Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 31

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 borderline 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 Behaviors, Emotional Dysregulation, and Cognitions (3)The client's experience of distress and disability was assessed to identify targets of therapy.The client's pattern of behaviors (e.g., self-harm, anger outbursts, apparent competence, active passivity) was assessed to help identify targets for therapy.The client's emotional dysregulation, including mood swings, sensitivity, and painful emptiness, was assessed in regard to targets for therapy.The client's cognitions were assessed, including biases such as dichotomous thinking, overgeneralization, and catastrophizing, to assist in identifying targets for therapy.Specific targets for therapy were identified.

4 Explore Childhood Abuse/Abandonment (4)Experiences of childhood physical or emotional abuse, neglect, or abandonment were explored.As the client identified instances of abuse and neglect, the feelings surrounding these experiences were processed.The client's experiences with perceived abandonment were highlighted and related to current fears of this experience occurring in the present.As the client's experience of abuse and abandonment in childhood was processed, the client denied any emotional impact of these experiences.The client denied any experience of abuse and abandonment in childhood and was urged to talk about these types of concerns as they deem it necessary in the future.

5 Assess Substance Use History (5)The client's use of alcohol and other mood-altering substances was assessed.The client's use of alcohol and other mood-altering substances can be treated as a self-harm behavior.The client's use of alcohol and other mood-altering substances can be treated as an impulsive behavior.The client was referred for a more in-depth substance use assessment.

6 Arrange Substance Abuse Evaluation (6)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.

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 Refer for Medication Evaluation (11)The client was assessed in regard to the need for psychotropic medication.The client was referred to a prescribing clinician to be evaluated for psychotropic medications to stabilize mood.The client has cooperated with a referral to a prescribing clinician and has attended the evaluation for psychotropic medications.The client has refused to attend a medication evaluation for psychotropic medications and was redirected to do so.

12 Monitor Medication Adherence (12)The client's adherence with prescribed medications was monitored, and effectiveness of the medication on their level of functioning was noted.The client reported that the medication has been beneficial in stabilizing mood and was encouraged to continue its use.The client reported that the medication has not been beneficial in stabilizing mood; this was reflected to the prescribing clinician.The client reported side effects of the medication that they found intolerable; these side effects were relayed to the prescribing clinician.

13 Monitor Misuse (13)The client was informed of the risks of misusing medications.The client reported appropriate use of medication and was encouraged to continue its use.The client reported misusing medication and was redirected; this was reflected to the prescribing clinician.

14 Orient to Dialectical Behavioral Therapy (DBT) (14)The client was oriented to DBT.The multiple facets of DBT were highlighted, including support, collaboration, mindfulness, distress tolerance, coping, and interpersonal skill building.The use of exchange and negotiation, balancing of the rational and emotional mind, and acceptance and change strategies were emphasized.

15 Teach Biosocial View (15)The biosocial view related to borderline personality disorder was emphasized with the client.Biological and environmental vulnerabilities were explored with the client.

16 Assign Reading on Borderline Personality Disorder (16)The client was asked to read selected materials that reinforce therapeutic interventions.Portions of DBT Skills Training Handouts and Worksheets (Linehan) or The Dialectical Behavioral Therapy Skills Workbook (McKay, Wood, & Brantley) were assigned to the client.The client has read assigned materials and key concepts were reinforced.The client has not read assigned materials that reinforce therapeutic interventions and was redirected to do so.

17 Solicit Agreement for DBT (17)Using commitment strategies and motivational interviewing, an agreement was solicited from the client to work collaboratively within the parameters of the DBT approach.The client was assigned “Addressing Readiness and Motivation” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).A written agreement was developed with the client to work collaboratively within the parameters of the DBT approach.The client has agreed to work within the DBT approach, including staying in therapy for the specified time period, attending scheduled therapy sessions, reducing self-harm and suicidal behaviors, staying sober, and participating in skills training to address the behavioral, emotional, and cognitive vulnerabilities targeted in treatment.The client was reinforced for commitment to working within the DBT program.The client has not agreed to work within the DBT program and was referred back to “treatment as usual.”

18 Explore Self-Harm Behavior (18)The client's history and nature of self-harm and suicidal behaviors were explored thoroughly.The client recalled a pattern of self-harm and suicidal behaviors that has dated back several years.The client's self-harm and suicidal behaviors were identified as being associated with feelings of depression, fear, and anger, as well as a lack of self-identity.

19 Assess Suicidal Behavior (19)The client's history and current status regarding suicidal gestures were assessed.The onset, frequency, triggers, seriousness/risks, means, access to means, intent and immediate consequences that may reward or maintain the self-harm behaviors were identified.Alternative responses to these thoughts and actions were proposed.

20 Arrange Hospitalization (20)As the client was judged to be harmful of self, arrangements were made for voluntary psychiatric hospitalization.As the client refused a necessary psychiatric hospitalization, the proper steps to involuntarily hospitalize the client were initiated.The client has been psychiatrically hospitalized.Ongoing contact with the psychiatric hospital has been maintained in order to coordinate the most helpful treatment while in the hospital.

21 Assign Self-Monitoring Forms (21)The client was informed of the usefulness of self-monitoring forms, such as DBT Diary Cards.The client was assigned self-monitoring forms to assess self-harm risk.The client completed assigned self-monitoring forms and these were reviewed at the start of each session.The client did not complete assigned self-monitoring forms and was redirected to do so.

22 Refer to Emergency Helpline (22)The client was provided with an emergency helpline telephone number that is available 24 hours a day.Positive feedback was provided as the client promised to use the emergency helpline telephone number rather than engaging in any self-harm behaviors.The client has not used the emergency helpline telephone system in place of engaging in self-harm behaviors and was reminded about this useful resource.

23 Provide Therapist Contact Information (23)The client was provided with the therapist's telephone number for phone coaching of skills learned in therapy.The client was provided with clear instructions for proper use of phone contact, including establishing limits.The client used the provided telephone number and was appropriate in its use.The client used the provided telephone number but was inappropriate in its use and was redirected in this area.The client has not used the provided telephone number and was reminded of its usefulness.

24 Elicit Contact Contract (24)An agreement was elicited from the client that they will initiate contact with the therapist or an emergency helpline if the suicidal urge becomes strong and before any self-injurious behavior is enacted.The client completed “No Self-Harm Contract” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was reinforced in promising to terminate self-mutilation behavior and to contact emergency personnel if urges for such behavior arise.The client has followed through on the non-self-harm contract by contacting emergency service personnel rather than enacting any suicidal gestures or self-mutilating behavior; the client was reinforced for this healthy use of support.The client's potential for suicide was consistently assessed despite the suicide prevention contract.

25 Teach Distress Tolerance Skills (25)The client was taught about how to apply DBT distress tolerance skills and chain analysis.The client was reinforced for using distress tolerance skills and chain analysis to identify and intervene to reduce self-harm and suicidal behaviors.The client struggled to understand distress tolerance skills and chain analysis and was provided with remedial information.

26 Assign Self-Monitoring Homework (26)The client was assigned self-monitoring homework (e.g., DBT Diary Card) to help guide in-session chain analysis and problem-solving.The client completed self-monitoring homework, and this was reviewed.The client did not complete self-monitoring homework and was redirected to do so.

27 Resolve Therapy-Interfering Behaviors (27)The client's pattern of therapy-interfering behavior (e.g., missing appointments, noncompliance, abruptly leaving therapy) was consistently monitored.The client was confronted for therapy-interfering behaviors.The clinician took appropriate responsibility for the clinician's own therapy-interfering behaviors.Therapy-interfering behaviors were resolved.

28 Use Strategies to Manage Maladaptive Behaviors, Thoughts, and Feelings (28)Validation, dialectical strategies, and cognitive-behavioral strategies were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.Therapeutic techniques as described in Dialectical Behavior Therapy in Clinical Practice (Dimeff & Koerner) were used to help the client manage symptoms.The client was assigned “Plan Before Acting” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).Validation was consistently used to help the client manage, reduce, and stabilize maladaptive behaviors, thoughts, and feelings.Dialectical strategies, such as metaphor or devil's advocacy, were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.Cognitive-behavioral strategies, such as cost-benefit analysis, chain analysis, and problem-solving were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.It was noted that the client has decreased maladaptive behaviors, thought patterns, and feelings.

29 Conduct Skills Training (29)Group skills training was used to teach responses to identified problem behaviors.Individual skills training was used to teach the client responses to personal vulnerabilities and skill deficits.The client was taught to analyze own behavior, mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance skills.The client has participated in skills training for specific behavioral problems, and the benefit of this treatment was reviewed.The client has not participated in group skills training and was redirected to do so.

30 Teach Skills for Regular Use (30)Behavioral strategies were taught to the client via instruction, modeling, and advising.Role-playing and exposure exercises were used to strengthen the client's use of behavioral strategies.The client was provided with regular homework assignments to help incorporate the behavioral strategies into everyday life.The client was reinforced for regular use and understanding of behavioral strategies.The client has struggled to understand the behavioral strategies and was provided with remedial information in this area.

31 Conduct Trauma Work (31)As the client's adaptive behavior patterns have been evident, work on posttraumatic sequelae was initiated.The client was assisted in using new adaptive behavior patterns and emotional regulation skills to reduce denial and increase insight into the effects of previous trauma.The client was helped to reduce maladaptive emotional and/or behavioral responses to trauma-related stimuli through the regular use of adaptive behavioral patterns and emotional skills.The client was assisted in reducing self-blame and increasing acceptance and tolerance.The client has been noted to be successful in using adaptive behavioral patterns and emotional regulation skills in managing the effects of previous trauma.The client has become more emotionally dysregulated because of the trauma work and was redirected to use behavioral and emotional regulation skills.

32 Explore Schema and Self-Talk (32)The client was assisted in exploring how their schema, underlying assumptions, and self-talk mediate trauma-related and other fears.The client's distorted schema, assumptions, and self-talk were reviewed.The client was reinforced for insight into self-talk, assumptions, and schema that support trauma-related and other fears.The client struggled to develop insight into self-talk, assumptions, and schema and was provided with tentative examples of these concepts.

33 Assign Exercises on Self-Talk (33)The client was assigned homework exercises in which they identify fearful self-talk and create reality-based alternatives.The client was assigned the homework exercise “Journal and Replace Self-Defeating Thoughts” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was directed to complete the “Daily Record of Dysfunctional Thoughts” from Cognitive Therapy of Depression (Beck, Rush, Shaw, & Emery).The client's replacement of fearful self-talk with reality-based alternatives was critiqued.The client was reinforced for successes at replacing fearful self-talk with reality-based alternatives.The client has not completed assignments for identifying and replacing dysfunctional self-talk and was redirected to do so.

34 Reinforce Positive Self-Talk (34)The client was reinforced for implementing positive, realistic self-talk that enhances self-confidence and increases adaptive action.The client noted several instances from daily life that reflected the implementation of positive self-talk, and these successful experiences were reinforced.

35 Develop Hierarchy of Triggers (35)The client was directed to develop a hierarchy of feared and avoided trauma-related stimuli.The client was helped to list many of the feared and avoided trauma-related stimuli.The client was assisted in developing a hierarchy of feared and avoided trauma-related stimuli.The client's journaling was used to assist in developing a hierarchy of feared and avoided trauma-related stimuli.

36 Direct Imaginal Exposure (36)Imaginal exposure was directed by having the client describe a chosen traumatic experience at an increasing, but client-chosen, level of detail.Cognitive restructuring techniques were integrated and repeated until the associated anxiety regarding childhood trauma was reduced and stabilized.The session was recorded and provided to the client to listen to between sessions.“Share the Painful Memory” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce) was assigned to help direct the client's imaginal exposure.The client's progress was reviewed and reinforced and problems solved.

37 Assign Homework on Exposure (37)The client was assigned homework exercises to perform exposure to feared stimuli and record experience.The client was directed to listen to the taped exposure session to consolidate skills for exposure to feared stimuli.The client was assigned “Gradually Reducing Your Phobic Fear” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client's use of exposure techniques was reviewed and reinforced.The client has struggled in implementation of exposure techniques and was provided with corrective feedback.The client has not attempted to use the exposure techniques and was redirected to do so.

38 Treat Posttraumatic Stress Disorder (PTSD) (38)The client was identified as having a comorbid PTSD diagnosis.The client was treated with prolonged exposure therapy.The client was treated with cognitive processing therapy.The client was treated with eye movement desensitization and reprocessing (EMDR).The client's PTSD symptoms have significantly decreased and positive reinforcement was provided for this.The client's PTSD symptoms have not significantly decreased, and additional treatment in this area was coordinated.

39 Encourage Trust in Own Evaluations (39)The client was encouraged to value, believe, and trust in their evaluations of self, others, and situations.The client was encouraged to examine situations in a nondefensive manner, independent of others' opinions.The client was encouraged to build self-reliance through trusting their own evaluations.The client was assigned “Forming Stable Relationships” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was reinforced for value, belief, and trust in their own evaluations of self, others, and situations.The client was redirected when tending to devalue, disbelieve, and distrust their own evaluations.

40 Encourage Positive Experiences (40)The client was encouraged to facilitate personal growth and “capacity for sustained joy” by choosing experiences that strengthen self-awareness, personal values, and appreciation of life.The client was encouraged to use spiritual practices and other relative life experiences to help increase positive experiences.

41 Teach Problem-Solving Skills (41)The client was taught problem-solving skills.The client was taught to define the problem specifically, brainstorm options, list pros and cons of each option, choose and implement an option, and evaluate the outcome.The client was assigned the homework exercise “Plan Before Acting” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).Modeling, role-playing, and behavioral rehearsal were used to apply this skill to several current conflicts.

42 Conduct Transference-Focused Therapy (42)Transference-Focused Therapy was conducted using client-therapist communications.The client was assisted in understanding split representations of self and difficulties with self-control.The client was taught about how to integrate split representations of self and develop more effective means to self-control.

43 Conduct Schema-Focused Therapy (43)Schema-Focused Therapy was conducted with the client.The client was assisted in learning and changing entrenched, self-defeating patterns.The client was focused on the relationship with the therapist and daily life outside of therapy.The client was assisted in exploring early developmental experience that included trauma.

44 Conduct Mentalization Therapy (44)Mentalization Therapy was conducted with the client.The client was assisted in learning to interpret the actions of self and others through meaningful and understanding examination of mental states such as desires, needs, feelings, beliefs, and reasons.

45 Relate Borderline Traits to Addictive Behavior (45)The client was presented with information about how poor impulse control, poor anger management, fear of abandonment, and intense mood swings increase the probability of addictive behavior.The client was assigned “Analyzing Acting-Out Behavior” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).Active listening was used as the client identified specific incidences from their own life when their borderline traits have led to addictive behavior.The client has reported, as therapy has progressed, decreased incidences of borderline behaviors, with a commensurate decrease in addictive behavior.The client has struggled to identify how poor impulse control, poor anger management, fears of abandonment, and intense mood swings have led to an increase in addictive behavior; the client was provided with specific feedback in this area.

46 Teach About a Higher Power (46)The client was presented with information about how faith in a higher power can aid in recovery from borderline traits and addiction.The client was assisted in processing and clarifying their own ideas and feelings regarding their 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 consider this concept at a later time.

47 Develop an Aftercare Plan (47)The client was assisted in developing an aftercare plan that will support recovery when feeling angry, anxious, abandoned, or depressed.The client was assigned “Personal Recovery Planning” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client has listed several components of an aftercare plan that will support sobriety (e.g., self-help groups and sponsors, family activities, counseling); feedback was provided about the completeness of this plan.The client was reinforced in describing active pursuit of the elements of the aftercare plan.The client has not followed through on an aftercare plan and was redirected to do so.

48 Assist Family Members in Listing Support for Recovery (48)Family members were assisted in identifying ways in which they could be supportive of the client's sobriety.The client reported family members assisting significantly in encouragement and other techniques to help recover from borderline traits and addiction; this validation was emphasized.The client's significant others were strongly encouraged to attend Al-Anon meetings on a regular basis to support recovery.The client reported that family members have not been supportive of recovery; this rejection was processed.

49 Educate the Family About Borderline Syndrome (49)Family members were taught about the client's borderline syndrome and the steps that the client must take to recover successfully.Family members were reinforced as they have displayed an understanding of the client's borderline syndrome and the steps that the client must take to recover successfully.Family members refused to accept the information about the client's borderline syndrome, and they did not display an understanding of the steps that the client must take to recover successfully; remedial feedback was provided.

50 Develop a 5-Year Plan (50)The client was taught about the concept of a 5-year recovery plan.The client was assisted in developing a realistic 5-year personal recovery plan.The client was reinforced for a reasonable 5-year recovery plan.The client was provided with redirection in areas where the recovery plan seemed unrealistic.

51 Assess Satisfaction (51)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.