The Adult Psychotherapy Progress Notes Planner. David J. Berghuis
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Childhood Abuse/Abandonment (4)Experiences of childhood physical or emotional abuse, neglect, or abandonment were explored.As the client identified instances of abuse and neglect, the feelings surrounding these experiences were processed.The client's experiences with perceived abandonment were highlighted and related to his/her/their current fears of this experience occurring in the present.As the client's experience of abuse and abandonment in his/her/their childhood was processed, he/she/they denied any emotional impact of these experiences on self.The client denied any experience of abuse and abandonment in his/her/their childhood, and he/she/they were urged to talk about these types of concerns as he/she/they deem it necessary in the future.
5 Assess Substance Use History (5)The client's use of alcohol and other mood-altering substances was assessed.The client's use of alcohol and other mood-altering substances can be treated as a self-harm behavior.The client's use of alcohol and other mood-altering substances can be treated as an impulsive behavior.The client was referred for a more in-depth substance use assessment.
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 Refer for Medication Evaluation (11)The client was assessed in regard to the need for psychotropic medication.The client was referred to a prescriber to be evaluated for psychotropic medications to stabilize his/her/their mood.The client has cooperated with a referral to a prescriber and has attended the evaluation for psychotropic medications.The client has refused to attend an evaluation for psychotropic medications and was redirected to do so.
12 Monitor Medication Adherence (12)The client's adherence with prescribed medications was monitored and effectiveness of the medication on his/her level of functioning was noted.The client reported that the medication has been beneficial in stabilizing his/her/their mood and he/she/they were encouraged to continue its use.The client reported that the medication has not been beneficial in stabilizing his/her/their mood; this was reflected to the prescribing clinician.The client reported side effects of the medication that he/she/they found intolerable; these side effects were relayed to the prescribing clinician.
13 Monitor Misuse (13)The client was informed of the risks of misusing medications.The client reported appropriate use of medication and was encouraged to continue its use.The client reported misusing medication and was redirected; this was reflected to the prescribing clinician.
14 Orient to DBT (14)The client was oriented to dialectical behavioral therapy (DBT).The multiple facets of DBT were highlighted, including support, collaboration, mindfulness, distress tolerance, coping, and skill building.The concept of dialectics was reviewed with the client.DBT topics were explained to the client, including the emphasis on exchange and negotiation, balancing the rational and emotional, and acceptance and change strategies.Information from Cognitive-Behavioral Treatment of Borderline Personality (Linehan) was reviewed with the client.
15 Teach Biosocial View (15)The biosocial view related to borderline personality disorder was emphasized with the client.Biological and environmental vulnerabilities were explored with the client.
16 Assign Reading on Borderline Personality Disorder (16)The client was asked to read selected sections of books or manuals that reinforce therapeutic interventions.Portions of DBT Skills Training Handouts and Worksheets (Linehan) were assigned to the client.Portions of The Dialectical Behavior Therapy Skills Workbook (McKay, Wood, and Brantley) were assigned to the client.The client has read assigned information from books or manuals and key concepts were reinforced.The client has not read assigned portions of books or manuals that reinforce therapeutic interventions and was redirected to do so.
17 Solicit Agreement for DBT (17)Using commitment strategies, an agreement was solicited from the client to work collaboratively within the parameters of the DBT approach.A written agreement was developed with the client to work collaboratively within the parameters of the DBT approach.An emphasis was placed on the agreement for DBT, including the expectation to stay in therapy for a specified time, attend scheduled therapy sessions, work toward reducing suicidal behaviors, and participating in skills training.The client has agreed to work within the DBT approach to address the behavioral, emotional, and cognitive vulnerabilities targeted in treatment.The client was reinforced for his/her/their commitment to working within the DBT program.The client has not agreed to work within the DBT program, and this resistance was processed.
18 Explore Self-Harm Behavior (18)The client's history and nature of self-harm behavior were explored thoroughly.The client helped to recall a pattern of self-harm behavior that has dated back several years.The client's self-harm behavior was identified as being associated with feelings of depression, fear, and anger, as well as a lack of self-identity.
19 Assess Suicidal Behavior (19)The client's history and current status regarding suicidal gestures were assessed.The secondary gain associated with suicidal gestures was identified.Triggers for suicidal thoughts were identified and alternative responses to these trigger situations were proposed.
20 Arrange Hospitalization (20)As the client was judged to be harmful of self, arrangements were made for a voluntary psychiatric hospitalization.As the client refused a necessary psychiatric hospitalization, the proper steps to involuntary hospitalization of the client were initiated.The client has been psychiatrically hospitalized.Ongoing contact with the psychiatric hospital has been maintained in order to coordinate the most helpful treatment while in the hospital.
21 Assign Self-Monitoring Forms (21)The client was informed of the usefulness of self-monitoring forms, such as DBT Diary Cards.The client was assigned self-monitoring forms to assess self-harm risk.The client completed assigned self-monitoring forms, and these were reviewed at the start of each session.The client did not complete assigned self-monitoring forms and was redirected to