Читать книгу The Addiction Progress Notes Planner - Группа авторов - Страница 34

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 experiences of childhood trauma.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 the 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 Assign Step 1 Exercise for Addiction and Childhood Trauma (3)A 12-step recovery program's Step 1 was used to help the client see the powerlessness and unmanageability that have resulted from using addiction to deal with the negative feelings associated with childhood traumas.The client was assigned the Step 1 exercise from The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client displayed an understanding of the concept presented regarding powerlessness and unmanageability regarding addiction and the negative feelings associated with childhood trauma.The client was able to endorse the concept of powerlessness and unmanageability that have resulted from using addiction to deal with negative feelings associated with childhood trauma; this progress was reinforced.The client denied any sense of powerlessness or unmanageability in regard to the use of addiction to deal with negative feelings associated with childhood traumas; the client was provided with tentative examples of this concern.

4 Explore Painful Childhood Experiences (4)The client's painful childhood experiences were explored.Active listening was provided as the client explained what it was like to grow up in their home environment, focusing on the abusive, neglectful experiences that they endured.The client was assisted in identifying the unhealthy emotional and behavioral patterns that have evolved from the painful family-of-origin experiences.The client was helped to identify a variety of emotional effects from the painful situations they endured in the family of origin.The client helped to identify a variety of behavioral patterns that have occurred owing to the painful experiences from the family of origin.The client was assigned “Share the Painful Memory” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client denied any pattern of unhealthy emotional or behavioral patterns that have occurred owing to painful experiences from the family of origin; this was accepted.The client has refused to discuss any details or feelings related to childhood emotional traumas; the client was urged to do so as they feel safe.

5 Administer Psychological Instruments (5)Psychological instruments designed to objectively assess childhood trauma effects on substance abuse were administered to the client.The Childhood Trauma Questionnaire (CTQ) was administered to the client.The Davidson Trauma Scale (DTS) was administered to the client.The Beck Depression Inventory–II (BDI-II) was administered to the client.The Beck Anxiety Inventory (BAI) was administered to the client.The Substance Abuse Subtle Screening Inventory–4 (SASSI-4) was administered to the client.The client was provided with feedback regarding the results of the psychological instruments administered.

6 Assess Level of Insight (6)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.

7 Assess for Correlated Disorders (7)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.

8 Assess for Culturally Based Confounding Issues (8)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.

9 Assess Severity of Impairment (9)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.

10 Encourage Feelings Expression (10)The client was supported and encouraged when they began to express feelings of rage, fear, and rejection relating to family abuse or neglect.The client was supported as they have continued to clarify their understanding of feelings associated with major traumatic incidents in childhood.As the client has clarified feelings and shared them within the session, feelings of emotional turmoil have diminished.The client continues to be very guarded about feelings of rage, fear, and rejection related to the family abuse or neglect and was encouraged to get in touch with these feelings as the client is capable of doing so.

11 Assign Feelings Journal (11)The client was assigned to record feelings in a journal that describes memories, behavior, and emotions tied to traumatic childhood experiences.The client was assigned “How the Trauma Affects Me” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client has followed through on the journaling assignment and has developed an increased awareness of the impact that childhood experiences have had on present feelings and behaviors; this progress was reviewed.The client was assisted in identifying how childhood experiences have influenced how the client parents their own children today.The client has not completed the assigned feelings journal and was redirected to do so.

12 Assign Books on Childhood Trauma (12)Reading materials relating to traumatic childhood experiences were recommended to the client to assist in developing insight.The client was advised to read It Will Never Happen to Me (Black), Outgrowing the Pain (Gil), or Healing the Child Within (Whitfield).The client has followed through on reading the recommended childhood trauma material, and insights related to that reading were processed.The client has not followed through on reading the recommended material and was redirected to do so.

13 Teach About Unhealthy Rules and Roles (13)The client was presented with information about the unhealthy rules and roles that develop in dysfunctional families.The client was assigned “Changing From Victim to Survivor” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assisted in identifying the pattern of unhealthy rules and roles that occurred in the family of origin.The client was able to identify the role that they played within the family dynamics.The client struggled to identify or admit to an unhealthy pattern of rules and roles in the family of origin; tentative examples were provided.The client has not completed the assigned homework and was redirected to do so.

14 Connect Childhood Trauma With Trust Issues (14)The client was presented with the concept that childhood trauma experiences have precipitated problems with trust, anger, self-esteem, and depression.The client accepted the concept presented regarding problems with trust, anger, self-esteem, and depression because of childhood experiences.The client rejected the concept that childhood trauma experiences relate to their problems with trust, anger, self-esteem, or depression; tentative examples were provided.

15 Identify Addictive Behavior as an Unhealthy Coping Skill (15)The client was asked about addiction behavior as a means of coping with emotional pain.The client's addictive behavior was confronted as an inappropriate way to cope with emotional pain.The client was assisted in identifying the self-defeating, negative consequences of addictive behavior.Verbal reinforcement was provided as the client identified the self-defeating, negative consequences of the negative behavior.The client denied any pattern of addictive behavior as a way to cope with emotional pain and was provided with specific examples of how this can occur.

16 Teach Healthy Ways to Cope With Pain (16)The client was asked to identify healthier, more constructive means of coping with emotional pain.The client was assigned “Setting and Maintaining Boundaries” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma) or “Deep Breathing Exercise” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was assisted in identifying healthier, more constructive means of coping with emotional pain (e.g., sharing pain with others, attending 12-step recovery program meetings, confronting and then forgiving the perpetrator, turning issues over to a higher power).The client was reinforced in endorsing a variety of healthier, more constructive means of coping with emotional pain.The client was reinforced while reporting a pattern of using healthier means for coping.The client has struggled to implement healthier coping mechanisms and continues to rely on addictive behavior; brainstorming techniques were used.The client denied any significant negative consequences from addictive behavior; additional examples were reviewed.

17 Refer for Medication Evaluation (17)The client was referred for a medication evaluation to help stabilize moods and decrease the intensity of angry feelings.The client agreed to follow through with the medication evaluation.The client was strongly opposed to being placed on medication to help stabilize moods and reduce emotional distress.

18 Monitor Effects of Medication (18)The client's response to the medication was discussed in today's therapy session.It was noted that the medication has helped the client to stabilize moods and decrease the intensity of angry feelings.It was noted that the client has had little or no improvement in moods or anger control since being placed on the medication.The client was reinforced as they have consistently taken the medication as prescribed.The client has failed to comply with taking the medication as prescribed and was redirected to do so.

19 Conduct Treatment for Borderline Traits (19)The client was oriented to dialectical behavioral therapy (DBT).The multiple facets of DBT were highlighted, including support, collaboration, challenge, problem-solving, and skill building.The biosocial view related to borderline personality disorder was emphasized, including the constitutional and social influences.The concept of dialectics was reviewed with the client.The client was provided with treatment specific for borderline traits.

20 Refer for PTSD Treatment (20)The client was identified as manifesting posttraumatic stress disorder (PTSD) symptoms.The client was provided with therapy for posttraumatic stress disorder.The client was coordinated for prolonged exposure therapy.The client was coordinated for cognitive processing therapy.The client was coordinated for eye movement desensitization and reprocessing therapy.The client has followed through on treatment for PTSD and was reinforced for this.The client has not followed through on treatment for PTSD and was reminded to do so.

21 Assign Feelings Letter (21)The client was assigned the task of writing a letter to their parents regarding feelings associated with the experience of childhood neglect or abuse.The client has followed through with writing a feelings letter to parents regarding childhood abuse/neglect and this letter was processed.It was reflected to the client that writing the letter regarding childhood abuse experiences has helped decrease feelings of shame and affirm the client as not being responsible for the abuse.The client has not followed through with writing the letter to parents regarding the childhood abuse or neglect experiences and was redirected to do so.

22 Support Confrontation of Perpetrator (22)A conjoint session was held where the client confronted the perpetrator of childhood abusive experiences.The client was supported in confrontation of the perpetrator of abuse and neglect while responsibility for that neglect was placed clearly on the perpetrator.The client found it very difficult to be direct in confrontation of the perpetrator of childhood abuse/neglect; the client was urged to be more direct.The perpetrator responded with defensive statements and denial in reaction to the client's confrontation regarding childhood abuse and neglect; the client was supported in rejecting this blame and denial.Since the confrontation of the perpetrator, the client has reported decreased feelings of shame and more clarity regarding not being responsible for the abuse that occurred; the benefits of this progress were reviewed.The client has declined confrontation of the perpetrator; the client was accepted for this decision and urged to consider confrontation at a later date.

23 Use Empty-Chair Exercise (23)The client was guided in an empty-chair exercise with the perpetrator of the abuse as the imagined person in the empty chair.The client was guided in an empty-chair exercise in which the nonperpetrating parent was imagined to be in the empty chair.The client was assisted in expressing feelings and clarifying the impact that the childhood experiences of abuse had.The client was assigned “It Wasn't My Fault” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was reinforced as they affirmed self as not being responsible for the abuse and placed responsibility clearly on the perpetrator.The client was supported in confronting the nonperpetrating parent for not protecting the client from the abusive experiences in childhood.

24 Reinforce Holding Perpetrator Responsible (24)Any and all statements that the client made that reflected placing blame on the perpetrators and nonprotective, nonnurturing adults for painful childhood experiences were reinforced.The client was consistently reminded that they were not responsible for the abuse and neglect that occurred in childhood but that it was the responsibility of childhood parents or caretakers.The client continues to struggle with self-blame for the abusive experiences of childhood; statements indicating self-blame were confronted and reframed.

25 Explore Victim Versus Survivor (25)The client was asked to consider the positive and negative consequences of considering self as a victim versus being a survivor of childhood trauma.The client's understanding of the advantages of self-perception as a survivor of abuse and neglect rather than a victim was processed.The client has continued to view self as a victim of painful childhood experiences and has not moved forward toward feeling empowered as a survivor; this stagnation was reflected to the client.

26 Reinforce Survivor Self-Perception (26)The client was encouraged and reinforced to perceive self as a survivor rather than a victim of childhood abuse or neglect.The client was assigned “Changing from Victim to Survivor” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).As the client increased statements that reflected a self-perception of survivorship rather than victimization, strong reinforcement was given.The client has continued to make statements of being a victim rather than statements of personal empowerment that reflect survivorship; the client was helped to reframe these statements into survivor statements.

27 Teach Share-Check Technique (27)The client was taught to build trust in relationships through the use of the share-check technique.The client reported beginning to share personal thoughts and feelings with others on a minimal basis in order to see if those feelings are dealt with respectfully and supportively; the results of this sharing were reviewed.The client expressed difficulty with building trust and intimacy with others; the client was reminded to do this in small steps.The client was reinforced in expressing insight into difficulty with building trust as related to childhood experiences of abuse and neglect.

28 Teach Trust in Others (28)The client was encouraged and taught the advantages of treating others as trustworthy while continuing to assess their character.Positive feedback was provided as the client reported beginning to increase trust and interaction with others.The client continues to struggle with issues of trust and to be withdrawn in social relationships; the client was reminded to increase trust in small steps.

29 Teach Healthy Problem-Solving and Communication (29)The client was taught healthy conflict resolution skills (e.g., active listening, using “I” messages, cooperation, compromise, mutual respect).The client reported an increase in using the healthy conflict resolution skills they have been taught.The client identified that they have regularly been using healthy conflict resolution skills (e.g., active listening, using “I” messages, cooperation, compromise, mutual respect); this experience was reviewed.The client has struggled to implement the use of healthy conflict resolution skills; barriers to this progress were brainstormed.

30 Teach Honest Communication Skills (30)The client was taught about healthy communication skills, including being honest, asking for wants, and sharing feelings.The client was provided with modeling, role-playing, and behavior rehearsal to teach more honest communication skills.The client was reinforced for more honest communication.The client continues to struggle in being straightforward with honesty, asking for wants, and sharing feelings; additional techniques were provided.

31 Teach Assertiveness Skills (31)The client was taught assertiveness skills through the use of modeling, behavior rehearsal, and role-playing.The client displayed an understanding of the assigned components of assertiveness.The client was assigned “Becoming Assertive” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, McInnis, & Bruce).The client used a journal to list assertive experiences; the journal was processed.The client listed several situations in which they have been able to be assertive; these were processed.The client reported finding it very difficult to implement assertiveness skills; small successes were encouraged.

32 Identify Unresolved Needs, Wishes, and Wants (32)The client was assisted in identifying, understanding, and verbalizing unresolved needs, wishes, and wants from childhood.The client was assigned “Corresponding With My Childhood Self” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma) to help a variety of needs, wishes, and wants from childhood.As the client has progressed in therapy, they have been helped to identify techniques for resolving childhood needs, wishes, and wants.The client was unable to consistently identify unmet needs, wishes, and wants from childhood; tentative examples were provided.The client was assisted with developing a written plan to meet each of their unmet needs, wishes, and wants.The client has implemented the plan to meet unmet needs, wishes, and wants; this was reviewed for successes and failures.The client has struggled to develop a written plan to meet each of their unmet needs, wishes, and wants and was redirected to do so.

33 Assign Books on Childhood Trauma (33)Reading materials relating to traumatic childhood experiences were recommended to the client to assist in developing insight.The client has followed through on reading the recommended childhood trauma material, and the insights related to that reading were processed.The client has been able to use the insights from the reading materials on childhood traumas in order to assist in identifying unresolved feelings, wishes, and wants; positive feedback was provided.The client has not followed through on reading the recommended childhood trauma material and was redirected to do so.

34 Assign Forgiveness Letter (34)The client was assigned to write a letter of forgiveness to the perpetrator of the childhood hurt.The client was assigned “Feelings and Forgiveness Letter” from the Adult Psycho- therapy Homework Planner (Jongsma).The client has followed through with writing a forgiveness letter to the perpetrator of the childhood hurt; as this letter was processed, the client reported experiencing a sense of putting the issue in the past.The client reported beginning the process of forgiving the perpetrator of childhood pain and others who may have been passive collaborators; the benefits of this progress were highlighted.The client has not followed through on writing the forgiveness letter to the perpetrator of childhood pain and was redirected to do so.

35 Assist With a Letter to the Parents (35)The client was assigned to write a letter to each parent or primary caregiver, detailing the childhood abuse and sharing what the client wants from each person in recovery.The client has followed through on writing a letter to each parent or primary caregiver and has processed this within the session.The client has shared the letter with the appropriate parent or primary caregiver, presenting information about the childhood abuse and sharing what they want from each person in recovery; this experience was processed.The client has not followed through with writing a letter to each parent or primary caregiver and was redirected to do so.The client has written the letter to each parent or primary caregiver but has declined to present this to the parent or caregiver; this decision was accepted.

36 Teach About a Higher Power (36)The client was presented with information about how faith in a higher power can aid in recovery from childhood trauma issues.The client was assisted in processing and clarifying ideas and feelings regarding the existence of a higher power.The client used faith in a higher power to assist in forgiving others and reestablishing self-esteem; the benefits were processed.The client rejected the concept of a higher power; the client was urged to be open to this concept.

37 View Perpetrators as Wounded Children (37)The client was presented with the concept that perpetrators were often wounded as children, too, and may need to be forgiven and turned over to a higher power.The client was noted to endorse the idea that the perpetrator(s) was/were also a wounded child.The client was noted to endorse the idea that the perpetrator needed to be forgiven and turned over to a higher power, in order to escape the client's harboring rage at the perpetrator.The client rejected any idea that the perpetrator(s) was/were wounded as a child and needed to be turned over to a higher power; the client was urged to remain open.

38 Recommend Books on Forgiveness (38)The client was recommended to read books on the topic of forgiveness.The client was referred to Forgive and Forget (Smedes).The client was referred to When Bad Things Happen to Good People (Kushner).The client has read the assigned material on forgiveness, and key points were processed.The client has not read books on the topic of forgiveness and was redirected to do so.

39 Teach Benefits of Forgiveness (39)The client was taught the benefits of forgiveness.The client was asked to identify how they have benefited from the process of forgiveness.The client was taught about how releasing hurt and anger, putting an issue in the past, and increasing trust of others can help with forgiveness.The client was reminded that forgiveness does not necessarily mean forgetting or fraternizing with abusive adults.

40 Assign Letter to Perpetrator (40)The client was assigned to write a forgiveness letter to the perpetrator of the abuse.The client was assigned “Feelings and Forgiveness Letter” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client has written a forgiveness letter to the perpetrator of the abuse, and this was processed within the session.The client has not written the letter to the perpetrator of the abuse, and this resistance was processed.

41 Substitute 12-Step Recovery Program for Family (41)The client was presented with the concept of how a home 12-step recovery group can function as a healthy family that the client never had.The client was assisted in realizing why they need a family to assist in recovery.The client was reinforced while displaying acceptance of the idea of using a home group of a 12-step program to assist in recovery.The client was resistant to acknowledging a need for a healthy family; this concept was reinforced.

42 Develop an Aftercare Plan (42)The client was assisted in developing an aftercare plan that will support recovery from childhood trauma and addiction issues, including regular attendance at 12-step program meetings.The client has listed several components of an aftercare program that will support sobriety (e.g., self-help groups and sponsors, family activities, counseling); the plan was critiqued.The client was reinforced while describing active pursuit of the elements of the aftercare plan.The client has not followed through on an aftercare program and was redirected to do so.

43 Assess Satisfaction (43)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.