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182 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 5. Assist in Legal Representation Decisions ( 5) A. The client was assisted in making decisions about the need for legal representation. B. The client was encouraged to meet with an attorney to discuss plans for resolvin g his/her legal issues. C. The client was referred to specific attorneys who are knowledgeable about mental illness concerns. D. The client has obtained counsel and has met with the attorney to make plans for resolving his/her legal conflicts, and this w as reviewed. E. The client does not have financial resources to hire an attorney; therefore, the court was asked to appoint a public defender. F. The client has declined any legal representation and was strongly urged to reconsider this decision. 6. Review Court Proceedings (6) A. The basic proceedings and people involved in court hearings were reviewed with the client. B. The client was quizzed about the role of each person involved in the court proceedings in order to test his/her understanding. C. The client displayed a more complete understanding of the events that will likely occur in his/her court hearing subsequent to reviewing these proceedings. D. The client has failed to show a complete understanding of his/her likely court involvement and was provided with remedial information in this area. 7. Graphically Display Criminal Proceedings (7) A. The steps in a criminal proceeding were graphically displayed, identifying the reasons for each step within the process. B. The client's legal concern s were broken down into specific steps (e. g., investigation, arrest, arraignment, pretrial conferences, trial, and sentencing). C. As a result of being provided information in an alternative format, the client has developed an increased understanding of h is/her criminal proceedings. D. The client failed to completely understand the process of his/her legal proceedings and was provided with additional, remedial information in this area. 8. Advocate and Refer for Psychological Testing ( 8) A. The court was requested to require a psychological evaluation of the client. B. The client was referred for an assessment of cognitive abilities and deficits, as well as personality functioning. C. The client underwent objective psychological testing to assess his/he r cognitive strengths and weaknesses, as well as personality functioning. D. The client cooperated with the psychological testing, and feedback about the results was given to him/her. E. The psychological testing confirmed the presence of specific cognit ive abilities and deficits, and personality dynamics. F. The client was not compliant with taking the psychological evaluation and was encouraged to participate completely. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
LEGAL CONCERNS 183 9. Coach Preparation for Court Hearings ( 9) A. The client was coached regarding his/her need to prepare himself/herself for court hearings (e. g., doing personal grooming, clothing selection, and gathering appropriate documentation). B. The client was provided with positive feedback regarding his/her giving a positive impression withi n the court setting. C. The client was provided with additional direction as he/she displayed poor preparation for his/her court hearings. 10. Review Court Protocol (1 0) A. Normal conventions within the court setting were reviewed with the client (e. g., referring to the judge as “Your Honor,” standing when the judge enters, and waiting for the appropriate time to speak). B. The client was provided with instruction on how to be a good witness (e. g., tell the truth, only answer the question asked, be prep ared for an opposing attorney to try to increase his/her anxiety). C. Role-playing techniques were used to help the client practice how to be a good witness. D. The client displayed a positive understanding of the behavioral expectations within the court setting and was encouraged for his/her mastery of this area. E. The client displayed a poor understanding of the behavioral expectations within the court setting and was provided with additional, remedial information in this area. 11. Role-Play Court He arings (11) A. Role-playing techniques were used to teach the client about the upcoming court hearing, with an emphasis on the expected progression of the hearing, typical conventions in the courtroom, and being an effective witness. B. During the role-playing, the client displayed a clear grasp of how to make a positive impression within the court setting and was given positive feedback in this area. C. During the role-playing, the client failed to present a positive impression and was provided with add itional feedback. 12. Refer to a Physician (1 2) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to c ooperate with this referral. 13. Educate about Psychotropic Medications (1 3) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she disp layed an understanding about the indications for and expected benefits of the medications. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
184 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client displayed a lack of understanding of the indications for and expected benefits of psychotropic medications and was provided with additional informatio n and feedback regarding his/her medications. 14. Monitor Medications (14) A. The client was monitored for compliance with his/her psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotrop ic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication effectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 15. Review Side Effects of the Medications (1 5) A. The possible side effects related to the client's medications were reviewed with him/her. B. The client identified signi ficant side effects, and these were reported to the medical staff. C. Possible side effects of the client's medications were reviewed, but he/she denied experiencing any side effects. 16. Advise Jail Staff ( 16) A. Appropriate authorization to release co nfidential information to the corrections staff was obtained. B. The corrections staff was advised about the client's mental illness symptoms. C. The corrections staff was provided with information and training regarding how to respond to the client. D. A jail mental health liason was contacted regarding the client's mental illness symptoms. E. The client declined to have any information provided to the jail staff, and this request was honored. 17. Advocate for Alternative Sentencing/Housing ( 17) A. Advocacy was provided toward the court and jail system for alternative sentencing/housing options for the mentally ill offender who is unable to cope in the typical jail setting. B. Alternative options (e. g., an electronic tether or a mental health unit wi thin the corrections facility) were identified as appropriate options for the client. C. Due to advocacy provided on the client's behalf, corrections and court personnel have identified more appropriate sentencing alternatives for him/her. D. Despite adv ocacy with the court and jail system, more appropriate sentencing/housing has not been provided. 18. Review Incarceration Impact on Mental Illness ( 18) A. The client was assisted in developing an understanding of how his/her mental illness symptoms may i nteract with his/her incarceration. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
LEGAL CONCERNS 185 B. The client identified specific ways in which his/her mental illness symptoms may interact with incarceration (e. g., increased paranoia, more acute anxiety, or difficulty managing mania), and this was reviewed. C. The client's more complete understanding of the interaction of his/her mental illness symptoms with his/her incarceration has assisted in helping him/her complete his/her jail sentence, and he/she was provided with positive feedback in this area. D. The cli ent displayed poor understanding of the impact of his/her mental illness symptoms interacting with his/her incarceration and was provided with additional feedback in this area. 19. Monitor Medications in Corrections Setting ( 19) A. The client was monitor ed for the appropriate provision and use of his/her medication within the corrections setting. B. The corrections staff was advised about the potential side effects that should be monitored regarding the client's psychiatric medications. C. The correctio ns staff was advised about the potential negative consequences that may result from neglecting the client's medications. D. As a result of regular advocacy regarding the client's medications, he/she has been more regular in his/her use of the medications. E. The client has not regularly taken his/her medications, and solutions to this problem were developed. 20. Review Personal Safety While Incarcerated (2 0) A. Personal safety considerations were reviewed with the client regarding the time that he/she i s incarcerated. B. The client was assisted in understanding how other inmates may treat him/her, how to get help if threatened or assaulted, and how to respond to others within the corrections setting. C. As a result of the client's increased understandi ng of personal safety considerations, he/she has been able to maintain his/her personal safety within the corrections setting. D. The client has failed to focus on his/her personal safety considerations and was provided with additional feedback in this ar ea. 21. Develop Responses to Hostility in Jail (2 1) A. The client was assisted in developing assertive, nonviolent responses to potentially hostile individuals in the corrections setting. B. The client was provided with positive feedback as he/she displ ayed increased understanding of how to respond to hostile individuals in the corrections setting. C. The client displayed poor understanding of how to cope with hostile individuals in the corrections setting and was provided with additional, remedial feed back in this area. 22. Facilitate Appointments with Court Officers (2 2) A. The client's attendance at appointments with court officers was monitored. B. The client was provided with encouragement to make certain that he/she regularly keeps his/her appoi ntments with court officers. C. The client's regular attendance at appointments with court officers was facilitated. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
186 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. As a result of regular involvement regarding the client's appointments with the court officers, he/she has been able to successfully c omplete the sentencing requirements imposed upon him/her. 23. Attend Probation Meetings (2 3) A. The client's probation meetings were attended on an intermittent basis to facilitate communication. B. The probation staff working with the client was educat ed about his/her strengths and limitations. C. As a result of involvement with the client's probation meetings, he/she has been able to successfully complete probation and other sentencing requirements that have been set forth by the court. 24. Support I nvolvement in Court-Mandated Activities ( 24) A. The client's involvement in court-mandated activities was supported in order to help him/her adhere to probation requirements. B. The client's involvement in court-mandated activities was facilitated in ord er to help him/her adhere to probation requirements. C. As a result of assistance provided to the client, he/she has been able to maintain his/her involvement in court-mandated activities (e. g., mental health treatment, job procurement, stable residence, or community service). D. The client has failed to complete his/her court-mandated activities, despite support and facilitation in these areas. 25. Educate Support System about the Legal System and Ramifications ( 25) A. The client's family, friends, and caregivers were educated about the legal system and the specific legal issues related to the client's current situation. B. As the client was not actively psychotic during his/her inappropriate behavior, his/her family, friends, and caregivers were encou raged to allow him/her to be appropriately incarcerated. C. Because the client's mental health symptoms have not been controlled, his/her family, friends, and caregivers were encouraged to allow mandatory hospitalization to occur. D. The client reported an increased level of assistance from his/her family and support system regarding his/her involvement in the legal system, and the positive effects of this were noted. E. The client's family, friends, and caregivers were supported for their choice to allo w him/her to experience the appropriate legal ramifications of his/her inappropriate behavior. F. The client's family, friends, and caregivers have not allowed him/her to experience the appropriate legal ramifications of his/her behavior and were challeng ed to do so. G. The client's support system has failed to assist him/her through the legal system, and they were provided with redirection in this area. 26. Encourage the Support System Contact during Incarceration ( 26) A. The client's support system wa s challenged to remain in contact with him/her, despite his/her incarceration. B. Members of the client's support system were encouraged for their regular contact with him/her, despite his/her incarceration. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
LEGAL CONCERNS 187 C. The client's support system has not kept in regular contact with him/her and were encouraged to maintain more regular contact. 27. Identify the Effect of Illegal Behaviors ( 27) A. The client was requested to identify ways in which his/her illegal behaviors have affected others. B. The client was assisted in empathizing with others by identifying his/her own emotional responses to prior instances of being victimized. C. The client was provided with positive feedback regarding his/her ability to relate his/her experiences of victimization with how his/her illegal behaviors have affected others. D. The client denied any connection between his/her own victimization and the effects of his/her illegal behaviors on others and was redirected in this area. 28. Encourage Restitution ( 28) A. The client w as encouraged to provide restitution to those whom he/she has victimized. B. The client was assisted in identifying options for restitution to those to whom he/she has victimized (e. g., financial reimbursement or community service). C. The client was pro vided with positive feedback regarding his/her provision of restitution to those whom he/she has victimized. D. The client has declined any use of restitution to those whom he/she has victimized and was urged to reconsider this decision. 29. Relate Menta l Illness Symptoms to Illegal Behaviors ( 29) A. The client's pattern of mental illness symptoms was explored as to how it has contributed to his/her legal conflicts. B. The client acknowledged that his/her mental illness symptoms have played an important part in his/her legal problems, and specific concerns in this area were developed. C. The client denied any connection between his/her mental illness symptoms and illegal behaviors and was provided with additional feedback in this area. 30. Refer for Th erapy (3 0) A. The client was referred for individual therapy to assist in developing alternatives to acting out when facing stressful circumstances. B. The client was referred to a group therapy program to assist in developing alternatives to acting out when facing stressful circumstances. C. The client and his/her significant other were referred to marital therapy to assist in developing adaptive relationship patterns to help decrease acting out. D. As a result of the client's psychotherapy, he/she has decreased his/her pattern of acting out in stressful circumstances. E. The client continues to act out in stressful circumstances, despite the use of psychotherapy. 31. Coordinate Substance Abuse Assessment (31) A. The client was assessed for substance abuse problems that may contribute to his/her legal concerns. B. The client was identified as having a concomitant substance abuse problem. C. Upon review, the client does not display evidence of a substance abuse problem. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
188 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client's mental health and substance abuse treatment services were coordinated in an integrated fashion. E. The client's substance abuse treatment providers have been furnished with increased information about the client's mental health diagnosis and treatment. F. The client' s mental health treatment providers have been provided with increased information about the client's substance abuse diagnosis and treatment. 32. Coordinate Guardianship Assessment ( 32) A. A psychological evaluation was coordinated to facilitate a guardi anship hearing, including an assessment of functional decision-making abilities (e. g., regarding treatment, finances). B. The client has participated in the psychological evaluation to facilitate a guardianship hearing, and the results of this evaluation were shared with him/her. C. The client's psychological evaluation was shared with the court to assist in the decision-making process for guardianship. D. The client has declined involvement in a psychological evaluation and was redirected to complete th is evaluation. 33. Assist in the Guardianship Process ( 33) A. Family members or other interested parties were assisted in obtaining guardianship of the client in order to increase supervision and monitoring of his/her behavior and treatment. B. The clie nt has agreed to have a guardian placed over him/her in order to monitor his/her behavior and treatment. C. Guardianship procedures have been instituted to assist family members or others in obtaining guardianship of the client, despite his/her belief tha t he/she does not need a guardian. 34. Educate the Potential Guardian about Person-Centered Planning ( 34) A. The client's potential guardian was educated about issues related to person-centered planning. B. The client's potential guardian was educated a bout the ability of mentally ill people to manage many aspects of their lives, despite serious and persistent symptoms. C. The client's potential guardian was provided with positive feedback regarding understanding of person-centered planning issues and t he client's ability to manage many aspects of his/her life. D. The client's potential guardian was urged to seek more information regarding the person-centered needs of the client. 35. Advocate against Unnecessary Guardianship Practices ( 35) A. Advocacy was provided for the client regarding unnecessary or overly restrictive guardianship orders or practices. B. Specific information and education was provided to the guardian and court personnel regarding the unnecessary or overly restrictive guardianship orders or practices that have been implemented. C. As a result of advocacy for the client against unnecessary or overly restrictive guardianship orders, the least restrictive, legally necessary guardianship was implemented. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
LEGAL CONCERNS 189 36. Assist in Developing Advan ced Directives ( 36) A. The client was assisted in developing an advanced directive should he/she decompensate and become unable to legally make such decisions. B. The client was assisted in developing specific wishes for treatment, emergency contact, medication needs, and other issues in case of his/her severe decompensation. C. The client was provided with positive feedback regarding his/her development of the advanced directive. D. The client has not developed an advanced directive and was redirected in this area. 37. Discuss End-of-Life Wishes ( 37) A. The client was engaged in a discussion regarding his/her wishes for end-of-life issues, including funeral arrangements, estate dispersal, and financial needs. B. The client has participated in develop ing specific arrangements for his/her end-of-life issues. C. The client has avoided any review of his/her end-of-life issues and was urged to apply himself/herself to this area. 38. Focus on Responsibilities Regarding Treatment (38) A. The client was fo cused on his/her responsibilities regarding treatment. B. The client was assisted in understanding his/her responsibilities (e. g., attendance at appointments, providing the clinician with accurate information, and confidentiality) regarding other clients in treatment. C. The client displayed an increased understanding of his/her responsibilities regarding treatment and was provided with positive feedback in this area. D. The client has failed to display a clear understanding regarding his/her responsibil ities for treatment and was provided with remedial information for this progress. 39. Advocate for the Client's Rights (39) A. Advocacy was provided for the client with other clinicians, family members, and legal personnel to adhere to his/her rights. B. The client was assisted in advocating with other clinicians, family members, and legal personnel to adhere to his/her rights. C. The client reported an increased experience of empowerment due to the client rights advocacy provided on his/her behalf. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
190 MANIA OR HYPOMANIA CLIENT PRESENTATION 1. Increased, Pressured Speech (1) * A. The client gave evidence of increased, pressured speech within the session. B. The client reported that his/her speech rate increases as he/she feels stressed. C. The client' s pressured speech has shown evidence of a decrease in intensity. D. The client showed no evidence of pressured speech in today's session. 2. Racing Thoughts (2) A. The client demonstrated a pattern of racing thoughts, moving from one subject to another without maintaining focus. B. The client reported that he/she experiences racing thoughts, including difficulty concentrating on one thought as other thoughts interfere. C. The client reported that at times of quiet reflection, he/she is disturbed by th oughts racing through his/her mind. D. The client reported that his/her thoughts are not racing as they had been, and he/she is able to stay focused. 3. Inflated Sense of Self (3) A. The client gave evidence of an inflated sense of self-esteem and an ex aggerated, euphoric belief in capabilities that denies any limitations or realistic obstacles. B. The client appears oblivious to his/her inflated sense of self-esteem or euphoric beliefs but sees others as standing in his/her way. C. In spite of attempt s to try to get the client to be more realistic, his/her inflated self-esteem and exaggerated, euphoric beliefs have persisted. D. The client's sense of self-esteem and beliefs in his/her capabilities have become more reality based. E. There has been no recent evidence of inflated self-esteem or exaggerated, euphoric beliefs. 4. Persecutory Delusions (3) A. The client described a pattern of persecutory delusions, including suspiciousness of others without reasonable cause. B. The client demonstrated a pattern of misinterpretation of benign events as having threatening personal significance. C. The client's history is replete with incidents in which he/she believed he/she was persecuted by others. D. The client is beginning to accept a more reality-based interpretation of events and relationships, which is much less threatening. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MANIA OR HYPOMANIA 191 E. The client no longer demonstrates a pattern of bizarre, persecutory delusions and has verbalized not feeling personally threatened. 5. Lack of Sleep (4) A. The client desc ribed a pattern of attaining far less sleep than would ordinarily be needed. B. The client has gone through periods of time when he/she did not sleep for 24 consecutive hours or more because his/her energy level was so high. C. As the client's mania has begun to diminish, he/she has begun to return to a more normal sleeping pattern. D. The client is getting six to eight hours of sleep per night. 6. Psychomotor Agitation (5) A. The client was restless and agitated within the session and reports an inabi lity to sit quietly and relax. B. The client's high energy level is reflected in increased motor activity, restlessness, and agitation. C. The client's motor activity has decreased, and the level of agitation has diminished. D. The client demonstrated n ormal motor activity and reports being able to stay calm and relaxed. 7. Loss of Inhibitions/Self-Damaging Activities (6) A. The client reported a behavior pattern that reflected a lack of normal inhibition and an increase in potentially self-damaging ac tivities. B. The client's impulsivity has been reflected in sexual acting out, poor financial decisions, and committing social offenses. C. The client has gained more control over his/her impulses and has returned to a normal level of inhibition and soci al propriety. 8. Expansive/Variable Mood (7) A. The client gave evidence of a very expansive mood that could easily turn to impatience and irritability if his/her behavior is blocked or confronted. B. The client related instances of feeling angry when o thers tried to control his/her expansive, grandiose ideas and mood. C. As the client's expansive mood has been controlled, his/her impatience and irritable anger have diminished. 9. Lack of Follow-Through (8) A. The client described a behavior pattern t hat portrayed a lack of follow-though on many projects, even though his/her energy level is high, since he/she lacks discipline and goal directiveness. B. The client's lack of follow-through has resulted in frustration on the part of others. C. The clien t has begun to exercise more discipline and goal directiveness in his/her behavior, resulting in the completion of projects. 10. Disregard for Social Mores (9) A. The client's behavior pattern confirmed his/her disregard for social mores within academic, social, or employment settings. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
192 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client verbalized that he/she sees social rules or mores as applying to others but not to himself/herself. C. The client is beginning to accept the need for rules within any society and to apply them to himself/her self. D. The client has not had a recent incident of disregard for social mores and is more compliant. 11. Bizarre Dress and Grooming (10) A. The client displays bizarre patterns of dressing. B. The client displays an unusual grooming pattern. C. The client's clothing is much more revealing that he/she normally wears. D. As the client is stabilized his/her mania/hypomania, his/her grooming and dressing pattern has returned to normal. INTERVENTIONS IMPLEM ENTED 1. Explore for Manic Signs (1) * A. The c lient's thoughts, feelings, and behavior were explored for classic signs of mania (e. g., pressured speech, impulsive behavior, euphoric mood, flight of ideas, high energy level, reduced need for sleep, and inflated self-esteem). B. The clinical assessment confirmed the presence of the classic signs of mania. C. The clinical assessment did not find adequate evidence to diagnose mania. 2. Assess Mania Intensity (2) A. The client was assessed for his/her current stage of elation: none, hypomanic, manic, or psychotic. B. The client's assessment indicated no current symptoms of mania. C. The client was assessed to be hypomanic. D. The client was assessed to be manic. E. The client's mania was so severe that periods of psychosis have been present. 3. Asse ss Ability to Remain Safe (3) A. An assessment was performed of the client's ability to remain safe within the community. B. The client was assessed in regard to his/her level of manic behavior, impulsivity, and propensity toward potentially unsafe situa tions. C. The natural and programmatic supports that can assist the client to remain safe within the community were assessed. D. Due to programmatic supports, the client has been assessed as being able to remain safe within the community, despite his/her symptoms of mania/hypomania. E. The client was judged to be unable to remain safe within the community due to his/her symptoms of mania and was referred for a more restrictive setting. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MANIA OR HYPOMANIA 193 4. Arrange for a More Restrictive Setting (4) A. Arrangements were made for the client to be hospitalized in a psychiatric setting based on the fact that his/her mania is so intense that he/she could be harmful to himself/herself or others or unable to care for his/her own basic needs. B. The client was not willing to su bmit voluntarily to hospitalization; therefore, commitment procedures were initiated. C. The client was supported for acknowledging the need for hospitalization and voluntarily admitting himself/herself to the psychiatric facility. 5. Develop a Short-Term Crisis Plan (5) A. A short-term, round-the-clock crisis plan was developed. B. It was determined that components of the client's short-term, round-the-clock crisis plan must include multiple caregivers, psychiatric involvement, and crisis assistance in order to maintain him/her within the community. C. With the implementation of the crisis plan, the client has been able to remain within the community as he/she stabilizes from his/her period of mania/hypomania. D. The client continues to decompensate a nd is not safe to maintain within the community, despite the use of the crisis plan, and arrangements for a more restrictive setting were initiated. 6. Remove Dangerous Items (6) A. Significant others were encouraged to remove dangerous items (e. g., shar p objects, weapons, and access to motor vehicles). B. Permission was obtained from the client to remove potentially dangerous items. C. Contact was made with significant others within the client's life to monitor his/her behavior and remove potential mea ns of suicide or impulsive harm. 7. Provide a Calm Setting (7) A. A plan was developed with the client that focused on reducing the level of stress that he/she receives in his/her environment. B. The client was assisted in developing a calmer setting fo r himself/herself, including low lighting and decreased stimulation. C. Steps have been taken to change the environment in such a way as to reduce the client's feelings of agitation associated with it. D. Arrangements have been made for the client to be visited, monitored, supervised, and encouraged more frequently by supportive people. 8. Refer for Psychiatric Evaluation (8) A. The client was referred for a psychiatric evaluation to consider psychotropic medication to control the manic state. B. The c lient has followed through with the psychiatric evaluation and pharmacotherapy has begun. C. The client has been resistive to cooperating with a psychiatric evaluation and was encouraged to follow through on this recommendation. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
194 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 9. Monitor Medication Rea ction (9) A. The client's reaction to the medication in terms of side effects and effectiveness were monitored. B. The client reported that the medication has been effective at reducing energy levels, flight of ideas, and the decreased need for sleep; he /she was urged to continue this medication regimen. C. The client has been reluctant to take the prescribed medication for his/her manic state, but was urged to follow through on the prescription. D. As the client has taken his/her medication, which has been successful in reducing the intensity of the mania, he/she has begun to feel that it is no longer necessary and has indicated a desire to stop taking it; he/she was urged to continue the medication as prescribed. 10. Monitor Ability to Participate in P sychotherapy (10) A. The client's pattern of symptom improvement was monitored, with a focus on how stable he/she is in regard to participation in psychotherapy. B. The client was judged to be significantly improved and capable of participating in psycho therapy. C. The client was judged to still be too manic to allow helpful participation in psychotherapy. 11. Conduct Family-Focused Treatment (11) A. The client and significant others were included in the treatment model. B. Family-focused treatment was used with the client and significant others as indicated in Bipolar Disorder: A Family-Focused Approach (Miklowitz and Goldstein). C. As family members were not available to participate in therapy, the family-focused treatment model was adapted to indivi dual therapy. 12. Assess Family Communication Patterns (12) A. Objective instruments were used to assess the family communication patterns. B. The level of expressed emotions within the family was specifically assessed. C. The Perceived Criticism Scale (Hooley and Teasdale) was used to assess family communication problems. D. The family was provided with feedback about their pattern of communication. E. The family has not been involved in the assessment of communication patterns, and the focus of treat ment was diverted to this resistance. 13. Educate about Mood Episodes (13) A. A variety of modalities were used to teach the family about signs and symptoms of the client's mood episodes. B. The phasic relapsing nature of the client's mood episodes was e mphasized. C. The client's mood episode concerns were normalized. D. The client's mood episodes were destigmatized. 14. Teach Stress Diathesis Model (14) A. The client was taught a stress diathesis model of Bipolar Disorder B. The biological predisposi tion to mood episodes was emphasized. C. The client was taught about how stress can make him/her more vulnerable to mood episodes. D. The manageability of mood episodes was emphasized. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MANIA OR HYPOMANIA 195 E. The client was reinforced for his/her clear understanding of the stress diathesis model of Bipolar Disorder. F. The client struggled to display a clear understanding of the stress diathesis model of Bipolar Disorder and was provided with additional remedial information in this area. 15. Provide Rationale for Treatment (15) A. The client was provided with the rationale for treatment involving ongoing medication and psychosocial treatment. B. The focus of treatment was emphasized, including recognizing, managing, and reducing biological and psychological vulnerabilities that could precipitate relapse. C. A discussion was held about the rationale for treatment. D. The client was reinforced for his/her understanding of the appropriate rationale for treatment. E. The client was redirected when he/she displayed a poor und erstanding of the rationale for treatment. 16. Identify Relapse Triggers (16) A. Sources of the client's stress and triggers of potential relapse were identified. B. Negative events, cognitive interpretations, aversive communication, poor sleep hygiene, and medication noncompliance were investigated as potential stressors or triggers of potential relapse. C. Cognitive-behavioral techniques were used to address the sources of stress and triggers for potential relapse. 17. Enhance Engagement in Medication Use (17) A. Motivational approaches were used to help enhance the client's level of engagement in his/her medication use and compliance to the medication regimen. B. Modeling, role-playing, and behavioral rehearsal were used to help the client use proble m-solving skills to work through several current conflicts. C. The client was taught about the risk for relapse when medication is discontinued. D. Commitment was obtained to continuous prescription adherence. E. As a result of motivational approaches f or medication compliance, the subject's use of medication has significantly improved. F. The client continues to be medication noncompliant despite use of motivational approaches; the client was refocused on this task. 18. Assess Prescription Noncomplianc e Factors (18) A. Factors that have precipitated the client's prescription noncompliance were assessed. B. The client was checked for specific thoughts, feelings, and stressors that might contribute to his/her prescription noncompliance. C. The client w as assigned “Why I Dislike Taking My Medication” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). D. A plan was developed for recognizing and addressing the factors that have precipitated the client's prescription noncompliance. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
196 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 19. Educa te about Lab Work (19) A. The client was educated about the need to stay compliant with necessary lab work involved in regulating his/her medication levels. B. The client was encouraged to stay compliant with necessary lab work. C. The client was reinfo rced for his/her compliance to completing necessary lab work to help regulate his/her medication levels. D. The client has not been regular in his/her compliance to lab work for regulating his/her medication levels and was redirected to do so. 20. Teach a bout Sleep Hygiene Importance (20) A. The client was taught about the importance of good sleep hygiene. B. The client was assigned the “Sleep Pattern Record” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client's sleep pattern was routinely assessed. D. Interventions for the client's sleep pattern were provided, as he/she has been noted to have a dysfunctional sleep pattern. 21. Educate about Symptoms of Relapse (21) A. The client was educated about the signs and symptoms of pending relapse. B. The client's family was educated about the signs and symptoms of pending relapse. 22. Develop Relapse Drill (22) A. The client and family were assisted in drawing up a “relapse drill,” detailing roles and responsibilities. B. Family members were asked to take responsibility for specific roles (e. g., who will call a meeting of the family to problem solve potential relapse; who will call physician, schedule a serum level, or contact emergency services, if needed). C. Obstacles to provi ding family support to the client's potential relapse were reviewed and problem solved. D. The family was asked to make a commitment to adherence to the plan. E. The family was reinforced for their commitment to the adherence to the plan. F. The family has not developed a clear commitment to the relapse prevention plan and was redirected in this area. 23. Assess and Educate about Aversive Communication (23) A. The family was assessed for the role of aversive communication in family distress and in the risk for the client's manic relapse. B. The family was educated about the role of aversive communication (e. g., highly expressed emotion) in developing greater family stress and in increasing the client's risk for manic relapse. C. The family displayed a clear understanding of the effects of aversive communication and this was reinforced. D. The family was provided with remedial feedback, as they did not display a clear understanding of the risk for relapse due to aversive communication. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MANIA OR HYPOMANIA 197 24. Teach Communi cation Skills (24) A. Behavioral techniques were used to teach communication skills. B. Communication skills such as offering positive feedback, active listening, making positive requests for behavioral change, and giving negative feedback in an honest, respectful manner were taught to the client and family. C. Behavioral techniques were used to teach the family healthy communication skills. D. Education, modeling, role-playing, corrective feedback, and positive reinforcement were used to teach communic ation skills. 25. Assign Communication Skills Homework (25) A. The client and family were assigned homework exercises to use and record newly learned communication skills. B. Family members have used newly learned communication skills, and the results we re processed within the session. C. Family members have not used the newly learned communication skills and were redirected to do so. 26. Differentiate Losses, Abilities, and Expectations (2 6) A. The client was assisted in differentiating between actual losses, abilities, and expectations, and imagined or exaggerated losses, abilities, and expectations. B. The client verbalized grief, fear, and anger regarding imagined losses in life and was provided with support and redirection in this area. C. The cli ent was able to differentiate between his/her real and imagined losses, abilities, and expectations and was provided with positive feedback in this area. D. The client continues to focus on imagined, exaggerated losses, abilities, and expectations and was focused on being more reality oriented in this area. 27. Confront Grandiosity (2 7) A. The client's grandiosity and demandingness were kindly but firmly confronted. B. The client has become less expansive in his/her mood and more socially appropriate du e to the consistent confrontation of his/her grandiosity and demandingness. C. The client has reacted with anger and irritability when his/her grandiosity was confronted. 28. Focus on Impulsive Behavior Consequences (2 8) A. The client's impulsive behavi or was repeatedly reviewed in order to help him/her identify the negative consequences that result from this pattern. B. The impulsive nature of the client's manic/hypomanic episode was reviewed regarding its negative consequences. C. The client was focu sed onto the need to identify his/her impulsive, manic/hypomanic symptoms as early as possible. D. The client was helped to identify the impulsive nature and negative consequences of his/her manic/hypomanic episodes and not to be so focused on just the he re and now, and he/she was provided with additional feedback in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
198 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 29. Increase Sensitivity to Effects of Behavior (2 9) A. Role-playing, role reversal, and behavioral rehearsal were used to increase the client's sensitivity to the negative effect s of his/her impulsive behavior. B. The client was reinforced for his/her increased sensitivity to the negative effects of his/her impulsive behavior on others. C. The client has had significant difficulty identifying negative consequences for his/her impulsive behavior, despite the use of role-playing, role reversal, and behavioral rehearsal. 30. Confront Mania and Enforce Rules ( 30) A. Unhealthy, impulsive, or manic behaviors that occur during contacts with the clinician were identified and confronted. B. Clear rules and roles in the relationship were identified and enforced with immediate, short-term consequences for breaking such boundaries. C. The client's unhealthy, impulsive, or manic behaviors have diminished in response to limit setting within the session. 31. Address Problem Solving (31) A. The client was asked to identify conflicts that can be addressed through problem-solving techniques. B. The family members were asked to give input about conflicts that could be addressed with problem-solving techniques. C. The client and family arrived at a list of conflicts that could be addressed with problem-solving techniques. 32. Teach Problem-Solving Skills (32) A. Behavioral techniques such as education, modeling, role-playing, corrective feedbac k, and positive reinforcement were used to teach the client and family problem-solving skills. B. Specific problem-solving skills were taught to the family, including defining the problem constructively and specifically, brainstorming options, evaluating options, choosing options, implementing a plan, evaluating the results, and reevaluating the plan. C. Family members were asked to use the problem-solving skills on specific situations. D. The family was reinforced for positive use of problem-solving ski lls. E. The family was redirected for failures to properly use problem-solving skills. 33. Assign Problem-Solving Homework (33) A. The client and family were assigned to use newly learned problem-solving skills and record their use. B. The client and fa mily were assigned “Plan Before Acting” in the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The results of the family members' use of problem-solving skills were reviewed within the session. 34. Reinforce Control Over Thought Process (3 4) A. The client was reinforced for controlling his/her slower speech. B. The client was reinforced for his/her more deliberate thought process. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MANIA OR HYPOMANIA 199 35. Reinforce Agitation Control (35) A. The client was reinforced for controlling his/her motor agitation and h elped to set goals for and limits on his/her behavior. B. The client was taught relaxation techniques to help him/her reduce the level of agitation and restlessness. C. The “Plan Before Acting” assignment from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was used to help model and teach increased behavioral control. D. It was noticed that the client has become less agitated and more relaxed. 36. Monitor Energy Level (36) A. The client's energy level was monitored, and he/she was reinforce d for increased control over behavior, pressured speech, and expression of ideas. B. The client has responded favorably to placing more structure and control over his/her behavior and reported less agitation and flight of ideas. C. The client continues t o have periods of increased agitation, pressured speech, and flight of ideas and was provided with remedial feedback in this area. 37. Schedule Maintenance Session (37) A. The client was scheduled for a maintenance session between 1 and 3 months after the rapy ends. B. The client was advised to contact the therapist if he/she needs to be seen prior to the maintenance session. C. The client's maintenance session was held, and he/she was reinforced for his/her successful implementation of therapy techniques. D. The client's maintenance session was held, and he/she was coordinated for further treatment, as his/her progress has not been sustained. 38. Test/Treat for Sexually Transmitted Diseases (STDs)/Pregnancy (3 8) A. Testing was arranged for STDs. B. The client was tested to determine if she is pregnant. C. Follow-up treatment for the client's STDs was coordinated. D. The client has tested positive for pregnancy and was assisted in processing this development. E. The client has tested negatively for S TDs, and this information was passed on to him/her. F. The client was informed that she is not pregnant. 39. Assist through Criminal Justice System ( 39) A. The client was assisted in working through the requirements of the criminal justice system. B. Advocacy and support were provided as the client is negotiating the criminal justice system. C. The client has been able to meet the requirements of the criminal justice system through the use of support and advocacy from the clinician. 40. List Relations hips Affected by Mental Illness (4 0) A. The client was assisted in developing a list of relationships that have been affected by his/her severe and persistent mental illness symptoms. B. The client's list of relationships affected by his/her severe and p ersistent mental illness symptoms was processed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
200 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client has minimized or denied that relationships have been affected by his/her symptoms and was redirected to reconsider this issue. 41. Provide Feedback about Behavior (4 1) A. The client was prov ided with feedback about how his/her behavior or verbal messages have an impact on others. B. The client was taught more effective and sensitive social skills. C. The client was able to accept the feedback provided and has improved in his/her relationshi p skills. D. The client denied any problems with his/her behavior or verbal messages, despite feedback, and has not improved his/her relationships with others. 42. Assign Reading on Bipolar Disorder (42) A. The client was assigned to read a book on Bipol ar Disorder. B. The client was assigned to read The Bipolar Disorder Survival Guide (Miklowitz). C. The client has read the assigned information on Bipolar Disorder, and key concepts were reviewed. D. The client has not read the assigned information on Bipolar Disorder and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
201 MEDICATION MANAGEMEN T CLIENT PRESENTATION 1. Failure to Take Medications (1) * A. The client has failed to consistently take his/her psychotropic medications as prescribed. B. A review of the client's medications indicates that he/she has not used the ex pected amounts. C. The client has become more regular in his/her use of his/her psychotropic medications. D. The client has been regularly taking his/her psychotropic medications as prescribed. 2. Negative Side Effects (2) A. The interactions from the client's medications are causing negative side effects. B. The client reported that he/she has great difficulty tolerating the side effects from his/her medication interaction. C. As the client's medications have been adjusted, he/she reported a decrease in the negative side effects. D. The side effects of the client's medications have been sufficiently decreased such as to increase his/her consistent use of medications. 3. Verbalized Fears of Side Effects (3) A. The client has verbalized his/her fears related to physical and/or emotional side effects of prescribed medications. B. The client dislikes the side effects of his/her prescribed medications. C. As the side effects of the client's medications have been decreased, he/she has become more comfor table and regular in using the medications. D. The client verbalized his/her acceptance of the side effects of the medications, which are outweighed by the beneficial aspects. 4. Failure to Respond to Medications (4) A. The client has not responded as e xpected to his/her prescribed medication regimen. B. The client's failure to respond as expected to his/her medications has been traced to his/her erratic use of them. C. The client's failure to respond as expected to prescribed medications has been trac ed to the confounding effects of polypharmacy. D. The client is now responding as expected to his/her prescribed medication regimen. 5. Lack of Medication Knowledge (5) A. The client displayed a lack of knowledge about his/her medications and their usef ulness or potential side effects. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
202 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client's lack of knowledge regarding his/her medications has led to poor decisions about using them. C. As the client has gained more knowledge about his/her medications, their usefulness, and potential side effec ts, he/she has been more regular with his/her use of them. 6. Unwilling to Take Prescribed Medications (6) A. The client has indicated reluctance to take his/her prescribed medications. B. The client has made specific statements about his/her unwillingn ess to take prescribed medications. C. The client has refused any medications. D. As treatment has progressed, the client has become more willing to take his/her prescribed medications. E. The client is regularly taking his/her medications. 7. Alcohol/ Drug Use (7) A. The client has been consuming alcohol along with his/her psychotropic medications, which has negatively affected the usefulness of his/her medications. B. The client has been using illicit street drugs along with his/her psychotropic medi cations, which has altered the benefits of his/her medications. C. As the client's substance abuse has decreased, the benefits of his/her psychotropic medications have increased. D. The client is free from drugs and alcohol, which has helped his/her medi cations to be more beneficial. INTERVENTIONS IMPLEM ENTED 1. Request a List of Medications (1) * A. The client was asked to identify all of his/her currently prescribed medications, including names, times administered, and dosage. B. The client was provid ed with feedback regarding the accuracy of his/her list of medications. 2. Request a Description of Medication Compliance to Compare with Data (2) A. The client was requested to provide an honest, realistic description of his/her medication compliance. B. The client's description of his/her medication usage was compared with information from his/her medical chart, information from his/her personal physician/psychiatrist, and other objective data. C. An objective data review indicates a substantial patte rn of compliance. D. An objective data review indicates poor medication compliance. E. The client was praised for his/her realistic description of his/her medication compliance. F. The client reported complete medication compliance, and this description was accepted. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planne r, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MEDICATION MANAGEMEN T 203 G. The client seemed to minimize his/her noncompliance with prescribed medications and was confronted about this. 3. Obtain Blood Levels (3) A. A blood draw was conducted, and the client's blood levels for specific medications have been assessed. B. The analysis of the client's blood chemistry indicates substantial compliance with his/her medication regimen. C. An analysis of the client's blood chemistry indicates substantial noncompliance with his/her medication regimen. D. The client' s suspected pattern of medication use (based on blood chemistry studies) was reflected to him/her. 4. Conduct Motivational Interviewing (4) A. Motivational interviewing techniques were used to help assess the client's preparation for change. B. The clie nt was assisted in identifying his/her stage of change regarding his/her substance abuse concerns. C. It was reflected to the client that he/she is currently building motivation for change. D. The client was assisted in strengthening his/her commitment t o change. E. The client was noted to be participating actively in treatment. 5. Review and Supplement Medication Knowledge (5) A. The client was requested to identify the reason for each of his/her medications. B. The client was provided with positive feedback as he/she displayed a clear understanding of the reasons for each of his/her medications. C. The client was provided with written information about his/her medications, the acceptable dosage levels, and the side effects. D. The client reported t hat he/she has read the written information provided to him/her and has gained a better understanding of his/her medications. E. The client has not read the written information provided to him/her and was redirected to do so. 6. Process Fears Regarding Medication ( 6) A. The client was requested to describe the fears that he/she may experience regarding the use of his/her medications. B. Myths and misinformation regarding the client's understanding and fears of his/her medications were corrected. C. The client's fears were reviewed, discussed, and processed to conclusion. D. The client was provided with positive feedback regarding his/her increased comfort with his/her use of medications. E. The client tended to minimize or deny his/her fears regardin g his/her medications, and he/she was encouraged to be more open about these concerns. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
204 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 7. Behavioral Experiments ( 7) A. The client was directed to conduct “behavioral experiments” in which bias predictions about medications are tested against the client' s past, present, and/or future experience using the medication. B. The client was assisted in identifying the criteria against which to test his/her experience with medication. C. The client has conducted the behavioral experiments to test his/her predic tions about the medication, and these conclusions were reviewed. D. The client has not engaged in the behavioral experiments and this resistance was problem-solved. 8. Reinforce Positive Cognitive Messages ( 8) A. The client was reinforced for positive, reality-based cognitive messages that enhance medication prescription compliance. B. The client used positive, reality-based cognitive messages, he/she was taught to use those messges to enhance his/her medication prescription compliance. C. The client h as not engaged in positive, reality-based cognitive message to enhance his/her medication prescription compliance, and was provided with specific examples in this area. 9. Refer to Family Psycho-Educational Program ( 9) A. The family was referred to a psy cho-educational program to help learn about the client's severe and persistent mental illness and the need for medication. B. The client was referred to a multi-group family psycho-educational program to help learn about the client's severe and persistent mental illness and the need for medication. C. The family was engaged in the psycho-educational program and has identified ways in which they have learned about the client's severe and persistent mental illness and the need for medication. D. The client 's family has not engaged in the psycho-educational program and was redirected to do so. 10. Use Family-Focused Treatment Therapy Model ( 10) A. The client was referred to therapy program based on the principles of family-focused treatment, as noted in Bipolar Disorder: A Family-Focused Treatment Approach (Miklowitz and Goldstein). B. Family-focused treatment was conducted to assist in improving communication patterns between the client and his/her family. C. The family and the client have engaged in the family-focused treatment, and the positive results of this treatment were reviewed. D. The family and the client have not engaged in the family-focused treatment and were encouraged to do so. 11. Refer to a Physician ( 11) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MEDICATION MANAGEMEN T 205 C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medication and was redirected to cooperate with this referral. 12. Review Side Effects of the Medications ( 12) A. The possible side effects related to the client's medications were reviewed with him/her. B. The client identified significant side effects, and these were reported to the medical staff. C. Possible side effects of the client's medications were reviewed, but he/she denied experiencing any side effects. 13. Inform Other Health Care Providers about the Medications ( 13) A. A written authorization to release confidential information was obtained to allow communication with the client's primary physician and other health care providers. B. The client's primary physician and other health care providers were informed of the medications he/she is currently using, their expected side effects, risks, and benefits. 14. Encourage or Assist with Regular Employment (14) A. The client was encouraged to obtain regular employment to increase income and defray medication costs. B. The client was assisted in seeking and obtaining regular employment. C. The client has found regular employment, and the economic benefits for his/her employment were reviewed. D. The client has not obtained regular employment and continues to struggle with his/her ability to pay for medications and was redirected in this area. E. The client was assisted in obtaining, completing, and filing forms for Social Security Disability benefits or other public aid. F. The client has completed all necessary documentation for filing for Social Security Disability benefits or other public aid, and this material was reviewed. G. The client's applicatio n for Social Security Disability benefits and other public aid has been incomplete, and he/she received assistance in completing these applications. 15. Coordinate Generic or Reduced-Cost Medication Programs (1 5) A. Free or low-cost medication programs t hrough drug manufacturers or other resources were requested for the client. B. The client was assisted in accessing free or low-cost medication programs. C. The client was directed to specific programs for obtaining free or low-cost medications from drug manufacturers or other resources. D. The client has not followed through on accessing reduced-cost medication programs and was redirected to do so. E. When appropriate, the use of generic drugs was advocated for as a way to decrease the client's cost fo r medications. F. The client's physician was consulted regarding the use of generic drugs rather than brand-name drugs. G. Generic drugs were contraindicated in this client's situation, and this was reflected to him/her and the pharmacist. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
206 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 16. Assess Su icidal Ideation (1 6) A. The client was asked to describe the frequency and intensity of his/her suicidal ideation, the details of any existing suicide plan, the history of any previous suicide attempts, or any family history of depression or suicide. B. The client was encouraged to be forthright regarding the current strength of his/her suicidal feelings and the ability to control such suicidal urges. C. The client was assessed as being at low risk of suicide. D. The client was assessed at being at high risk of suicide, and further intervention was necessary. 17. Remove Medications (1 7) A. As the client was assessed to be at risk for suicide, his/her medications were removed from his/her immediate access. B. Significant others were encouraged to remov e medications or other potentially lethal means of suicide from the client's easy access. C. Arrangement was made to coordinate regular delivery of the client's medications as they have been removed from his/her immediate access. D. Due to the client's s uicide risk, he/she was monitored in the actual taking of his/her medications. E. As the client has decreased his/her suicide risk, he/she has been provided with increased control over his/her medications. 18. Refer to a Supervised Environment (1 8) A. Because the client was judged to be uncontrollably harmful to himself/herself, arrangements were made for psychiatric hospitalization. B. Due to concerns about the client's inability to manage himself/herself within a less restrictive setting, he/she was r eferred to a crisis residential facility. C. The client was supported for cooperating voluntarily with admission to a more supervised environment. D. The client refused to voluntarily admit himself/herself to a more supervised environment; therefore, civ il commitment procedures were initiated. 19. Refer for Personality Testing (19) A. The client was referred for psychological testing to assist in obtaining a more complete clinical picture. B. The client was compliant with the testing, which indicated a specific diagnosis. C. The psychological test results confirm previous diagnostic expectations. D. The psychological testing results indicate that the client's mental illness concerns have significantly abated, and this was reviewed. E. The client was not compliant with the psychological testing and was redirected to this referral. 20. Educate about Lifestyle Effects on the Medications (2 0) A. The client was educated about lifestyle habits (e. g., tobacco use, diet) that can be modified to decrease the side effects of the medications. B. The client displayed an understanding of the effects of his/her lifestyle habits on the efficacy of his/her medications and was provided with positive feedback. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MEDICATION MANAGEMEN T 207 C. The client has made substantial changes in his/her li festyle habits, which have increased the efficacy of his/her medications, and this was reinforced. D. The client has failed to make any lifestyle changes to assist with medication efficacy and was redirected to do so. 21. Coordinate Dosing in Ranges to F acilitate Client Control (21) A. The client's prescribing physician was approached regarding writing dosages to be within a certain range, when possible, in order to increase the client's authority over his/her own medication regimen. B. In an effort to increase the client's authority over and investment in the medication process, the physician has written orders so that the client can make minimal modifications in his/her medications, in consultation with the clinician. C. The client's authority over hi s/her own regimen of medications was emphasized. D. The client described increased investment in and authority over his/her medication process as he/she has been allowed to vary his/her medications within the confines of the physician's order, and this wa s reinforced. E. The client was assisted in learning how to vary his/her medications within the prescribed dosage range, depending on his/her own daily needs. F. The client does not display increased investment in the medication process, despite being provided with an increased allowance to modify his/her medications, and this was reflected to him/her. 22. Assess Ability to Administer Medications ( 22) A. The client's ability to properly self-administer medications was assessed. B. The client displayed the ability to self-administer medications and was provided with this authority over his/her own medications. C. The client was judged to be unable to self-administer his/her medications; therefore, appropriate supervision was arranged. 23. Recruit Suppo rt Network to Administer Medications ( 23) A. An appropriate authorization to release confidential information was obtained from the client in order to recruit members of his/her support network to administer medications to him/her. B. Specific members of the client's support network have agreed to administer medications to him/her, and the benefits of this were reviewed. C. No specific individuals from within the client's support network will agree to administer medications to him/her, so alternative sup ports were recruited. 24. Arrange Daily Medication Drop-Offs ( 24) A. Daily medication drop-offs were arranged, with instructions for the client on which dosages to take at each time of day. B. The client has been more regular with his/her medications as a result of the daily medication drop-offs, and the benefits were reflected to him/her. C. The client continues to take medication on a sporadic basis, despite daily medication drop-offs; redirection was provided on this practice. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
208 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 25. Encourage a Consis tent Place and Time for Taking Medications ( 25) A. The client was encouraged to take his/her medications at a specific, consistent place and time every day. B. The client was encouraged for his/her use of a specific, consistent place and time for taking his/her medications. C. The client continues to take his/her medications on a sporadic basis and was provided with additional encouragement to be more consistent. 26. Arrange Prescription Distribution in a Compartmentalized Medication Box ( 26) A. Arrange ments were made for the client's prescriptions to be distributed in a multidose, compartmentalized daily medication box. B. The client was monitored for his/her accurate usage of the compartmentalized daily medication box. C. The client was reinforced fo r the appropriate use of the compartmentalized daily medication box. D. The client has failed to properly take his/her medications, despite the use of a compartmentalized daily medication box, and this was reflected to him/her. 27. Monitor Expected Use o f Medications ( 27) A. The number of pills left in the client's prescription of psychotropic medications was counted and compared with the expected amount that should remain. B. Discrepancies within the expected and actual amounts of the medications remai ning were reviewed with the client and medical staff. C. The client's remaining medications correspond with the amount expected to remain, and this was reviewed with him/her. 28. Coordinate All Prescriptions from One Pharmacy ( 28) A. Arrangements were m ade to transfer all of the client's prescriptions, including nonpsychiatric medications, to one pharmacy. B. The client's variety of prescribing clinicians were requested to use the same pharmacy for all of his/her prescriptions. C. The client described that he/she finds it easier to obtain all of his/her medications from the same pharmacy, and the benefits of this simplified process were reviewed. 29. Coordinate Family/Couple's Therapy (29) A. Conjoint sessions with the client's significant other and o ther family members were coordinated to promote an understanding of his/her illness and the impact of the illness on his/her and the family's needs. B. The client's family members were supported for participating in the conjoint sessions and increasing th eir understanding of his/her illness and the impact on his/her and the family's needs. C. The client reported an increased understanding from his/her significant other or family members subsequent to conjoint sessions and was urged to allow family members to assist him/her in his/her medication management. D. The client, his/her significant other, and other family members have not regularly participated in conjoint sessions and were redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
MEDICATION MANAGEMEN T 209 30. Train the Support Network in Medication Managem ent (30) A. The client's family members, peers, and others in his/her support network were trained in the proper use and administration of medications. B. The client's support network was directed to encourage and reinforce him/her when he/she complies w ith his/her medication regimen. C. The client's support system has been more involved in helping him/her manage his/her medications, and the effects of this were processed with him/her. D. The client's support network has not been regularly involved with his/her medication management, despite training and encouragement, and they were encouraged again to provide support in this area. 31. Coordinate Family Transportation for Client ( 31) A. Family members were asked to provide the client with transportatio n to the clinic or pharmacy. B. Family members have regularly provided the client with transportation to the clinic or pharmacy and were encouraged to continue this. C. Family members have not regularly coordinated transportation for the client and were urged to become more consistent in this area. 32. Process Social Concerns Regarding Medications ( 32) A. The client was requested to identify social concerns that he/she may experience regarding medication uses (e. g., stigmatization and loss of independen ce). B. The client identified his/her social concerns related to medication usage, and these were processed to resolution. C. The client failed to identify his/her social or emotional concerns that affect his/her medication usage and was provided with co mmon concerns that others have experienced, including stigmatization or loss of independence. 33. Advocate for Less Complicated Dosing Times ( 33) A. Advocacy was provided to the client's physician for less complicated dosing times for his/her medications. B. The client's physician has agreed to use less complicated dosing times for his/her medications. C. The client's physician has not agreed to less complicated dosing times for the client's medications, despite advocacy. 34. Explore Substance Use ( 34) A. The client was assessed for substance abuse that may affect his/her medication efficacy. B. The client was identified as having a concomitant substance abuse problem. C. Upon review, the client does not display evidence of a substance abuse problem. 35. Educate about Substance Abuse ( 35) A. The client was educated about the negative effects of substance abuse on his/her symptoms. B. The client was educated about the depotentiating effects of mood-altering substances on his/her medications. C. The client was provided with positive feedback regarding his/her understanding of the effects of mood-altering substance use on his/her medications. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
210 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client continues to use substances despite the effects on his/her symptoms and medication efficacy and was provided with additional confrontation in this area. 36. Refer for Substance Abuse Treatment ( 36) A. The client was referred to a 12-step recovery program (e. g., Alcoholics Anonymous or Narcotics Anonymous). B. The client was referred to a substanc e abuse treatment program. C. The client has been admitted to a substance abuse treatment program and was supported for this follow-through. D. The client has refused the referral to a substance abuse treatment program, and this refusal was processed. 37. Process Improvement Due to Medications ( 37) A. The client was requested to identify how his/her reduction in mental illness symptoms has improved his/her social or family system. B. The client identified ways in which his/her mental illness symptoms h ave decreased and how this has improved his/her social and family relationships, and he/she was provided with positive feedback in this area. C. The client failed to identify ways in which his/her medications have improved his/her symptoms and relationshi ps and was provided with examples of these changes. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
211 OBSESSIVE-COMPULSIVE DISORDER (OCD) CLIENT PRESENTATION 1. Recurrent/Persistent Thoughts (1) * A. The client described recurrent and persistent thoughts or impulses that are viewed as senseless, intrusive, and time consuming and that interfere with his/h er daily routine. B. The intensity of the recurrent and persistent thoughts and impulses is so severe that the client is unable to efficiently perform daily duties or interact in social relationships. C. The strength of the client's obsessive thoughts ha s diminished, and he/she has become more efficient in his/her daily routine. D. The client reported that the obsessive thoughts are under significant control and he/she is able to focus attention and effort on the task at hand. 2. Failed Control Attempts (2) A. The client reported failure at attempts to control or ignore his/her obsessive thoughts or impulses. B. The client described many different failed attempts at learning to control or ignore his/her obsessions. C. The client is beginning to experi ence some success at controlling and ignoring his/her obsessive thoughts and impulses. 3. Recognize Internal Source of Obsessions (3) A. The client has a poor understanding that his/her obsessive thoughts are a product of his/her own mind. B. The client reported that he/she recognizes the obsessive thoughts are a product of his/her own mind and are not coming from some outside source or power. C. The client acknowledged that the obsessive thoughts are related to anxiety and are not a sign of any psychot ic process. 4. Compulsive Behaviors (4) A. The client described repetitive and intentional behaviors that are performed in a ritualistic fashion. B. The client's compulsive behavior pattern follows rigid rules and has many repetitions to it. C. The rep etitive and intentional behaviors of the client are performed in response to obsessive thoughts. D. The client's repetitive and compulsive behavior is engaged in to prevent some dreaded situation from occurring, which the client is often not able to defin e clearly. E. The client's repetitive and compulsive behavior rituals are not connected in any realistic way with what the client is trying to prevent or neutralize. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
212 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER F. The client's anxiety over some dreaded event has diminished significantly, and his/he r compulsive rituals have also decreased in frequency. G. The client has not engaged in any ritualistic behaviors designed to prevent some dreaded situation. 5. Compulsions Seen as Unreasonable (5) A. The client acknowledged that his/her repetitive and compulsive behaviors are excessive and unreasonable. B. The client's recognition of his/her compulsive behaviors as excessive and unreasonable has provided good motivation for cooperation with treatment and follow-through on attempt to change. INTERVENTIO NS IMPLEMENTED 1. Develop Trust (1) * A. Today's clinical contact focused on building the level of trust with the client through consistent eye contact, active listening, unconditional positive regard, and warm acceptance. B. Empathy and support were pro vided for the client's expression of thoughts and feelings during today's clinical contact. C. The client was provided with support and feedback as he/she described his/her maladaptive pattern of anxiety. D. As the client has remained mistrustful and rel uctant to share his/her underlying thoughts and feelings, he/she was provided with additional reassurance. E. The client verbally recognized that he/she has difficulty establishing trust because he/she has often felt let down by others in the past, and he /she was accepted for this insight. 2. Assess OCD History (2) A. Active listening was used as the client described the nature, history, and severity of his/her obsessive thoughts and compulsive behaviors. B. Through a clinical interview, the client desc ribed a severe degree of interference in his/her daily routine and ability to perform a task efficiently because of the significant problem with obsessive thoughts and compulsive behaviors. C. The Anxiety Disorder's Interview Schedule for DSM-IV (Di Nardo, Brown, and Barlow) was used to assess the client's frequency, intensity, duration, and history of obsessions and compulsions. D. The client was noted to have made many attempts to ignore or control the compulsive behaviors and obsessive thoughts, but wit hout any consistent success. E. It was noted that the client gave evidence of compulsive behaviors within the interview. * The numbers in parentheses correlate to the num ber of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
OBSESSIVE-COMPULSIVE DISORDER (OCD) 213 3. Conduct Psychological Testing (3) A. Psychological testing was administered to evaluate the nature and severity of the client's obsessive-compulsive problem. B. The Yale-Brown Obsessive-Compulsive Scale (Goodman and colleagues) was used to assess the depth and breadth of the client's OCD symptoms. C. The psychological testing results indicate that the client experiences significan t interference in his/her daily life from obsessive-compulsive rituals. D. The psychological testing indicated a rather mild degree of Obsessive-Compulsive Disorder within the client. E. The results of the psychological testing were interpreted to the cl ient. 4. Refer for Physical Evaluation (4) A. The client was referred to a physician to undergo a thorough examination to rule out any medical etiologies for anger outbursts and to receive recommendations for further treatment options. B. The client has followed through on the physician evaluation referral and specific medical etiologies for anger outbursts were reviewed. C. The client was supported as he/she is seeking medical treatment that may decrease his/her anger outbursts. D. The client has foll owed through on the physician evaluation referral but no specific medical etiologies for anger outbursts have been identified. E. The client declined evaluation by a physician for a prescription of psychotropic medication, and was redirected to cooperate with this referral. 5. Follow Up on Physical Evaluation Recommendations (5) A. The client was supported in following up on the recommendations from the medical evaluation. B. The client's follow-up on the recommendations from the medical evaluation has been monitored. C. The client has been following up on the recommendations from the medical evaluation, and the benefits and trials of this were reviewed. D. The client has not regularly followed up on his/her medical evaluation recommendations, and was redirected to do so. 6. Review Psychoactive Chemicals (6) A. The client's use of psychoactive chemicals, such as nicotine, caffeine, alcohol, or street drugs was reviewed. B. The client's pattern of psychoactive chemical use was connected to his/her sym ptoms. C. The client was supported as he/she identified that his/her psychoactive chemical use is affecting his/her anxiety symptoms. D. As the client has decreased his/her psychoactive chemical use, anxiety symptoms have been noted to decrease as well. E. The client denies any connection between his/her psychoactive chemical use and his/her anxiety symptoms and has continued to utilize psychoactive chemicals, despite encouragement to discontinue this. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
214 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 7. Recommend Substance Abuse Evaluation and/or Term ination (7) A. It was recommended to the client that he/she terminate the consumption of substances that could contribute to anxiety. B. The client was referred for a substance abuse evaluation to more completely assess his/her substance abuse concerns a nd how they may trigger anxiety. C. The client was referred for substance abuse treatment to assist him/her in discontinuing his/her consumption of substances. D. As the client has decreased his/her use of trigger substances, he/she has experienced a decrease in anxiety, and this was reviewed. E. The client has declined any evaluation or treatment related to his/her substance use, and was encouraged to seek this out at a later time. 8. Differentiate Anxiety Symptoms (8) A. The client was assisted in di fferentiating anxiety symptoms that are a direct affect of his/her severe and persistent mental illness, as opposed to a separate diagnosis of an anxiety disorder. B. The client was provided with feedback regarding his/her differentiation of symptoms that are related to his/her severe and persistent mental illness, as opposed to a separate diagnosis. C. The client has identified a specific anxiety disorder, which is freestanding from his/her severe and persistent mental illness, and this was reviewed with in the session. D. The client has been unsuccessful in identifying ways in which his/her anxiety symptoms are related to his/her mental illness versus a separate anxiety disorder and was provided with some examples of each area. 9. Acknowledge Anxiety Re lated to Delusional Experiences (9) A. It was acknowledged that both real and delusional experiences could cause anxiety. B. The client was provided with support regarding his/her anxieties and worries, which are related to both the real experiences and delusional experiences. C. The client described a decreased pattern of anxiety due to the support provided to him/her. 10. Identify Diagnostic Classification (10) A. The client was assisted in identifying a specific diagnostic classification for his/her anxiety symptoms. B. Utilizing a description of anxiety symptoms such as that found in Bourne's The Anxiety and Phobia Workbook, the client was taken through a detailed review of his/her anxiety symptoms, diagnosis, and treatment needs. C. The client ha s failed to clearly understand and classify his/her anxiety symptoms and was given additional feedback in this area. 11. Refer to Physician (11) A. A referral to a physician was made for the purpose of evaluating the client for a prescription of psychotro pic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medication, and was redirected to cooperate with this referral. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
OBSESSIVE-COMPULSIVE DISORDER (OCD) 215 12. Educate about Psychotropic Medication (12) A. The client was taught about the indications for and the expec ted benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medication. C. The client displayed a lack of understanding of t he indications for and expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. 13. Monitor Medications (13) A. The client was monitored for compliance with his/her psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medication. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the clie nt's medication effectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 14. Enroll in Group Therapy (14) A. The client was enrolled in intensive (e. g., daily) group therapy for exposure and ritual prevention. B. The client was enrolled in a nonintensive (e. g., weekly) group for exposure and ritual prevention therapy. C. The client was enrolled in a small (closed enrollment) group for ex posure and ritual prevention for OCD, as described in Obsessive-Compulsive Disorder (Foa and Franklin). D. The client has been enrolled in group therapy; the benefits of this program were reviewed. E. The client has not participated in group therapy, and the barriers to this treatment were reviewed. 15. Assign Reading Materials (15) A. The client was assigned to read psychoeducational chapters of books or treatment manuals on the rationale for exposure and ritual prevention therapy. B. The client was as signed to read psychoeducational chapters of books or treatment manuals for the rationale for cognitive restructuring for OCD. C. The client was assigned to read information from Mastery of Obsessive-Compulsive Disorder (Kozak and Foa). D. The client was assigned to read information from Stop Obsessing (Foa and Wilson). E. The client has read the assigned material on the rationale for OCD treatment; key points were reviewed. F. The client has not read the assigned information on the rationale for OCD tr eatment and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
216 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 16. Discuss Usefulness of Treatment (16) A. A discussion was held about how treatment serves as an arena to desensitize learned fear, reality test obsessional fears and underlying beliefs, and build confidence in manag ing fears without compulsions. B. The client was provided with a rationale for treatment as described in Mastery of Obsessive-Compulsive Disorder (Kozak and Foa). C. Positive feedback was provided to the client as he/she displayed a clear understanding a bout the usefulness of treatment. D. The client did not display a clear understanding of the usefulness of treatment and was provided with additional feedback in this area. 17. Explore Schema and Self-Talk (17) A. The client was assisted in exploring how his/her schema and self-talk mediate his/her obessional fears and compulsive behaviors. B. The client's schema and self-talk were reviewed as described in Mastery of Obsessive-Compulsive Disorder (Kozak and Foa). C. The client's schema and self-talk wer e reviewed as described in Obsessive-Compulsive Disorder (Salkovskis and Kirk). D. The client was reinforced for his/her insight into his/her self-talk and schema that support his/her obsessional fears and compulsive behaviors. E. The client struggled to develop insight into his/her own self-talk and schema and was provided with tentative examples of these concepts. 18. Teach Thought-Stopping Techniques (18) A. The client was taught to interrupt obsessive thoughts by shouting “STOP” to himself/herself silently while picturing a red traffic signal and then thinking about a calming scene. B. The client was assisted in developing his/her own thought-stopping techniques and images. C. Positive feedback was provided to the client for his/her helpful use of t hought-stopping techniques. D. The client does not regularly use thought-stopping techniques and was redirected to do so. 19. Assign Thought-Stopping Techniques between Sessions (19) A. The client was assigned the use of thought-stopping techniques on a daily basis between sessions. B. The client was assigned “Making Use of the Thought-Stopping Technique” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client's implementation of thought-stopping techniques was reviewed and succe sses were reinforced. D. The client's use of thought-stopping techniques was reviewed; successes were reinforced and failures were redirected. 20. Assess Cues (20) A. The client was assessed in regard to the nature of any external cues (e. g., persons, ob jects, situations) that precipitate the client's obsessions and compulsions. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
OBSESSIVE-COMPULSIVE DISORDER (OCD) 217 B. The client was assessed in regard to the nature of any internal cues (e. g., thoughts, images, impulses) that precipitate the client's obsessions and compulsions. C. The clie nt was provided with feedback about his/her identification of cues. 21. Construct a Hierarchy of Fear Cues (21) A. The client was directed to construct a hierarchy of feared internal and external cues. B. The client was assisted in developing a hierarchy of internal and external fear cues. 22. Select Likely Successful Imaginal Exposure (22) A. The client was assisted in identifying initial imaginal exposures with a bias toward those that have a likelihood of being successful experiences for the client. B. Cognitive restructuring techniques were used within and after the imaginal exposure of the OCD cues. C. Imaginal exposure and cognitive restructuring techniques were used as described in Mastery of Obsessive-Compulsive Disorder (Kozak and Foa). D. Imaginal exposure and cognitive restructuring techniques were used as described in Treatment of Obsessive-Compulsive Disorder (Mc Gran and Sanderson). E. The client was provided with feedback about his/her use of imaginal exposures. 23. Assign Cue Exposure Pr actice (23) A. The client was assigned a homework exercise in which he/she repeats the exposure to the internal and/or external OCD cues. B. The client was instructed to use restructured cognitions between sessions and to record his/her responses. C. The client was assigned to use “Reducing the Strength of Compulsive Behaviors” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). D. The client's use of the cue exposure homework was reviewed and his/her success was reinforced. E. Corrective feedback was provided to the client for his/her struggles in using restructured cognitions during exposure to OCD cues. F. The client was assisted in using restructured cognitions as described in Mastery of Obsessive-Compulsive Disorder (Kozak and Foa). 24. Differentiate between Lapse and Relapse (24) A. A discussion was held with the client regarding the distinction between a lapse and a relapse. B. A lapse was associated with an initial and reversible return of symptoms, fear, or urges to avoid. C. A relapse was associated with the decision to return to fearful and avoidant patterns. D. The client was provided with support and encouragement as he/she displayed an understanding of the difference between a lapse and a relapse. 25. Discuss Management of Lapse Risk Situations (25) A. The client was assisted in identifying future situations or circumstances in which lapses could occur. B. The session focused on rehearsing the management of future situations or circumstances in which lapses could occur. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
218 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was reinforced for his/her appropriate use of lapse management skills. D. The client was redirected in regard to his/her poor use of lapse management skills. 26. Encourage Routine Use of Strategies (26) A. The client was instructed to routi nely use the strategies that he/she has learned in therapy (e. g., cognitive restructuring, exposure). B. The client was urged to find ways to build his/her new strategies into his/her life as much as possible. C. The client was reinforced as he/she repor ted ways in which he/she has incorporated coping strategies into his/her life and routine. D. The client was redirected about ways to incorporate his/her new strategies into his/her routine and life. 27. Schedule Maintenance Sessions (27) A. Maintenance sessions were proposed to help maintain therapeutic gains and adjust to life without anger outbursts. B. The client was reinforced for agreeing to the scheduled maintenance sessions. C. The client refused to schedule maintenance sessions, and this was pr ocessed. 28. Enlist Support System (28) A. The client's support system was enlisted in the implementation of specific stress reduction techniques. B. The client's support system was enthusiastic and supportive of the client's stress reduction techniques, and the client was encouraged to utilize this support on a regular basis. C. The client's support system has declined significant involvement in helping the client to implement specific stress reduction techniques, so alternative means of development sup port for stress reduction were developed. D. The client has declined support from his/her family, friends, and caretakers and was urged to utilize this support. 29. Explore Unresolved Conflicts (29) A. As the client's unresolved life conflicts were explo red, he/she verbalized and clarified feelings connected to those conflicts. B. The client was supported as he/she identified key life conflicts that raise his/her anxiety level and intensify the OCD symptoms. C. As the client was helped to clarify and sh are his/her feelings regarding current unresolved life conflicts, his/her level of anxiety diminished and the OCD symptoms were reduced. D. The client has been guarded about his/her feelings regarding current life conflicts and was encouraged to be more o pen in this area. 30. Encourage Feelings Sharing (30) A. The client was encouraged, supported, and assisted in identifying and expressing feelings related to key unresolved life issues. B. As the client shared his/her feelings regarding life issues, he/s he reported a decreased level of emotional intensity around these issues; he/she was reinforced for this progress. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
OBSESSIVE-COMPULSIVE DISORDER (OCD) 219 C. It was difficult for the client to get in touch with, clarify, and express emotions, as his/her pattern is to detach himself/herself from feelings; this pattern was reflected to the client. 31. Assign Ericksonian Task (31) A. The client was assigned an Ericksonian task of performing a behavior that is centered around the obsession or compulsion instead of trying to avoid it. B. As the cli ent has faced the issue directly and performed a task, bringing feelings to the surface, the results of this were processed. C. As the client has processed his/her feelings regarding the anxiety-provoking issue, the intensity of those feelings has been no ted to be diminishing. D. The client has not used the Ericksonian task and was redirected to do so. 32. Develop Ritual Interruption (32) A. The client was helped to develop a ritual of a very unpleasant task that he/she agrees to perform each time he/she experiences obsessive thoughts. B. The client has begun to implement the distasteful ritual at the times of experiencing obsessive thoughts; his/her experience was reviewed. C. The client reports that engaging in the distasteful ritual has interrupted t he obsessive thoughts and the current pattern of compulsion; his/her progress was reinforced. D. The client has not used the ritual interruption technique and was reminded to use this helpful technique. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
220 PANIC/AGORAPHOBIA CLIENT PRESENTATION 1. Severe Panic Symptoms (1) * A. The client has experienced sudden and unexpected severe panic symptoms that have occurred repeatedly and have resulted in persistent concern about additional attacks. B. The client h as significantly modified his/her normal behavior patterns in an effort to avoid panic attacks. C. The frequency and severity of the panic attacks have diminished significantly. D. The client reported that he/she has not experienced any recent panic atta ck symptoms. 2. Fear of Environmental Situations Triggering Anxiety (2) A. The client described fear of environmental situations that he/she believes may trigger intense anxiety symptoms. B. The client's fear of environmental situations has resulted in his/her avoidance behavior directed toward those environmental situations. C. The client has a significant fear of leaving home and being in open or crowded public situations. D. The client's phobic fear has diminished, and he/she has left the home envir onment without being crippled by anxiety. E. The client is able to leave home normally and function within public environments. 3. Recognition That Fear Is Unreasonable (3) A. The client's phobic fear has persisted in spite of the fact that he/she ackno wledges that the fear is unreasonable. B. The client has made many attempts to ignore or overcome his/her unreasonable fear, but has been unsuccessful. 4. Increasing Isolation (4) A. The client described situations in which he/she has declined involveme nt with others due to a fear of traveling or leaving a safe environment, such as his/her home. B. The client reported that he/she has become increasingly isolated due to his/her fear of traveling or leaving a safe environment. C. The client has severely constricted his/her involvement with others. D. Although the client experiences some symptoms of panic, he/she still feels capable of leaving home. E. The client has been able to leave his/her safe environment on a regular basis. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PANIC/AGORAPHOBIA 221 5. Avoids Public Places and Large Groups (5) A. The client avoids public places, such as malls or large stores. B. The client avoids large groups of people. C. The client has constricted his/her involvement with others in order to avoid social situations. D. The client has b egun to reach out socially and feels more comfortable in public places or with large groups of people. E. The client reported enjoying involvement with large groups of people and feels comfortable going to public places. 6. Panic without Agoraphobia (6) A. The client does not display evidence of Agoraphobia. B. Although the client experiences symptoms of panic, he/she still feels capable of leaving home. INTERVENTIONS IMPLEM ENTED 1. Develop Trust (1) * A. Today's clinical contact focused on building th e level of trust with the client through consistent eye contact, active listening, unconditional positive regard, and warm acceptance. B. Empathy and support were provided for the client's expression of thoughts and feelings during today's clinical contac t. C. The client was provided with support and feedback as he/she described his/her maladaptive pattern of anxiety. D. As the client has remained mistrustful and reluctant to share his/her underlying thoughts and feelings, he/she was provided with additi onal reassurance. E. The client verbally recognized that he/she has difficulty establishing trust because he/she has often felt let down by others in the past and was accepted for this insight. 2. Assess Nature of Panic Symptoms (2) A. The client was as ked about the frequency, intensity, duration, and history of his/her panic symptoms, fear, and avoidance. B. The Anxiety Disorder's Interview Schedule for DSM-IV (Di Nardo, Brown, and Barlow) was used to assess the client's panic symptoms. C. The assessme nt of the client's panic symptoms indicated that his/her symptoms are extreme and severely interfere with his/her life. D. The assessment of the client's panic symptoms indicates that these symptoms are moderate and occasionally interfere with his/her dai ly functioning. E. The results of the assessment of the client's panic symptoms indicate that these symptoms are mild and rarely interfere with his/her daily functioning. F. The results of the assessment of the client's panic symptoms were reviewed with the client. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Trea tment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
222 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 3. Explore Panic Stimulus Situations (3) A. The client was assisted in identifying specific stimulus situations that precipitate panic symptoms. B. The client could not describe any specific stimulus situations that produce panic; he/she was helped to identify that they occur unexpectedly and without any pattern. C. The client was helped to identify that his/her panic symptoms occur when he/she leaves the confines of his/her home environment and enters public situations where there are many people. 4. Administer Assessments for Agoraphobia Symptoms (4) A. The client was administered psychological instruments designed to objectively assess his/her level of Agoraphobia symptoms. B. The client administered The Mobility Inventory for Agoraphob ia (Chambless, Coputo, and Gracely). C. The client was provided with feedback regarding the results of the assessment of his/her level of Agoraphobia symptoms. D. The client declined to participate in the objective assessment of his/her level of Agorapho bia symptoms, and this resistance was processed. 5. Administer Assessments for Anxiety Symptoms (5) A. The client was administered psychological instruments designed to objectively assess his/her level of anxiety symptoms. B. The client was administered The Anxiety Sensitivity Index (Reiss, Peterson, and Grusky). C. The client was provided with feedback regarding the results of the assessment of his/her level of anxiety symptoms. D. The client declined to participate in the objective assessment of his/ her level of anxiety symptoms, and this resistance was processed. 6. Refer for Physical Evaluation (6) A. The client was referred to a physician to undergo a thorough examination to rule out any medical etiologies for his/her anxiety symptoms and to rece ive recommendations for further treatment options. B. The client has followed through on the physician evaluation referral and specific medical etiologies for anxiety symptoms were reviewed. C. The client was supported as he/she is seeking out medical tr eatment that may decrease his/her anxiety symptoms. D. The client has followed through on the physician evaluation referral but no specific medical etiologies for anxiety symptoms have been identified. E. The client declined evaluation by a physician for a prescription of psychotropic medication and was redirected to cooperate with this referral. 7. Follow Up on Physical Evaluation Recommendations (7) A. The client was supported in following up on the recommendations from the medical evaluation. B. The client's follow-up on the recommendations from the medical evaluation has been monitored. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PANIC/AGORAPHOBIA 223 C. The client has been following up on the recommendations from the medical evaluation. D. The client has not regularly followed up on his/her medical evaluation r ecommendations and was redirected to do so. 8. Review Psychoactive Chemicals (8) A. The client's use of psychoactive chemicals, such as nicotine, caffeine, alcohol, or street drugs was reviewed. B. The client's pattern of psychoactive chemical use was c onnected to his/her symptoms. C. The client was supported as he/she identified that his/her psychoactive chemical use is affecting his/her anxiety symptoms. D. As the client has decreased his/her psychoactive chemical use, anxiety symptoms have been noted to decrease as well. E. The client denies any connection between his/her psychoactive chemical use and his/her anxiety symptoms and has continued to utilize psychoactive chemicals, despite encouragement to discontinue this. 9. Recommend Substance Abuse Evaluation and/or Termination (9) A. It was recommended to the client that he/she terminate the consumption of substances that could contribute to anxiety. B. The client was referred for a substance abuse evaluation to more completely assess his/her substance abuse concerns and how they may trigger anxiety. C. The client was referred for substance abuse treatment to assist him/her in discontinuing his/her consumption of substances. D. As the client has decreased his/her use of trigger substances, he/sh e has experienced a decrease in anxiety, and this was reviewed. E. The client has declined any evaluation or treatment related to his/her substance use and was encouraged to seek this out at a later time. 10. Differentiate Anxiety Symptoms (10) A. The cl ient was assisted in differentiating anxiety symptoms that are a direct affect of his/her severe and persistent mental illness, as opposed to a separate diagnosis of an anxiety disorder. B. The client was provided with feedback regarding his/her different iation of symptoms that are related to his/her severe and persistent mental illness, as opposed to a separate diagnosis. C. The client has identified a specific anxiety disorder, which is freestanding from his/her severe and persistent mental illness, and this was reviewed within the session. D. The client has been unsuccessful in identifying ways in which his/her anxiety symptoms are related to his/her mental illness or a separate anxiety disorder. 11. Acknowledge Anxiety Related to Delusional Experience s (11) A. It was acknowledged that both real and delusional experiences could cause anxiety. B. The client was provided with support regarding his/her anxieties and worries, which are related to both the real experiences and delusional experiences. C. The client described a decreased pattern of anxiety due to the support provided to him/her. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
224 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 12. Identify Diagnostic Classification (12) A. The client was assisted in identifying a specific diagnostic classification for his/her anxiety symptoms. B. Utilizi ng a description of anxiety symptoms such as that found in Bourne's The Anxiety and Phobia Workbook, the client was taken through a detailed review of his/her anxiety symptoms, diagnosis, and treatment needs. C. The client has failed to clearly understand and classify his/her anxiety symptoms and was given additional feedback in this area. 13. Refer to Physician (13) A. A referral to a physician was made for the purpose of evaluating the client for a prescription of psychotropic medications. B. The clien t was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medication and was redirected to cooperate with this referral. 14. Educate about Psychotropic Medication (14) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medication. C. The client displayed a lack of understanding of the indications for and expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. 15. Monitor Medications (15) A. The client was monitored for compliance with his/her psychotropic medication regimen. B. The cl ient was provided with positive feedback about his/her regular use of psychotropic medication. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication effectiveness a nd side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 16. Discuss Nature of Panic Symptoms (16) A. A discussion was held about how panic attacks are “false alarms” of danger, but are not medically dangerous. B. A discussion was held about how panic attacks are not a sign of weakness or craziness. C. The client's panic attacks were discussed, including how they are a common symptom but can lead to un necessary avoidance, thereby reinforcing the panic attack. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PANIC/AGORAPHOBIA 225 17. Assign Information on Panic Disorders and Agoraphobia (17) A. The client was assigned to read psychoeducational chapters of books or treatment manuals about Panic Disorders and Agoraphobia. B. The client was assigned specific chapters from Mastery of Your Anxiety and Panic (Barlow and Craske). C. The client was assigned to read chapters from Don't Panic: Taking Control of Anxiety Attacks (Wilson). D. The client was assigned to read Living wi th Fear (Marks). E. The client has read the assigned information on Panic Disorders and Agoraphobia, and key points were discussed. F. The client has not read the assigned information on Panic Disorders and Agoraphobia and was redirected to do so. 18. Discuss Benefits of Exposure (18) A. The client was taught about how exposure can serve as an arena to desensitize learned fear, build confidence, and create success experiences. B. A discussion was held about the use of exposure to decrease fear, build co nfidence, and feel safer. C. The client was reinforced as he/she indicated a clear understanding of how exposure can help to conquer panic and Agoraphobia symptoms. D. The client did not display understanding about how exposure can help overcome his/her Agoraphobia and panic symptoms and was provided with remedial feedback in this area. 19. Assign Reading on Exposure (19) A. The client was assigned to read about exposure in books or treatment manuals on social anxiety. B. The client was assigned to read excerpts from Mastery of Your Anxiety and Panic (Barlow and Craske). C. The client was assigned portions of Living with Fear (Marks). D. The client's information about exposure was reviewed and processed. E. The client has not read the information on e xposure and was redirected to do so. 20. Train about Coping Strategies (20) A. The client was taught progressive relaxation methods and debriefing exercises. B. The client was trained in the use of coping strategies to manage symptoms of panic attacks. C. The client was taught coping strategies such as staying focused on behavioral goals, muscular relaxation, evenly paced diaphragmatic breathing, and positive self-talk in order to manage his/her symptoms. D. The client has become proficient in coping te chniques for his/her panic attacks; he/she was reinforced for the regular use of these techniques. E. The client has not regularly used coping techniques for panic attacks and was provided with additional training in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
226 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 21. Urge External Focus (21 ) A. The client was urged to keep his/her focus on external stimuli and behavioral responsibilities rather than be preoccupied with internal states and physiological changes. B. The client was reinforced as he/she had made a commitment to not allow panic symptoms to take control of his/her life and to not avoid and escape normal responsibilities and activities. C. The client has been successful at turning his/her focus away from internal anxiety states and toward behavioral responsibilities; he/she was r einforced for this progress. D. The client has not maintained an external focus in order to keep panic symptoms from taking control of his/her life and was reminded about this helpful technique. 22. Assign Information on Breathing and Relaxation (22) A. The client was assigned to read information about progressive muscle relaxation. B. The client was assigned information on paced diaphragmatic breathing. C. The client was directed to read portions of Mastery of Your Anxiety and Panic (Barlow and Craske). D. The client has read the assigned information on progressive muscle relaxation and paced diaphragmatic breathing, and his/her key learnings were reviewed. E. The client has not read the assigned information on progressive muscle relaxation and paced diaphragmatic breathing and was redirected to do so. 23. Counteract Panic Myths (23) A. The client was consistently reassured of the fact that there is no connection between panic symptoms and heart attack, loss of control over behavior, or serious mental illness. B. The client was reinforced as he/she verbalized an understanding that panic symptoms do not promote serious physical or mental illness. 24. Utilize Modeling/Behavioral Rehearsal (24) A. Modeling and behavioral rehearsal were used to train the client in positive self-talk that reassured him/her of the ability to work through and endure anxiety symptoms without serious consequences. B. The client has implemented positive self-talk to reassure himself/herself of the ability to endure anxiety wit hout serious consequences; he/she was reinforced for this progress. C. The client has not used positive self-talk to help endure anxiety and was provided with additional direction in this area. 25. Identify Distorted Thoughts (25) A. The client was assis ted in identifying the distorted schemas and related automatic thoughts that mediate anxiety responses. B. The client was taught the role of distorted thinking in precipitating emotional responses. C. The client was reinforced as he/she verbalized an und erstanding of the cognitive beliefs and messages that mediate his/her anxiety responses. D. The client was assisted in replacing distorted messages with positive, realistic cognitions. E. The client failed to identify his/her distorted thoughts and cogni tions and was provided with tentative examples in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PANIC/AGORAPHOBIA 227 26. Assign Reading Materials (26) A. The client was assigned to read psychoeducational chapters of books or treatment manuals on cognitive restructuring. B. The client was assigned to read psyc hoeducational chapters of books or treatment manuals for the rationale for cognitive restructuring for panic/Agoraphobia. C. The client was assigned information from Mastery of Your Anxiety and Panic (Barlow and Craske). D. The client has read the assign ed material on cognitive restructuring; key points were reviewed. E. The client has not read the assigned information on the rationale for panic/Agoraphobia treatment and was redirected to do so. 27. Assign Exercises on Self-Talk (27) A. The client was a ssigned homework exercises in which he/she identifies fearful self-talk and creates reality-based alternatives. B. The client was directed to do assignments from 10 Simple Solutions to Panic (Antony and Mc Cabe). C. The client was directed to complete ass ignments from Mastery of Your Anxiety and Panic (Barlow and Craske). D. The client was reinforced for his/her successes at replacing fearful self-talk with reality-based alternatives. E. The client was provided with corrective feedback for his/her failur es to replace fearful self-talk with reality-based alternatives. F. The client has not completed his/her assigned homework regarding fearful self-talk and was redirected to do so. 28. Teach Sensation Exposure Techniques (28) A. The client was taught abou t sensation exposure techniques. B. The client was taught about generating feared physical sensations through exercise (e. g., breathing rapidly until slightly light-headed) and the use of coping strategies to keep himself/herself calm. C. The client was assigned information about sensation exposure techniques in 10 Simple Solutions to Panic (Antony and Mc Cabe). D. The client was assigned information about sensation exposure techniques in Mastery of Your Anxiety and Panic —Therapist's Guide (Craske, Barlow, and Meadows). E. The client displayed a clear understanding of the sensation exposure technique and was reinforced for his/her understanding. F. The client struggled to understand the sensation exposure technique and was provided with remedial feedback. 29. Assign Material on Sensation Exposure (29) A. The client was assigned to read about sensation (interceptive) exposure in books or treatment manuals on Panic Disorder and Agoraphobia. B. The client was assigned to read Mastery of Your Anxiety and Pa nic (Barlow and Craske). C. The client was asked to read 10 Simple Solutions to Panic (Antony and Mc Cabe). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
228 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client has read the assigned information on the sensation exposure techniques and was reinforced for his/her understanding of these concepts. E. The client does not display an understanding of the sensation exposure technique and was provided with remedial feedback in this area. 30. Assign Homework on Sensation Exposure (30) A. The client was assigned homework exercises to perform sensation exposure and record his/her experiences. B. The client was assigned sensation exposure homework from Mastery of Your Anxiety and Panic (Barlow and Craske). C. The client was assigned sensation exposure homework from 10 Simple Solutions to Panic (Antony a nd Mc Cabe). D. The “Panic Attack Rating Form” from the Adolescent Psychotherapy Homework Planner, 2nd ed. (Jongsma, Peterson, and Mc Innis) was used to help the client's experiences of anxiety during sensation exposure. E. The client's use of sensation ex posure techniques was reviewed and reinforced. F. The client has struggled in his/her implementation of sensation exposure techniques and was provided with corrective feedback. G. The client has not attempted to use the sensation exposure techniques and was redirected to do so. 31. Construct Anxiety Stimuli Hierarchy (31) A. The client was assisted in constructing a hierarchy of anxiety-producing situations associated with two or three spheres of worry. B. It was difficult for the client to develop a h ierarchy of stimulus situations, as the causes of his/her anxiety remains quite vague; he/she was assisted in completing the hierarchy. C. The client was successful at creating a focused hierarchy of specific stimulus situations that provoke anxiety in a gradually increasing manner; this hierarchy was reviewed. 32. Select Initial Exposures (32) A. Initial exposures were selected from the hierarchy of anxiety-producing situations, with a bias toward likelihood of being successful. B. A plan was developed with the client for managing the symptoms that may occur during the initial exposure. C. The client was assisted in rehearsing the plan for managing the exposure-related symptoms within his/her imagination. D. Positive feedback was provided for the clien t's helpful use of Symptom management techniques. E. The client was redirected for ways to improve his/her symptom management techniques. 33. Assign Information on Situational Exposure (33) A. The client was assigned to read information about situational (exteroceptive) exposure in books or treatment manuals on Panic Disorder and Agoraphobia. B. The client was assigned to read Mastery of Your Anxiety and Panic (Barlow and Craske). C. The client was assigned to read Living with Fear (Marks). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PANIC/AGORAPHOBIA 229 D. The clie nt has read the assigned information on situational exposure and his/her key learnings were reviewed. E. The client has not read the assigned information on situational exposure and was redirected to do so. 34. Assign Homework on Situational Exposures (34 ) A. The client was assigned homework exercises to perform situational exposures and record his/her experiences. B. The client was assigned “Gradually Facing a Phobic Fear” from the Adolescent Psychotherapy Homework Planner, 2nd ed. (Jongsma, Peterson, a nd Mc Innis). C. The client was assigned situational exposures homework from Mastery of Your Anxiety and Panic (Barlow and Craske). D. The client was assigned situational exposures homework from 10 Simple Solutions to Panic (Antony and Mc Cabe). E. The cl ient's use of situational exposure techniques was reviewed and reinforced. F. The client has struggled in his/her implementation of situational exposure techniques and was provided with corrective feedback. G. The client has not attempted to use the situ ational exposure techniques and was redirected to do so. 35. Differentiate between Lapse and Relapse (35) A. A discussion was held with the client regarding the distinction between a lapse and a relapse. B. A lapse was associated with an initial and reve rsible return of symptoms, fear, or urges to avoid. C. A relapse was associated with the decision to return to fearful and avoidant patterns. D. The client was provided with support and encouragement as he/she displayed an understanding of the difference between a lapse and a relapse. E. The client struggled to understand the difference between a lapse and a relapse and was provided with remedial feedback in this area. 36. Discuss Management of Lapse Risk Situations (36) A. The client was assisted in id entifying future situations or circumstances in which lapses could occur. B. The session focused on rehearsing the management of future situations or circumstances in which lapses could occur. C. The client was reinforced for his/her appropriate us of la pse management skills. D. The client was redirected in regard to his/her poor use of lapse management skills. 37. Encourage Routine Use of Strategies (37) A. The client was instructed to routinely use the strategies that he/she has learned in therapy (e. g., cognitive restructuring, exposure). B. The client was urged to find ways to build his/her new strategies into his/her life as much as possible. C. The client was reinforced as he/she reported ways in which he/she has incorporated coping strategies in to his/her life and routine. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
230 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client was redirected about ways to incorporate his/her new strategies into his/her routine and life. 38. Develop a Coping Card (38) A. The client was provided with a coping card on which specific coping strategies wer e listed. B. The client was assisted in developing his/her coping card in order to list his/her helpful coping strategies. C. The client was encouraged to use his/her coping card when struggling with anxiety-producing situations. 39. Explore Secondary Ga in (39) A. Secondary gain was identified for the client's panic symptoms because of his/her tendency to escape or avoid certain situations. B. The client denied any role for secondary gain that results from his/her modification of life to accommodate pan ic; he/she was provided with tentative examples. C. The client was reinforced for accepting the role of secondary gain in promoting and maintaining the panic symptoms and encouraged to overcome this gain through living a more normal life. 40. Differentiat e Current Fear from Past Pain (40) A. The client was taught to verbalize the separate realities of the current fear and the emotionally painful experience from the past that has been evoked by the phobic stimulus. B. The client was reinforced when he/she expressed insight into the unresolved fear from the past that is linked to his/her current phobic fear. C. The irrational nature of the client's current phobic fear was emphasized and clarified. D. The client's unresolved emotional issue from the past w as clarified. 41. Encourage Sharing of Feelings (41) A. The client was encouraged to share the emotionally painful experience from the past that has been evoked by the phobic stimulus. B. The client was taught to separate the realities of the irrationall y feared object or situation and the painful experience from his/her past. 42. Support Activity Rather than Escape (42) A. The client was urged to engage in activities rather than escape into a pattern of avoidance. B. The client was reinforced as he/she reviewed his/her pattern of engagement rather than escape. C. The client continues to focus on escape and was urged to increase his/her engagement in small steps. 43. Enlist Support System (43) A. The client's support system was enlisted in the implemen tation of specific stress reduction techniques. B. The client's support system was enthusiastic and supportive of the client's stress reduction techniques, and the client was encouraged to utilize this support on a regular basis. C. The client's suppor t system has declined significant involvement in helping the client to implement specific stress reduction techniques, so alternative means of development support for stress reduction were developed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PANIC/AGORAPHOBIA 231 D. The client has declined support from his/her family, friends, and caretakers, and was urged to utilize this support. 44. Schedule a Booster Session (44) A. The client was scheduled for a booster session between 1 and 3 months after therapy ends. B. The client was advised to contact the therapist if he/sh e needs to be seen prior to the booster session. C. The client's booster session was held, and he/she was reinforced for his/her successful implementation of therapy techniques. D. The client's booster session was held, and he/she was encouraged to atten d further treatment, as his/her progress has not been sustained. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
232 PARANOIA CLIENT PRESENTATION 1. Fixed Persecutory Delusions (1) * A. The client described a pattern of fixed persecutory delusions regarding others, their intentions, and possible harm. B. The client described beliefs that others are persecuting him/her or intend to do him/her harm, but was unable to identify these as delusions. C. As treatment has progressed, the client reports a decrease in persecutory thoughts. D. The client reported that he/she now understands that his/her former persecutory beliefs were due to his/her mental illness. 2. Extreme Distrust (2) A. The client described a pattern of consistent distrust of others generally. B. The client described an extreme distrust of a significant other in his/her life without sufficient basis. C. The client's level of distrust toward others has diminished. D. The client verbalized trust in the significant other that he/she had previously held in extreme distrust. E. The client displayed normal levels of trust toward others. 3. Expectation of Harm by Others (3) A. The client described an expectation of being exploited or harmed by others. B. The client displayed an animated fear of being exploited or harmed by others. C. The client's fear of being harmed by others has diminished. D. The client no longer holds to an irrational belief that he/she is being plotted against by others. 4. Misinterpretation of Benign Events (4) A. The client demonstrated a pattern of misinterpretation of benign events as having threatening personal significance. B. The client is beginning to accept a more reality-based interpretation of benign events as nonthreatening. C. The client no longer demonstrates a pattern of misinterpretation of benign events and has verbalized not feeling personally threatened. 5. Audito ry/Visual Hallucinations (5) A. The client has experienced auditory hallucinations suggesting harm, threats to safety, or disloyalty. * The numbers in parentheses correlate to the number of the Behavioral Definiti on statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARANOIA 233 B. The client has experienced visual hallucinations suggesting harm, threats to safety, or disloyalty. C. The client's hallucinations have decreased in intensity and frequency. D. The client reported no longer experiencing hallucinations of any type. 6. Avoids Others (6) A. The client acknowledged that he/she is inclined to keep an emotional and social distance from others for fear of being hurt or being taken advantage of by them. B. The client is beginning to show some trust of others as demonstrated by increased social interaction. C. The client described relationships with others that involve a degree of vulnerabil ity and intimacy with which he/she has become comfortable. 7. Easily Offended/Quick to Anger (7) A. The client's history is replete with incidents in which he/she has become easily offended and was quick to anger. B. The client described a pattern of de fensiveness in which he/she easily feels threatened by others and becomes angry with them. C. The client described a pattern of projection of threatening motivations onto others to which he/she reacts with irritability, defensiveness, and anger. D. The c lient has become less defensive and has not shown any recent incidents of unreasonable anger. 8. Suspicious of Treatment (8) A. The client described irrational persecutory beliefs regarding his/her treatment. B. The client displayed a pattern of unwilli ngness to take advantage of treatment due to his/her irrational persecutory beliefs. C. As a more trusting therapeutic relationship has been developed, the client reports decreased suspiciousness of his/her treatment. D. The client displayed a willingnes s to take advantage of treatment regardless of persecutory beliefs. E. The client has displayed no persecutory beliefs associated with his/her treatment. 9. Violence Potential (9) A. The client described urges to become violent as a defensive reaction t o his/her delusion or hallucination that some person or agency is a threat to self or others. B. The client reported that he/she has initiated physical encounters that have injured others as a defensive reaction to his/her delusions or hallucinations. C. The client has decreased his/her pattern of violence as a defensive reaction to delusions or hallucinations. D. As the client's delusions and hallucinations have decreased, his/her potential for being violent has decreased as well. E. The client shows n o current evidence of irrational urges to become violent. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
234 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER INTERVENTIONS IMPLEM ENTED 1. Review History of Paranoia Symptoms (1) * A. The client was requested to identify his/her history of persecutory hallucinations, delusions, or other paranoia symptoms. B. The client was provided with positive feedback as he/she gave a description of his/her history of persecutory hallucinations, delusions, or other paranoia symptoms. C. The client tended to minimize his/her history of paranoia symptoms and was provided with gentle confrontation in this area. 2. Assess Paranoia (2) A. The nature and extent of the client's current paranoia were assessed with special attention to severely delusional components. B. The client identified those people and/or agencies that are distrusted and was allowed to give his/her irrational explanation for this distrust. C. The client was accepted as he/she demonstrated a pattern of severe delusional aspects to his/her paranoia, although his/her delusions were not endorsed. D. The cl ient was gently confronted regarding being extremely guarded and defensive, refusing to openly describe the nature and severity of his/her distrust. E. The client was supported for demonstrating a decrease in his/her level of paranoia. 3. Conduct Anteced ent and Coping Interview (3) A. The Antecedent and Coping Interview (ACI) was used to identify the factors relevant to each symptom related to paranoid ideation. B. Emotional and behavioral reactions were identified for the client's paranoid ideation. C. Coping strategies were identified for the client's paranoid ideation. 4. Arrange for Psychological Testing ( 4) A. The client was referred for psychological testing to evaluate the extent and severity of his/her paranoia. B. The client was compliant w ith the testing, which indicated a significant pattern of paranoia. C. The psychological test results indicate only mild levels of paranoia, and this was reviewed. D. The psychological testing results indicate that the client's paranoia has significantly abated, and this was reviewed. E. The client was not compliant with the psychological testing and was redirected to this referral. 5. Obtain Information from Other Sources ( 5) A. A proper authorization to release information was obtained in order to se ek out information about the client. B. Family members have been asked to provide information about the client's pattern of paranoia. C. Other sources (e. g., police officers) have been sought out for additional information. * The numbers in parentheses correlate to the number of the Therapeutic Inte rvention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARANOIA 235 D. Based on the information o btained, the conclusion is drawn that the client displays significant paranoia. E. Based on the information obtained, the conclusion is drawn that the client does not display significant paranoia. 6. Assess Reality Orientation ( 6) A. The client's immedi ate ability to maintain reality orientation was assessed. B. The client was assessed regarding his/her threat to safety of himself/herself and others. C. The client was judged to be reality-oriented and not a significant threat to the safety of himself/h erself and others. D. Due to the client's poor reality orientation, he/she was judged to be a threat to the safety of himself/herself and others, and steps were coordinated to place the client in a more structured environment. 7. Provide Direct Instructi ons ( 7) A. The client was provided with direct, basic instructions and with firm reassurance of his/her safety and maintenance of confidentiality. B. The client has become less agitated as he/she has felt reassured and was encouraged to maintain this sta bility. C. The client continues to be quite agitated, despite being provided with direct, basic instructions and firm reassurances. 8. Refer for an Evaluation for Hospitalization ( 8) A. The client was immediately referred for an evaluation by a psychiat rist or other clinician regarding his/her psychotic symptoms and the need for psychiatric hospitalization. B. The client was not judged to be in need of psychiatric hospitalization. C. The client was judged to be in need of psychiatric hospitalization, a nd this was immediately coordinated. 9. Coordinate Hospitalization ( 9) A. The client was referred for a voluntary admission to a psychiatric hospital, as he/she is so out of touch with reality as to pose a threat to himself/herself or others. B. As the client has refused the necessary admission to a psychiatric hospital, steps were taken for the client to be hospitalized involuntarily. C. The client has been admitted to a psychiatric hospital and was encouraged to use this treatment to stabilize himself /herself. 10. Arrange for a Stable, Supervised Setting ( 10) A. A stable, supervised setting was arranged for the client to remain in at least until the acute psychotic episode is stabilized. B. The client has been admitted to a crisis adult foster care placement in order to provide a stable, supervised setting. C. The client is using a friend or family member's home to provide a stable, supervised setting until his/her psychotic episode is stabilized and was assisted with coordinating the details of this arrangement. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
236 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 11. Provide Empathetic Acceptance (11) A. Empathetic listening was provided to the client, displaying respect for him/her by accepting him/her, despite his/her angry or delusional presentation. B. Acceptance was communicated to the client, despite his/her angry or delusional presentation, but the client's paranoid delusions were not confirmed. C. As the client has been provided with unconditional acceptance, his/her anger, agitation, and paranoia have subsided. 12. Demonstrate Calm Demea nor (12) A. A calm demeanor was demonstrated to the client when he/she disclosed bizarre or antagonistic beliefs. B. As a result of the calm demeanor demonstrated to the client, he/she appears to have decreased his/her fear of rejection. C. The client c ontinues to display fears related to rejection, despite the calm acceptance with which he/she has been provided, and additional feedback was provided to him/her in this area. 13. Reflect Emotions (1 3) A. Indicators of the client's intense emotions (e. g., posture, facial expression, or general presentation) were reflected to him/her. B. Empathy was displayed for the client who was experiencing significant distress related to his/her paranoid delusions. C. The client acknowledged his/her emotions related to paranoid delusions, and these were processed. D. The client tended to deny or minimize emotions related to his/her pattern of delusions, and these were tentatively presented to him/her. 14. Ask Open-Ended Questions (1 4) A. The client was asked open-ended questions about some of his/her delusions or paranoid beliefs. B. The client's paranoid beliefs were accepted as his/her thoughts, although not confirmed. C. Arguing with the client about his/her paranoid beliefs was consistently avoided. D. The cl ient has been more open about his/her delusions or paranoid beliefs and was provided with positive feedback about this openness. 15. Physician Referral ( 15) A. The client was referred to a physician to undergo a thorough examination to rule out any medic al etiologies for his/her paranoia and to receive recommendations for further treatment options. B. The client has followed through on the physician evaluation referral, and specific medical etiologies for his/her experience of paranoia were reviewed. C. The client was supported as he/she is seeking out treatment for the medical concerns that are leading to his/her experience of paranoid thoughts. D. The client has followed through on the physician evaluation referral, but no specific medical etiologies for his/her paranoia have been identified. E. The client declined evaluation by a physician regarding his/her paranoia and was redirected to cooperate with this referral. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARANOIA 237 16. Refer for Vision/Hearing Exams ( 16) A. The client was referred to an audiologi st for a clinical assessment of his/her hearing abilities. B. The client was referred to an ophthalmologist for a specific evaluation of his/her vision needs. C. Expert clinical review of the client's hearing and vision indicated deficits in these areas, as well as suggestions for remediation. D. No concerns were identified through the expert clinical evaluations of hearing and vision. 17. Support/Monitor Physical Evaluation Recommendations ( 17) A. The client was supported in following up on the recomm endations from the medical evaluation. B. The client's follow-up on the recommendations from the medical evaluation has been monitored. C. The client was reinforced for following up on the recommendations from the medical evaluation. D. The client has n ot regularly followed up on his/her medical evaluation recommendations and was redirected to do so. 18. Refer for Psychological Evaluation ( 18) A. The client was referred for a complete psychological evaluation in order to rule out cognitive disorders (e. g., dementia) as a cause for the paranoia. B. The client has completed his/her psychological evaluation, and the results of this evaluation were processed. C. The client has not submitted to a psychological evaluation and was redirected to do so. 19. Evaluate Substance Abuse ( 19) A. The client was evaluated for his/her use of substances, the severity of his/her substance abuse, and treatment needs/options. B. The client was referred to a clinician knowledgeable in both substance abuse and severe and persistent mental illness treatment in order to assess his/her substance abuse concerns and treatment needs. C. The client was compliant with the substance abuse evaluation, and the results of the evaluation were discussed with him/her. D. The client did not participate in the substance abuse evaluation and was encouraged to do so. 20. Refer for Substance Abuse Treatment ( 20) A. The client was referred to a 12-step recovery program (e. g., Alcoholics Anonymous or Narcotics Anonymous). B. The client was r eferred to a substance abuse treatment program. C. The client has been admitted to a substance abuse treatment program and was supported for this follow-through. D. The client has refused the referral to a substance abuse treatment program, and this refu sal was processed. 21. Identify Delusions as Symptoms ( 21) A. The client was gently informed that his/her delusional, persecutory beliefs are based in a mental illness and not in reality. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
238 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was educated about the symptoms of and the treatmen t for his/her mental illness. C. The client was provided with positive feedback, as he/she was able to accept the assertion that his/her delusional, persecutory beliefs are symptoms of his/her mental illness. D. The client denied that his/her delusional, persecutory beliefs are symptoms of his/her mental illness and was provided with additional feedback in this area. 22. Refer to a Physician ( 22) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client was ass isted in filling his/her prescription for psychotropic medications. E. The client declined evaluation by a physician for a prescription of psychotropic medication and was redirected to cooperate with this referral. 23. Educate about Psychotropic Medicati ons ( 23) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefit s of the medications. C. An emphasis was placed on the safety the client should be able to experience about his/her medications and that it is not intended to be harmful to him/her. D. The client displayed a lack of understanding of the indications for a nd expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. 24. Monitor Medications ( 24) A. The client was monitored for compliance with his/her psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication ef fectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 25. Ensure Medication Adherence ( 25) A. Direct, supervised administration of the client's medications was arranged. B. Liquid forms of medications were requested to ensure the client's regular adherence to his/her regimen. C. The client has become more regular with his/her medications, and the positive psychiatric benefits of his/he r adherence were reviewed. D. The client continues to have significant symptoms, despite regular medication adherence, and additional psychiatric evaluation was arranged. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARANOIA 239 26. Review Side Effects of Medications (2 6) A. The possible side effects related t o the client's medications were reviewed with the client. B. The client identified significant side effects, and these were reported to the medical staff. C. Possible side effects of the client's medications were reviewed, but he/she denied experiencing any side effects. D. The client was monitored for signs of tardive dyskinesia. 27. Advocate for Medications to Reduce Side Effects (2 7) A. Advocacy was provided with the client's physician/psychiatrist for an adjustment in his/her medications to reduce or eliminate tardive dyskinesia. B. The client's physician has been able to modify his/her medications in order to maintain efficacy and decrease the likelihood of long-term side effects (e. g., tardive dyskinesia). C. The client's medications cannot be m odified to reduce the likelihood of long-term side effects (e. g., tardive dyskinesia) without reducing efficacy, and this was presented to him/her. D. The client has identified his/her willingness to have reduced efficacy of his/her medications in order t o reduce the likelihood of long-term side effects (e. g., tardive dyskinesia), and this was processed. E. The client has elected to accept the risk for long-term side effects (e. g., tardive dyskinesia) in order to have greater efficacy in his/her medicatio ns, and the risks and benefits of this decision were reviewed. 28. Assess Tardive Symptoms (2 8) A. Arrangements were made for assessment of the client's tardive symptoms, using the client, the staff, or personal observation. B. Objective measurement of the client's tardive symptoms was performed by qualified personnel using a specific instrument (e. g., the Abnormal Involuntary Movement Scale [AIMS]). C. The client displayed no evidence of tardive symptoms, and this was reflected to him/her. D. The clie nt displayed both subjective and objective evidence of tardive symptoms, and this was reported to the physician who prescribed his/her psychotropic medications. 29. Explore Paranoid Thinking (29) A. The client was referred for cognitive-behavioral therapy to explore his/her paranoid thoughts. B. The client was provided with cognitive-behavioral therapy to educate him/her about his/her paranoid thoughts. C. Skills training was provided to the client regarding his/her paranoid thoughts. D. Behavioral expe riments were conducted in order to help the client understand more about his/her paranoid thoughts. E. As a result of the therapy, the client has come to understand more about his/her paranoid thoughts. F. Despite significant therapy to help understand h is/her paranoid thinking, the client does not display any insight in this area. 30. Teach about Cognitive Restructuring and Behavioral Experiments (30) A. The client was taught about how cognitive restructuring can be used to reality test delusional thoughts, decrease fears, develop personal skills, and build confidence. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
240 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. Behavioral experiments were used to help test the reality of the client's delusional thoughts. C. As a result of Cognitive Restructuring and Behavioral Experiments the client is less fearful, more confident, and more reality oriented. D. Despite the use of Cognitive Restructuring and Behavioral Experiments the client continues to display significant delusional thoughts, fearfulness, skill deficits, and a lack of confidence; he/she wa s provided with remedial assistance in this area. 31. Explore Schema (31) A. The client was assisted in exploring his/her schema and self-talk that mediate his/her paranoid thoughts. B. The client was assisted in challenging the biases that support his/h er paranoid thoughts. C. The client was assisted in generating alternative appraisals that could be tested for truthfulness. D. The client has gained greater reality orientation through exploring and testing his/her schema and self talk. E. Despite expl oring the client's schema and self-talk, he/she continues to have significant paranoid thoughts; this pattern was summarized to him/her. 32. Assign Reality-Testing Homework (32) A. The client was given a homework exercise in which he/she identifies a few biased beliefs and creates reality-based alternatives. B. The client was directed to utilize the “Check Suspicions Against Reality” task in the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client's success in becoming more reality orie nted though the homework exercises was reinforced. D. The client was provided with corrective feedback toward improving his/her skills and being reality oriented. 33. Identify Reality Testing Activities (33) A. The client was encouraged to participate in activities that can help him/her to test his/her paranoid predictions against reality-based alternatives. B. The client was assisted in listing activities that may help him/her to test his/her predictions against reality-based alternatives. C. The clien t has engaged in activities that can help to test his/her paranoid predictions against reality-based alternatives, and the results of his/her experiments were reviewed. D. The client has not engaged in activities that can help to test his/her paranoid pre dictions and was redirected to do so. 34. Select Successful Behavioral Experiments (34) A. The client was assisted in selecting initial behavioral experiments that will have a high likelihood of being successful. B. Cognitive restructuring techniques wer e used within and after the exercise in order to reinforce successes and identify obstacles to problem solving. 35. Teach about Coping Package (35) A. The client was taught a variety of techniques to help manage anxiety symptoms. B. The client was taught calming strategies, such as relaxation and breathing techniques. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARANOIA 241 C. The client was taught cognitive techniques, such as thought-stopping, positive self-talk, and attention-focusing skills (e. g., distraction from urges, staying focused, behavioral goals o f abstinence). D. The client has used his/her coping package techniques to help reduce his/her anxiety symptoms; this program was reinforced. E. The client has not used the coping package for managing anxiety symptoms and was redirected to do so. 36. Teach Social and Communication Skills (36) A. The client was taught general social and communication skills. B. Instruction, modeling and role-playing were used to help build the client's general social and communicational skills. C. The client's increased social skills were reinforced. D. Despite attempts at increasing the subject's social and communication skills, he/she still has significant deficits in this area, and was provided with remedial treatment in this area. 37. Assign Information on Social an d Communication Skills (37) A. The client was assigned to read about general social and/or communication skills in books or treatment manuals on building social skills. B. The client was assigned to read Your Perfect Right (Alberti and Emmons). C. The c lient was assigned to read Conversationally Speaking (Garner). D. The client has read the assigned information on social and communication skills, and key points were reviewed. E. The client has not read the information on social and communication skills and was redirected to do so. 38. Coordinate Externally Focused Activities ( 38) A. The client was encouraged to gradually increase his/her involvement in community activities, volunteering, and other externally focused activities. B. The client was assis ted in finding specific opportunities to increase his/her external focus by becoming involved in activities. C. The client was supported for becoming regularly involved in community activities and for reporting an increase in his/her external focus. D. The client has not been able to focus on community activities, and his/her struggles in this area were problem solved. 39. Encourage Social Relationships ( 39) A. The client was encouraged to increase his/her involvement in social relationships. B. Verbal reinforcement was used when the client reported attempts at increasing his/her social contacts. C. The client has not increased his/her social relationships and was redirected in this area. 40. Accompany to Social/Recreational Events (4 0) A. The client was accompanied to social/recreational events in order to increase his/her involvement in community-based activities. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
242 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The level of contact with or support from the clinician during the outing was controlled by the client. C. The client was reinforced for successfully negotiating the social/recreational event with close contact from the clinician. D. The client was reinforced for successfully negotiating the social/recreational event with limited contact from the clinician. E. The client has declined any support from the clinician during social/recreational events and was reminded of the availability of this support. 41. Educate the Family about Symptoms of Mental Illness ( 41) A. The client's family, friends, and caregivers were educated about the s ymptoms of mental illness, with specific emphasis on the nonvolitional aspects of some symptoms. B. The client's family members were supported for their increased understanding about the symptoms of mental illness and the nonvolitional aspects of some sym ptoms. C. The client's family members, friends, and caregivers rejected the information regarding his/her symptoms of mental illness and the nonvolitional aspects of some symptoms, and they were given additional feedback in this area. 42. Teach Calm Resp onses to Paranoia ( 42) A. The client's family, friends, and caregivers were taught to give calm, assertive responses to paranoid behaviors. B. Modeling and role-playing techniques were used to teach to the client's family, friends, and caregivers how to give calm, assertive responses to his/her paranoid behaviors. C. The client's family, friends, and caregivers were cautioned against issuing challenges that are too vigorous for his/her delusional beliefs. D. The client's family, friends, and caregivers were given positive feedback regarding their calm, assertive responses to his/her paranoid behavior. E. The client's family, friends, and caregivers tend to react too strongly to his/her pattern of delusional beliefs, causing increased stress and conflict s within the relationship; this overreaction was processed. 43. Explore Stressors that Trigger Psychosis (4 3) A. The client was probed for recent stressors that may have triggered his/her most recent psychotic episode. B. The client was provided with emo tional support and feedback as he/she described the stressors that have contributed to his/her most recent psychotic episode. C. The client's feelings regarding his/her stressors were processed. D. The client maintained a pattern of denial and minimizati on regarding his/her stressors and psychosis and was provided with additional feedback in this area. 44. Teach Social Skills ( 44) A. The client was taught skills to help reduce his/her stress (e. g., using assertiveness, problem-solving, or other stress r eduction techniques). B. The client was referred for training to increase his/her social skills. C. The client was reinforced for displaying a better understanding of social skills and for using them to help decrease his/her stress level. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARANOIA 243 D. The client displayed poor social skills and was redirected to use the social skills for which he/she has been trained. 45. Reduce Threats in the Environment (4 5) A. The client was assisted in identifying and implementing strategies for reducing stress in his/her environment. B. The client was provided with feedback as he/she identified specific threats in the environment. C. The client was assisted in reducing threats in the environment (e. g., finding a safer place to live, arranging for regular visits from the cli nician, arranging for family members to call more frequently, checking his/her perceptions with others). 46. Refer to a Support Group (4 6) A. The client was referred to a support group for individuals with severe and persistent mental illness. B. The cl ient has attended the support group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. C. The client reported that he/she has not experienced any positive benefit from the use of a support grou p but was encouraged to continue to attend. D. The client has not used the support group for individuals with severe and persistent mental illness and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
244 PARENTING CLIENT PRESENTATION 1. Symptoms Affect Interactions with the Child (1) * A. The client's severe and persistent mental illness symptoms often affect his/her interactions with his/her child. B. The client's child often appears to be confused by t he client's erratic behavior due to his/her severe and persistent mental illness symptoms. C. As treatment has progressed, the client's severe and persistent mental illness symptoms have improved. 2. Loss of Custody (2) A. The client's child is at risk of being removed from his/her custody due to safety concerns or his/her inability to care for the child. B. The client has lost custody of his/her child due to safety concerns or inability to care for the child. C. The client has decompensated due to the increased stress and emotional response related to losing custody of his/her child. D. The client has become more focused and more open to treatment subsequent to losing custody of his/her child. E. As the client has stabilized in treatment, he/she has pursued regaining custody of his/her child. 3. Lack of Interest (3) A. The client described a pattern of very limited or only superficial interest in the child's activities. B. The client displayed a pattern of limited interest in his/her child's activi ties. C. The client's severe and persistent mental illness has caused a decreased level of involvement in the child's activities. D. The client has taken steps to become more involved in his/her child's activities. 4. Difficulty Coping with Parenting (4 ) A. The client described a sense of being overwhelmed by the day-to-day stressors of parenting. B. The client reported a lack of coping skills for the day-to-day stressors of parenting. C. As the client's severe and persistent mental illness has stabil ized, he/she reports an increased ability to function with day-to-day stressors. 5. Disagreement with Significant Other (5) A. The client described a pattern of disagreement with his/her partner regarding child rearing practices. * The numbers in parentheses cor relate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARENTING 245 B. The client described that his/her severe and persistent mental illness symptoms have exacerbated his/her relationship conflicts. C. The client described a pattern of increasing relationship stress due to disagreements regarding child rearing practices. D. The client reporte d a decrease in his/her level of relationship stress. 6. Extended Family Involvement (6) A. Members of the client's extended family have expressed concern about the welfare of his/her child. B. Members of the client's extended family have taken responsi bility for his/her child. C. Support and assistance have been provided by the client's extended family to assist him/her in maintaining involvement in his/her child. D. As the client has stabilized, his/her extended family has decreased their involvement in his/her parenting. 7. Child's Manipulation (7) A. The client described a pattern of ineffectiveness in his/her parenting style due to his/her severe and persistent mental illness symptoms. B. The client's child has often taken advantage of the clien t's pattern of ineffective parenting. C. As the client's severe and persistent mental illness has stabilized, he/she reports an increased pattern of effectiveness in his/her parenting skills. D. Through the client's increased parenting effectiveness and other natural supports, his/her child has been unable to take advantage of him/her. 8. Shame, Embarrassment, and Confusion (8) A. The client's child described feeling shame and embarrassment due to the client's mental illness symptoms. B. The client's c hild is often confused about his/her parent's mental illness symptoms. C. As treatment has progressed, the client's child has displayed increased understanding and acceptance of the client's mental illness. INTERVENTIONS IMPLEM ENTED 1. Explore Parenting Concerns (1) * A. The client's history of parenting concerns was explored. B. The client was provided with positive feedback for being open and honest regarding his/her history of parenting concerns. C. The client tended to minimize his/her parenting dif ficulties, and this was reflected to him/her. 2. Create a Family Genogram (2) A. The client's description of family members, patterns of interactions, rules, and secrets was translated into a graphic genogram. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
246 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. A family session was conducted in which a genogram was developed that was complete, denoting family members, patterns of interaction, rules, and secrets. C. The dysfunctional communication patterns between family members were highlighted. D. Family members were supported as they acknowledged t he lack of healthy communication that permeates the extended family. E. The client displayed an increased understanding of his/her family's pattern of unhealthy communication and was encouraged for this progress. F. The client failed to develop insight i nto family interactions and was given tentative interpretations of these patterns. 3. Develop a Time line of Parenting and Illness (3) A. The client was assisted in developing a time line of important events regarding parenting (e. g., births, relationshi ps beginning and/or ending, loss or return of custody/visitation). B. The client's parenting time line was compared with milestones related to his/her illness (e. g., onset of symptoms, hospitalizations). C. The interaction between the client's mental ill ness symptoms and parenting struggles was processed with him/her. D. The client was supported for the insight of identifying a pattern of increased stress related to his/her parenting that correlates with increases in his/her symptom pattern. E. The clie nt denied any connection between his/her mental illness symptoms and parenting concerns and was encouraged to keep this connection in mind. 4. Review Current Parenting Concerns (4) A. The client was asked to review current concerns and successes regardin g parenting, including the child's challenging behaviors, the approach taken with the child, and legal issues. B. The client's partner was requested to provide input regarding current parenting concerns. C. The client was reminded to focus on the succes ses and positive traits of the child. D. The client was supported and encouraged as he/she gave an accurate portrayal of his/her current parenting concerns. E. The client tended to minimize and deny his/her current parenting concerns and was provided with confrontation in this area. F. The client tended to be quite negative about the child and was reminded to balance this with more positive feedback. 5. Psychological Testing ( 5) A. A psychological evaluation was conducted to determine the extent of the client's ability to bond with the child. B. The client approached the psychological testing in an honest, straightforward manner and was cooperative with any requests presented to him/her. C. The client was uncooperative and resistant to engage during t he evaluation process and was advised to use this testing to discover more about himself/herself. D. The results of the psychological evaluation were reviewed with the client. 6. Educate about Mental Illness ( 6) A. The client was educated about the expe cted or common symptoms of his/her mental illness that may negatively impact his/her ability to function in the parent role. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARENTING 247 B. As the client's symptoms of mental illness were discussed, he/she displayed an understanding of how these symptoms may affect h is/her functioning as a parent. C. The client struggled to identify how symptoms of his/her mental illness may negatively impact his/her parenting and was given additional feedback in this area. 7. Assign Reading on Mental Illness ( 7) A. The client and his/her family were referred to books that provide information regarding the etiology, symptoms, and treatment of severe and persistent mental illness. B. Schizophrenia: The Facts by Tsuang and Faraone and Bipolar Disorder: A Guide for Patients and Famili es by Mondimore were recommended to the client and his/her family. C. The client and his/her family have read books regarding the etiology, symptoms, and treatment of mental illness, and this information was reviewed within the session. D. The client and his/her family have not read information regarding the etiology, symptoms, and treatment of severe and persistent mental illness and were redirected to do so. 8. Discuss Mental Illness Effect on Parenting ( 8) A. The effect of the client's personal exper ience of severe and persistent mental illness was reviewed to identify how these symptoms have affected his/her ability to parent effectively. B. The client was praised for his/her openness and insight regarding how his/her mental illness symptoms have af fected his/her parenting. C. As the client has gained insight into his/her pattern of parenting, he/she has become more effective, and this was reviewed within the session. D. The client has minimized and denied any effect of his/her severe and persisten t mental illness symptoms on his/her ability to parent effectively and was provided with contrary feedback. 9. Refer to a Physician ( 9) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The cl ient was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluati on by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 10. Educate about and Monitor Psychotropic Medications (1 0) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The client was monitored for compliance with, effectiveness o f, and side effects from his/her psychotropic medication regimen. D. The client was provided with positive feedback about his/her regular use of psychotropic medications. E. Concerns about the client's medication effectiveness and side effects were commu nicated to the physician. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
248 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER F. Although the client was monitored for medication side effects, he/she reported no concerns in this area. G. The client displayed a lack of understanding of the indications for and expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. 11. Obtain Day Care (1 1) A. The client was assisted in obtaining day care services for his/her children during his/her appointment for mental illness treatment. B. The client was reinforced for obtaining regular day care services to assist with the supervision of his/her children during his/her appointments and becoming more regular in attending appointments. C. The client has not obtained day care services for the times when he/she is at appointments for his/her mental illness treatment and was redirected in this area. 12. Review Side Effects of Medications (1 2) A. The possible side effects related to the client's medications were reviewed with the client. B. The client identified significant side effects, and these were reported to the medical staff. C. Possible side effects of the client's medications were reviewed, but he/she denied experiencing any side effects. 13. Refer to a Parenting Class (1 3) A. The c lient was referred to a parenting class to teach him/her new skills for parenting. B. The client has attended the parenting class, and his/her implementation of new parenting skills was reviewed. C. The client has not attended the parenting class and was redirected to do so. 14. Assign Parenting Books (1 4) A. The client was assigned to read material that provides guidance on effective parenting methods. B. The client was assigned to read 1-2-3 Magic: Effective Discipline for Children 2-12, Second Edition, by Phelan; Parenting Teens with Love and Logic: Preparing Adolescents for Responsible Adulthood by Cline and Fay; or Positive Parenting from A to Z by Joslin. C. The client has read the assigned parenting material, and this information was processed. D. The client has not read the assigned parenting material and was redirected to do so. 15. Practice Parenting Skills (1 5) A. Role-playing, modeling, and behavioral rehearsal were used to help the client practice implementation of new parenting skills. B. The client was reinforced for his/her display of understanding regarding new parenting skills. C. The client failed to display understanding of new parenting skills and was provided with remedial information in this area. 16. Focus the Couple on a Pa renting Plan (1 6) A. A conjoint session was arranged to help the client and his/her partner to develop mutually acceptable plans for parenting of the child. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARENTING 249 B. The conjoint session was focused on the types of parenting approaches to be used with the child. C. The client and his/her partner have identified specific approaches to be used with the child and were encouraged for this plan. D. The client and his/her partner were reinforced for using parenting techniques in a similar manner. E. The client and his/her partner have been unable to agree on a mutually acceptable plan for parenting the child and were encouraged to continue to focus on this area. 17. Regularly Review Parenting Plans ( 17) A. The client and his/her partner were encouraged to regular ly review their parenting plan. B. Conjoint sessions were scheduled to focus on the review of the parenting plan. C. The client was assisted in making appropriate adjustments to his/her parenting plan. D. The client and his/her significant other have no t reviewed the parenting plan and were encouraged to do so. 18. Explore Mental Illness Effects on Parenting ( 18) A. Situations in which the client's mental illness symptoms may affect interactions with the child were explored. B. The client identified s pecific situations in which his/her mental illness symptoms may affect interactions with the child and was provided with positive support and encouragement in this area. C. The client seemed to be denying the effect of his/her mental illness symptoms on i nteraction with the child and was confronted about this denial. 19. Develop Contingency Plans ( 19) A. The client and his/her partner were assisted in developing contingency plans for areas in which the client's mental illness symptoms may affect interact ions with the child (e. g., removing the car keys when the client becomes manic). B. The client and his/her partner were supported for developing a contingency plan for situations in which the client's mental illness symptoms may affect interaction with th e child. C. The client and his/her partner were reinforced for their regular use of contingency plans. D. The client and his/her partner have not developed or used contingency plans and were redirected in this area. 20. Develop Emergency Child Care List (20) A. The client and his/her partner were directed to develop a listing of family members and other individuals who can provide short-term supervision to the child when the client is feeling overwhelmed by his/her parenting responsibilities. B. The cl ient and his/her partner were reinforced for developing a list of support network members who are willing to provide short-term supervision to the client's child. C. The client was supported for regularly using members of his/her support network to superv ise the child when the client is feeling overwhelmed by his/her parenting responsibilities. D. The client has not listed or used family members and other individuals who can provide short-term supervision for the child and was reminded of this resource. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
250 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 21. Coordinate Child Care during Acute Phases (2 1) A. The assistance of the extended family was enlisted in order to provide supervision and parenting to the child during acute stages of the client's mental illness. B. The client was reassured and reinfo rced regarding the longer-term supervision of the child provided by members of the extended family. C. The client has not agreed to have the child supervised by extended family members during his/her acute stages of mental illness and was strongly encoura ged to do so. 22. Coordinate Respite Services (2 2) A. The client was directed to funding resources for obtaining respite services. B. Respite services were coordinated for the client in order to provide short-or long-term periods of relief from the add itional stress of parenting. C. The client was encouraged to use respite funds and services in order to obtain relief from the stress of parenting. D. The client was reinforced for his/her use of respite services in order to improve the overall relations hip with the child. E. The client has not used the respite services and was encouraged to do so. 23. Suggest One-to-One Time (2 3) A. The client was urged to set specific times to spend alone with each child. B. The client was encouraged to treat his/he r one-to-one time with each child as a priority while still being flexible enough to reschedule if his/her mental illness symptoms are more acute. C. The client's use of one-to-one time with his/her child was reviewed. D. The client was supported for usi ng good judgment in rescheduling one-to-one time when his/her mental illness symptoms were more acute. E. The client has not appropriately used one-to-one time with each child and was provided with feedback in this area. 24. Teach Relaxation Techniques ( 24) A. The client was taught deep muscle relaxation and deep breathing techniques as ways to reduce muscle tension. B. The Relaxation and Stress Reduction Workbook (Davis, Eshelman, and Mc Kay) was used to provide the client with examples of techniques to help himself/herself relax. C. The client was reinforced for implementing the relaxation techniques. D. The client has not implemented the relaxation techniques presented to him/her and continues to feel quite stressed; use of relaxation procedures was again encouraged. 25. Brainstorm Diversionary Activities ( 25) A. The client was assisted in brainstorming diversionary activities that can relieve parenting stress (e. g., going for a walk, calling a friend, or engaging in a hobby). B. The client identif ied a variety of diversionary activities that would appeal to him/her and was encouraged to use these. C. The client was provided with positive feedback as he/she has regularly used diversionary activities to relieve parenting stress. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARENTING 251 D. The client has n ot used diversionary activities to relieve parenting stress and was encouraged to do so. 26. Coordinate Conjoint Sessions with the Child ( 26) A. Conjoint sessions were coordinated for the client's child to ask questions about the client's mental illness symptoms. B. The client was assisted in responding to the child's questions at an age-appropriate level. C. The child was provided with additional information regarding his/her questions about the client's mental illness symptoms. 27. Provide Written In formation to the Child ( 27) A. The child was provided with age-appropriate written information about his/her parent's mental illness. B. The child was provided with information from When Parents Have Problems: A Book for Teens and Older Children with an Abusive, Alcoholic or Mentally Ill Parent by Miller. C. The child has read the information about his/her parent's mental illness, and this material was reviewed. D. The child has not read the information about his/her parent's mental illness and was encouraged to do so. 28. Coach about Talking for the Child's Understanding ( 28) A. The client was coached about how to talk about his/her mental illness concerns in a manner in which the child can understand. B. The client was provided with examples of how to talk to the child in an age-appropriate manner about his/her mental illness symptoms. C. The client's talks with the child about his/her mental illness symptoms were reviewed, and he/she was provided with feedback in this area. D. The client has not d iscussed his/her mental illness concerns with his/her child and was encouraged to do so. 29. Explore the Child's Feelings ( 29) A. The client's child's feelings regarding his/her parent's mental illness were explored. B. Specific incidents of when the cl ient's symptoms have had a painful impact on the child's life were identified. C. The child was provided with support and encouragement regarding his/her emotional response to his/her parent's mental illness. D. The child tends to minimize his/her emotio ns and painful experiences and was encouraged to talk about these emotions as he/she feels capable. 30. Reinforce Acceptance of the Child's Emotions (3 0) A. The client was focused on the need to accept, without judgment, the feelings of his/her child. B. Reassurance was provided to the client that his/her child's feelings are not a personal attack on the client. C. The client was reinforced for his/her willingness to accept the child's emotions. D. The client has not been willing to accept his/her chil d's emotions and was provided with feedback in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
252 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 31. Refer to a Support Group for Children (31) A. The client and his/her child were referred to a multifamily support group for family members of an individual with a mental illness. B. The clien t's child was referred to an age-appropriate support group for family members of an individual with a mental illness. C. The client's child reported being helped by attending a support group for children with a mentally ill family member, and this attenda nce was reinforced. D. The client's child has not attended a support group and was encouraged to do so. 32. Identify the Child's Accommodations (3 2) A. The client and the child were assisted in identifying mild accommodations that can be made to increas e functioning in the relationship. B. The client and his/her child were reinforced for implementing mild accommodations to increase functioning in the relationship. C. The client and his/her child identified accommodations that were inappropriate for a c hild to make for the parent and were provided with feedback in this area. 33. Brainstorm Responses to Teasing ( 33) A. The client's child was assisted in brainstorming about how to respond to teasing or other interference from peers related to the parent' s mental illness symptoms. B. The client's child was supported for his/her appropriate response to teasing or other interference from peers due to the parent's mental illness symptoms. C. The client's child has often responded in inappropriate ways to te asing and other interference from peers and was provided with feedback in this area. 34. Define Inability to Parent ( 34) A. The client's assistance was enlisted in developing a description of the level of decompensation at which he/she would see himself/ herself as temporarily unable to function as a parent. B. The client was encouraged to commit to temporarily relinquishing responsibility as a parent when he/she decompensates to a critical level. C. The client has agreed to temporarily relinquish his/he r role as a parent when he/she decompensates and was encouraged for planning ahead in this manner. D. The client has temporarily given up his/her parenting role due to decompensation and was supported for this difficult decision. E. The client has refuse d to temporarily give up his/her parenting role when decompensating and was encouraged to review this decision. 35. Teach about Child Protection Guidelines ( 35) A. The client was assisted in understanding the general guidelines under which the court or c hild protection agency will operate. B. The client was reinforced for displaying an understanding of the general guidelines under which the court or child protective agency will operate (whether he/she agrees with these guidelines or not). C. The client failed to display an understanding of the general guidelines under which the court or child protection agency will operate and was provided with remedial information in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PARENTING 253 36. Assist in Custody/Child Protection Case ( 36) A. The client was assiste d in understanding the multiple, intricate steps that occur during a custody or child protection case. B. The client was supported for displaying an increased understanding of the intricate steps that occur during a custody or child protection case. C. Court hearings were attended to provide emotional support to the client. D. The client displayed a poor understanding of the steps that are occurring in his/her custody or child protection case and was provided with additional feedback in this area. 37. Refer to an Attorney ( 37) A. The client was referred to an attorney. B. The client has followed up on the referral to an attorney, and the benefits of this were processed with the client. C. The client has not contacted an attorney and was encouraged to do so. 38. Explore a Working Relationship with the Former Spouse ( 38) A. The degree of cooperative parenting that occurs with the client's former spouse was explored. B. Emphasis was placed on the need for the relationship with the client's former spous e to be a working relationship, focusing on the mutual job of raising their child. C. The client was encouraged to find friendship and other emotional needs outside of the relationship with his/her former spouse when this confounds working together in the best interests of their children. D. The client was supported for displaying a healthier relationship with his/her former spouse by emphasizing the needs of their child. E. The client continues to have an unhealthy, dysfunctional relationship with his/h er spouse and was provided with additional feedback in this area. 39. Keep the Estranged Spouse Informed ( 39) A. A proper authorization to release information was obtained to allow information to be provided to the client's estranged spouse. B. The clie nt's estranged spouse was informed of the client's general level of functioning as it relates to his/her ability to care for the child. C. As a result of increased information, the client's estranged spouse has been more cooperative in assisting the clien t with maximizing his/her contact and care for their child, and this was reviewed within the session. D. The client has declined to allow information to be provided to his/her estranged spouse, and this decision was honored. E. Information was provided t o the client's estranged spouse, but the information has been used against the client without care as to how it relates to his/her ability to care for the child. 40. Discourage Major Decisions during Acute Illness (40) A. The client was discouraged from making long-term, major life decisions during the acute phase of his/her illness. B. The client was reinforced for agreeing to refrain from making any long-term, major life decisions during the acute phase of his/her illness. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
254 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client continues to m ake life-changing decisions during the acute phase of his/her mental illness and was cautioned against this. 41. Weigh the Pros and Cons of Giving Up Custody (41) A. The client was assisted in identifying the pros and cons of giving up custody of his/her child. B. Empathic listening was provided to the client regarding his/her choice about giving up custody of his/her child without endorsing one choice or another. C. The severe pain that is involved in giving up custody of his/her child was acknowledged. D. The client has declined to make any decisions related to his/her child custody rights and was provided with feedback in this area. 42. Refer for Grief Counseling (4 2) A. The client was referred for grief counseling due to his/her decision to give u p custody of his/her child. B. The client was supported for following through on the grief counseling. C. The client has not followed through on the referral for grief counseling and was redirected to do so. 43. Review the Decision to Have Children ( 43) A. The client and his/her intimate partner were focused on the pros and cons of the choice to attempt to have children. B. The client and his/her intimate partner have reviewed the pros and cons of the choice to have children and have decided to proceed with having children; they were provided with feedback in this area. C. The client and his/her intimate partner were supported for reviewing the pros and cons regarding having children and deciding not to have children. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
255 POSTTRAUMATIC STRESS DISORDER (PTSD) CLIENT PRESENTATION 1. Exposure to Death/Injury to Others (1) * A. The client has a history of having been exposed to the death or serious injury of others that resulted in feelings of intense fear, helplessness, or ho rror. B. The client's severe emotional response to fear has somewhat diminished. C. The client can now recall being a witness to the traumatic incident without experiencing the intense emotional response of fear, helplessness, or horror. 2. Exposure to Threatened Death/Injury to Self (1) A. The client has been a victim of a threat of death or serious injury to himself/herself that has resulted in an intense emotional response of fear, helplessness, or horror. B. The client's intense emotional response to the traumatic event has somewhat diminished. C. The client can now recall the traumatic event of being threatened with death or serious injury without an intense emotional response. 3. Intrusive Thoughts (2) A. The client described experiencing intru sive, distressing thoughts or images that recall the traumatic event and its associated intense emotional response. B. The client reported experiencing less difficulty with intrusive, distressing thoughts of the traumatic event. C. The client reported no longer experiencing intrusive, distressing thoughts of the traumatic event. 4. Disturbing Dreams (3) A. The client described disturbing dreams that he/she experiences and are associated with the traumatic event. B. The frequency and intensity of the di sturbing dreams associated with the traumatic event have decreased. C. The client reported no longer experiencing disturbing dreams associated with the traumatic event. 5. Flashbacks (4) A. The client reported experiencing illusions about or flashbacks to the traumatic event. B. The frequency and intensity of the client's flashback experiences have diminished. C. The client reported no longer experiencing flashbacks to the traumatic event. 6. Distressful Reminders (5) A. The client experienced intens e distress when exposed to reminders of the traumatic event. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
256 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNER B. The client reported having been exposed to some reminders of the traumatic event without experiencing overwhelming distress. 7. Physiological Reactivity (6) A. The client experiences physio logical reactivity associated with fear and anger when he/she is exposed to the internal or external cues that symbolize the traumatic event. B. The client's physiological reactivity has diminished when he/she is exposed to internal or external cues of th e traumatic event. C. The client reported no longer experiencing physiological reactivity when exposed to internal or external cues of the traumatic event. 8. Thought/Feeling/Conversation Avoidance (7) A. The client described trying to avoid thinking, f eeling, or talking about the traumatic event because of the associated negative emotional response. B. The client is making less effort to avoid thoughts, feelings, or conversations about the traumatic event. C. The client reported that he/she is now abl e to talk or think about the traumatic event without feeling overwhelmed with negative emotions. 9. Place/People Avoidance (8) A. The client reported a pattern of avoidance of activity, places, or people associated with the traumatic event because he/she is fearful of the negative emotions that may be triggered. B. The client is able to tolerate contact with people, places, or activities associated with the traumatic event without feeling overwhelmed. 10. Blocked Recall (9) A. The client stated that he/ she has an inability to recall some important aspect of the traumatic event. B. The client's amnesia regarding some important aspects of the traumatic event has begun to lessen. C. The client can now recall almost all of the important aspects of the trau matic event, as his/her amnesia has terminated. 11. Lack of Interest (10) A. The client has developed a lack of interest and a pattern of lack of participation in activities that had previously been rewarding and pleasurable. B. The client has begun to s how some interest in participation in previously rewarding activities. C. The client is not showing a normal interest in participation in rewarding activities. 12. Detachment (11) A. The client described feeling a sense of detachment from others. B. The client reported regaining a sense of attachment in participation with others. C. The client reported that he/she no longer feels alienated from others and is able to participate in social and intimate interactions. 13. Blunted Emotions (12) A. The clien t reported an inability to experience the full range of emotions, including love. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
POSTTRAUMATIC STRESS DISORDER (PTSD) 257 B. The client reported beginning to be in touch with his/her feelings again. C. The client is able to experience the full range of emotions. 14. Pessimistic/Fatalistic (13) A. Since the traumatic event occurred, the client has had a pessimistic and fatalistic attitude regarding the future. B. The client is beginning to experience a somewhat hopeful attitude regarding the future. C. The client's pessimistic, fatalistic att itude regarding the future has terminated, and he/she has begun to make plans and talk about the future with a more hopeful attitude. 15. Sleep Disturbance (14) A. Since the traumatic event occurred, the client has experienced a desire to sleep much more than normal. B. Since the traumatic event occurred, the client has found it very difficult to initiate and maintain sleep. C. Since the traumatic event occurred, the client has had a fear of sleeping. D. The client's sleep disturbance has terminated, an d he/she has returned to a normal sleep pattern. 16. Irritability (15) A. The client described a pattern of irritability that was not present before the traumatic event occurred. B. The client reported incidents of becoming angry and losing his/her tempe r easily, resulting in explosive outbursts. C. The client's irritability has diminished somewhat, and the intensity of the explosive outbursts has lessened. D. The client reported no recent incidents of explosive, angry outbursts. 17. Lack of Concentrati on (16) A. The client described a pattern of lack of concentration that began with the exposure to the traumatic event. B. The client reported that he/she is now able to focus more clearly on cognitive processing. C. The client's ability to concentrate has returned to normal levels. 18. Hypervigilance (17) A. The client described a pattern of hypervigilance. B. The client's hypervigilant pattern has diminished. C. The client reported no longer experiencing hypervigilance. 19. Exaggerated Startle Respo nse (18) A. The client described having experienced an exaggerated startle response. B. The client's exaggerated startle response has diminished. C. The client no longer experiences an exaggerated startle response. 20. Depression (19) A. The client des cribed experiencing sad affect, lack of energy, social withdrawal, and guilt feelings as part of a depressive reaction. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
258 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNER B. The client's depression symptoms have diminished considerably. C. The client reported that he/she is no longer experiencing symptom s of depression. 21. Alcohol/Drug Abuse (20) A. Since the traumatic experience, the client has engaged in a pattern of alcohol and/or drug abuse as a maladaptive coping mechanism. B. The client's alcohol and/or drug abuse has diminished as he/she has wor ked through the traumatic event. C. The client reported no longer engaging in any alcohol or drug abuse. 22. Suicidal Thoughts (21) A. The client reported experiencing suicidal thoughts since the onset of PTSD. B. The client's suicidal thoughts have bec ome less intense and less frequent. C. The client reported no longer experiencing any suicidal thoughts. 23. Interpersonal Conflict (22) A. The client described a pattern of interpersonal conflict, especially in regard to intimate relationships. B. As the client has worked through his/her reaction to the traumatic event, there has been less conflict within personal relationships. C. The client's partner reported that he/she is irritable, withdrawn, and preoccupied with the traumatic event. D. The clien t and his/her partner reported increased communication and satisfaction with the interpersonal relationship. 24. Violent Threat/Behavior (23) A. The client described having engaged in violent verbal threats since experiencing the traumatic event. B. The client's irritability has been magnified into physically violent behavior. C. As the client has worked through the emotions associated with the traumatic event, his/her verbal and physical violence has diminished. D. The client reported having no recent experiences with verbal or physical violence or threats of violence. 25. Employment Conflicts (24) A. The client has been unable to maintain employment due to authority/coworker conflict or anxiety symptoms. B. As the client has worked through the feelin gs associated with the traumatic event, he/she has been more reliable and responsible within the employment setting. C. The client has resumed his/her employment duties and attendance in a consistent and reliable manner. 26. Symptoms for One Month or More (25) A. The client stated that his/her symptoms of PTSD have been present for more than a month. B. The client's symptoms that have been present for more than a month have diminished. C. The client no longer experiences PTSD symptoms. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
POSTTRAUMATIC STRESS DISORDER (PTSD) 259 INTERVENTIONS IMP LEMENTED 1. Develop Trust (1) * A. Today's clinical contact focused on building the level of trust with the client through consistent eye contact, active listening, unconditional positive regard, and warm acceptance. B. Empathy and support were provided for the client's expression of thoughts and feelings during today's clinical contact. C. The client was provided with support and feedback as he/she described his/her maladaptive pattern of anxiety. D. As the client has remained mistrustful and reluctant to share his/her underlying thoughts and feelings, he/she was provided with additional reassurance. E. The client verbally recognized that he/she has difficulty establishing trust because he/she has often felt let down by others in the past, and he/she w as accepted for this insight. 2. Assess Nature of PTSD Symptoms (2) A. The client was asked about the frequency, intensity, duration, and history of his/her PTSD symptoms, fear, and avoidance. B. The Anxiety Disorder's Interview Schedule for DSM-IV (Di N ardo, Brown, and Barlow) was used to assess the client's PTSD symptoms. C. The assessment of the client's PTSD symptoms indicated that his/her symptoms are extreme and severely interfere with his/her life. D. The assessment of the client's PTSD symptoms indicate that these symptoms are moderate and occasionally interfere with his/her functioning. E. The results of the assessment of the client's PTSD symptoms indicate that these symptoms are mild and rarely interfere with his/her daily functioning. F. The results of the assessment of the client's PTSD symptoms were reviewed with the client. 3. Refer/Conduct Psychological Testing (3) A. Psychological testing was administered to assess for the presence and strength of the PTSD symptoms. B. The psychologi cal testing confirmed the presence of significant PTSD symptoms. C. The psychological testing confirmed mild PTSD symptoms. D. The psychological testing revealed that there are no significant PTSD symptoms present. E. The results of the psychological te sting were presented to the client. 4. Assess Stimuli (4) A. Specific stimuli that may precipitate the client's fears and avoidance were reviewed. B. Specific thoughts and possible delusions were reviewed as to how they contribute to the client's fears and avoidance. C. Specific situations that have precipitated the client's fears and avoidance were reviewed. * The numbers in parentheses correlate to the number of the Therapeutic Intervention sta tement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
260 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNER D. Upon the review of the stimuli, thoughts and situations that precipitated the client's fears and avoidance, he/she has been able to decrease his/her level of fear and avoidance. 5. Differentiate Anxiety Symptoms (5) A. The client was assisted in differentiating anxiety symptoms that are a direct affect of his/her severe and persistent mental illness, as opposed to a separate diagnosis of an anxiety disorder. B. The client was provided with feedback regarding his/her differentiation of symptoms that are related to his/her severe and persistent mental illness, as opposed to a separate diagnosis. C. The client has identified a specific anxiety disorder, which is freestanding from his/her severe and persistent mental illness, and this was reviewed within the session. D. The client has been unsuccessful in identifying ways in which his/her anxiety symptoms are related to his/her mental illness o r a separate anxiety disorder. 6. Acknowledge Anxiety Related to Delusional Experiences (6) A. It was acknowledged that both real and delusional experiences could cause anxiety. B. The client was provided with support regarding his/her anxieties and wor ries, which are related to both the real experiences and delusional experiences. C. The client described a decreased pattern of anxiety due to the support provided to him/her. 7. Identify with Recovery from Trauma (7) A. The client was provided with a d escription of Posttraumatic Stress Disorder. B. Information from Overcoming Posttraumatic Stress Disorder (Smyth) was used to help describe symptoms. C. The client was assisted in identify how he/she may recover from trauma. 8. Explore Facts of Traumati c Event (8) A. The client was gently encouraged to tell the entire story of the traumatic event. B. The client was given the opportunity to share what he/she recalls about the traumatic event. C. Today's therapy session explored the sequence of events b efore, during, and after the traumatic event. 9. Assess Depression (9) A. The depth of the client's depression and his/her suicide potential were assessed. B. Since the client has significant depression and verbalizes suicidal urges, steps were taken to provide more intense treatment and constant supervision. C. The client's depression was not noted to be particularly serious, and he/she has denied any current suicidal ideation. 10. Assess Chemical Dependence (10) A. The client was asked to describe hi s/her use of alcohol and/or drugs as a means of escape from negative emotions. B. The client was supported as he/she acknowledged that he/she has abused alcohol and/or drugs as a means of coping with the negative consequences associated with the traumatic event. C. The client was quite defensive about giving information regarding his/her substance abuse history and minimized any such behavior; this was reflected to him/her and he/she was urged to be more open. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
POSTTRAUMATIC STRESS DISORDER (PTSD) 261 11. Request Substance Use Information from Su pport System (11) A. The client's family and peers were asked to provide additional information regarding the client's substance use history. B. The treatment staff that have worked closely with the client were asked to provide an objective review of the client's substance abuse history. C. Auxiliary information about this client's substance use pattern was consistent with the client's own description. D. Auxiliary information collected about the client's substance use was not consistent with the client 's description of his/her own substance use. 12. Administer Objective Assessment of Substance Use (12) A. The client was administered an objective assessment of his/her substance use. B. The Alcohol Severity Index was administered to the client. C. The findings of the objective assessment of the client's alcohol use were reviewed with the client. 13. Teach Contributing Factors to Substance Abuse (13) A. The client was taught the familial, emotional, and social factors that have contributed to the develo pment of his/her chemical dependence. B. The client was supported as he/she verbalized an understanding of the factors contributing to his/her chemical dependence and acknowledged it as a problem. C. The client's denial led to a refusal to acknowledge hi s/her chemical dependence and any factors that have contributed to it; this was reflected to him/her. 14. Refer to Chemical Dependence Treatment (14) A. The client was referred for chemical dependence treatment. B. The client consented to chemical depend ence treatment referral, as he/she has acknowledged it as a significant problem. C. The client refused to accept a referral for chemical dependence treatment and continued to deny that substance abuse is a problem. D. The client was reinforced for follow ing through on obtaining chemical dependence treatment. E. The client's treatment focus was switched to his/her chemical dependence problem. 15. Refer for Medication Evaluation (15) A. The client was referred for a medication evaluation to help stabilize his/her moods and decrease the intensity of his/her feelings. B. The client was reinforced as he/she agreed to follow through with the medication evaluation. C. The client was strongly opposed to being placed on medication to help stabilize his/her mood s and reduce emotional distress; his/her objections were processed. 16. Monitor Effects of Medication (16) A. The client's response to the medication was discussed in today's therapy session. B. The client reported that the medication has helped to stabi lize his/her moods and decrease the intensity of his/her feelings; he/she was directed to share this information with the prescribing clinician. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
262 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNER C. The client reports little to no improvement in his/her moods or anger control since being placed on the med ication; he/she was directed to share this information with the prescribing clinician. D. The client was reinforced for consistently taking the medication as prescribed. E. The client has failed to comply with taking the medication as prescribed; he/she was encouraged to take the medication as prescribed. 17. Discuss PTSD Symptoms (17) A. A discussion was held about how PTSD results from exposure to trauma and results in intrusive recollections, unwarranted fears, anxiety, and a vulnerability to other ne gative emotions. B. The client was provided with specific examples of how PTSD symptoms occur and affect individuals. C. The client displayed a clear understanding of the dynamics of PTSD and was provided with positive feedback. D. The client has strugg led to understand the dynamics of PTSD and was provided with remedial feedback in this area. 18. Assign Reading on Anxiety (18) A. The client was assigned to read psychoeducational chapters of books or treatment manuals on PTSD. B. The client was assigne d information from Finding Life Beyond Trauma (Follette and Pistorello). C. The client has read the assigned information on PTSD, and key points were reviewed. D. The client has not read the assigned information on PTSD and was redirected to do so. 19. Discuss Treatment Rationale (19) A. The client was taught about the overall rationale behind treatment of PTSD. B. The client was assisted in identifying the appropriate goals for PTSD treatment. C. The client was taught about coping skills, cognitive re structuring, and exposure techniques. D. The client was taught about techniques that will help to build confidence, desensitize and overcome fears, and see oneself, others, and the world in a less fearful and/or depressing manner. E. The client was reinf orced for his/her clear understanding of the rationale for treatment of PTSD. F. The client struggled to understand the rationale behind the treatment for PTSD and was provided with additional feedback in this area. 20. Assign Written Information on PTSD (20) A. The client was assigned to read about stress inoculation, cognitive restructuring, and/or exposure-based therapy in chapters of books or treatment manuals on PTSD. B. The client was assigned specific chapters from Reclaiming Your Life After Rape (Rothbaum and Foa). C. The client was assigned specific chapters from Feeling Good: The New Mood Therapy (Burns). D. The client has read the assigned information on PTSD; key concepts were reviewed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
POSTTRAUMATIC STRESS DISORDER (PTSD) 263 E. The client has not read the assigned information on PTSD and was redirected to do so. 21. Teach Stress Inoculation Training (21) A. The client was taught strategies from stress inoculation training, such as relaxation, breathing, covert modeling, and role-play. B. The client was taught stress inoculation techniques for managing fears until a sense of mastery is evident from A Clinical Handbook for Treating PTSD (Meichenbaum). C. The client was assisted in practicing stress inoculation training techniques. D. The client displayed a clear understanding of the use of stress inoculation training. E. The client has not displayed a clear understanding of the stress inoculation training techniques and was provided with additional feedback in this area. 22. Assess Anger Control (22) A. A history of the client' s anger control problems was taken in today's therapy session. B. Active listening was used as the client shared instances in which poor control of his/her anger resulted in verbal threats of violence, actual harm or injury to others, or destruction of property. C. The client identified events or situations that frequently trigger a loss of control of his/her anger and was helped to see his/her patterns. D. The client was asked to identify the common targets of his/her anger to help gain greater insight into the factors contributing to his/her lack of control. E. Today's therapy session helped the client realize how his/her anger control problems are often associated with underlying, painful emotions about the traumatic event. F. The client was quite gu arded about his/her anger control problems and was urged to be more open in this area. 23. Teach Anger Management Techniques (23) A. The client was taught mediational and self-control strategies to help improve his/her anger control. B. The client was ta ught guided imagery and relaxation techniques to help improve his/her anger control. C. Role-playing and modeling techniques were used to demonstrate effective ways to control anger. D. The client was strongly encouraged to express his/her anger through controlled, respectful verbalizations and healthy physical outlets. E. A reward system was designed to reinforce the client for demonstrating good anger control. 24. Encourage Physical Exercise (24) A. The client was assisted in developing a physical exe rcise routine as a means of coping with stress and developing an improved sense of well-being. B. The client was reinforced for following through on implementing a regular exercise regimen as a stress release technique. C. The client has failed to consis tently implement a physical exercise routine and was encouraged to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
264 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNER 25. Recommend Exercising Your Way to Better Mental Health (25) A. The book Exercising Your Way to Better Mental Health (Leith) was recommended to the client as a means of encouragin g physical exercise. B. The client has followed through with reading the book on exercise and mental health; the key points of this material were reviewed. C. The client was assisted in implementing a consistent exercise regimen. D. The client has not f ollowed through with reading the book on exercise nor has he/she implemented a regular physical exercise regimen. 26. Monitor Sleep Patterns (26) A. The client was encouraged to keep a record of how much sleep he/she gets every night. B. The client was t rained in the use of relaxation techniques to help induce sleep. C. The client was trained in the use of positive imagery to help induce sleep. D. The client was referred for a medication evaluation to determine whether medication is needed to help him/h er sleep. 27. Identify Distorted Thoughts (27) A. The client was assisted in identifying the distorted schemas and related automatic thoughts that mediate PTSD responses. B. The client was taught the role of distorted thinking in precipitating emotional responses. C. The client was reinforced as he/she verbalized an understanding of the cognitive beliefs and messages that mediate his/her PTSD responses. D. The client was assisted in replacing distorted messages with positive, realistic cognitions. E. The client failed to identify his/her distorted thoughts and cognitions and was provided with tentative examples in this area. 28. Read about Cognitive Restructuring of Fears (28) A. The client was assigned to read about cognitive restructuring of fears or worries in books or treatment manuals. B. Overcoming Post-Traumatic Stress Disorder (Smyth) was assigned to the client to help teach about cognitive restructuring. C. Key components of cognitive restructuring and exposure therapy were reviewed. D. The client and parents have not done the assigned reading on cognitive restructuring and were redirected to do so. 29. Assign Self-Talk Homework (29) A. The client was assigned homework exercises in which he/she identifies fearful self-talk and creates realit y-based alternatives. B. The “Negative Thoughts Trigger Negative Feelings” exercise from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was used to help the client develop healthy self-talk. C. The client was directed to do homework exercise s about self-talk and reality-based alternatives as described in Overcoming Post-Traumatic Stress Disorder (Smyth). D. The client has completed his/her homework related to self-talk and creating reality-based alternatives; he/she was provided with positiv e reinforcement for his/her success in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
POSTTRAUMATIC STRESS DISORDER (PTSD) 265 E. The client has completed his/her homework related to self-talk and creating reality-based alternatives; he/she was provided with corrective feedback for his/her failure to identify and replace self-talk with reality-based alternatives. F. The client has not attempted his/her homework related to fearful self-talk and reality-based alternatives and was redirected to do so. 30. Construct Anxiety Stimuli Hierarchy (30) A. The client was assisted in constru cting a hierarchy of anxiety-producing situations associated with two or three spheres of worry. B. It was difficult for the client to develop a hierarchy of stimulus situations, as the causes of his/her anxiety remain quite vague; he/she was assisted in completing the hierarchy. C. The client was successful at creating a focused hierarchy of specific stimulus situations that provoke anxiety in a gradually increasing manner; this hierarchy was reviewed. 31. Assign Homework on Exposures (31) A. The client was assigned homework exercises to perform exposure to feared stimuli and record his/her experience. B. The client was assigned situational exposures homework from Posttraumatic Distress Disorder (Resick and Calhoun). C. The client's use of exposure tec hniques was reviewed and reinforced. D. The client has struggled in his/her implementation of exposure techniques and was provided with corrective feedback. E. The client has not attempted to use the exposure techniques and was redirected to do so. 32. Use Imaginal Exposure (32) A. The client was asked to describe a traumatic experience at an increasing, but client-chosen, level of detail. B. The client was asked to continue to describe his/her traumatic experience at his/her own chosen level of detail until the associated anxiety reduces and stabilizes. C. The client was provided with recordings of the session and was asked to listen to it between sessions. D. The client was directed to do imaginal exposures as described in Posttraumatic Distress Diso rder (Resick and Calhoun). E. The client was reinforced for his/her progress in imaginal exposure. F. The client was assisted in problem-solving obstacles to his/her imaginal exposure. 33. Assign Reading Material on Exposure (33) A. The client was assig ned to read about exposure in books or treatment manuals on PTSD. B. The client was assigned to read information from Reclaiming Your Life After Rape (Rothbaum and Foa). C. The client was assigned to read information from Overcoming Post-Traumatic Stress Disorder (Smyth). D. The client has read the information on exposure techniques, and key points were reviewed. E. The client has not read the information on exposure techniques and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
266 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNER 34. Teach Thought Stopping (34) A. The client was taught a thought-stopping technique. B. The client was taught to internally voice the word STOP immediately upon noticing unwanted trauma or otherwise negative unwanted thoughts. C. The client was taught to imagine something representing the concept of stopping (e. g., a stop sign or stoplight) immediately upon noticing unwanted trauma or otherwise negative unwanted thoughts. D. The client was assisted in reviewing his/her use of thought-stopping techniques and was provided with positive feedback for his/her appropriate use of this technique. E. Redirection was provided, as the client has not learned to use the thought-stopping technique. 35. Teach Self-Dialogue Procedure (35) A. The client was taught self-dialogue procedures as described in Posttrau matic Distress Disorder (Resick and Calhoun). B. The client was taught self-dialogue techniques to learn to recognize maladaptive self-talk, challenge its bias, cope with engendered feelings, overcome avoidance, and reinforce accomplishments. C. The clie nt was reinforced for his/her use of self-dialogue procedures. D. The client has found significant obstacles to using self-dialogue procedures and was assisted in problem-solving these concerns. 36. Employ EMDR Techniques (36) A. The client was trained i n the use of the eye movement desensitization and reprocessing (EMDR) technique to reduce his/her emotional reactivity to the traumatic event. B. The client reported that the EMDR technique has been helpful in reducing his/her emotional reactivity to the traumatic event. C. The client reported partial success with the use of the EMDR technique to reduce emotional distress. D. The client reported little to no improvement with the use of the EMDR technique to decrease his/her emotional reactivity to the tr aumatic event. 37. Discuss Lapse versus Relapse (37) A. The client was assisted in differentiating between a lapse and a relapse. B. A lapse was associated with the initial and reversible return of symptoms, fear, or urges to avoid. C. A relapse was ass ociated with the decision to return to fearful and avoidant patterns. D. The client was reinforced for his/her ability to respond to a lapse without relapsing. 38. Identify and Rehearse Response to Lapse Situations (38) A. The client was asked to identif y the future situations or circumstances in which lapses could occur. B. The client was asked to rehearse the management of his/her potential lapse situations. C. The client was reinforced as he/she identified and rehearsed how to cope with potential lap se situations. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
POSTTRAUMATIC STRESS DISORDER (PTSD) 267 39. Encourage Use of Therapy Strategies (39) A. The client was encouraged to routinely use strategies used in therapy. B. The client was urged to use cognitive restructuring, social skill, and exposure techniques while building social inte ractions and relationships. C. The client was reinforced for his/her regular use of therapy techniques within social interactions and relationships. D. The client was unable to identify many situations in which he/she has used therapy techniques to help build social interactions and social relationships and was redirected to seek these situations out. 40. Develop a Coping Card (40) A. The client was provided with a coping card on which specific coping strategies were listed. B. The client was assisted i n developing his/her coping card in order to list his/her helpful coping strategies. C. The client was encouraged to use his/her coping card when struggling with anxiety producing situations. 41. Conduct Family/Conjoint Session (41) A. A conjoint session was held to facilitate healing the hurt that the client's PTSD symptoms have caused to others. B. The client was supported while apologizing to significant others for the irritability, withdrawal, and angry outbursts that are part of his/her PTSD symptom pattern. C. Support was provided as the client's significant others verbalized the negative impact that the client's PTSD symptoms have had on their lives. D. Significant others indicated support for the client and accepted apologies for previous hurts that his/her behavior caused; the benefits of this progress were highlighted. 42. Refer for Group Therapy (42) A. The client was referred for group therapy to help him/her share and work through his/her feelings about the trauma with other individuals wh o have experienced traumatic incidents. B. The client was given the directive to self-disclose at least once during the group therapy session about his/her traumatic experience. C. It was emphasized to the client that his/her involvement in group therapy has helped him/her realize that he/she is not alone in experiencing painful emotions surrounding a traumatic event. D. It was reflected to the client that his/her active participation in group therapy has helped him/her share and work through many of his /her emotions pertaining to the traumatic event. E. The client has not made productive use of the group therapy sessions and has been reluctant to share his/her feelings about the traumatic event; he/she was encouraged to use this helpful technique. 43. Reinforce Reality-Based Cognitions (43) A. The client was taught positive, reality-based self-talk to replace his/her distorted cognitive messages. B. The client was reinforced for implementing positive, reality-based cognitive messages that enhance self-confidence and increase adaptive action. C. The client has begun to verbalize hopeful and positive statements regarding the future and was reinforced for doing so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
268 PSYCHOSIS CLIENT PRESENTATION 1. Bizarre Thought Content (1) * A. The client demonstrated delusional thought content. B. The client has experienced persecutory delusions. C. The client's delusional thoughts have diminished in frequency and intensity. D. The client no longer experiences delusional thoughts. 2. Illogical Thought/Speech (2) A. The client's speech and thought patterns are incoherent and illogical. B. The client demonstrated loose association of ideas and vague speech. C. The client's il logical thought and speech have become less frequent. D. The client no longer gives evidence of illogical forms of thought and speech. 3. Perception Disturbance (3) A. The client has experienced auditory hallucinations. B. The client has experienced vi sual hallucinations. C. The client's hallucinations have diminished in frequency. D. The client reported no longer experiencing hallucinations. 4. Disorganized Behavior (4) A. The client's behavior was characterized by disorganization, confusion, and s evere lack of goal direction. B. The client displayed impulsiveness or repetitive behaviors that appear to be disjunct from reality. C. The client's behavior has become more organized and goal directed. 5. Paranoia (5) A. The client displayed paranoid thoughts and reactions, including extreme distrust, fear, and apprehension. B. The client's level of distrust of others is so pervasive and obsessive that his/her daily functioning is disrupted. C. The client is unable to fulfill job and family responsib ilities because of his/her preoccupation with issues of distrust and paranoia. D. The client's level of trust is growing, and he/she displays decreased paranoid thoughts and reactions and is more able to perform daily duties and responsibilities. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the compani on chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PSYCHOSIS 269 6. Psyc homotor Abnormalities (6) A. The client demonstrated a marked decrease in reactivity to his/her environment. B. The client demonstrated various catatonic patterns (e. g., stupor, rigidity, posturing, negativism, and excitement). C. The client gave eviden ce of unusual mannerisms or grimacing. D. The client's psychomotor abnormalities have diminished, and his/her pattern of relating has become more typical and less alienating. 7. Agitation (7) A. The client displayed a high degree of irritability and unp redictability in his/her actions. B. The client displayed agitation through anger outbursts and impulsive physical acting out. C. The client is difficult to approach due to his/her extreme agitation. D. As treatment has progressed, the client has decrea sed his/her level of agitation and is less irritable, angry, unpredictable, or impulsive. 8. Bizarre Dress/Grooming (8) A. The client has not given adequate attention to his/her personal grooming. B. The client presents in unusual clothing and bizarre m anner of dress due to his/her diminished contact with reality. C. As the client's psychosis has stabilized, he/she has become more normalized in his/her dress and grooming. 9. Disturbed Affect (9) A. The client presented with blunted affect. B. The cli ent gave evidence of a lack of affect. C. At times the client's affect was inappropriate for the context of the situation. D. The client's affect has become more appropriate and energized. 10. Relationship Withdrawal (10) A. The client has been withdra wn from involvement with the external world and preoccupied with egocentric ideas and fantasies. B. The client has shown a slight improvement in his/her ability to demonstrate relationship skills. C. The client has shown an interest in relating to others in a more appropriate manner. INTERVENTIONS IMPLEM ENTED 1. Approach in a Calm Manner (1) * A. Due to the client's acute psychotic symptoms, he/she was approached in a calm, confident, open, direct yet soothing manner. B. Body language when approaching t he client focused on a slow approach, facing toward the client, and speaking slowly and clearly. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the c ompanion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
270 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. As the client has been approached in a calmer manner, his/her psychotic agitation has decreased. D. The client continues to display increased agitation, d espite the use of calm, open, and soothing mannerisms. 2. Identify History of Psychosis ( 2) A. The client was asked to identify his/her history of hallucinations, delusions, or other psychotic symptoms. B. The client was provided with positive feedback as he/she was clearly able to identify his/her pattern of psychotic symptoms. C. The client denied any pattern of psychotic symptoms and was provided with contrary feedback in this area. 3. Identify Current Psychotic Symptoms ( 3) A. The client was asked about his/her current pattern of psychotic symptoms. B. The client was reinforced for displaying understanding of his/her current pattern of psychotic symptoms. C. The client denied any current psychotic symptoms and was provided with contrary feedback in this area. 4. Refer for Psychological Testing (4) A. The client was referred for psychological testing to evaluate the depth of his/her psychosis. B. The client was compliant with the testing, which indicated a significant pattern of psychotic sympto ms. C. The psychological test results indicate only mild psychotic symptoms, and this was reviewed. D. The psychological testing results indicate that the client's psychosis has significantly abated, and this was reviewed. E. The client was not complian t with the psychological testing and was redirected to this referral. 5. Obtain a History from the Family ( 5) A. The client's family members were asked to provide information about his/her history of psychotic behaviors. B. The client's family members p rovided information about his/her history of psychotic behaviors, and this was processed with him/her. 6. Refer to a Physician (6) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 7. Refer to a Supervised Environment (7) A. Because the client was judged to be uncontrollably harmful to himself/herself, arrangements were m ade for psychiatric hospitalization. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PSYCHOSIS 271 B. Due to concerns about the client's inability to manage himself/herself within a less restrictive setting, he/she was referred to a crisis residential facility. C. The client was supported for cooperating voluntaril y with admission to a more supervised environment. D. The client refused to voluntarily admit himself/herself to a more supervised environment; therefore, civil commitment procedures were initiated. 8. Arrange for a Stable Setting ( 8) A. Arrangements we re made for the client to remain in a stable, supervised setting. B. The client has been able to decrease his/her psychotic symptoms as he/she has remained in a stable, supervised setting, and the benefits of this were reviewed with him/her. C. Despite r emaining in a stable, supervised setting, the client has continued to decompensate and he/she was admitted to a more intensive treatment setting. 9. Coordinate Mobile Crisis Response Services (9) A. Arrangements were made for mobile crisis response servi ces for the client, including a physical exam, psychiatric evaluation, medication access, and triage to inpatient care. B. The client was sought out in his/her home environment for the mobile crisis response services. C. Mobile crisis response services h ave assisted the client in becoming stabilized. D. The client continues to decompensate despite the use of mobile crisis response services, and a more structured placement was arranged. 10. Assess Suicidal Ideation (1 0) A. The client was asked to describ e the frequency and intensity of his/her suicidal ideation, the details of any existing suicide plan, the history of any previous suicide attempts, and any family history of depression or suicide. B. The client was encouraged to be forthright regarding th e current strength of his/her suicidal feelings and the ability to control such suicidal urges. C. The client was monitored on an ongoing basis for his/her suicide potential. D. Precautionary steps were taken to keep the client from committing suicide, i ncluding more direct supervision or placement in a locked, monitored environment. 11. Remove Potentially Hazardous Materials (1 1) A. Significant others were encouraged to remove firearms and other potentially lethal means of suicide from the client's eas y access. B. With the client's permission, potentially hazardous materials were removed and stored until he/she has become more stable. C. The client declined to allow hazardous materials to be removed, and he/she was provided with feedback about this de cision and the additional steps that may be taken to assure his/her safety. 12. Develop a Short-Term Crisis Plan (1 2) A. A short-term round-the-clock crisis plan was developed. B. It was determined that components of the client's short-term round-the-clock crisis plan must include multiple caregivers, psychiatric involvement, and/or crisis assistance in order to maintain him/her within the community. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
272 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. As the crisis plan has been implemented, the client has been able to remain within the community as h e/she stabilizes from his/her period of psychosis. D. The client continues to decompensate and is not safe to maintain within the community, despite the use of the crisis plan, and arrangements for a more restrictive setting were initiated. 13. Coordinate Access to Professional Consultation ( 13) A. The client and his/her caregivers were told how to access round-the-clock professional consultation. B. The client was supported for using the 24-hour, professionally staffed crisis line to help decrease his/h er agitation and psychosis. C. The client's caregivers were reinforced for accessing professional consultation on an as-needed basis to help determine how best to cope with his/her difficult behaviors in this less restrictive setting. D. The client and h is/her caregivers have not used the available professional consultation and were encouraged to do so. 14. Provide Cues to Focus on Reality ( 14) A. The client was provided with visual and verbal cues to increase his/her focus on reality. B. The date, tim e, and place were written in a clearly visible area to help anchor the client in reality. C. Verbal interactions with the client focused on the here and now. 15. Use a Wristband ( 15) A. A wristband was placed on the client's arm with the date, place, an d his/her name written clearly. B. The client was reinforced for being more reality-focused with the use of the wristband. C. The client continues with illogical and unrealistic psychotic thoughts, despite implementing visual cues with the client (e. g., a wristband on the arm). 16. Focus on Concrete Events ( 16) A. Conversations with the client focused on real events in basic, concrete terms. B. As the client displayed his/her psychotic process, he/she was consistently refocused onto actual, current eve nts described in basic, concrete terms. C. As the client has been focused onto more concrete information, he/she has decreased his/her bizarre or irrational comments in favor of more reality-based thoughts. D. The client continues to experience psychotic process, despite others focusing on real events in basic, concrete terms. 17. Reinforce a Focus on Reality ( 17) A. The client was provided with positive reinforcement as he/she displayed an appropriate focus on reality. B. As the client became more rea lity-focused, he/she was gradually returned to a less restrictive environment and decreased supervision. C. The client has relapsed into more delusional thought and other psychotic processes, despite being reinforced for his/her appropriate focus on reali ty. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PSYCHOSIS 273 18. Investigate Sleep-Inducing Medications with the Physician ( 18) A. The client's treating physician was consulted regarding the need for sleep-inducing medications to provide the client and his/her caregivers time to regroup relative to this curren t psychotic episode. B. The treating physician has prescribed sleep-inducing medications that have helped the client to sleep, which has resulted in a more reality-based orientation. C. Caregivers were supported for providing intensive support to the cli ent subsequent to his/her being induced to sleep. D. The treating physician has declined to use sleep-inducing medication. 19. Educate about Psychotropic Medications ( 19) A. The client was taught about the indications for and the expected benefits of ps ychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The client displayed a lack of understanding of the indications fo r and expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. 20. Monitor Medications (2 0) A. The client was monitored for compliance with his/her psychotropic medication regi men. B. The client was provided with positive feedback about his/her regular use of psychotropic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication effectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 21. Review Side Effects of Medications (2 1) A. The possible side effects rela ted to the client's medications were reviewed with the client. B. The client identified significant side effects, and these were reported to the medical staff. C. Possible side effects of the client's medications were reviewed, but he/she denied experien cing any side effects. 22. Assess Tardive Symptoms (2 2) A. Arrangements were made for an assessment of the client's tardive symptoms. B. Objective measurement of the client's tardive symptoms was performed by qualified personnel using a specific instrum ent [e. g., the Abnormal Involuntary Movement Scale (AIMS)]. C. The client displayed no evidence of tardive symptoms, and this was reflected to him/her. D. The client displayed both subjective and objective evidence of tardive symptoms, and this was repor ted to the physician who prescribed the client's psychotropic medications. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
274 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 23. Educate the Family about Symptoms of Mental Illness ( 23) A. The client's family, friends, and caregivers were educated about the symptoms of mental illness, with specific emph asis on the nonvolitional aspects of some symptoms. B. The client's family members, friends, and caregivers were supported for their increased understanding about the symptoms of mental illness and the nonvolitional aspects of some symptoms. C. The clien t's family members, friends, and caregivers rejected the information regarding his/her symptoms of mental illness and the nonvolitional aspects of some symptoms and were given additional feedback in this area. 24. Role-Play Response to Anger Outbursts ( 24) A. Specific responses to the client's anger outbursts were role-played with his/her family members. B. The client's family, friends, and caregivers were advised to focus on providing short, specific directions and to avoid arguing about reality. C. The client's family, friends, and caregivers were reinforced for their understanding of assertive, safe, direct responses to his/her anger outbursts. D. The client's family, friends, and caregivers remain confused about how to respond directly to his/her an ger outbursts in an assertive, safe manner; further direction was provided to them. 25. Refer to Family Psychoeducational Program (25) A. The family was referred to a psychoeducational program to help demonstrate techniques to cope with the client's psych otic behaviors. B. The client was referred to a multigroup family psychoeducational program to help learn and share about techniques to cope with the client's psychotic behaviors. C. The family was engaged in the psychoeducational program and has identif ied ways in which they have learned to cope with the client's psychotic behaviors. D. The client's family has not engaged in the psychoeducational program and was redirected to do so. 26. Identify Psychosis Triggers ( 26) A. The client was requested to i dentify specific behaviors, situations, and feelings that occurred prior to decompensation or psychotic episodes. B. The client identified specific behaviors, situations, and feelings that occurred prior to his/her decompensation, and these triggers were processed. C. The client was unable to identify specific behaviors, situations, and feelings that have occurred prior to decompensation and was given suggestions in these areas. 27. Identify Symptoms Maintenance Cycles (27) A. The client was assisted in identifying emotional reactions that tend to maintain his/her symptoms. B. The client was assisted in identifying how the effects of his/her psychotic symptoms may exacerbate those symptoms. C. Examples were used to identify the self-reinforcing nature o f some psychotic symptoms (e. g., withdrawal leading to isolation and loneliness; paranoid accusations leading to negative actions of others that falsely support the delusion). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PSYCHOSIS 275 D. The client was reinforced for his/her insight into the effects of his/her ps ychosis. E. The client has not understood or accepted the effects of his/her psychotic symptoms, and was provided with remedial assistance in this area. 28. Assess Adaptive and Maladaptive Strategies (28) A. The client was assessed for his/her adaptive a nd maladaptive strategies for coping with his/her psychotic symptoms. B. Inquiries were made regarding how the client uses deficit strategies to cope with his/her psychotic symptoms. C. The client was provided with feedback about his/her use of maladapti ve and adaptive strategies for coping with his/her psychotic symptoms. 29. Use Cognitive-Behavioral Strategies (29) A. Cognitive-behavioral strategies were used to help the client learn coping and compensation strategies for managing his/her psychotic sym ptoms. B. The client was referred for cognitive-behavioral therapy to help the coping compensation strategies for managing his/her psychotic symptoms. C. The client was asked to provide examples of the cognitive-behavioral strategies that he/she has learned in order to cope with his/her psychotic symptoms. D. The client was reinforced for his/her use of cognitive-behavioral strategies. E. The client has not used cognitive-behavioral strategies to cope with his/her psychotic symptoms and was redirect to do so. 30. Desensitize Fearfulness of Hallucinations ( 30) A. The client was encouraged to talk about his/her hallucinations, their frequency, intensity, and meaning, in order to desensitize his/her level of fear. B. “What Do You Hear and See?” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was used to help the client talk about his/her hallucinations. C. As the client talked about his/her hallucinations, he/she was provided with support, encouragement, and empathy. D. The client was r einforced for reporting a decreased sense of fear related to his/her hallucinations, now seeing them as simply a symptom. E. The client continues to exhibit significant fear related to his/her hallucinations and was provided with additional support in thi s area. 31. Teach Coping and Compensation Strategies (31) A. The client was taught coping and compensations strategies for managing his/her psychotic symptoms. B. The client was taught self-calming techniques and attention switching/narrowing techniques to help manage his/her psychotic symptoms. C. The client was taught healthy internal cognition techniques, such as realistic self-talk or realistic attribution of the source of the symptom in order to help manage his/her psychotic symptoms. D. The client was taught to increase adaptive personal and social activity to help manage his/her psychotic symptoms. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
276 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client was reinforced for his/her use of coping and compensation strategies. F. The client has not used the coping and compensation strategie s and was redirected to do so. 32. Teach/Refer for Communication and Social Skills (3 2) A. The client was referred for an assertiveness-training group that will educate and facilitate assertiveness skills and other adaptive communication techniques. B. Role-playing, modeling, and behavioral rehearsal were used to train the client in assertiveness skills, communication, and social skills. C. The client has demonstrated a clearer understanding of important social skills and was provided with positive feedb ack in this area. D. The client could not demonstrate a clear understanding of important social and communication skills and was provided with additional feedback in this area. 33. Practice New Skills In Session and Out (33) A. The client was asked to pr actice new skills in reality testing, changing his/her maladaptive beliefs and managing his/her symptoms within the session. B. The client was provided with homework assignments between sessions that focus on practicing his/her new skills, reality testing, changing maladaptive beliefs, and managing his/her symptoms. C. The client was helped to process his/her maintenance exercises. D. The client has not completed his/her maintenance exercises and was redirected to do so. 34. Identify Emotional Indicators of Stress (3 4) A. The client was requested to identify three emotional indicators of stress and how they affect his/her functioning. B. The client identified three emotional indicators of stress (e. g., anxiousness, uncertainty, and anger) as well as how they affect his/her functioning, and these indicators were processed. C. The client failed to identify indicators of stress and how they affect his/her functioning and was provided with feedback in this area. 35. Identify Physical Indicators of Stress ( 35) A. The client was requested to identify three physical indicators of stress and how they affect his/her functioning. B. The client identified three physical indicators of stress (e. g., tense muscles, headaches, psychomotor agitation) and how they aff ect his/her functioning, and these indicators were processed. C. The client failed to identify physical indicators of stress and was provided with additional feedback in this area. 36. Teach Stress Management Strategies (36) A. The client was taught stre ss management strategies to help him/her decrease his/her overall subjective level of stress. B. The client was taught relaxation techniques to help him/her manage his/her level of stress. C. The client was taught positive self-talk, problem-solving, and communication skills to help him/her decrease his/her level of stress. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
PSYCHOSIS 277 D. The client was taught lifestyle management considerations that may help to decrease his/her level of stress. E. The client has implemented many stress management techniques, and t he benefits of these techniques were reviewed and reinforced. F. The client has not utilized many stress management techniques and was redirected to do so. 37. Refer to an Activity Therapist (3 7) A. The client was referred to an activity therapist for re commendations regarding physical fitness activities that are available to help reduce his/her stress level. B. The client was referred to community physical fitness resources (e. g., health clubs and other recreational programs). C. The client has been ac tively participating in community physical fitness programs and was reinforced for this. D. The client has declined involvement in community physical fitness programs and was redirected to do so. 38. Identify Decompensation (3 8) A. The client was assist ed in identifying symptoms that indicate that he/she is decompensating. B. The client identified several symptoms of his/her decompensation, and these were reviewed. C. The client has failed to identify symptoms of his/her decompensation and was provided with additional feedback in this area. 39. Train Support Network about Decompensation Indicators ( 39) A. The client's support network was trained about the indicators of decompensation. B. The client's support network was focused on when to take approp riate action to get professional services for him/her. C. The client's support network has displayed an understanding of his/her decompensation indicators and the appropriate time to obtain professional services for him/her and was encouraged to use this information. D. Members of the client's support network have displayed a poor understanding of decompensation and when to obtain professional services for him/her and were provided with additional feedback in this area. 40. Encourage Discontinuation of S ubstance Use (4 0) A. The client was encouraged to decrease or to discontinue his/her substance use, including drugs, alcohol, nicotine, and caffeine. B. The client was reinforced for decreasing his/her substance use. C. The client was reinforced for dis continuing his/her substance use. D. The client continues to use a variety of substances and was refocused on the need to discontinue his/her substance use. 41. Refer for Substance Abuse Treatment (4 1) A. The client was evaluated regarding his/her use o f substances, the severity of his/her substance abuse, and treatment needs/options. B. The client was referred to a substance abuse program knowledgeable in the treatment of both substance abuse and severe and persistent mental illness. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
278 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was compliant with the substance abuse evaluation, and the results of the evaluation were discussed with him/her, resulting in admission to a substance abuse program. D. The client declined to participate in the substance abuse evaluation or treatment and wa s encouraged to do so. 42. Teach Coping Skills to Caregivers (42) A. Caregivers for the client were taught problem-solving and assertiveness skills, as well as respite care options to assist in meeting their own needs when they feel overly stressed by his/her psychosis. B. Caregivers for the client have appropriately used problem-solving and assertiveness skills, as well as respite care to help meet their own needs when they feel overly stressed by his/her psychosis and were encouraged for this as a posi tive way to care for him/her. C. Caregivers for the client have not used coping skills to help meet their own needs when they feel overly stressed by his/her psychosis and were redirected in this area. 43. Encourage Emotions Regarding Mental Illness (4 3) A. The client was encouraged to express his/her feelings related to the acceptance of his/her mental illness. B. The client was provided with positive support and empathy as he/she expressed his/her emotions related to his/her mental illness. C. As the client has expressed his/her feelings, he/she reports a greater acceptance of his/her mental illness, and this was processed. D. The client tends to deny and minimize his/her feelings related to the acceptance of his/her mental illness and was provided w ith additional feedback in this area. 44. Explain Psychosis ( 44) A. The client was provided with information related to the psychotic process, it's biochemical component, and its confusing effect on rational thought. B. The client's questions regarding his/her psychotic process were answered. C. As the client has gained a greater understanding of his/her psychotic process, he/she has been observed to be more at ease with his/her pattern of symptoms. D. The client failed to understand the nature of his/ her psychotic process and was provided with additional feedback in this area. 45. Refer to a Support Group ( 45) A. The client was referred to a support group for individuals with severe and persistent mental illness. B. The client has attended the suppo rt group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. C. The client reported that he/she has not experienced any positive benefit from the use of a support group but was encouraged to con tinue to attend. D. The client has not used the support group for individuals with severe and persistent mental illness and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
279 RECREATIONAL DEFICIT S CLIENT PRESENTATION 1. Lack of Involvement (1) * A. The client described a history of limited involvement in recreational activities. B. The client displayed a pattern of limited involvement in recreational activities. C. The clien t has become more involved in his/her chosen recreational activities. D. As treatment has progressed, the client has significantly increased his/her involvement in recreational activities. 2. Lack of Interest (2) A. The client displayed a lack of intere st in leisure activities. B. The client's involvement in leisure activity options has declined. C. The client regularly declines any involvement in leisure activities due to his/her deflated mood. D. As the client has stabilized, he/she displayed increa sed interest in leisure activities. 3. Limited Knowledge/Experience (3) A. The client displayed a limited knowledge of recreational opportunities that are available to him/her. B. The client described a pattern of inexperience in recreational activities. C. As the client has experienced and learned about recreational opportunities, he/she has increased his/her desire for involvement in recreational activities. 4. Embarrassment (4) A. The client described that he/she is often embarrassed about his/her presentation and therefore declines involvement in recreational activities. B. The client displayed signs of embarrassment (e. g., shyness, anxiousness, and a lack of involvement in recreational activities). C. As the client has become more self-assured, he/she reports decreased embarrassment in recreational activities. 5. Frustration/Agitation (4) A. The client often becomes frustrated or agitated when involved in recreational activities. B. The client expressed feelings of frustration and sees this as a barrier to his/her involvement in recreational activities. C. As the client has learned anger control techniques, his/her pattern of frustration and agitation in recreational activities has significantly decreased. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
280 THE SEVERE AND PERSISTEN T MENTAL ILLNESS PRO GRESS NOTES PLANNER 6. Symptoms Disrupt Recreational Act ivities (5) A. The client described that his/her mental illness symptoms often disrupt involvement in recreational activity. B. The client's poor reality orientation makes it difficult for him/her to appropriately interact with others in recreational act ivities. C. The client finds it difficult to maintain recreational interest due to his/her widely varying moods. D. As the client has stabilized his/her mental illness symptoms, he/she has become more capable of involvement in recreational activities. 7. Discrimination (6) A. The client described a pattern of discrimination due to his/her mental illness symptoms, which prohibits involvement in community activities. B. The client has often been barred from involvement in community activities due to his/ her bizarre behavior or other symptoms of his/her mental illness. C. The client is often discouraged from involvement in community activities by those who have organized the activities. D. As advocacy has been provided for and by the client, discriminati on regarding his/her involvement in community activities has declined. 8. Negative Medication Effects (7) A. The client reports decreased coordination due to his/her medications, which decreases his/her ability to be involved in some recreational activit ies (e. g., sports). B. The client's medications are known to have negative side effects, which will decrease his/her ability to perform in some recreational activities. C. The client has replaced those activities that are affected by his/her medication w ith other activities not affected by the medication. 9. Lack of Invitations (8) A. The client described that he/she is rarely invited to recreational activities due to limited social contact. B. The client has rarely been invited to recreational activit ies due to his/her poor social skills. C. The client rarely reciprocates invitations to recreational activities. D. As the client has learned increased social skills and stabilized his/her mental illness symptoms, he/she reports increased social contacts. 10. Lack of Funds (9) A. The client described that he/she is often unable to pay for recreational activities. B. The client is often unable to obtain transportation to recreational activities. C. As the client's severe and persistent mental illness s ymptoms have stabilized, he/she reports increased ability to procure funds for transportation and involvement in recreational activities. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
RECREATIONAL DEFICIT S 281 INTERVENTIONS IMPLEM ENTED 1. Request a History of Recreational Involvement (1) * A. The client was requested to relat e his/her history or pattern of recreational involvement. B. The client was assisted in developing an understanding of his/her pattern of recreational deficiencies. C. The client displayed an increased understanding of his/her syndrome of recreational pr oblems and how they relate to his/her severe and persistent mental illness symptoms and was provided with positive feedback about this insight. D. The client has a very limited understanding of his/her pattern of recreational problems and was provided wit h additional feedback in this area. 2. Develop a Graphic Display ( 2) A. A graphic time line display was used to help the client chart his/her pattern of recreational difficulties. B. The client identified his/her pattern of recreational involvement, str uggle, failure, and the effects of these problems and was assisted in charting them on a time line. C. The client displayed a greater understanding of his/her pattern of decreased recreational involvement and was given support and feedback in this area. D. The client failed to understand his/her pattern of recreational struggles and was redirected in this area. 3. Educate about Mental Illness ( 3) A. The client was educated about the expected or common symptoms of his/her mental illness that may negative ly impact his/her recreational enjoyment. B. As the client's symptoms of mental illness were discussed, he/she displayed an understanding of how these symptoms may affect his/her level of involvement in recreational activities. C. The client struggled to identify how symptoms of his/her mental illness may negatively impact his/her recreational activities and was given additional feedback in this area. 4. Connect Mental Illness and Social/Recreational Problems ( 4) A. The client was assisted in making the connection between his/her mental illness symptoms and social/recreational problems. B. The client was reinforced for displaying an understanding of how his/her mental illness symptoms affect his/her social/recreational problems. C. The client has faile d to make the connection between his/her mental illness symptoms and social/recreational problems and was provided with additional information in this area. 5. Identify Inexperience ( 5) A. The client was asked to identify the recreational areas in which he/she has had little experience due to his/her severe and persistent mental illness. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Pl anner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |