The Adult Psychotherapy Progress Notes Planner. David J. Berghuis
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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.
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 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.
10 Enhance Motivation (10)Directive, client-centered, empathic, and motivation-enhancing treatment interventions were utilized.Rapport was established with the client through reflective listening and asking permission before providing information or advice.Motivational interviewing techniques were used to help develop greater rapport.
11 Use Open-Ended Questions to Explore Motivation (11)Open-ended questions were used to help the client explore his/her/their own motivation for change.The client was affirmed for his/her/their change-related statements and efforts.
12 Elicit Discrepancy (12)The client was asked about his/her/their level of dissatisfaction with the status quo.The client was assisted in identifying the pros and cons of potential changes.The client was assisted in identifying the discrepancy gap between his/her/their current behavior and his/her/their desired life goals.Care was taken to avoid direct confrontation or argumentation.
13 Identify Trust Loss (13)The client was reminded that his/her/their behavior of broken promises, insensitivity, and trampling on the rights of others results in broken relationships as others lose trust in him/her/them.The client was consistently reminded that any meaningful relationship is based on trust that the other person will treat one with kindness and respect.The client's behavior pattern was reviewed to understand how he/she/they treated others with a lack of respect and a lack of kindness and how these actions resulted in the loss of trust in the relationship.Support and encouragement were provided to the client as he/she/they identified how his/her/their behavior has caused a lack of trust in the relationship.The client denied any connection between his/her/their behavior and the loss of trust in the relationship and was gently offered examples in this area.
14 Teach the Need for Lawfulness (14)The client's pattern of unlawful behavior was reviewed and he/she/they were reminded that if everyone in society adopted his/her/their unlawful attitude, anarchy would result.The client was taught that respect for law and order and the rights of others is the only way that a civilized society can function.The client was reinforced as he/she/they acknowledged the need for lawfulness and how this will result in trust and a civilized society.The client denied any pattern of lawlessness to his/her/their behavior, despite facts to the contrary, and was confronted for this denial.
15 Solicit Commitment to Lawfulness (15)The client was asked to give his/her/their commitment to conforming to the laws of society.The client was asked to give a rationale for a prosocial, law-abiding lifestyle being adopted.The client was asked to list 10 reasons why he/she/they would commit self to a law-abiding lifestyle.Positive feedback was given to the client for his/her/their commitment to lawfulness.The client declined to commit to living in a lawful manner and was provided with additional feedback regarding the negative consequences for such refusal.
16 Inhibit Future Lawlessness (16)The client was firmly and consistently reminded of the negative legal consequences that would accrue to him/her/them if continued lawlessness was practiced.The client was asked to list six future negative consequences of continued antisocial behavior.The client's list of negative consequences of continued antisocial behavior was reviewed and processed.The client has not completed a list of negative consequences of antisocial behavior and was redirected to do so.
17 Review Broken Relationships (17)The client was asked to list any and all relationships that have been lost due to his/her/their pattern of antisocial behavior.As lost relationships were reviewed, the client was confronted with his/her/their responsibility for the actions that resulted in the broken relationships.As broken relationships were reviewed, the client was asked to identify what behavior of his/her/their own led to the broken relationship.The client was provided with support as he/she/they seemed to openly describe his/her/their broken relationships.
18 Confront Lack of Sensitivity (18)The client was firmly and consistently confronted with the reality of his/her/their own behavior that caused pain to others and resulted in their breaking off the relationship.The client was asked to identify how he/she/they were insensitive to the needs and feelings of others.Role-reversal techniques were used to attempt to get the client in touch with the pain he/she/they have caused in others due to disrespect, disloyalty, aggression, or dishonesty.The client was provided with positive feedback as he/she/they took responsibility for broken relationships.The client has not taken responsibility for broken relationships and was provided with confrontation for this denial.
19 Confront Self-Centeredness (19)The client was taught, through role-playing and role-reversal, the value of being empathetic to the needs, rights, and feelings of others.It was reflected to the client that he/she/they present his/her/their attitude of “look out for number one” as the only way to live.Active-listening skills were used as the client justified his/her/their self-focused attitude as the way that he/she/they learned to live because of the abuse and abandonment suffered as a child.Attempts were made to get the client to view his/her/their own behavior from another person's perspective.The client was provided with positive feedback and verbal reinforcement whenever he/she/they made comments that were less self-centered.
20 Teach the Value of Honesty (20)The client was asked to list the benefits of honesty and reliability for self and others.The client was taught the absolute necessity for honesty as the basis for trust in all forms of human relationships as examples of the different forms of relationships that are based in trust and honesty were reviewed.The client was asked to list the positive effects for others when he/she/they are honest and reliable.Positive feedback was provided as the client identified the positive effects for others when he/she/they are honest and reliable.It was reflected to the client that he/she/they continue to be dishonest in relationships.
21 List Honesty Consequences (21)The client was asked to list the positive effects for others when he/she/they are honest and reliable.The client was taught that pain and disappointment result when honesty and reliability are not given the highest priority in one's life.The client was provided with positive feedback for his/her/their understanding of the effects of honesty versus dishonesty.The client failed to identify the effects of honesty and dishonesty and was gently offered examples in this area.
22 Solicit a Commitment to Honesty (22)The client was asked to make a commitment to live a life based in honesty and reliability.The client was asked to sign a behavioral contract that focuses on keeping promises and being responsible to others.The client was asked to list five reasons why he/she/they should make a commitment to be honest and reliable.Positive feedback was provided as the client committed to living a life based in honesty and reliability.
23 Teach Empathy (23)The client was taught, through role-playing and role reversal, the value of being empathetic to the needs, rights, and feelings of others.The client was asked to commit self to acting more sensitively to the rights and feelings of others.The client was encouraged as he/she/they committed to acting more sensitively regarding the rights and feelings of others.
24 Use Role Reversal Techniques (24)The client was reminded of the consequences of his/her/their lack of empathy for others.The client was taught about his/her/their lack of empathy and the consequences of this behavior for others through the use of role reversal techniques.The client gained new insight into the consequences of his/her/their behavior for others and was provided with encouragement.
25 Confront Disrespect (25)The client was confronted consistently and firmly when he/she/they exhibited an attitude of disrespect and rudeness toward the rights and feelings of others.It was emphasized to the client firmly and consistently that others have a right to boundaries and privacy and respect for