Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 28

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 bipolar 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 Mood Episodes (3)An assessment was conducted of the client's current and past mood episodes, including the features, frequency, intensity, and duration of the mood episodes.The Young Mania Rating Scale, Montgomery-Asberg Depression Rating Scale, or Inventory to Diagnose Depression was used to assess the client's current and past mood episodes.The results of the mood episode assessment reflected severe mood concerns and this was presented to the client.The results of the mood episode assessment reflected moderate mood concerns and this was presented to the client.The results of the mood episode assessment reflected mild mood concerns and this was presented to the client.

4 Assign Step 1 Exercise for Addiction and Mania/Hypomania (4)A 12-step recovery program's Step 1 was used to help the client see the powerlessness and unmanageability that have resulted from using addictive behavior to cope with the manic/hypomanic symptoms.The client displayed an understanding of the concept presented regarding powerlessness, unmanageability, addiction, and manic/hypomanic symptoms.The client was able to endorse the concept of powerlessness and unmanageability that have resulted from using addiction to deal with manic/hypomanic symptoms; this progress was reinforced.The client rejected the concept of powerlessness and unmanageability over their symptoms; the client was asked to monitor these issues.

5 Teach About the Symptoms of Mania/Hypomania and Addiction (5)The client was taught about the signs and symptoms of mania/hypomania and how these symptoms can foster addictive behavior.The client was assigned “Early Warning Signs of Mania/Hypomania” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was noted to have an increased understanding about symptoms of mania/hypomania.The client was able to connect addictive behavior to their symptoms of mania/hypomania; this insight was highlighted.The client struggled to understand symptoms of mania/hypomania and how they can lead to addictive behaviors; the client was provided with additional feedback.

6 Explore Addiction/Mania/Hypomania Connection (6)The client's addictive behavior history was explored, along with their pattern of manic/hypomanic states.The client was assigned “Mania, Addiction and Recovery” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).Active listening was provided as the client identified that they have often engaged in addictive behavior when experiencing manic/hypomanic states.The client denied any pattern of behavior relating to manic/hypomanic states and addictive behaviors; the client was urged to monitor this dynamic.

7 Refer for Physician Assessment Regarding Etiology (7)The client was referred to a physician to rule out nonpsychiatric medical etiologies for bipolar disorder.The client was referred to a physician to rule out substance-induced etiologies for bipolar disorder.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.

8 Arrange Substance Abuse Evaluation (8)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.

9 Administer Assessment for Mania/Hypomania Symptoms (9)The client was administered psychological instruments designed to objectively assess the strength of mania/hypomania symptoms.The Beck Depression Inventory-II or the Beck Hopelessness Scale was administered to the client.The Perceived Criticism Scale was administered to the client.The client has completed the assessment of mania/hypomania symptoms, but minimal traits were identified; these results were reported to the client.The client has completed the assessment of mania/hypomania symptoms, and significant traits were identified; these results were reported to the client.The client refused to participate in the psychological assessment of mania/hypomania symptoms, and the focus was turned toward this defensiveness.

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 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 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.

14 Explore Suicide Potential (14)The client's experience of suicidal urges and history of suicidal behavior were explored.Because the client's suicidal urges were assessed to be very serious, immediate referral to a more intensive supervised level of care was made.Because of the client's suicidal urges, and unwillingness to be voluntarily admitted to a more intensive, supervised level of care, involuntary commitment procedures were begun.The client identified suicidal urges as being present but contracted to contact others if the urges became strong.It was noted that the client has stated that they do experience suicidal urges but feels that they are clearly under control and that there is no risk of engagement in suicidal behavior.

15 Monitor Ongoing Suicide Potential (15)The client was asked to report any suicidal urges or increase in the strength of these urges.The client stated that suicidal urges are diminishing and that they are under control; the client was praised for this progress.The client stated that they have no longer experienced thoughts of self-harm; the client will continue to be monitored.The client stated that their suicidal urges are strong and present a threat; a transfer to a more supervised setting was coordinated.

16 Arrange Hospitalization (16)Arrangements were made for the client to be hospitalized in a psychiatric setting based on the fact that their mania is so intense that they could cause harm to self or others or be unable to care for their own basic needs.The client acknowledged the need for the recommended hospitalization and was voluntarily admitted to the psychiatric facility.The client was not willing to voluntarily submit to hospitalization; therefore, commitment procedures were initiated.

17 Teach About a Higher Power (17)The client was presented with information about how faith in a higher power can aid in recovery from mania/hypomania symptoms 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 idea of a higher power.The client rejected the concept of a higher power; the client was urged to remain open to this idea.

18 Use Step 3 (18)The client was taught about a 12-step program's third step, focusing on how to turn over problems to a higher power.The client was taught about trusting that a higher power is going to help resolve the situation.The client participated in turning problems over to a higher power and is trusting that the higher power is going to help resolve the situation; this progress was reinforced.The client rejected the idea of turning problems over to a higher power and does not feel that this will be helpful to resolve the situation; the client was urged to remain open to this idea.

19 Review Step 3 Implementation (19)The client was assigned to turn over one problem each day to a higher power.The client's implementation of the third-step exercise of turning problems over to a higher power was reviewed.The client reported success in turning problems over to a higher power and was verbally reinforced and encouraged.The client reported difficulty or failure in attempting to turn problems over to a higher power, and these difficulties/failures were reviewed, resolved, and redirected.As the client has successfully turned problems over to a higher power, the client has been noted to have an increased pattern of relief from problems and addictive behavior.

20 Arrange for a More Restrictive Setting (20)Arrangements were made for the client to be evaluated for and/or hospitalized in a psychiatric setting based on the fact that their mania is so intense that the client could cause harm to self or others or be unable to care for basic needs.The client was supported for acknowledging the need for hospitalization and voluntary admission to the psychiatric facility.The client was not willing to submit voluntarily to hospitalization; therefore, commitment procedures were initiated.

21 Refer for Medication Evaluation (21)The client was referred for a medication evaluation to consider psychotropic medication to control the manic state.The client has followed through with the medication evaluation and pharmacotherapy has begun.The client has been resistive to cooperating with a medication evaluation and was encouraged to follow through on this recommendation.

22 Refer to Outpatient Systematic Care Team (22)The client was referred to an outpatient systematic care team to help manage medications and provide support services.The client has followed through with the referral to an outpatient systematic care team and support services have begun.The client has not engaged with the outpatient systematic care team and was redirected to follow through on this recommendation.

23 Monitor Medication Reaction (23)The client's reaction to the medication in terms of side effects and effectiveness was monitored.The client reported that the medication has been effective at reducing energy levels, flight of ideas, and the decreased need for sleep; the client was urged to continue this medication regimen.The client has been reluctant to take the prescribed medication for their manic state but was urged to follow through on the prescription.As the client has taken medication, which has been successful in reducing the intensity of the mania, they have begun to feel that it is no longer necessary and indicated a desire to stop taking it; the client was urged to continue the medication as prescribed.

24 Maintain Reviews of Psychotropic Medication (24)The client's adherence with the psychotropic medication prescription was reviewed.The client indicated a desire to terminate medication because the client “doesn't feel normal”; the client was encouraged to continue to use the medication, in consultation with the prescribing clinician.The client was monitored regarding compliance with the psychotropic medication in regard to their belief that they no longer need the medication because the client has stabilized.The client was reinforced for maintaining medication use in accordance with the prescribing clinician's expectations.The client was confronted for nonadherence with the psychotropic medication regimen.

25 Monitor Ability to Participate in Group Psychotherapy (25)The client's pattern of symptom improvement was monitored, with a focus on how stable the client is in regard to participation in group psychotherapy.The client was judged to be significantly improved and capable of participating in group psychotherapy.The client was judged to still be too manic to allow helpful participation in group psychotherapy.

26 Educate About Mood Episodes (26)A variety of modalities were used to teach the family about signs and symptoms of the client's mood episodes.The phasic relapsing nature of the client's mood episodes was emphasized.The client's mood episode concerns were normalized.The client's mood episodes were destigmatized.

27 Teach Stress Diathesis Model (27)The client was taught a stress diathesis model of bipolar disorder.The biological predisposition to mood episodes was emphasized.The client was taught about how stress can make them more vulnerable to mood episodes.The manageability of mood episodes was emphasized.The client was reinforced for their clear understanding of the stress diathesis model of bipolar disorder.The client struggled to display a clear understanding of the stress diathesis model of bipolar disorder and was provided with additional remedial information in this area.

28 Provide Rationale for Treatment (28)The client was provided with the rationale for treatment involving ongoing medication and psychosocial treatment.The focus of treatment was emphasized, including recognizing, managing, and reducing biological and psychological vulnerabilities that could precipitate relapse.A discussion was held about the rationale for treatment.The client was reinforced for understanding of the appropriate rationale for treatment.The client was redirected when displaying a poor understanding of the rationale for treatment.

29 Enhance Motivation for Medication Adherence (29)Motivational interviewing techniques were used to help the client identify and increase motivation for medication adherence.The client was asked about satisfaction with the current level of medication adherence and mood stability.The client was assisted in identifying the benefits of changing their approach to the medication.The client was assisted in assessing optimism for making changes in the medication adherence pattern.The client was assisted in developing specific tactics for medication adherence.

30 Educate About Medication Adherence (30)The client was educated about the importance of medication adherence.The client was taught about the risk for relapse that occurs when medication is discontinued.The client was asked to make a commitment to prescription adherence.The client was reinforced for understanding and commitment to prescription adherence.The client was redirected when displaying poor understanding or commitment to prescription adherence.

31 Assess Prescription Nonadherence Factors (31)Factors that have precipitated the client's prescription nonadherence were assessed.The client was checked for specific thoughts, feelings, and stressors that might contribute to prescription nonadherence.The client was assigned “Why I Dislike Taking My Medication” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).A plan was developed for recognizing and addressing the factors that have precipitated the client's prescription nonadherence.

32 Coordinate Group Psychoeducational Program (32)The client was admitted to a group psychoeducational program that teaches clients the psychological, biological, and social influences in the development of bipolar disorder.The client's involvement in the group psychoeducational program focused on the biological and psychological treatment of the disorder.The client has followed through on involvement in a group psychoeducational program and key topics were reviewed.The client has not followed through on involvement in a group psychoeducational program and was redirected to do so.

33 Teach Illness Management Skills (33)The client was taught about illness management skills.The client was taught about identifying early warning signs, common triggers, and coping strategies.The client was taught about problem-solving regarding life goals and development of a personal care plan.

34 Use Cognitive Therapy Techniques (34)Cognitive therapy techniques were used to identify, challenge, and change cognitive appraisals that make the client vulnerable to manic or depressive episodes.The client was reinforced for greater insight into their cognitive appraisals.

35 Assign Homework (28)The client was assigned homework exercises in which they do behavioral experiments to test biased versus alternative predictions.The client was assigned “Journal and Replace Self-Defeating Thoughts” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assisted in reviewing their insight regarding biased versus alternative predictions and successes were reinforced.The client was provided with corrective feedback toward improvement of understanding of biased or alternative predictions.

36 Teach Coping and Relapse Prevention Skills (36)The client was taught coping and relapse prevention skills via cognitive-behavioral techniques.The client was taught about delaying impulsive actions, structuring and scheduling daily activities, keeping a regular sleep routine, avoiding unrealistic goals striving, and using relaxation procedures.The client was taught about identifying and avoiding episode triggers.The client was assigned “Keeping a Daily Rhythm” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was reinforced for understanding of taught skills.The client did not understand the provided skills and additional information was provided.

37 Conduct Family-Focused Treatment (37)The client and significant others were included in the treatment model.Family-focused treatment was used with the client and significant others as indicated in Bipolar Disorder: A Family-Focused Treatment Approach (Miklowitz & Goldstein).As family members were not available to participate in therapy, the family-focused treatment model was adapted to individual therapy.

38 Assess Family Communication (38)Objective instruments were used to assess the family communication.The level of expressed emotions within the family was specifically assessed.The family was educated about the role of aversive communication (e.g., highly expressed emotion), how it increases risk of relapse, and how change in communication style can reduce that risk.The family displayed a clear understanding of the effects of aversive communication and this was reinforced.The family was provided with feedback about their style of communication.The family has not been involved in the assessment of communication style, and the focus of treatment was diverted to this resistance.

39 Teach Communication Skills (39)Behavioral techniques were used to teach assertive communication skills.Assertive communication skills, such as offering positive feedback, active listening, making positive requests for behavioral change, and giving negative feedback in an honest, respectful manner, were taught to the client and family.Behavioral techniques were used to teach the family healthy communication skills.Education, modeling, role-playing, corrective feedback, and positive reinforcement were used to teach communication skills.The family was taught the HARD acronym: honest, appropriate, respectful, and direct.

40 Address Problem-Solving (40)The client was asked to identify conflicts that can be addressed through using problem-solving techniques.The family members were asked to give input about conflicts that could be addressed using problem-solving techniques.The client and family arrived at a list of conflicts that could be addressed using problem-solving techniques.

41 Teach Problem-Solving Skills (41)Cognitive behavioral techniques, such as education, modeling, role-playing, corrective feedback, and positive reinforcement, were used to teach the client and family problem-solving skills.Specific problem-solving skills were taught to the family, including defining the problem constructively and specifically, brainstorming options, evaluating options, choosing options, implementing a plan, evaluating the results, and reevaluating the plan.The client was assigned “Applying Problem-Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).Family members were asked to use the problem-solving skills in specific situations.The family was reinforced for positive use of problem-solving skills.The family was redirected for failure to properly use problem-solving skills.

42 Assign Problem-Solving Homework (42)The client and family were assigned to use newly learned problem-solving skills and record their use.The client and family were assigned “Plan Before Acting” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client and family were assigned “Problem Solving: An Alternative to Impulsive Action” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The results of the family members’ use of problem-solving skills were reviewed within the session.The family members’ appropriate use of problem-solving skills was reinforced.The family members’ obstacles were resolved toward sustained, effective use.

43 Develop Relapse Drill (43)The client and family were assisted in drawing up a “relapse drill,” detailing roles and responsibilities.Family members were asked to take responsibility for specific roles (e.g., who will call a meeting of the family to address potential relapse; who will call the physician, schedule a serum level, or contact emergency services, if needed).Obstacles to providing family support to the client's potential relapse were reviewed and resolved.The family was asked to make a commitment to adherence to the plan.The family was reinforced for their commitment to adherence to the plan.The family has not developed a clear commitment to the relapse prevention plan and was redirected in this area.

44 Conduct Interpersonal and Social Rhythm Therapy (44)An assessment was conducted of the client's daily activities using an interview and the social rhythm metric.Information from the interview and social rhythm metric helped to conduct interpersonal and social rhythm therapy.

45 Establish Routine Daily Activities (45)The client was provided with the rationale for an optimal social rhythm.The client was assisted in establishing a more routine pattern of daily activities.The client was assisted in identifying a routine pattern of sleeping, eating, solitary and social activities, and exercise.A form was developed to help review and schedule activities.An emphasis was placed on creating a predictable rhythm for each day.

46 Teach About Sleep Hygiene Importance (46)The client was taught about the importance of good sleep hygiene.The client was assigned the “Sleep Pattern Record” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client's sleep pattern was routinely assessed.Interventions for the client's sleep pattern were provided, as they have been noted to have a dysfunctional sleep pattern.

47 Engage in Behavioral Activation (47)The client was engaged in “behavioral activation” by collaboratively identifying and scheduling activities that have a high likelihood for pleasure and mastery.The client was directed to complete tasks from the “Identify and Schedule Pleasant Activities” assignment from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).Rehearsal, role-playing, role reversal, and other techniques were used to engage the client in behavioral activation.The client was reinforced for successes in scheduling activities that have a high likelihood for pleasure and mastery.The client has not engaged in pleasurable activities and was redirected to do so.

48 Conduct Interpersonal Portion of Therapy (48)The interpersonal component of the interpersonal and social rhythm therapy techniques was initiated.An assessment was completed of the client's current and past significant relationships, including themes related to grief, interpersonal role disputes, role transitions, and skill deficits.The client was supported in reviewing concerns related to interpersonal relationships.

49 Use Interpersonal Therapy Techniques to Resolve Interpersonal Problems (49)Interpersonal therapy techniques were used to explore and resolve issues surrounding grief, role disputes, and role transitions.The client was provided with direction and training in regard to skill deficits.Support and strategies for resolving identified interpersonal issues were provided.

50 Establish a Rescue Protocol (50)A rescue protocol was developed in order to identify and manage clinical deterioration.Specific factors that would trigger the rescue protocol were identified.Specific factors of the rescue protocol were developed, including medication use, sleep pattern restoration, daily routine, and conflict-free social support.The client and significant others were reinforced for their use of the rescue protocol.The client and significant others were redirected in regard to the use of the rescue protocol.

51 Schedule “Maintenance Sessions” (51)The client was scheduled for a “maintenance session” between 1 and 3 months after therapy ends.The client was advised to contact the therapist if they need to be seen before the “maintenance session.”The client's “maintenance session” was held and the client was reinforced for successful implementation of therapy techniques.The client's “maintenance session” was held and the client was coordinated for further treatment, as progress has not been sustained.

52 Assign Reading on Bipolar Disorder (52)The client was assigned to read a book on bipolar disorder.The client was assigned to read The Bipolar Disorder Survival Guide (Miklowitz).The client was assigned to read The Bipolar Disorder Workbook (Forester & Gregory).The client was assigned to read Bipolar 101 (White & Preston).The client has read the assigned information on bipolar disorder and key concepts were reviewed.The client has not read the assigned information on bipolar disorder and was redirected to do so.

53 Outline Recovery Components (53)The client was assisted in outlining the essential components for managing manic/hypomanic states and addiction (i.e., taking medication, complying with medical monitoring, continuing therapy, attending therapy groups regularly, using a higher power, getting a sponsor, helping others in recovery).The client was assigned “Personal Recovery Planning” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was reinforced in endorsing recovery plan components.The client has implemented recovery plan components to assist in managing manic/hypomanic states and addiction; this was reinforced.The client has not been using recovery plan components and was redirected to do so.

54 Discuss Discharge Plan/Environment (54)Today's session focused on discharge planning and on assisting the client in deciding what environment is needed in early recovery.Active listening was provided as the client endorsed a healthy discharge plan and identified the environment needed in early recovery.The client has been reluctant to endorse specific discharge plans and was urged to be more direct in this area.The client is uncertain about the recovery environment that they must use in order to have a successful early recovery; specific feedback was provided.

55 Assign Step 4 Exercise (55)The client was taught about a 12-step recovery program's Step 4, focusing on the detailing of the exact nature of their wrongs.The client was directed to write an autobiography detailing the exact nature of their wrongs.The client has completed the autobiography, has detailed the exact nature of their wrongs, and has shared this with someone in recovery; the reaction of the support person was processed.The client has not completed the Step 4 exercise and was redirected to do so.

56 Develop Recovery Plan (56)The client was taught about the importance of working a program of recovery that includes attending recovery group meetings regularly and helping others.The client was assisted in developing a recovery program.The client was reinforced in describing active pursuit of the elements of the recovery program.The client has not followed through on a recovery program and was redirected to do so.

57 Develop 12-Step Program Contact (57)A contact with a representative of a 12-step program was coordinated.The client was assigned to talk to the 12-step program contact person about manic/hypomanic states and addiction.The client reported a helpful conversation with a 12-step recovery program contact person, including insight into manic/hypomanic states and addiction; this progress was reinforced.The client has not made contact with a 12-step recovery program's representative and was encouraged 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.