The Adult Psychotherapy Progress Notes Planner. David J. Berghuis

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      34 Conduct Interpersonal and Social Rhythm Therapy (34)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.

      35 Establish Routine Daily Activities (35)The client was assisted in establishing a more routine pattern of daily activities.The client was assigned “Identify and Schedule Pleasant Activities” in the Adult Psychotherapy Homework Planner (Jongsma).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.

      36 Teach About Sleep Hygiene Importance (36)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).The client's sleep pattern was routinely assessed.Interventions for the client's sleep pattern were provided, as he/she/they have been noted to have a dysfunctional sleep pattern.

      37 Engage in Behavioral Activation (37)The client was engaged in “behavioral activation” by scheduling activities that have a high likelihood for pleasure and mastery.The client was directed to complete tasks from the “Identify and Schedule Pleasant Events” assignment from the Adult Psychotherapy Homework Planner (Jongsma).Rehearsal, role-playing, role reversal, and other techniques were used to engage the client in behavioral activation.The client was reinforced for his/her/their 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.

      38 Conduct Interpersonal Portion of Therapy (38)The interpersonal component of the interpersonal and social rhythm therapy techniques was initiated.An assessment was completed of the client's current past significant relationships, including themes related to grief, interpersonal role disputes, role transitions, and skill deficits.The client was supported as he/she/they reviewed concerns related to interpersonal relationships.

      39 Use Interpersonal Therapy Techniques to Resolve Interpersonal Problems (39)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.

      40 Establish a Rescue Protocol (40)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 was provided with “Keeping a Daily Rhythm” in the Adult Psychotherapy Homework Planner (Jongsma).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.

      41 Schedule “Maintenance Sessions” (41)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 he/she/they need to be seen prior to the “maintenance session.”The client's “maintenance session” was held and he/she/they were reinforced for his/her/their successful implementation of therapy techniques.The client's “maintenance session” was held and he/she/they were coordinated for further treatment, as his/her/their progress has not been sustained.

      42 Assign Reading on Bipolar Disorder (42)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 and Gregory).The client was assigned to read Bipolar 101 (White and 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.

      43 Pledge Support (43)The client was reassured on a regular basis that the therapist would be available to consistently listen to and support him/her/them.The client reacted favorably to the therapist's pledge of support and has begun to show trust in the relationship by sharing thoughts and feelings.

      44 Explore Abandonment Fears (44)The client's fear of abandonment by sources of love and nurturance was explored.Active listening skills were used as the client confirmed that he/she/they struggle with the fear that those who have provided love and nurturance to him/her/them will eventually abandon him/her/them.The client denied any fear of abandonment by sources of love and nurturance; he/she/they were urged to monitor this on an as-needed basis.

      45 Differentiate Losses (45)The client was helped to differentiate between real and imagined, as well as actual and exaggerated, losses.The client was supported as he/she/they verbalized grief, fear, and anger regarding real or imagined losses in life.The client was helped to make a differentiation between his/her/their real and imagined losses, rejections, and abandonment.The client was quite guarded and unrealistic about his/her/their pattern of losses and was provided with feedback in this area.

      46 Probe Losses (46)Real or perceived losses in the client's life were explored.Active listening was used as the client confirmed that he/she/they have unresolved feelings regarding losses that have been experienced.It was interpreted to the client that his/her/their experience of loss has precipitated fears of abandonment in other relationships.The client denied any significant losses in his/her/their life, and this was accepted.

      47 Process Losses (47)The client's experiences of loss were processed in an attempt to help him/her/them put them into proper perspective.The client was helped to identify adaptive ways to replace the losses that were experienced.The client failed to process and develops adaptive ways to replace losses that have been experienced and was gently offered examples of how to do this.

      48 Explore Family-of-Origin History (48)The client was supported as he/she/they shared experiences from his/her/their family-of-origin history that have caused feelings of low self-esteem and fear of abandonment.The client was supported as he/she/they revealed experiences with critical and rejecting parents that led to feelings of low self-esteem.The client disclosed experiences of childhood abandonment by parent figures; these have been noted to lead to the fear of abandonment in current relationships.The client was quite guarded about his/her/their family-of-origin history and was urged to be more open in this area, as he/she/they feel capable of doing so.

      49 Use ACT Approach (49)Acceptance and commitment therapy (ACT) was applied.The client was assisted in accepting and openly experiencing depressive thoughts and feelings, without being overly impacted by them.The client was assisted in committing his/her/their time and efforts to activities that are consistent with identified personally meaningful values.The client has engaged well in the ACT approach and applied these concepts to his/her/their symptoms and lifestyle.The client has not engaged well in the ACT approach and remedial efforts were applied.

      50 Assign Positive Affirmations (50)The client was assigned to write at least one positive affirmation statement on a daily basis regarding oneself and the future.The client was assigned “Positive Self-Talk” exercise from the Adult Psychotherapy Homework Planner (Jongsma).The client has followed through on the assignment of writing positive affirmation statements and reported that he/she/they are feeling more positive about the future.The client was reinforced for making positive statements regarding oneself and his/her/their ability to cope with the stresses of life.The client has not followed through on the assignment of writing positive affirmation statements and was encouraged to do so.

      51 Teach Normalization of Sadness (51)The client was taught about the variation in mood that is within the normal sphere.The client reported that he/she/they are developing an increased tolerance to mood swings and is not attributing them to significant depression; this progress was reinforced.The client is verbalizing more hopeful and СКАЧАТЬ