The Adult Psychotherapy Progress Notes Planner. David J. Berghuis

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СКАЧАТЬ being open and direct about his/her/their expression of painful feelings; he/she/they were 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 Inventory to Diagnose Depression (Zimmerman, Coryell, Corenthal, and Wilson) 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 Administer Psychological Tests for Depression (4)Psychological testing was arranged to objectively assess the client's depression and suicide risk.The Beck Depression Inventory–II was used to assess the client's depression and suicide risk.The Beck Hopelessness Scale was used to assess the client's depression and suicide risk.The Perceived Criticism Scale (Hooley and Teasdale) was used to assess the client's depression.The results of the testing indicated severe concerns related to the client's depression and suicide risk, and this was reflected to the client.The results of the testing indicated moderate concerns related to the client's depression and suicide risk, and this was reflected to the client.The results of the testing indicated mild concerns related to the client's depression and suicide risk, and this was reflected to the client.

      5 Refer for Physician Assessment Regarding Etiology (5)The client was referred to a physician to rule out nonpsychiatric medical etiologies (e.g. thyroid dysregulation, sedative use) for his/her/their bipolar disorder.The client was referred to a physician to rule out substance-induced etiologies for his/her/their 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.

      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 his/her/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 his/her/their 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 his/her/their clinical presentation.The client was assessed for gender-related issues that could help to better understand his/her/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 his/her/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 his/her/their 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 his/her/their impairment in social, relational, vocational, and occupational endeavors.It was reflected to the client that his/her/their impairment appears to create mild to moderate effects on the client's functioning.It was reflected to the client that his/her/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 Explore Suicide Potential (11)The client's experience of suicidal urges and his/her/their history of suicidal behavior were explored.It was noted that the client has stated that he/she/they do experience suicidal urges but feel that they are clearly under his/her/their control and that there is no risk of engagement in suicidal behavior.The client identified suicidal urges as being present but contracted to contact others if the urges became strong.Because the client's suicidal urges were assessed to be very serious, immediate referral to a more intensive supervised level of care was made.Due to the client's suicidal urges, and his/her/their unwillingness to voluntarily self-admit to a more intensive, supervised level of care, involuntary commitment procedures were begun.

      12 Monitor Ongoing Suicide Potential (12)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 his/her/their control; he/she/they were praised for this progress.The client stated that he/she/they have no longer experienced thoughts of self-harm; he/she/they will continue to be monitored.The client stated that his/her/their suicide urges are strong and present a threat; a transfer to a more supervised setting was coordinated.

      13 Refer for Hospitalization (13)Because the client was judged to be harmful to self, a referral was made for immediate hospitalization.The client was resistive to hospitalization for treatment of his/her/their suicide potential, so a commitment procedure was utilized.The client cooperated with hospitalization to treat the serious suicidal urges.

      14 Refer to Medication Prescriber (14)A referral to a medication prescriber was made for the purpose of evaluating the client for a prescription for psychotropic medication.The client has followed through on a referral to a physician and has been assessed for a prescription of psychotropic medication.The client has been prescribed antidepressant medication.The client has refused the prescription of psychotropic medication prescribed by the physician.

      15 Monitor Medication Adherence (15)As the client has taken the antidepressant medication prescribed by his/her/their prescriber, the effectiveness and side effects of the medication were monitored.The client reported that the antidepressant medication has been beneficial in reducing sleep interference and in stabilizing mood; the benefits of this progress were reviewed.The client reported that the antidepressant medication has not been beneficial; this was relayed to the prescribing clinician.The client was assessed for side effects from his/her/their medication.The client has not consistently taken the prescribed antidepressant medication and was redirected to do so.

      16 Monitor Ability to Participate in Psychotherapy (16)The client's pattern of symptom improvement was monitored, with a focus on how stable he/she/they are in regard to participation in СКАЧАТЬ