Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 25
INTERVENTIONS IMPLEMENTED
Оглавление1 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 Conduct Psychosocial Assessment (3)A thorough psychosocial assessment was conducted, including the past and present symptoms of ADHD and their effects on educational, occupational, and social functioning.The psychosocial assessment reflects significant concerns related to ADHD, and this was communicated to the client.The psychosocial assessment reflects minimal concerns related to ADHD, and this was reflected to the client.
4 Coordinate Psychological Testing (4)The client was administered psychological testing in order to establish or rule out the presence of ADHD problems.The Connors Adult ADHD Rating Scale (CAARS) was administered to the client.The Substance Abuse Subtle Screening Inventory–4 (SASSI-4) was administered to the client.Psychological testing has established the presence of an ADHD problem.Psychological testing has identified other possible psychopathology.Psychological testing has ruled out other psychopathology.The psychological testing failed to confirm the presence of ADHD.
5 Refer to a Specialist to Remediate Learning Disabilities (5)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 and was redirected to do so.
6 Refer for Physician Assessment Regarding Etiology (6)The client was referred to a physician to rule out nonpsychiatric medical etiologies for ADHD.The client was referred to a physician to rule out substance-induced etiologies for the client's level of ADHD.The client has complied with the referral to a physician and the results of this evaluation were reviewed.The client has not complied with the referral for a medical evaluation and was redirected to do so.
7 Process Medical and Psychological Evaluation (7)Results and recommendations of the medical evaluation were processed with the client and all questions were answered.The results and recommendations of the psychological evaluation were processed with the client and all questions were answered.As a result of the physician's evaluation, the client was prescribed medication to assist in the control of ADHD symptomatology.As a result of the psychological evaluation, the client was provided with several different techniques to assist in the control of ADHD symptomatology.
8 Hold a Conjoint Session to Give Evaluation Feedback (8)A conjoint session was held with the client and significant others in order to present the results of the psychological and medical evaluations.All questions regarding the evaluation results were processed.The client's family members were solicited for support regarding compliance with treatment for ADHD symptoms.The client's family members were verbally reinforced as they gave strong support to the client regarding medical and psychological treatment for ADHD symptoms.
9 Arrange Substance Abuse Evaluation (9)The client's use of alcohol and other mood-altering substances was assessed.The client was assessed to have a pattern of mild substance use.The client was assessed to have a pattern of moderate substance use.The client was assessed to have a pattern of severe substance use.The client was referred for a substance use treatment.The client was found to not have any substance use concerns.
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 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.
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 Identify Difficult ADHD Behaviors (14)The psychological testing was reviewed to assist the client in identifying the specific ADHD behaviors that have caused the most difficulty.The client was supported as they listed such things as distractibility, lack of concentration, impulsivity, restlessness, and disorganization as the most difficult.The client was assisted in identifying specific behaviors that will be treatment targets.The client was resistive to becoming specific about identifying ADHD behaviors that cause the most difficulty; the client was encouraged to do this as they feel capable.
15 Review Evaluation Results (15)The results of the psychological testing and physician's evaluation were reviewed again with the client in order to assist in the choice of the most difficult, problematic behaviors to address in counseling.The client was assisted in selecting those behaviors that are most difficult as focal points for treatment.The client was supported as they agreed to concentrate efforts to change on these most difficult behavior areas.
16 Have Others Rank ADHD Symptoms (16)The client was asked to have extended family members and close collaterals complete a ranking of the behaviors they see as interfering the most with daily functioning.Collateral contacts were asked to rate areas, such as the client's mood swings, temper outbursts, ease of being stressed, short attention span, and failure to complete projects.The client's extended family members’ and close collaterals’ rankings of the client's ADHD symptoms were reviewed and processed.
17 Develop Negative Consequences of ADHD (17)The client was asked to make a list of negative consequences of ADHD that the client has experienced.The client was asked to identify other problems that could result from continuation of problematic behavior.The client was assigned the exercise “Impulsive Behavior Journal” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assisted in reviewing the list of negative consequences of ADHD.
18 Accept Powerlessness and Unmanageability Over ADHD Symptoms (18)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 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 their 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.
19 Teach About the Relationship Between ADHD and Addiction (19)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.
20 Develop an ADHD and Addiction Recovery Program (20)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 the “Mastering Your Adult ADHD” exercise in Mastery of Your Adult ADHD: Client Workbook (Safren et al.).The client was reinforced while identifying 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.
21 Teach About a Higher Power (21)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.
22 Refer for Psychotropic Medication (22)A referral to a prescribing clinician was made for the purpose of evaluating the client for a prescription of psychotropic medications.The client was assigned “Why I Dislike Taking My Medication” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).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.
23 Monitor Medication Compliance and Effectiveness (23)The client reported that the medication has helped to improve their attention, concentration, and impulse control without any side effects, and the benefits of this were reviewed.The client was assigned “Evaluating Medication Effects” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The client reported little to no improvement while taking the medication and was redirected to their physician.The client has not complied with taking medication on a regular basis and was redirected to do so.The client was encouraged to report the side effects of the medication to the prescribing physician or psychiatrist.
24 Educate About ADHD (24)The client was educated about the symptoms of ADHD.The client was assigned “Symptoms and Fixes for ADHD” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The therapy session helped the client gain a greater understanding and appreciation of the symptoms of ADHD.The client was given the opportunity to express thoughts and feelings about having ADHD.The client has not reviewed information about how to cope with the client's ADHD symptoms and was redirected to this information.
25 Develop Rationale for Treatment (25)A discussion was held with the client in regard to the rationale for treatment.Treatment targets were identified, including organizational and planning skills, management of distractibility, cognitive restructuring, and overcoming procrastination.Concepts for the rationale for treatment were reviewed in accordance with the information provided in Mastery of Your Adult ADHD: Therapist Manual (Safren et al.).
26 Teach Self-Monitoring (26)The client was taught how to monitor their own ADHD symptoms.The client was assigned specific monitoring tasks for use in therapy.
27 Assign Reading on ADHD (27)The client was instructed to read information about ADHD in adults.The client was instructed to read Mastery of Your Adult ADHD: Client Workbook (Safren et al.) or The Attention Deficit Disorder in Adults Workbook (Weiss) to increase knowledge and understanding of ADHD.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 was redirected to do so.
28 Assign Self-Help Readings on ADHD (28)The client was assigned self-help reading to facilitate understanding of ADHD.The client was assigned Driven to Distraction (Hallowell & Ratey).The client was assigned ADHD: Attention-Deficit Hyperactivity Disorder in Children, Adolescents, and Adults (Wender).The client was assigned to read Putting on the Brakes (Quinn & Stern).The client was assigned to read You Mean I'm Not Lazy, Stupid, or Crazy!? (Kelly & Ramundo).The client was assisted in processing the material that they read.The client has not read the assigned information on ADHD and was redirected to do so.
29 Engage Significant Other (29)The client was allowed to invite a significant other to participate in the therapy.The significant other was taught to help support the change and reduce friction in the relationship introduced by the ADHD.It was reflected that the significant other has been helpful in supporting the client's changes and reducing friction in the relationship.The significant other has struggled to be helpful to the client's change process and was provided with remedial feedback in this area.
30 Teach About the Use of a Reminder Calendar (30)The client was taught about the use of making lists and of using a calendar to remind them about appointments and daily obligations.The client has implemented structured reminders and organizers, and these have been noted to be helpful in reducing forgetfulness and completing necessary tasks.The client has failed to use the structured reminders and continues to forget about daily obligations; the client was redirected to use these organizers.
31 Develop Organizational Skills (31)The client was assisted in developing a procedure for classifying and managing mail and other papers.The client was assisted in developing a procedure for remembering scheduled appointments.The client was reinforced for use of organization and classification systems.The client was redirected when they did not use helpful classification and organizational skills.
32 Teach Problem-Solving Skills (32)The client was taught problem-solving skills as an approach to planning.The client was taught to break down each plan into manageable, time-limited steps in order to reduce the influence of distractibility.The client was assigned “Getting Organized” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was reinforced for regular use of problem-solving skills.The client has not regularly used problem-solving skills and was redirected to do so.
33 Practice Problem-Solving (33)The client was assigned homework to apply problem-solving skills to an everyday problem.The client was assigned the exercise “Problem-Solving: An Alternative to Impulsive Action” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client's use of problem-solving skills in everyday problems was reviewed.The client was provided with positive feedback about the ways in which they have appropriately used problem-solving skills.The client was provided with corrective feedback toward improving use of problem-solving skills.
34 Identify Typical Attention Span (34)The client was asked to do various tasks to the point that they indicated distraction.The client attempted various tasks, continuing until distraction was indicated; this was used as an approximate measure of the client's typical attention span.
35 Teach Stimulus Control Techniques (35)The client was taught techniques that use external structure such as lists, files, and daily rituals to improve on-task behavior.The client was taught to remove distracting stimuli from their environment when performing a task requiring focus.The client was urged to self-reward for successful focus and follow-through with on-task behavior.The client followed through with implementing techniques to increase on-task behavior and was reinforced for doing so.The client did not follow through with implementing on-task behavior and was encouraged to do so.
36 Break Tasks into Smaller Units (36)The client was taught to break down tasks into meaningful units based on the client's demonstrated attention span.The client was assisted in breaking down tasks into meaningful units.
37 Teach Use of Cues (37)The client was taught to use timers or other cues to remind them to stop task units.The client was taught about reducing off-task time or distractions by limiting the length of time expected to focus on one area.The client was reinforced for use of timers and cues.The client does not regularly use timers and cues and was redirected to do so.
38 Change Maladaptive Self-Talk (38)Cognitive therapy techniques were used to help the client identify and change maladaptive self-talk.The client was assisted in challenging the biases that lead to maladaptive self-talk and to generate alternative thoughts.The client was assigned “Negative Thoughts Trigger Negative Feelings” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was reinforced for regular use of healthier self-talk.The client has not regularly used healthy self-talk and was redirected to do so.
39 Discuss Metacognitive Therapy Approach (39)The client was taught about using a metacognitive approach to examine “thinking about their thinking.”The client was assisted in developing a more adaptive plan based on new, less-threatening metacognitive appraisals.The client was provided with positive reinforcement for use of a metacognitive approach to examining their thinking.The client was provided with corrective feedback toward improving ability to examine thinking.
40 Practice Cognitive Knowledge and Skills (40)The client was assigned homework to implement cognitive knowledge and skills in relevant tasks.The client's cognitive knowledge and skills were reviewed.The client was provided with corrective feedback for their struggles in implementing cognitive knowledge and skills.The client was reinforced for regular use of cognitive knowledge and skills.
41 End Procrastination (41)The client was assisted in identifying the positives and negatives of procrastination.The client was challenged to change their pattern of procrastination.
42 Develop Specific Plans for Overcoming Procrastination (42)The client was asked to apply problem-solving skills to planning as a first step in overcoming procrastination.The client was assisted in breaking down each plan into manageable, time-limited steps to reduce the influence of distractibility and increase the likelihood of successful completion.The client was reinforced for use of problem-solving skills as a way to overcome procrastination.The client has not regularly used problem-solving skills to overcome procrastination and was provided with remedial feedback in this area.
43 Embrace Action Over Procrastination (43)The client was taught to apply cognitive restructuring skills to challenge thoughts encouraging the use of procrastination.The client was taught to change their thoughts toward embracing action.
44 Develop Calendars and Lists (44)The client was assisted in developing calendars to record details of scheduled activities and obligations.The client was assisted in developing lists of responsibilities.The client was directed to keep their calendars and lists with them on a regular basis and mark off each item as it is completed.
45 Assign Practice of Ending Procrastination (45)The client was assigned specific homework tasks to accomplish without procrastination.The client was assigned “Self-Monitoring/Self-Reward Program” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was urged to use techniques learned in therapy to complete homework without procrastination.The client was provided with corrective feedback toward improving this skill and decreasing procrastination.
46 Develop Distraction-Free Environment (46)The client was assisted in designing and implementing an environment that is free of extraneous stimulation.The client was directed to use their environment as place of study, concentration, and learning.The client was provided with ideas about how to organize the environment to be free of extraneous stimulation.
47 Teach Self-Control Strategies (47)The client was taught the self-control strategy of “stop, listen, think, and act” to assist in curbing impulsive behavior.The client was taught problem-solving self-talk as a means of reducing impulsivity.The client was assigned “From Recklessness to Calculated Risks” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).Role-playing was used to help the client apply self-control strategies to daily life situations that are affected by ADHD symptoms.The client reported success at applying self-control strategies and indicated that impulsivity has been diminished; this progress was reinforced.The client has not learned the self-control strategies and was provided with remedial feedback in this area.
48 Select Situations to Apply Skills (48)The client was directed to identify situations in which they will be challenged to apply new strategies for managing ADHD.The client was urged to start the application of new strategies with a situation that was highly likely to be successful.The client was assisted in identifying a hierarchy of gradually more challenging situations to apply new techniques.
49 Consolidate New Skills (49)The client was assisted in consolidating the use of new ADHD management skills.Techniques such as imagery were used to help the client consolidate new ADHD management skills.Techniques such as behavioral rehearsal, modeling, role-playing, and in vivo exposure/ behavioral experiments were introduced to help the client consolidate the use of new ADHD management skills.
50 Build Communication Skills (50)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 increasing social and communication skills.The client was redirected in areas in which they continue to struggle with communication and social skills.
51 Assign Books/Manuals on Building Social Skills (51)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).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.
52 Review Incidents of Intrusive Comments (52)The client was assisted in reviewing social situations in which they were intrusive or talked excessively without thoughtfulness.The client was redirected toward greater social success through modeling, role-playing, and instruction.The client was reinforced for the ability to change from intrusive thoughtless comments to better social functioning.
53 Teach Problem-Solving Techniques Requiring Thought Before Action (53)The client was taught about problem-solving techniques that require thought before taking action and how they can apply these to interpersonal conflict situations.The client was assigned “Applying Problem-Solving to Interpersonal Conflicts” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assigned “Staying Attentive and Other Negotiating Skills” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was reinforced for use of problem-solving skills.The client has not used problem-solving skills and was redirected to do so.
54 Teach Relaxation Techniques (54)The client was taught various relaxation techniques, including deep muscle relaxation, rhythmic breathing, meditation, and guided imagery to be used when stress levels increase.The client was assigned “Self-Soothing: Calm Down, Slow Down” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).It was noted that the client has implemented relaxation procedures to reduce tension and physical restlessness and reported that this technique is beneficial.The client has not followed through on implementation of relaxation techniques to reduce restlessness and tension and was encouraged to do so.
55 Review Symptoms and Fixes (55)The client was assisted in reviewing the symptoms that have been problematic and the newly learned coping skills that they will use to manage the symptoms.The client was assigned “Symptoms and Fixes for ADD (now ADHD)” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).
56 Teach Mindful Meditation (56)The client was provided with a rational for mindful meditation to enhance attentional regulation.The client was taught mindful meditation skills.The client was encouraged to apply mindful meditation skills in other tasks requiring attentional focus.The client engaged accurately in mindful meditation and was reinforced for using this skill.The client struggled to use mindful meditation skills and was provided with remedial feedback.
57 Develop an Aftercare Program (57)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 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.
58 Assess Satisfaction (58)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.
