The Adult Psychotherapy Progress Notes Planner. David J. Berghuis
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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10 Social Withdrawal (8)The client has withdrawn from social relationships that were important to him/her/them.As the client's depression has deepened, he/she/they have increasingly self-isolated.The client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.
INTERVENTIONS IMPLEMENTED
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 to experience difficulty 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