances in which ADHD symptoms have prompted addictive behavior.As ADHD symptoms have decreased, the client has identified a corresponding decrease in addictive behavior; this progress was highlighted.

13 Develop an ADHD and Addiction Recovery Program (13)The client was assisted in developing a program of recovery that includes the elements necessary to bring ADHD and addictive behavior under control.The client was assigned “Developing a Recovery Program” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was reinforced as they identified specific portions of their ADHD/addiction recovery program, including the use of medication, behavior modification, environmental controls, aftercare meetings, and further therapy.It was noted that the client has begun to use the recovery program.The client has not used their specific recovery program and was redirected to pursue these elements.

14 Teach About a Higher Power (14)The client was presented with information about how faith in a higher power can aid in recovery from ADHD traits and addiction.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 concept of a higher power.The client rejected the idea of a higher power and was urged to remain open to this concept.

15 Refer to a Specialist to Remediate Learning Disabilities (15)The client was referred to an education specialist to design remedial procedures for learning disabilities present in addition to ADHD.The client reported meeting with the educational specialist, who has been able to design remedial procedures for learning disabilities.The client described benefits from the remedial procedures used to counter the effects of learning disabilities.The client has not yet met with an education specialist to design remedial procedures for learning disabilities and was redirected to do so.

16 Refer for Medication Evaluation (16)A referral to a prescribing clinician was made for the purpose of evaluating the client for a prescription of psychotropic medications.The client has followed through on a referral to a prescribing clinician and has been assessed for a prescription of psychotropic medication, but none were prescribed.Psychotropic medications have been prescribed for the client.The client has been monitored for side effects of the medication.The client has refused a prescription of psychotropic medication provided by the prescribing clinician.

17 Monitor Medication Compliance and Effectiveness (17)The client reported that the medication has helped to improve attention, concentration, and impulse control without any side effects, and the benefits of this were reviewed.The client was assigned the exercise “Evaluating Medication Effects” from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The client reported little to no improvement while taking the medication and was redirected to the prescribing clinician.The client has not complied with taking medication on a regular basis and was redirected to do so.The client and parents were encouraged to report the side effects of the medication to the prescribing clinician.

18 Educate Family About ADHD (18)The client's parents and siblings were educated about the symptoms of ADHD.The therapy session helped the client's parents and siblings gain a greater understanding and appreciation of the symptoms of ADHD.The family members were given the opportunity to express their thoughts and feelings about having a child or sibling with ADHD.

19 Discuss Treatment Options (19)The various treatment options available for ADHD were discussed with the client and/or parents.The options regarding behavioral parent training, classroom-based behavioral management programs, peer-based programs, medication, and cognitive behavioral therapy were reviewed.Pros and cons of each of the various treatment options were reviewed.Risks and benefits of each treatment option were reviewed to assist the parents in making fully informed decisions.The appropriate treatment for the client's developmental age was discussed.

20 Assign Parents to Read ADHD Information (20)The parents were assigned to read information to increase their knowledge about symptoms of ADHD.The client's parents were directed to read Taking Charge of ADHD (Barkley).The parents were directed to read Parenting Children With ADHD: 10 Lessons That Medicine Cannot Teach (Monastra).The parents were assigned to read The Family ADHD Solution: A Scientific Approach to Maximizing Your Child's Attention and Minimizing Parental Stress (Bertin).The parents have read the information about ADHD, and key points were processed.The client's parents have not read the information about ADHD and were redirected to do so.

21 Assign Client to Read About ADHD (21)The client was instructed to read information about ADHD and adolescence.The client was instructed to read ADHD—A Teenager's Guide (Crist) to increase knowledge and understanding of ADHD.The client was instructed to read The ADHD Workbook for Teens: Activities to Help You Gain Motivation and Confidence (Honos-Webb) to increase knowledge about ADHD and ways to manage symptoms.The client was instructed to read Take Control of ADHD: The Ultimate Guide for Teens With ADHD (Spodak & Stephano) to increase knowledge about ADHD and ways to manage symptoms.The client identified several helpful strategies learned from readings assigned to help improve attention span, academic performance, social skills, and impulse control.The client has not read the helpful information on ADHD and teenagers and was redirected to do so.

22 Explain Benefit of Behavioral Interactions (22)Today's session focused on how parent and child behavioral interactions can reduce the frequency of impulsive, disruptive, and negative attention-seeking behaviors and increase desired prosocial behavior.The use of prompting and reinforcing positive behaviors was reviewed.An emphasis was also placed on the use of clear instruction, time-out, and other loss-of-privilege practices for problem behavior.The Kazdin Method for Parenting the Defiant Child (Kazdin) was recommended.Parents and Adolescents Living Together: The Basics (Patterson & Forgatch) was recommended to the parents.

23 Teach Parents to Define Aspects of Situation (23)The parents were taught how to specifically define and identify their child's problem behaviors.The parents were taught how to identify their reactions to their child's behavior, and whether the reaction encourages or discourages the behavior.The parents were assigned “Switching From Defense to Offense” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The parents were taught to generate alternatives to their child's problem behavior.Positive feedback was provided to the parents for their skill at specifically defining and identifying problem behaviors, reactions, outcomes, and alternatives.Parents were provided with remedial feedback as they struggled to correctly identify their child's problem behaviors and their own reactions, responses, and alternatives.

24 Teach About Functions of ADHD Behavior (24)The parents were taught about the possible functions of ADHD behavior.Alternative functions for ADHD behavior, such as avoidance, attention-seeking, gaining a desired object/activity, or regulating sensory stimulation, were reviewed.Parents were assisted in reviewing how to test which function is being served by the behavior.The parents were taught about how to use parent training methods to manage behavior depending on the function it serves.

25 Assign Home Exercises to Implement Parenting Techniques (25)The parents were assigned home exercises in which they implement parenting techniques and record results of the implementation exercises.The parents were assigned “Clear Rules, Positive Reinforcement, Appropriate Consequences” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The parents' implementation of homework exercises was reviewed within the session.Corrective feedback was used to help develop improved, appropriate, and consistent use of skills.The parents have not completed the assigned homework and were redirected to do so.

26 Refer to Parent Management Training Course (26)The parents were referred to a parent management training course.The parents have completed the parent management training course and the key concepts were reviewed.The parents have not used the parent management training course and were redirected to do so.

27 Consult With Teachers (27)Consultation was held with the client's teachers to implement strategies to improve school performance.The client was assigned a seat near the teacher or in a low-distraction work area to help themr remain on task.The client, teacher, and therapist agreed to the use of a prearranged signal to redirect the client to task when attention begins to wander.The client's schedule was modified to allow for breaks between tasks or difficult assignments to help maintain attention and concentration.The teachers were encouraged to obtain and provide frequent feedback to help maintain the client's attention, interest, and motivation.The client was directed to arrange for a listening friend.

28 Institute Behavioral Classroom Management Interventions (28)The parents and pertinent school personnel were consulted in order to implement an age-appropriate behavioral classroom management intervention.The behavioral classroom management interventions were focused on reinforcing appropriate behavior at school and at home, using timeout for undesirable behavior and a daily report card for monitoring progress.The behavioral classroom management program has been used and the benefits were reviewed.The behavioral classroom management program has not been used and problems with this intervention were resolved.

29 Refer for Behavioral Peer Intervention (29)Behavioral peer intervention as described by Pelham et al. in “Summer Treatment Programs for Attention-Deficit Hyperactivity Disorder” was used.Behavioral peer intervention involving brief social skills training, followed by coached group play, was used.Contingency management systems were used as a portion of the behavioral peer intervention, including point systems and timeouts.Objective observations, frequency counts, and adult ratings of social behavior were used as outcome measures.

30 Provide Psychoeducation About ADHD (30)The parents were provided with psychoeducation about ADHD or ADHD and addiction.A rationale for treatment was discussed with the client where the focus will be on improvement of cognitive and behavioral skills, such as organization, planning, adaptive thinking, and reducing distraction and procrastination.The client and parents had a clear understanding of the rationale for treatment, and this was reinforced.The client and parents seemed to struggle with understanding the rationale for treatment and were provided with additional information in this area.

31 Teach Organization and Planning Skills (31)The client was taught organizational and planning skills.The client was taught about tasks such as using a calendar and a daily task list.The client was reinforced for regular use of organizational and planning tools.The client has not used the organizational planning techniques and was redirected to do so.

32 Teach Distraction Delay Techniques (32)The client was taught a distraction delay technique involving writing own distractions while working and coming back to them after a set amount of time.The client was taught cue-controlled techniques involving checking in to assess if they were still working on the task at hand or had gotten distracted.The client identified implementing one or both distraction delay techniques and has found success in reducing distractions.The client attempted one or both of the distraction delay techniques and reported minimal usefulness in reducing distractions; additional support was provided.The client did not attempt to use the distraction delay techniques and was assisted in problem-solving.

33 Use Cognitive Restructuring Skills (33)Cognitive restructuring was used to teach adaptive thinking skills and respond adaptively to task-interfering thinking (anxious, depressive, or overly positive thinking) that does not recognize the effects of attentional deficits.The client was reinforced for understanding of adaptive thinking skills.The client has applied adaptive thinking skills in daily life and was encouraged for this step.The client was unable to apply adaptive thinking skills into daily life and remedial information was provided.

34 Teach Procrastination Reduction Skills (34)The client was taught skills to reduce procrastination, such as scheduling tasks, breaking tasks down into manageable steps, learning to set realistic goals for completing tasks, and rethinking beliefs about perfectionism.The client has implemented newly learned skills and identified a significant decrease in procrastination incidences.The client has not implemented newly learned skills and was redirected to attempt this.

35 Conduct Relapse Prevention (35)Newly learned skills were reviewed with the client, continued use was encouraged, and coping with potential future difficulties was rehearsed.The client was asked to schedule a self-check-in 1 month after the last treatment session.The client showed understanding of the newly learned skills and committed to a self-check-in and was provided with positive feedback.

36 Implement Organizational System (36)The parents were assisted in developing an organizational system to increase the client's on-task behavior and completion of school assignments, chores, or work responsibilities.The parents were encouraged to communicate regularly with the teachers through the use of notebooks or planning agendas to help the client complete school or homework on a regular, consistent basis.The client and parents were encouraged to use a calendar or chart to help remind the client of when they were expected to complete chores or household responsibilities.The client and parents were instructed to ask the teacher for a course syllabus and use a calendar to help plan large or long-term projects by breaking them into smaller steps.The client and parents were encouraged to purchase a binder notebook to help the client keep track of school or homework assignments.The family was assigned the exercise “Getting It Done” from the Adolescent Psycho- therapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The client and parents have not implemented an organizational system to increase the client's on-task behavior, and they were redirected to do so.

37 Develop Routine Schedule (37)The client and parents were assisted in developing a routine schedule to increase the completion of school/homework assignments.The client and parents were assisted in developing a list of chores for the client and identified times and dates when the chores are expected to be completed.A reward system was designed to reinforce the completion of school, household, or work-related responsibilities.The client, parents, and therapist signed a contingency contract specifying the consequences for the client's success or failure in completing school assignments or household responsibilities.The client and parents have not developed a routine schedule to increase the completion of school/homework assignments and were redirected to do so.

38 Use the “Getting It Done” Program (38)The parents and teachers were encouraged to use a school contract and reward system to reinforce completion of the client's assignments.The parents and teachers were given the “Getting It Done” program from the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce) to help the client complete school and homework assignments regularly.The parents and teachers were encouraged to use the school contract and reward system outlined in the “Getting It Done” program to reinforce the regular completion of school assignments.The parents and teachers have used the school contract and reward system to reinforce the client's regular completion of school assignments, and the benefits of this program were reviewed.The parents and teachers have not used the school contract and reward system to reinforce the client's regular completion of school assignments and were redirected to do so.

39 Teach Test-Taking Strategies (39)The client and therapist reviewed a list of effective test-taking strategies to improve academic performance.The client was encouraged to review classroom material regularly and study for tests over an extended period of time.The client was instructed to read the directions twice before responding to the questions on a test.The client was taught to recheck work to correct any careless mistakes or to improve an answer.The client was encouraged to read Test-Taking Strategies (Kesselman-Turkel & Peterson) as a supplement to therapy.

40 Teach Self-Control Strategies (40)The client was taught meditational and self-control strategies (e.g., relaxation techniques, “stop, think, listen, and act”) to help delay the need for immediate gratification and inhibit impulses.The client was encouraged to use active-listening skills to delay the impulse to act out or react without considering the consequences of their actions.The client was asked to identify the benefits of delaying the need for immediate gratification in favor of longer-term gains.The client was assisted in developing an action plan to achieve longer-term goals.The client was assigned “Problem-Solving Exercise” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).

41 Focus on Delay of Gratification (41)The therapy session focused on helping the parents increase the structure in the home to help the client delay needs for immediate gratification in order to achieve longer-term goals.The parents were supported as they established the rule that the client is not permitted to engage in social, recreational, or leisure activities until completing chores or homework.The parents were supported as they identified consequences for the client's failure to complete responsibilities; the client verbalized recognition of these consequences.The client and parents were encouraged as they designed a schedule of dates and times when the client is expected to complete chores and homework.

42 Build Communication Skills (42)Instruction, modeling, and role-playing techniques were used to help build the client's general social and communication skills.The client was assisted in practicing general social and communication skills.The client was reinforced for increased social and communication skills.The client was redirected in areas in which they continue to struggle with communication and social skills.

43 Use Social Skills Exercises (43)The parents were assisted in designing exercises that facilitate the client's use of social skills in various everyday situations.The client's use of social skills in various everyday situations was reviewed and processed.The client was provided with positive feedback for helpful use of social skills in everyday situations.The client has not used social skills in everyday situations and was provided with redirection in this area.

44 Assign Books/Manuals on Building Social Skills (44)The client was assigned to read about general social and/or communication skills in books or treatment manuals on building social skills.The client was assigned to read Your Perfect Right (Alberti & Emmons).The client was assigned to read Conversationally Speaking (Garner).The client was assigned the “Social Skills Exercise” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).Key points from the client's reading material were reviewed and processed.The client has not read the assigned information on social and communication skills and was redirected to do so.

45 Teach Problem-Solving Skills (45)The client was taught effective problem-solving skills (i.e., identify the problem, brainstorm alternate solutions, select an option, implement a course of action, and evaluate) in the therapy session.The client was encouraged to use effective problem-solving strategies to solve or overcome a problem or stressor that they are currently facing.The client was given a directive to use problem-solving strategies at home or school on at least three occasions before the next therapy session.

46 Assign Problem-Solving Exercises (46)The client and parents were taught problem-solving techniques for daily life through the use of role-playing and modeling.The parents were helped to identify exercises that could facilitate the client's use of problem-solving in various everyday situations.The client and parents reported using techniques and exercises for problem-solving with positive success.The client and parents reported minimal success using problem-solving techniques and exercises and were provided with support.

47 Relate Learning Problems, Negative Emotions, Addictive Behavior (47)The client was presented with the concept that negative experiences regarding learning have caused negative emotions, which have in turn led to addictive behaviors.The client accepted the concept presented, that they have experienced strong negative emotions related to learning problems, which have led to addiction problems.The client rejected the concept that negative learning experiences have led to strong negative emotions and addiction problems; the client was urged to be aware of this dynamic.

48 Use Alternative Behaviors for Negative Emotions (48)The client was presented with a variety of constructive coping behaviors that can be used to cope with negative emotions (e.g., focus cognitively, breathe deeply, make lists, reduce distractions, shorten learning sessions, repeat instructions verbally).Alternative coping behaviors were role-played and modeled with the client as alternatives for dealing with negative emotions.The client was reinforced while displaying an understanding of a variety of alternative coping behaviors to cope with negative emotions.The client identified that they have regularly used alternative coping behaviors to deal with negative emotions and thereby decreased addiction behavior; this progress was highlighted.The client has not used alternative coping behaviors for negative emotions and has continued to use addictive behaviors; the client was redirected to the alternative coping behaviors.

49 Teach Relaxation Techniques (49)The client was taught various relaxation techniques, including progressive relaxation, guided imagery, and/or biofeedback, to be used to help reduce tension.The client was assigned to relax twice a day for 10 to 20 minutes, using newly learned relaxation techniques.The client has implemented relaxation procedures to reduce tension and physical restlessness and has reported that this technique is beneficial; this progress was reinforced.The client has not followed through on implementation of relaxation techniques to reduce restlessness and tension and was encouraged to do so.

50 Relax When Frustrated by Learning Problems (50)The client was encouraged to incorporate relaxation skills as a coping and focusing mechanism when feeling tense and frustrated by a learning situation or an urge to use substances.The client reported regular use of relaxation skills as a coping and focusing mechanism; the experience was processed.The client was assisted in identifying benefits from the use of relaxation skills when frustrated by learning situations or urges to use substances.The client acknowledged that they have not used relaxation skills when frustrated by learning situations or urges to use substances and was redirected to do so.

51 Develop Physical Fitness Program (51)After the client obtained approval from their personal physician, they were assisted in developing an exercise program.The client has followed through on the exercise program and has gradually increased exercise level by 10% each week; the client was reinforced.The client reported now exercising at a training heart rate for at least 20 minutes, at least three times per week; the benefits of this activity were catalogued.The client has not followed through on establishing a daily exercise routine and was encouraged to do so.

52 Develop an Aftercare Program (52)The client was assisted in developing an aftercare plan that will support recovery from ADHD and addictive behavior problems, including regular attendance at 12-step meetings, getting a sponsor, and continuing necessary therapy.The client was assigned “Aftercare Plan Components” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client has listed several components of an aftercare plan that will support sobriety (e.g., self-help groups, sponsors) as well as specific techniques to assist with ADHD concerns; the client was encouraged to use these skills.The client was reinforced while describing active pursuit of the elements of the aftercare program.The client has not followed through on an aftercare plan and was redirected to do so.

53 Assess Satisfaction (53)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.