The Adult Psychotherapy Progress Notes Planner. David J. Berghuis

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      1 Depressed Affect (1)¹The client reported that he/she/they feel deeply sad and have periods of tearfulness on an almost daily basis.The client's depressed affect was clearly evident within the session as tears were shed on more than one occasion.The client reports an irritable mood.The client reported that he/she/they have begun to feel less sad and can experience periods of joy.The client appeared to be happier within the session and there is no evidence of tearfulness.

      2 Loss of Appetite (2)The client reported that he/she/they have not had a normal and consistent appetite.The client's loss of appetite has resulted in a significant weight loss associated with the depression.As the depression has begun to lift, the client's appetite has increased.The client reported that his/her/their appetite is at normal levels.

      3 Lack of Activity Enjoyment (3)The client reported a diminished interest in or enjoyment of activities that were previously found pleasurable.The client has begun to involve oneself with activities that he/she/they previously found pleasurable.The client has returned to an active interest in and enjoyment of activities.

      4 Psychomotor Agitation (4)The client demonstrated psychomotor agitation within the session.The client reported that with the onset of the depression, he/she/they have felt unable to relax or sit quietly.The client reported a significant decrease in psychomotor agitation and the ability to sit more quietly.It was evident within the session that the client has become more relaxed and less agitated.

      5 Psychomotor Retardation (4)The client demonstrated evidence of psychomotor retardation within the session.The client moved and responded very slowly, showing a lack of energy and motivation.As the depression has lifted, the client has responded more quickly and psychomotor retardation has diminished.

      6 Sleeplessness/Hypersomnia (5)The client reported periods of inability to sleep and other periods of sleeping for many hours without the desire to get out of bed.The client's problem with sleep interference has diminished as the depression has lifted.Medication has improved the client's problems with sleep disturbance.

      7 Lack of Energy (6)The client reported that he/she/they feel a very low level of energy compared to normal times in his/her/their life.It was evident within the session that the client has low levels of energy, as demonstrated by slowness of walking, minimal movement, lack of animation, and slow responses.The client's energy level has increased as the depression has lifted.It was evident within the session that the client is demonstrating normal levels of energy.

      8 Lack of Concentration (7)The client reported that he/she/they are unable to maintain concentration and are easily distracted.The client reported that he/she/they are unable to read material with good comprehension because of being easily distracted.The client reported increased ability to concentrate as his/her/their depression has lifted.

      9 Indecisiveness (7)The client reported a decrease in his/her/their ability to make decisions based on lack of confidence, low self-esteem, and low energy.It was evident within the session that the client does not have normal decision-making capabilities.The client reported an increased ability to make decisions as the depression is lifting.

      10 Social Withdrawal (8)The client has withdrawn from social relationships that were important to him/her/them.As the client's depression has deepened, he/she/they have increasingly self-isolated.The client has begun to reach out to social contacts as the depression has begun to lift.The client has resumed normal social interactions.

      11 Suicidal Thoughts/Gestures (9)The client expressed that he/she/they are experiencing suicidal thoughts but have not taken any action on these thoughts.The client reported suicidal thoughts that have resulted in suicidal gestures.Suicidal urges have been reported as diminished as the depression has lifted.The client denied any suicidal thoughts or gestures and is more hopeful about the future.

      12 Feelings of Hopelessness/Worthlessness (10)The client has experienced feelings of hopelessness and worthlessness that began as the depression deepened.The client's feelings of hopelessness and worthlessness have diminished as the depression is beginning to lift.The client expressed feelings of hope for the future and affirmation of his/her/their own self-worth.

      13 Inappropriate Guilt (10)The client described feelings of pervasive, irrational guilt.Although the client verbalized an understanding that his/her/their guilt was irrational, it continues to plague him/her/them.The depth of irrational guilt has lifted as the depression has subsided.The client no longer expresses feelings of irrational guilt.

      14 Low Self-Esteem (11)The client stated that he/she/they have a very negative self-perception.The client's low self-esteem was evident within the session as he/she/they made many self-disparaging remarks and maintained very little eye contact.The client's self-esteem has increased as he/she/they are beginning to affirm his/her/their self-worth.The client verbalized positive feelings toward oneself.

      15 Unresolved Grief (12)The client has experienced losses about which he/she/they have been unable to resolve feelings of grief.The client's feelings of grief have turned to major depression as energy has diminished and sadness/hopelessness dominate his/her/their life.The client has begun to resolve the feelings of grief associated with the loss in his/her/their life.The client has verbalized feelings of hopefulness regarding the future and acceptance of the loss of the past.

      16 Hallucinations/Delusions (13)The client has experienced mood-related hallucinations or delusions indicating that the depression has a psychotic component.The client's thought disorder has begun to diminish as the depression has been treated.The client reported no longer experiencing any thought disorder symptoms.

      17 Recurrent Depression Pattern (14)The client reported a recurrent pattern of depressive episodes that have been treated with a variety of approaches.The client has a history of depression within the family that parallels his/her/their own experience of depression.

      18 Manic Episode (15)The client reported the experience of one hypomanic, manic, or mixed mood episode.The client reported multiple hypomanic, manic, or mixed mood episodes.

      1 Establish Rapport (1)²Caring 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 his/her/their bipolar depression symptoms.The client began to express feelings more freely as rapport and trust level have increased.The client has continued СКАЧАТЬ