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Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jongsma, Jr., Series Ed itor The Severe and Persistent Mental Illness Progress Notes Planner Second Edition David J. Berghuis Arthur E. Jongsma, Jr. JOHN WILEY & SONS, I NC. Practice Pla nner®

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

The Severe and Persistent Mental Illness Progress Notes Planner

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Practice Planner s® Series Treatment Planners The Complete Adult Psychotherapy Treatment Planner, Fourth Edition The Child Psychotherapy Treatment Planner, Fourth Edition The Adolescent Psychotherapy Treatment Planner, Fourth Edition The Addiction Treatment Planner, Third Edition The Continuum of Care Treatment Planner The Couples Psychotherapy Treatment Planner The Employee Assistance Treatment Planner The Pastoral Counselin g Treatment Planner The Older Adult Psychotherapy Treatment Planner The Behavioral Medicine Treatment Planner The Group Therapy Treatment Planner The Gay and Lesbian Psychotherapy Treatment Planner The Family Therapy Treatment Planner The Severe and Persis tent Mental Illness Treatment Planner The Mental Retardation and Developmental Disability Treatment Planner The Social Work and Human Services Treatment Planner The Crisis Counseling and Traumatic Events Treatment Planner The Personality Disorders Treatmen t Planner The Rehabilitation Psychology Treatment Planner The Special Education Treatment Planner The Juvenile Justice and Residential Care Treatment Planner The School Counseling and School Social Work Treatment Planner The Sexual Abuse Victim and Sexual Offender Treatment Planner The Probation and Parole Treatment Planner The Psychopharmacology Treatment Planner The Speech-Language Pathology Treatment Planner The Suicide and Homicide Treatment Planner The College Student Counseling Treatment Planner The P arenting Skills Treatment Planner The Early Childhood Intervention Treatment Planner The Co-Occurring Disorders Treatment Planner The Complete Women's Psychotherapy Treatment Planner Progress Note Planners The Child Psychotherapy Progress Notes Planner, Th ird Edition The Adolescent Psychotherapy Progress Notes Planner, Third Edition The Adult Psychotherapy Progress Notes Planner, Third Edition The Addiction Progress Notes Planner, Second Edition The Severe and Persistent Mental Illness Progress Notes Planne r The Couples Psychotherapy Progress Notes Planner The Family Therapy Progress Notes Planner Homework Planners Brief Couples Therapy Homework Planner Brief Employee Assistance Homework Planner Brief Family Therapy Homework Planner Grief Counseling Homework Planner Group Therapy Homework Planner Divorce Counseling Homework Planner School Counseling and School Social Work Homework Planner Child Therapy Activity and Homework Planner Addiction Treatment Homework Planner, Third Edition Adolescent Psychotherapy H omework Planner II Adolescent Psychotherapy Homework Planner, Second Edition Adult Psychotherapy Homework Planner, Second Edition Child Psychotherapy Homework Planner, Second Edition Parenting Skills Homework Planner Client Education Handout Planners Adult Client Education Handout Planner Child and Adolescent Client Education Handout Planner Couples and Family Client Education Handout Planner Complete Planners The Complete Depression Treatment and Homework Planner The Complete Anxiety Treatment and Homework Planner

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jongsma, Jr., Series Ed itor The Severe and Persistent Mental Illness Progress Notes Planner Second Edition David J. Berghuis Arthur E. Jongsma, Jr. JOHN WILEY & SONS, I NC. Practice Pla nner®

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

This book is printed on acid-free paper. Copyright © 2008 by David J. Berghuis and Arthur E. Jongsma, Jr. All rights r eserved. Published by John Wiley & Sons, Inc., Hoboken, New Jersey. Published simultaneously in Canada. No part of this publication may be reproduced, stored in a retrieval system, or transm itted in any form or by any means, electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the 1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through payment of the appr opriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 750-8400, fax (978) 646-8600, or on the web at www. copyright. com. Requests to the Publisher for permissio n should be addressed to the Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 748-6008, or online at http:www. wiley. com/go. permissions. Limit of Liability/Disclaimer of Warranty: While the publ isher and author have used their best e fforts in preparing this book, they make no representations or warranties with respect to the accuracy or completeness of the contents of this book and specifically disclaim any implied warranties of merchantability o r fitness for a particular purpose. No warranty may be created or extended by sales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation. You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit or any other commercial damages, i ncluding but not limited to special, incidental, consequential, or other damages. This publication is designed to provide accurate and au thoritative information in regard to the su bject matter covered. It is sold with the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical, psychological or any other expert assistance is required, the services of a competent professional person should be sought. Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley & Sons, Inc. is aware of a claim, the product names appear i n initial capital or all capital letters. Readers, however, should contact the appropriate companies for more complete information regarding trademarks and registration. All references to diagnostic codes are reprinted with permission from the Diagnostic a nd Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000. American Psychiatric Association. For general information on our other products and services please contact our Customer Care Department within the U. S. at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002. Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books. For more information about Wiley produc ts, visit our web site at www. wiley. com. ISBN 978-0-470-18014-3 Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

To my father, Donald W. Berghuis, with love. —D. J. B. To Justin David De Graaf and Carter Warren De Graaf, my grandsons, gifts from God, filled with promise. —A. E. J.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

xi CONTENTS Practice Plan ners® Series Preface xiii Acknow ledgments xv Introduction 1 Activities of Daily Living (ADL) 3 Aging 14 Anger Management 27 Anxiety 39 Borderline Personality 50 Chemical Dependence 59 Depression 76 Employment Problems 89 Family Conflicts 99 Financial Needs 111 Grief and Loss 120 Healt h Issues 131 Homelessness 142 Independent Activities of Daily Living (IADL) 153 Intimate Relationship Conflicts 166 Legal Concerns 179 Mania or Hypomania 190 Medication Management 201 Obsessive-Compulsive Disorder (OCD) 211 Panic/Agoraphobia 220 Paranoia 232 Parenting 244 Posttraumatic Stress Disorder (PTSD) 255 Psychosis 268 Recreational Deficits 279 Self-Determination Deficits 290

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

xii CONTENTS Sexuality Concerns 302 Social Anxiety 315 Social Skills Deficits 325 Specific Fears and Avoidance 336 Suicidal Ideation 346

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

xiii PRACTICE PLANNER S® SERIES PREFACE The practice of psychotherapy has a dimension that did not exist 30, 20, or even 15 years ago — accountability. Treatment programs, public agencies, clinics, and even group and solo practitioners must now justify the treat ment of patients to outside review entities that control the payment of fees. This development has resulted in an explosion of paperwork. Clinicians must now document what has been done in treatment, what is planned for the future, and what the anticipated outcomes of the interventions are. The books and software in this Practice Planners ® series are designed to help practitioners fulfill these documentation requirements efficiently and professionally. The Practice Planners ® series is growing rapidly. It now includes not only the original Complete Adult Psychotherapy Treatment Planner, Fourth Edition, The Child Psychotherapy Treatment Planner, Fourth Edition, and The Adolescent Psychotherapy Treatment Planner, Fourth Edition, but also Treatment Planners targe ted to specialty areas of practice, including: women, addictions, juvenile justice/residential care, couples therapy, employee assistance, behavioral medicine, therapy with older adults, pastoral counseling, family therapy, group therapy, psychopharmacolog y, neuropsychology, therapy with gays and lesbians, special education, school counseling, probation and parole, therapy with sexual abuse victims and offenders, and more. Several of the Treatment Planner books now have companion Progress Notes Planners (e. g., Adult, Adolescent, Child, Addictions, Severe and Persistent Mental Illness, Couples). More of these planners that provide a menu of progress statements that elaborate on the client's symptom presentation and the provider's therapeutic intervention are in production. Each Progress Notes Planner statement is directly integrated with “Behavioral Definitions” and “Therapeutic Interventions” items from the companion Treatment Planner. The list of therapeutic Homework Planners is also growing from the Homew ork Planner for Adults, to Adolescent, Child, Couples, Group, Family, Addictions, Divorce, Grief, Employee Assistance, and School Counseling/School Social Work Homework Planners. Each of these books can be used alone or in conjunction with their companion Treatment Planner. Homework assignments are designed around each presenting problem (e. g., Anxiety, Depression, Chemical Dependence, Anger Management, Panic, Eating Disorders) that is the focus of a chapter in its corresponding Treatment Planner. Client E ducation Handout Planners, another branch in the series, provides brochures and handouts to help educate and inform adult, child, adolescent, couples, and family clients on a myriad of presenting problems mental health issues, as well as life skills techni ques. The list of presenting problems for which information is provided mirrors the list of presenting problems in the Treatment Planner of the title similar to that of the Handout Planner. Thus, the problems for which educational material is provided in the Child and Adolescent Client Education Handout Planner reflect the presenting problems listed in The Child and The Adolescent Psychotherapy

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

xiv PRACTICE PLANNERS® SERIES PREFACE Treatment Planner books. The handouts are included on CD-ROMs for easy printing from your computer and are ideal for use in waiting rooms, at presentations, as newsletters, or as information for clients struggling with mental illness issues. In addition, the series also includes Thera Scribe®, the latest version of the popular treatment planning, clinical record-keeping software. Thera Scribe allows the user to import the data from any of the Treatment Planner, Progress Notes Planner, or Homework Planner books into the software's expandable database. Then the point-and-click method can create a detailed, neatly organi zed, individualized, and customized treatment plan along with optional integrated progress notes and homework assignments. Adjunctive books, such as The Psychotherapy Documentation Primer, and Clinical, Forensic, Child, Couples and Family, Continuum of Ca re, and Chemical Dependence Documentation Sourcebook, contain forms and resources to aid the mental health practice management. The goal of the series is to provide practitioners with the resources they need in order to provide high-quality care in the era of accountability —or, to put it simply, we seek to help you spend more time on patients and less time on paperwork. ARTHUR E. J ONGSMA JR. Grand Rapids, Michigan

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

xv ACKNOWLEDGMENTS We need to thank many people who helped make this book a reality. The pr ofessional community that found these books to be so helpful has made it necessary for the series to be expanded, and this is the latest installment, making the Practice Planners a complete treatment package. So we thank the clinicians who find our books he lpful. A special nod goes to the staff at Newaygo County Mental Health and Ionia County Community Mental Health Services, both in Michigan. We are indebted to the clients who have taught us so much about how to work with severe and persistent mental illnes s, and we thank them as well. D. J. B. A. E. J.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

1 INTRODUCTION ABOUT PRACTICE PLANNERS® PROGRESS NOTES Progress notes are not only the primary source for documenting the therapeutic process, but also one of the main factors in determining the client's eligibility for reimbursable treatment. The purpose of the Progress Notes Planner series is to assist the practitioner in easily and quickly constructing progress notes that are thoroughly unified with the client's treatment plan. Each Progress Notes Planner: Saves you hours of time-consuming paperwork. Offers the freedom to develop customized progress notes. Features over 1,000 prewritten progress notes summarizing patient presentation and treatment delivered. Provides an array of treatment approaches that correspond with the behavioral problems and DSM-IV diagnostic categories in the corresponding companion Treatment Planner. Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including The Joint Commission (TJC), the Council on Accredi tation (COA), the Commission Accreditation of Rehabitation Facilities (CARF), and the National Committee for Quality Assurance (NCQA). HOW TO USE THIS PROGRESS NOTES PLANN ER This Progress Notes Planner provides a menu of sentences that can be selected for constructing progress notes based on the behavioral definitions (or client's symptom presentation) and therapeutic interventions from its companion Treatment Planner. All progress notes must be tied to the patient's treatment plan. Session notes should ela borate on the problems, symptoms, and interventions contained in the plan. Each chapter title is a reflection of the client's potential presenting problem. The first section of the chapter, “Client Presentation,” provides a detailed menu of statements tha t may describe how that presenting problem manifested itself in behavioral signs and symptoms. The numbers in parentheses within the Client Presentation section correspond to the numbers of the Behavioral Definitions from the Treatment Planner. The secon d section of each chapter, “Interventions Implemented,” provides a menu of statements related to the action that was taken within the session to assist the client in making pro-gress. The numbering of the items in the Interventions Implemented section foll ows exactly the numbering of Therapeutic Intervention items in the corresponding Treatment Planner. All item lists begin with a few keywords. These words are meant to convey the theme or content of the sentences that are contained in that listing. The cl inician may peruse the list of keywords to find content that matches the client's presentation and the clinician's intervention. It is expected that the clinician may modify the prewritten statements contained in this book to fit the exact circumstances o f the client's presentation and treatment. To maintain complete client records, in addition to progress note statements that may be selected and individualized from this

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

2 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER book, the date, time, and length of a session; those present within the session; the p rovider; provider's credentials' and a signature must be entered in the client's record. A FINAL NOTE ABOUT P ROGRESS NOTES AND HI PAA Federal regulations under the Health Insurance Portability and Account ability Act (HIPAA) govern the privacy of a client's psychotherapy notes, as well as other protected health information (PHI). PHI and psychotherapy notes must be kept secure, and the client must sign a specific authorization to release this confidential information to anyone beyond the client's therapist o r treatment team. Further, psychotherapy notes receive other special treatment under HIPAA; for example, they may not be altered after they are initially drafted. Instead, the clinician must create and file formal amendments to the notes if he or she wishe s to expand, delete, or otherwise change them. Our Thera Scribe software provides functionality to help clinicians maintain the proper rules concerning handling PHI, by giving the ability to lock progress notes once they are created, to acknowledge patient consent for the release of PHI, and to track amendments to psychotherapy notes over time. Does the information contained in this book, when entered into a client's record as a progress note, qualify as a “psychotherapy note” and therefore merit confident ial protection under HIPAA regulations? If the progress note that is created by selecting sentences from the database contained in this book is kept in a location sepa rate from the client's PHI data, then the note could qualify as psychotherapy note data that is more protected than general PHI. However, because the sentences contained in this book convey generic information regarding the client's progress, the clinician may decide to keep the notes mixed in with the client's PHI and not consider it psycho-therapy note data. In short, how you treat the information (separated from or integrated with PHI) can determine if this progress note planner data is psychotherapy note information. If you modify or edit these generic sentences to reflect more personal in formation about the client or you add sentences that contain confidential information, the argument for keeping these notes separate from PHI and treating them as psy chotherapy notes becomes stronger. For some therapists, our sentences alone reflect enoug h per sonal information to qualify as psychotherapy notes, and they will keep these notes separate from the client's PHI and require specific authorization from the client to share them with a clearly identified recipient for a clearly identified purpose.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

3 ACTIVITIES OF DAILY LIVING (ADL) CLIENT PRESENTATION 1. Substandard Grooming and Hygiene (1) * A. The client came to the session poorly groomed. B. The client displayed poor grooming, as evidenced by strong body odor, disheveled hair, or dirty clothing. C. Others have noted that the client displays substandard grooming and hygiene. D. The client has begun to show an increased focus on his/her hygiene and grooming. E. The client's hygiene and grooming have been appropriate, with clean clothing and no st rong body odor. 2. Failure to Use Basic Hygiene Techniques (2) A. The client gave evidence of a failure to use basic hygiene techniques, such as bathing, brushing his/her teeth, or washing his/her clothes. B. When questioned about his/her basic hygiene techniques, the client reported that he/she rarely bathes, brushes his/her teeth, or washes his/her clothes. C. The client has begun to bathe, brush his/her teeth, and dress himself/herself in clean clothes on a regular basis. D. The client displayed inc reased personal care through the use of basic hygiene techniques. 3. Medical Problems (3) A. The client's poor hygiene has caused specific medical problems. B. The client is experiencing dental difficulties due to his/her poor hygiene. C. Due to the cl ient's poor personal hygiene, he/she is experiencing medical problems that put others at risk. D. As the client has improved his/her personal hygiene, his/her medical problems have decreased. 4. Poor Diet (4) A. Due to the client's inability to cook mea ls properly, he/she has experienced deficiencies in his/her diet. B. The client makes poor food selections, which has caused deficiencies in his/her diet. C. The client has displayed an increased understanding of and willingness to use a healthier diet. D. As the client's diet has improved, his/her overall level of physical functioning has improved. 5. Impaired Reality Testing (5) A. The client's impaired reality testing and bizarre behaviors cause problems with his/her performance of activities of dai ly living (ADL). * 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

4 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client's decreased reality testing causes him/her to have a decreased motivation to perform ADLs. C. As the client has become more reality focused, his/her completion of ADLs has increased. 6. Social Skills Deficits (6) A. The c lient displayed poor social interaction skills. B. The client displayed poor eye contact, insufficient interpersonal attending, and awkward social responses. C. As the client's severe and persistent mental illness symptoms have stabilized, his/her intera ction skills have increased. D. The client now displays more appropriate eye contact, interpersonal attending skills, and social responses. 7. Others Excuse Poor ADLs (7) A. The client described a history of others excusing his/her poor performance on A DLs. B. The client's family and friends rarely confront him/her on his/her poor performance on ADLs, as they believe this to be an inevitable component of his/her mental illness. C. Friends and family members have become more direct with the client about giving feedback regarding his/her performance on ADLs. D. The client's performance on ADLs has increased, as others have expected increased responsibility from him/her. 8. Inadequate Knowledge Regarding ADLs (8) A. The client displayed an inadequate le vel of knowledge or functioning in basic skills around the home. B. The client indicated that he/she has little experience in doing basic ADLs around the home (e. g., cleaning floors, washing dishes, disposing of garbage, keeping fresh food available). C. As the client has gained specific knowledge about how to perform basic duties around the home, his/her ADLs have become more appropriate. 9. Losses Due to Poor Hygiene (9) A. The client described that he/she has experienced loss of relationship, employm ent, or other social opportunities due to his/her poor hygiene and inadequate attention to grooming. B. The client's family, friends, and employer have all indicated a decreased desire to be involved with him/her due to his/her poor hygiene and inadequate attention to grooming. C. As the client's hygiene and grooming have improved, he/she has experienced improvement in relationships, employer acceptance, and other social opportunities.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ACTIVITIES OF DAILY LIVING (ADL) 5 INTERVENTIONS IMPLEM ENTED 1. Prepare an Inventory of ADLs (1) * A. The client was assisted in preparing an inventory of positive and negative functioning regarding his/her ADLs. B. The client's inventory of positive and negative functioning regarding ADLs was reviewed within the session. C. The client was given positive f eedback regarding his/her accurate inventory of positive and negative functioning regarding ADLs. D. The client has prepared his/her inventory of positive and negative functioning regarding ADLs but needed additional feedback to develop an accurate assess ment. E. The client has not prepared an inventory of positive and negative functioning regarding ADLs and was redirected to do so. 2. Assign Obtaining Feedback (2) A. The client was asked to identify a trusted individual from whom he/she can obtain help ful feedback regarding daily hygiene and grooming. B. The client has received helpful feedback regarding his/her daily hygiene and grooming, and this was reviewed within the session. C. The client has declined to seek or use any feedback regarding his/he r daily hygiene and grooming and was redirected to complete this assignment. 3. Review Diet (3) A. The client's diet was reviewed. B. The client was referred to a dietician for an assessment regarding basic nutritional knowledge and skills, usual diet, and nutritional deficiencies. C. The client reported that he/she has met with the dietician, and the results of his/her assessment were reviewed. D. The client displayed an understanding of his/her nutritional functioning as the assessment was reviewed. E. The client displayed a lack of understanding about the information contained in the nutritional assessment and was provided with additional feedback in this area. F. The client has not followed through on his/her referral to a dietician and was redire cted to do so. 4. Review Rejection (4) A. The client was asked to identify painful experiences in which rejection was experienced due to the lack of performance of basic ADLs. B. The client was provided with empathy as he/she identified painful experien ces in which rejection was experienced due to the lack of performance of basic ADLs. C. The client's broken relationships, loss of employment, and other painful experiences were reviewed within the session. * 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

6 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client could not identify painful experi ences related to poor performance of basic ADLs and was asked to continue to focus in these areas. 5. Review Medical Risks (5) A. Specific medical risks associated with poor hygiene and nutrition or lack of attention to other ADLs were reviewed. B. Medi cal risks (e. g., dental problems, risk of infection, lice, and other health problems) were identified and discussed. C. The client was assisted in developing an understanding about the medical risks associated with poor nutrition and hygiene or lack of at tention to other ADLs. D. The client agreed that he/she is at a higher medical risk due to poor nutrition and hygiene or lack of attention to other ADLs and was focused on remediation efforts. E. The client rejected the identified concerns regarding medi cal risks. 6. Facilitate Expressing Emotions (6) A. The client was assisted in expressing his/her emotions related to impaired performance in ADLs. B. The client was assisted in identifying specific emotions regarding impaired performance in ADLs (e. g., embarrassment, depression, and low self-esteem). C. Empathy was provided to the client as he/she expressed his/her emotions regarding impaired performance in ADLs. D. The client was reluctant to admit to any negative emotions regarding impaired perform ance of ADLs and was provided with feedback about likely emotions that he/she may experience. 7. Identify Secondary Gain (7) A. The possible secondary gain associated with decreased ADL functioning was reviewed. B. The client identified specific seconda ry gains that he/she has attained for decreased functioning in ADLs (e. g., less involvement in potentially difficult social situations), and these were reviewed within the session. C. The client denied any pattern of secondary gain related to decreased fu nctioning in his/her ADLs and was provided with hypothetical examples of the secondary gains. 8. Refer for Psychological Testing (8) A. The client was referred for an assessment of cognitive abilities and deficits. B. Objective psychological testing was administered to the client to assess his/her cognitive strengths and weaknesses. C. The client cooperated with the psychological testing, and he/she received feedback about the results. D. The psychological testing confirmed the presence of specific cog nitive abilities and deficits. E. The client was not compliant with taking the psychological evaluation and was encouraged to participate completely. 9. Recommend Remediating Programs (9) A. The client was referred to remediating programs that are focus ed on removing deficits for performing ADLs, including skill-building groups, token economies, or behavior-shaping programs.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ACTIVITIES OF DAILY LIVING (ADL) 7 B. The client was assisted in remediating his/her deficits for performing ADLs through the use of skill-building groups, token eco nomies, and behavior-shaping programs. C. As specific programs have assisted the client in removing deficits for performing ADLs, his/her ADLs have gradually increased. 10. Educate about Mental Illness and Decompensation (10) A. The client was educated about the expected or common symptoms of his/her mental illness, which may negatively impact basic ADL functioning. B. As his/her symptoms of mental illness were discussed, the client displayed an understanding of how these symptoms may affect his/her ADL functioning. C. The client's poor performance on ADLs was interpreted as an indicator of psychiatric decompensation. D. The client's pattern of poor ADLs and psychiatric decompensation was shared with the client, caregivers, and medical staff. E. The c lient acknowledged his/her poor performance on ADLs as prodromals of his/her psychiatric decompensation, and this was supported during the session. F. The client, caregivers, and medical staff concurred regarding the client's general psychiatric decompens ation. G. The client denied psychiatric decompensation, despite being told that his/her poor performance on ADLs is an indication of psychiatric decompensation. 11. Refer to a Physician (11) A. The client was referred to a physician for an evaluation fo r 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 ps ychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 12. Educate about Psychotropic Medications (12) A. The client was taught about th e 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 displa yed 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. 13. Monitor Medications (13) A. The client was monitored for com pliance 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 medica tions.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

8 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. Concerns about the effectiveness and side effects of the client's medications were communicated to the physician. E. Although the client was monitored for side effects from the medications, he/she reported no concerns in this area. 14. Organiz e Medications (14) A. The client was provided with a pillbox for organizing and coordinating each dose of his/her medications. B. The client was taught about the proper use of the medication compliance packaging/reminder system. C. The client was tested on his/her understanding of the use of the medication compliance packaging/reminder system. D. The client was provided with positive feedback about his/her regular use of the pillbox to organize his/her medications. E. The client has not used the pillbo x to organize his/her medications and was redirected to do so. 15. Coordinate Medication Compliance Oversight (15) A. Family members and/or caregivers were instructed on how to regularly dispense and/or monitor the client's medication compliance. B. Family members and/or caregivers indicated an understanding of how to monitor the client's medication compliance. C. The client's medication compliance was reviewed, and family members and/or caregivers indicated that he/she is regularly medication compliant. D. Family members and/or caregivers indicated that the client is not medication compliant, and this was reviewed with the client. 16. Arrange for a Physical Examination (16) A. A full physical examination was arranged for the client, and the physician was encouraged to prescribe remediation programs to aid the client in performing ADLs. B. A physician examined the client, and specific negative medical effects of low functioning on ADLs were identified. C. The physician has identified specific recomme ndations to help remediate the effects of the client's poor ADL skills. D. The physician has not identified any physical effects related to the client's poor performance on ADLs. E. Specific ADL remediation behaviors were reviewed with the client. 17. Refer to a Dentist (17) A. The client was referred to a dentist to determine dental treatment needs. B. Specific dental treatment needs were identified, and ongoing dental treatment was coordinated. C. No specific dental treatment needs were identified, but a routine follow-up appointment was made. D. The client has not followed through on the referral for dental services 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

ACTIVITIES OF DAILY LIVING (ADL) 9 18. Provide Educational Material (18) A. The client was provided with educational material to help him /her learn basic personal hygiene skills. B. The client was referred to specific portions of books and videos on the topic of personal hygiene. C. The client was referred to written material such as The Complete Guide to Better Dental Care (Taintor and T aintor) or The New Wellness Encyclopedia (Editors of University of California-Berkeley). D. The client has surveyed the educational material, and important points were reviewed within the session. E. The client has not reviewed the educational material a nd was requested to do so. 19. Refer for One-to-One Training (19) A. The client was referred to the agency medical staff for one-to-one training in basic hygiene needs and techniques. B. The client has reviewed specific hygiene needs and techniques with the agency medical staff and was supported for this. C. The client has not yet met with agency medical staff for one-to-one training in basic hygiene needs and techniques and was redirected to do so. 20. Refer to a Psychoeducational Group (20) A. The c lient was referred to a psychoeducational group focused on teaching personal hygiene skills. B. The psychoeducational group was used to help the client learn to give and receive feedback about hygiene skill implementation. C. The client has attended a ps ychoeducational group and received feedback about hygiene skill implementation, which was processed within the session. D. The client was verbally reinforced for using the group feedback about hygiene skill implementation. E. The client has not attended the psychoeducational group for hygiene skill implementation and was redirected to do so. 21. Encourage Scheduled Hygiene Performance (21) A. The client was encouraged to perform basic hygiene skills on a regular schedule (e. g., the same time and in the same order each day). B. The client was reinforced for his/her pattern of performing basic hygiene skills on a regular schedule. C. The client has not performed his/her personal hygiene skills on a scheduled basis and was redirected to do so. 22. Refer to Behavioral Treatment (22) A. The client was referred to a behavioral treatment specialist to develop and implement a program to monitor and reward the regular use of ADL techniques. B. An individualized behavioral treatment plan has been developed to monitor and reward the client's regular use of ADL techniques.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

10 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. As the client has increased his/her regular use of ADL techniques, he/she has earned rewards within the behavioral treatment plan. D. The client's increased completion of ADLs through the use of a behavioral treatment plan was reviewed. E. The client was assisted in developing a self-monitoring program for performing his/her ADLs. F. The client has resisted compliance with a behavioral treatment plan to monitor and reward the regular use of his/her ADL techniques and was redirected to do so. 23. Provide Feedback (23) A. The client was provided with feedback about progress in his/her use of self-monitoring to improve personal hygiene. B. The client appeared to react positively to the fee dback that was given regarding his/her progress in the use of self-monitoring to improve performance of ADLs. C. The client accepted the negative feedback that was given regarding his/her lack of use of self-monitoring to improve personal hygiene. 24. Review Community Resources (24) A. A list of community resources was reviewed with the client to assist him/her in improving his/her personal appearance (e. g., laundromat/dry cleaner, hair salon/barber). B. As community resources were reviewed, the client displayed an understanding and commitment to use appropriate community resources. C. The client has not used community resources to improve his/her personal appearance and was provided with additional encouragement to do so. 25. Arrange for a Tour of Com munity Resources (25) A. Arrangements were made for the client to tour community facilities for cleaning and pressing clothes, cutting and styling hair, or purchasing soap and deodorant. B. As the community resources were reviewed, the client showed an i ncreased understanding of how these resources can be used to improve performance of ADLs. C. The client continued to display a lack of understanding about the use of community facilities to assist in performing ADLs, and this information was reiterated. 26. Assess for Substance Abuse (26) A. The client was assessed for substance abuse that may exacerbate poor performance in ADLs. B. The client was identified as having a concomitant substance abuse problem. C. Upon review, the client does not display ev idence of a substance abuse problem. 27. Refer for Substance Abuse Treatment (27) 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 substance abuse treatment pro gram. 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.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ACTIVITIES OF DAILY LIVING (ADL) 11 28. Teach Housekeeping Skills (28) A. The client was taught about basic housekeeping skills through references to books on this subject. B. As the client has been taught basic housekeeping skills, he/she has displayed an increased understanding of these needs and techniques. C. The client continues to display a lack of understanding of basic housekeeping skills, and this information was presented again in a different fashion. 29. Provide Cleaning Feedback (29) A. The client was given feedback about the care of his/her perso nal area, apartment, or home. B. The client appeared to be reinforced by the positive feedback that he/she has received about his/her personal area, apartment, or home. C. The client was given negative feedback, which prompted him/her to pledge to improv e his/her personal area, apartment, or home. 30. Encourage Family Members and/or Caregivers to Assign Chores (30) A. The client's family members and/or caregivers were encouraged to provide regular assignment to the client of basic chores around the home. B. Family members and/or caregivers were reinforced for having provided regular assignment of basic chores around the home. C. Family members and/or caregivers have not provided regular assignment of basic chores around the home and were redirected to do so. 31. Teach Cooking Techniques (31) A. The client was taught some basic cooking techniques. B. Cookbooks were used to teach the client basic cooking techniques. C. As the client has been taught about basic cooking techniques, he/she has displayed an increased understanding of food preparation. D. The client displayed a lack of understanding of food preparation procedures and was provided with additional remedial information in this area. 32. Refer/Conduct a Dietary Group (32) A. The client was r eferred to a psychoeducational group focused on teaching cooking skills and dietary needs. B. The client displayed an increased understanding of dietary needs and cooking skills as a result of involvement in the psychoeducational group. C. The client has not attended the psychoeducational group focused on teaching cooking skills and dietary needs and was redirected to do so. 33. Facilitate a Community Education Class (33) A. The client's enrollment in a community education cooking class or seminar was f acilitated. B. The client was supported for his/her regular attendance to a community education cooking class or seminar. C. The client has not regularly attended the community education class or seminar, and his/her irregular attendance was processed to resolution.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

12 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 34. Review for Safety Hazards (34) A. The client's living situation was inspected for potential safety hazards. B. The client has identified potential safety hazards and these were reviewed. C. The client was assisted in remediating his/he r potential safety hazards in his/her home. D. The client has not remediated his/her potential home safety hazards and was redirected to do so. 35. Assist in Advocating Resolution of Safety Hazards (35) A. The client was assisted with requests to the a ppropriate parties (landlord, home providers, or family members) to remediate home safety hazards. B. The client was supported in his/her advocacy to remediate home safety hazards, insect infestations, and other concerns that would confound ADLs. C. The client has not appropriately advocated for himself/herself regarding seeking resolution of home safety hazards, and he/she was given additional direction in this area. 36. Facilitate Involvement in Programs for Safety Equipment (36) A. Arrangements were made for the client to become involved in programs that assist him/her in procuring safety equipment (e. g., free smoke or carbon monoxide detectors). B. The client was provided with support for his/her pursuit of programs that assist with procuring safety equipment. C. The client has not used programs to assist himself/herself with procuring needed safety equipment and was directed to follow up on this. 37. Teach about High-Risk Sexual Behaviors (37) A. The client was taught about high-risk sexual behav iors. B. The client was referred to a free condom program to decrease the risk in his/her sexual behaviors. C. The client's understanding of his/her high-risk sexual behaviors and how to remediate these concerns was reviewed. D. The client has implement ed precautions to decrease his/her risk of sexually transmitted disease and was provided with positive feedback for these changes. E. The client does not appear to understand or use appropriate precautions regarding his/her high-risk sexual behaviors and was reeducated about these issues. 38. Teach Remediation of High-Risk Drug Use Behaviors (38) A. The client was taught about the serious risk that is involved with sharing needles for drug abuse. B. The client was referred to a needle exchange program. C. The client was referred to a substance abuse treatment program. D. The client reported a decreased pattern of high-risk drug abuse behaviors and was provided with positive reinforcement for this change. E. The client has not used techniques to decrea se his/her high-risk drug abuse behaviors 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

ACTIVITIES OF DAILY LIVING (ADL) 13 39. Assist in Developing Intervention Plans (39) A. The client was assisted in developing intervention plans to avoid injury, poisoning, or other self-care problems during periods of mania, psychosis, or other decompensation. B. The client reiterated specific procedures to obtain assistance when decompensating, including calling a treatment hotline, contacting a therapist or physician, or going to the hospital emergency department, an d was supported for his/her plan. C. The client displayed an understanding of his/her crisis intervention plan and was provided with positive feedback and reminders in this area. D. The client has not developed a crisis intervention plan and was provided with more direct information in this area.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

14 AGING CLIENT PRESENTATION 1. Advanced Age (1) * A. As the client has grown older, he/she has become more dependent on others. B. The client's advanced age has exacerbated his/her severe and persistent mental illness concerns. C. The client displayed den ial regarding the effects of aging on his/her ability to function independently. D. The effects of the client's advanced age have been ameliorated through the use of an enhanced support network and greater supervision. 2. Decreased Intensity of Symptoms (2) A. As the client has advanced in age, he/she has reported a gradual decrease in the intensity of his/her severe and persistent mental illness symptoms. B. The client's overall level of functioning has gradually increased as he/she has aged. C. As th e client has aged, he/she displays less intense thought disorder symptoms and more ability to control his/her symptoms. 3. Cognitive Decline (3) A. The client presented with clear evidence of impaired abstract thinking and a tendency to think in a rather concrete manner. B. The client showed evidence of short-and long-term memory deficits. C. The client displayed periods of confusion. D. The client has struggled to learn new information. E. As the client has complied with treatment approaches, he/she has reported an amelioration of his/her cognitive difficulties. 4. Loss of Social Support System (4) A. The client reported that he/she has been losing his/her support system due to the infirmity or death of members of his/her family of origin and frien ds. B. Individuals whom the client has regularly relied upon have been less capable of providing support to the client. C. The client has begun to develop a new social support system. 5. Little Interest from Offspring (5) A. The client reported that he /she receives little or no support or attention from his/her children. B. The client's children identified that they struggle with providing support for the client due to his/her long history of severe and persistent mental illness. * 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

AGING 15 C. As the client has improved the relationship with his/her children, he/she has enjoyed increased support from them. 6. Serious Medical Condition (6) A. The client presented with serious medical problems related to his/her advanced age that are having a negative impact on d aily living. B. The client has pursued treatment for his/her medical condition. C. The client has refused treatment for his/her medical condition. D. The client has not sought treatment for his/her medical condition because of a lack of insurance and fi nancial resources. E. The client's serious medical condition is now under treatment and is showing signs of improvement. 7. Medication Side Effects (7) A. The client displayed specific physical deficits due to long-term use of psychotropic medications ( e. g., tardive dyskinesia). B. The client displayed tremors, grimaces, twitches, and involuntary vocal tics due to the long-term use of psychotropic medications. C. The client expressed concern about continued use of psychotropic medications due to the lo ng-term physical deficits he/she has experienced. D. Medication adjustment has assisted in reducing the effects of the long-term use of psychotropic medications. 8. Spiritual Confusion (8) A. The client reported concerns about spiritual confusion due to uncertainty about the meaning or purpose in life and fears surrounding mortality issues. B. The client's severe and persistent mental illness issues have confounded his/her attempts to find meaning or purpose in life. C. The client has sought out spirit ual guidance to help resolve concerns about mortality issues and the meaning and purpose of his/her life. D. The client reported that he/she has become more at peace due to involvement in spiritual activities. 9. Decreased ADLs/IADLs (9) A. The client h as displayed a decreased ability to perform activities of daily living (ADLs) (e. g., personal hygiene needs, caring for home, meal preparation) due to his/her advanced age. B. The client reported that he/she has had to decrease his/her independent activit ies of daily living (IADLs); (e. g., grocery shopping, other activities within the community) due to his/her age-related infirmities. C. As treatment has progressed, the client has identified ways to modify his/her performance of ADLs/IADLs and is now perf orming these more regularly. D. The client has received support for his/her performance of ADLs/IADLs and is performing these more regularly.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

16 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 10. Suicidal Ideation (10) A. The client reported experiencing recent suicidal ideation but denied having any s pecific plan to implement suicidal urges. B. The client reported ongoing suicidal ideation and has developed a specific plan for suicide. C. The frequency and intensity of the client's suicidal urges have diminished. D. The client was admitted to a psyc hiatric facility because he/she had a specific suicide plan and strong suicidal urges. E. The client stated that he/she has not experienced any recent suicidal ideation. 11. Abuse Vulnerability (11) A. The client displayed increased vulnerability to sex ual, physical, and psychological abuse due to his/her age-related limitations. B. The client reported an increased exposure to sexual, physical, or psychological abuse. C. The client's vulnerability to abuse has declined as he/she has developed better co ping mechanisms. D. The client reported feeling safer regarding the potential of being subjected to sexual, physical, or psychological abuse. 12. Anger Outbursts (12) A. The client has displayed anger outbursts due to his/her frustration over age-relate d declining abilities. B. The client often vents his/her anger in an inappropriate manner when he/she experiences the effects of his/her aging. C. As treatment has progressed, the client has developed better frustration coping mechanisms and has decrease d his/her pattern of anger outbursts. D. The client does not often display anger outbursts. INTERVENTIONS IMPLEM ENTED 1. Identify Aging Issues and Fears (1) * A. The client was requested to identify negative situations that have occurred due to aging iss ues. B. The client was requested to list fears about concerns related to aging issues. C. Empathic listening was used as the client discussed his/her fears about concerns related to aging issues. D. The client received support and encouragement as he/sh e identified some of the concerns that have occurred due to his/her advancing age. E. The client did not clearly identify concerns or fears related to aging issues and was redirected to review these areas. 2. Provide Aging Information (2) A. The client was provided with general information regarding the aging process. * The numbers in parentheses correlate to the number of t he 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

AGING 17 B. The client was encouraged to read books on the aging process (e. g., The Practical Guide to Aging by Cassel or Alzheimer's and Dementia: Questions You Have... Answers You Need by Hay). C. The client has read material regarding the aging process, and this was discussed within the clinical contact. D. The client has not read material regarding the aging process and was redirected to do so. 3. Clarify Emotions (3) A. The client was en couraged to share his/her emotions regarding aging issues (e. g., fear of abandonment, sadness regarding loss of abilities). B. The client has continued to share his/her feelings and has been assisted in identifying causes for them. C. Distorted cognitive messages contribute to the client's emotional response. D. The client demonstrated a sad affect and tearfulness when describing his/her feelings. E. As the client has developed better coping mechanisms, he/she reports a decrease in his/her feelings of a bandonment and sadness. 4. Teach Healthy Anger Expression (4) A. The client was taught about healthy ways to express anger (e. g., using writing, drawing, or the empty-chair technique). B. Writing, drawing, and the empty-chair technique have been helpful in allowing the client to express feelings of anger, hurt, or sadness. C. The client appeared uncomfortable with the use of anger expression techniques, had difficulty verbalizing his/her angry emotions, and was provided with additional encouragement in this area. 5. Coordinate Caregiver Training (5) A. Training was coordinated for caregivers in techniques of physical management and diffusion of the client's anger. B. The caregivers have been trained in physical management and anger diffusion technique s. C. Caregivers have used physical management and anger diffusion techniques to assist the client in decreasing his/her angry outbursts. 6. List Benefits of Aging Process (6) A. The client was asked to prepare a list of benefits that are related to the aging process. B. The client was provided with support and feedback as he/she shared his/her list of benefits that are related to the aging process (e. g., decreased work expectations, new residential opportunities). C. The client denied any benefits tha t are related to the aging process and was redirected to these areas. 7. Provide Information Regarding Aging and Mental Illness (7) A. The client was provided with specific information about the impact of the aging process on his/her mental illness. B. The tendency for severe and persistent mental illness symptoms to decrease in intensity as an individual ages was presented and discussed.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

18 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client described his/her own pattern of decreased mental illness symptoms as he/she has aged. D. The client denied that he/she has experienced a pattern of decreased mental illness symptoms as he/she has aged. 8. Referral for a Physical Evaluation (8) A. The client was referred for a complete physical evaluation by a medical professional who is knowledgeable i n both geriatric and mental illness concerns. B. The client has completed his/her physical evaluation, and the results of this evaluation were processed. C. The client has not submitted to a physical evaluation and was redirected to do so. 9. Support an d Monitor Physical Evaluation Recommendations (9) 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 have been monitored. C. The cl ient was reinforced for following up on the recommendations from the medical evaluation. D. The client has not regularly followed up on his/her medical evaluation recommendations and was redirected to do so. 10. Assist in Physical Health Needs Expression (10) A. The client was taught how to express his/her physical health needs to the medical staff. B. The client's bizarre descriptions of his/her physical health problems were “translated” to the medical staff to assist in providing more clear communicat ion. C. Role playing was used to practice asking questions of or reporting concerns to the medical staff. D. The client has provided more information to the medical staff as a result of more assertive and clear expression of needs. E. The client continu es to fail to express his/her physical health needs to the medical staff and was given additional direction. 11. Interpret and Investigate Decompensation (11) A. The client's psychiatric decompensation was interpreted as a possible reaction to medical instability and the stress that is associated with it. B. As the client has decompensated psychiatrically, inquiries have been made about his/her medical needs. C. The client accepted the interpretation that he/she is struggling with medical concerns, feel s more stressed, and has been decompensating psychiatrically due to these problems. D. The client denied any medical difficulties that have led to his/her psychiatric decompensation, and he/she was given further education in this area. 12. Obtain and Rev iew Physical Health Information (12) A. Having procured the necessary authorization from the client to release confidential material, information was obtained about the physical health concerns that he/she experiences.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

AGING 19 B. The physician has provided infor mation about the client's physical health, and this was reviewed with him/her. C. The client's physical health report has not been received from the physician, so an additional request for information was sent. D. Health concerns and recovery needs were reviewed with the client on a regular basis. E. The client was asked specific questions about his/her understanding of his/her recovery needs and health concerns. F. The client was provided with positive feedback as he/she displayed understanding of his/ her physical health concerns. G. The client has continued to display poor understanding of his/her physical health concerns, and these data were reviewed again. 13. Refer to a Physician (13) A. The client was referred to a physician for an evaluation fo r 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 ps ychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 14. Educate about Psychotropic Medications (14) A. The client was taught about th e indications for and the expected benefits of his/her 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 clien t 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. D. The client was monitored for compliance with his/her p sychotropic medication regimen. E. The client was provided with positive feedback about his/her regular use of psychotropic medications. F. Concerns about the effectiveness and side effects of the client's medications were communicated to the physician. G. Although the client was monitored for side effects from the medications, he/she reported no concerns in this area. 15. Assess Ability to Adhere to Medication Regimen (15) A. The client was assessed regarding his/her ability to regularly adhere to his /her medication regimen. B. The client was asked about the times, dosages, and types of medications he/she should be taking. C. The client's ongoing use of his/her medications was closely monitored to make certain that he/she was adhering to his/her medi cation regimen.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

20 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client was provided with positive feedback as he/she displayed the ability to adhere to his/her medication regimen. E. The client displayed a lack of understanding about his/her medications, has failed to adhere to his/her medicati on regimen, and was directed to have others dispense his/her medications to him/her. 16. Organize and Monitor Medications (16) A. The client was provided with a pillbox for organizing and coordinating each dose of his/her medications. B. The client was taught about the proper use of the medication compliance packaging/reminder system; he/she was tested on his/her understanding of the use of the medication compliance packaging/reminder system. C. The client was provided with positive feedback about his/h er regular use of the pillbox to organize his/her medications. D. The client has not used the pillbox to organize his/her medications and was redirected to do so. E. The number of pills left in the client's prescription of psychotropic medications was co unted and compared with the expected amount that should remain. F. Discrepancies within the expected and actual amounts of medications remaining were reviewed with the client and medical staff. G. The client's remaining medications correspond with the am ount expected to remain, and this was reviewed with the client. 17. Coordinate/Facilitate Multiple Physicians' Communication (17) A. Authorizations from the client to release confidential information were obtained so that multiple physicians can communic ate with each other regarding the medications that are prescribed. B. The client's physicians were contacted regarding the use of multiple medications and encouraged to consult with each other regarding the client's overall medication needs. C. The clien t declined to provide authorizations to release confidential information for his/her multiple physicians. D. The client's multiple physicians worked together to provide a coordinated review of his/her complete medication regime. E. Specific changes in th e client's medication regime were instituted after his/her multiple physicians conferred. F. No changes have been made subsequent to the client's multiple physicians conferring. G. The client's multiple physicians have not been in regular contact to revi ew his/her variety of medications. 18. Evaluate and Develop Support for ADLs/IADLs (18) A. The client's overall level of functioning in ADLs and IADLs were evaluated, identifying strengths, weaknesses, and expected future levels of functioning. B. Conce rns about the client's ability to perform his/her ADLs and IADLs in the future were identified. C. Specific supports were developed for helping the client to maintain his/her ADLs and IADLs.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

AGING 21 D. Contact was made with the family, community resources, and s taff to assist them in developing support treatment for the client's ADLs and IADLs. 19. Review Hearing and Vision Needs (19) A. An increase in the client's auditory and visual hallucinations was noted, not accompanied by other severe and persistent ment al illness symptoms, which triggered a review of his/her hearing and vision needs. B. The client reported difficulties relating to hearing and vision, and exams in these areas were coordinated. C. Upon inquiry, the client denied any pattern of hearing or vision concerns. 20. Refer for Vision/Hearing Exams (20) A. The client was referred to an audiologist 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 n eeds. 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. 21. Refer to Supe rvised Residence (21) A. The client was referred to an appropriate supervised residential care center. B. The client agreed with the referral to a supervised residential care center. C. The client has been accepted at a supervised residential care cente r. D. The client has refused to accept a referral to an appropriate residential care center and was given additional encouragement to do so. 22. Advocate with Housing Programs (22) A. Advocacy was performed with age-appropriate housing programs to assis t the housing program in accepting the client and to provide needed adaptations for him/her. B. Training was provided to the housing program staff to assist them in adapting to the client's needs. C. Housing staff were trained about the client's symptoms, prodromals, and treatment techniques used for him/her. D. Housing staff displayed an increased understanding and comfort level with the client after receiving training. E. Despite advocacy, the housing program has been reluctant to accept the client. 23. Differentiate Hospitalization and Age-Appropriate Residence (23) A. The client's history of institutionalization was reviewed with him/her. B. The client was taught the difference between his/her previous psychiatric hospitalizations and a relatively restrictive residential placement due to aging concerns. C. The client's hard-won independence from restrictive psychiatric settings was acknowledged, and the restrictive residence due to aging was differentiated from the restrictive psychiatric setting. D. The client displayed understanding and acceptance of the more restrictive residential placement due to aging concerns.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

22 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client continues to balk at the suggestion of a more restrictive residential placement due to aging concerns and was redirect ed in this area. 24. Empathize Regarding Losses (24) A. The client's history of significant losses due to death, geographical move, aging, or physical/mental disability was reviewed. B. The client was provided with support and empathy as he/she expresse d feelings regarding his/her history of losses. C. The client was reluctant to express his/her emotions regarding his/her pattern of loss but was encouraged to do so. 25. Educate about Grief and Mental Illness (25) A. The client was educated about the t ypical pattern of grief. B. The client was educated about how the grief process may impact his/her severe and persistent mental illness symptoms. C. The client failed to understand the effect of the grief process on his/her severe and persistent mental i llness symptoms, and this information was reviewed again. 26. Refer for Individual/Group Therapy (26) A. The client was referred for individual therapy to work through the grief associated with his/her losses. B. The client has followed through on parti cipating in individual therapy focused on grief and was provided with reinforcement for this. C. The client was referred to a support group for grief and loss issues. D. The client was referred to a support group for chronic mental illness concerns. E. The client has become involved in a support group and reports that this is helpful. F. The client has not followed through on the referral to therapy and was encouraged to do so. 27. Develop Social Skills (27) A. The client was assisted in developing s ocial skills. B. The client was provided with positive support as he/she displayed increased social skills. C. The client has struggled to develop social skills and was provided with additional feedback in this area. 28. Coordinate Social Activities (28 ) A. The client was linked to age-appropriate social activities. B. The client has become more involved in age-appropriate social activities and was given positive reinforcement for these choices. C. The client has refused involvement in age-appropriate social activities and was redirected to investigate available options. 29. Refer to a Recreational Therapist (29) A. The client was referred to a recreational therapist for an evaluation of recreational abilities, needs, and opportunities.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

AGING 23 B. The clien t has followed through with the recommendation to see a recreational therapist, and the results of this evaluation have been shared with the client. C. The client has not followed through on the referral to a recreational therapist and was redirected to d o so. 30. Focus on Self-Regulation (30) A. The client was focused on the need to regulate his/her own social involvement depending on his/her needs and symptoms. B. The client identified that he/she varies the frequency and intensity of social contacts in order to modulate his/her stress level and was given feedback about this technique. C. The client reported a decreased stress level due to his/her modulation of social contact, and the success of this was reviewed. D. The client reported that he/she d oes not modulate his/her social involvement depending on his/her needs and symptoms and was redirected to use this technique. 31. Identify New Opportunities (31) A. The client was assisted in identifying activities in which he/she can now be engaged as h is/her psychotic symptoms have gradually abated. B. The client listed many activities in which he/she wishes to engage as psychotic symptoms have gradually abated, and this list was reviewed. C. The client failed to identify activities in which he/she wi shes to engage as his/her mental illness symptoms lessen and was given additional feedback in this area. 32. Identify Relationships to Restore (32) A. The client was requested to identify important relationships that he/she would like to restore. B. The client declined to identify any relationships that he/she would like to restore and was given additional feedback in this area. 33. Develop a Plan for Restoring Relationships (33) A. The client was assisted in developing a specific plan for restoring re lationships. B. The client has implemented his/her plan for restoring relationships, and this was reviewed. C. The client has struggled to identify how he/she wishes to restore relationships and was given additional feedback in this area. 34. Provide In formation to Family and Caregivers (34) A. The family and caregivers were provided with adequate information and training relative to the client's mental illness, physical health, and aging concerns. B. The family and caregivers were recommended to read material regarding coping with providing care to someone with severe mental illness. C. Specific books were recommended to the client's family and caregivers (e. g., Surviving Schizophrenia by Torrey or Helping Someone with Mental Illness by Carter and Gol ant). D. Family members and caregivers were assisted in processing the information and training that has been provided regarding the client's mental illness, physical health, and aging concerns. E. The family and caregivers continued to struggle with the client's mental illness, physical health, and aging concerns and were provided with additional feedback in these areas.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

24 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 35. Empathize with the Caregiver (35) A. The caregiver was allowed to vent about difficulties that are related to supervising the cli ent. B. Empathy was displayed as the caregiver was focused on making a commitment for continued care. C. The caregiver was assisted in developing alternative plans for the client's care. D. The caregiver was confronted when he/she began to deride the cl ient. 36. Educate the Caregiver and Family Members (36) A. The client's caregivers and family members were educated about programs, techniques, and options for caring for older adults. B. The client's caregivers and family members were referred to guide books regarding caring for older adults. C. The client's caregivers and family members were referred to specific materials (e. g., Coping with Your Difficult Older Parent by Lebow, Cane, and Lebow) regarding caring for older adults. D. The client's caregi vers and family members were assisted in processing key concepts from their reading and learning about how to care for older adults. 37. Assess Elder Abuse (37) A. The client was assessed for whether he/she has been a victim of elder abuse in any form. B. Concerns related to abuse of the client were identified, and immediate steps were taken to secure his/her safety. C. Elder abuse was suspected, and the appropriate adult protective services agency has been informed. D. There is no evidence that the cl ient has been a victim of elder abuse in any form. E. The client was gently, empathetically probed for his/her emotional reaction to being the victim of abuse. F. The client was cautious and defensive about describing his/her emotional reaction to his/he r abuse and was provided with support and feedback in this area. G. The client struggled to identify and coherently express his/her emotions regarding the abuse done to him/her and was provided with support and feedback in this area. 38. Facilitate Chang es to Stop Abuse (38) A. The client was assisted in making specific changes related to his/her residence in order to immediately terminate the abuse he/she has suffered. B. The client was assisted in making changes in the programs in which he/she is invo lved to terminate the abuse that has occurred to him/her within those programs. C. The client was assisted in making any necessary changes to assist in terminating the abuse he/she has been experiencing. D. The client has failed to make changes to help t erminate the abuse and was redirected and assisted to make these changes. E. Applicable abuse reporting procedures as outlined in local law were followed regarding the suspected or identified elder abuse. F. Agency guidelines were followed regarding the suspected or identified elder abuse.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

AGING 25 G. Peer or supervisory support was obtained regarding reporting suspected or confirmed elder abuse. 39. Educate about Elder Abuse (39) A. The client and caregivers were assisted in defining and identifying elder abu se. B. The client and caregivers were provided specific information about steps to take if they identify elder abuse. C. The client and caregiver were supported for displaying an understanding of the definition and criteria for elder abuse and how to res pond. D. The client and caregiver continue to be confused and uncertain about the concepts related to elder abuse and were provided with additional feedback in this area. 40. Advocate Change in Guardian/Payee (40) A. The client was urged to request a ch ange in his/her legal guardian or payee procedures in order to stem financial abuse. B. The court was petitioned for a change in the client's legal guardian status in order to stem financial abuse. C. The client's legal guardian or payee procedures have been changed in an effort to discontinue the financial abuse. D. The client declined to make any changes in his/her legal guardian or payee procedures and was redirected to do so. 41. Review Specialized Needs Due to Physical Deterioration (41) A. The fo cus of today's clinical contact was on the client's specialized needs that he/she will face due to the natural deterioration of physical capabilities that are associated with aging. B. The client was reinforced for displaying an understanding of the speci alized needs that he/she will require due to his/her physical decompensation due to aging. C. The client does not appear to understand or accept the specialized needs that he/she may experience due to his/her natural deterioration of physical capabilities and was provided with additional feedback in this area. 42. Coordinate Information Regarding Programs (42) A. The client was provided with information regarding residential or other programs that are available to him/her as he/she ages. B. The client w as assisted with a tour of residential programs that are available to him/her as he/she ages. C. The client was reinforced for displaying an increased understanding of the options available to him/her as he/she ages. D. The client struggled to understand the residential programs and other programs that he/she may need as he/she ages and was given additional feedback in this area. 43. Develop a Written Plan for Incapacitation (43) A. The client was directed to develop a written plan to detail his/her wis hes should he/she be legally unable to make his/her own decisions. B. The client was assisted in developing a written plan to detail his/her wishes should he/she become legally unable to make his/her own decisions.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

26 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was reinforced for develo ping a plan for guardianship, advanced medical directives, and last will and testament. D. The client has not developed a plan for his/her possible incapacitation 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

27 ANGER MANAGEMENT CLIENT PRESENTATION 1. Explosive, Destructive Outbursts (1) * A. The client described a history of loss of temper in which he/she has destroyed property in fits of rage. B. The client described a history of loss of temper that dates back many years, involving verbal outbursts, as well as property destruction. C. As treatment has progressed, the client has reported increased control over his/her temper and a significant reduction in incidents of poor anger management. D. The client has h ad no recent incidents of explosive outbursts that have resulted in destruction of any property or intimidating verbal assaults. 2. Explosive, Assaultive Outbursts (1) A. The client described a history of loss of anger control to the point of physical as saults on others who were the target of his/her anger. B. The client has been arrested for assaultive attacks on others when he/she has lost control of his/her temper. C. The client has used assaultive acts as well as threats and intimidation to control others. D. The client has made a commitment to control his/her temper and terminate all assaultive behavior. E. There have been no recent incidents of assaultive attacks on anyone, in spite of the client having experienced periods of anger. 3. Violent O utbursts Due to Altered Perception of Reality (2) A. The client described a history of violent actions that have occurred during a psychotic episode of perceived threat. B. The client reported that his/her pattern of hallucinations and delusions have cau sed a threatening altered perception of reality, which has led to violent actions. C. As the client has gained a better reality orientation that is less threatening, his/her violent actions have diminished. D. The client reported no recent incidents of v iolent actions committed as a result of threatening hallucinations or delusions. 4. Loss of Inhibition or Regard for Consequences (3) A. The client reported a pattern of impulsive anger outbursts that have occurred when he/she has lost his/her natural in hibition. * 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

28 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client identified a pattern of impulsive anger outbursts without regard to the painful consequences that occur due to these anger outbursts. C. As the client has become more stable in his/her mood, he/she has reported a decrease in impul sive anger outbursts. D. The client reported that he/she is able to inhibit his/her impulses to react in an angry manner and considers the consequences for his/her actions. E. The client reported that he/she has not engaged in any recent incidents of imp ulsive anger outbursts. 5. Hostile Overreaction (4) A. The client described a history of reacting angrily to rather insignificant irritants in his/her daily life. B. The client indicated that he/she recognizes that he/she becomes too angry in the face o f rather minor frustrations and irritants. C. Minor irritants have resulted in explosive, angry outbursts that have led to destruction of property and/or striking out physically at others. D. The client has made significant progress at increasing his/her frustration tolerance and reducing explosive overreactivity to minor irritants. E. The client has not overreacted with anger to minor frustrations or irritants. 6. Paranoid Ideation (5) A. The client described a history of incidents in which he/she has become easily offended and was quick to anger. B. The client described a pattern of defensiveness in which he/she feels easily threatened by others and becomes angry with them. C. The client described periods during which he/she projects threatening mot ivations onto others, then reacts with irritability, defensiveness, and anger. D. The client reported a decreased pattern of inappropriate paranoid thought, which has led to fewer anger outbursts. E. The client has become less defensive and has not shown any recent incidents of unreasonable anger. 7. Intimidation and Control (6) A. The client identified a pattern of violent actions, threats, or verbally abusive language used to intimidate and control others when feeling threatened. B. The client presen ted in a hostile, angry, uncooperative, and intimidating manner during the clinical contact. C. The client is trying to act in a more cooperative manner within social and employment settings. D. The client is showing less irritability and argumentativene ss. E. The client displayed a willingness to not have to be in control of all situations. 8. Challenges Authority (7) A. The client's history shows a consistent pattern of challenging or disrespectful treatment of authority figures. B. The client ackno wledged that he/she becomes angry quickly when someone in authority gives direction to him/her.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANGER MANAGEMENT 29 C. The client's disrespectful treatment of authority figures has often erupted in explosive, aggressive outbursts. D. The client has made progress in controll ing his/her overreactivity to taking direction from those in authority and is responding with more acts of cooperation. E. The client now takes direction from authority figures without reacting angrily. 9. Angry, Tense Body Language (8) A. The client pr esented with verbalizations of anger as well as tense, rigid muscles and glaring facial expressions. B. The client expressed his/her anger with bodily signs of muscle tension, clenched fists, and refusal to make eye contact. C. The client appeared more r elaxed, less angry, and did not exhibit physical signs of aggression. D. The client's family and/or caregiver reported that he/she has been more relaxed within the home setting and has not shown glaring looks or pounded his/her fists on the table. 10. History of Abuse (9) A. The client has vague memories of inappropriate, abusive verbal, physical, and/or sexual contact. B. The client recalled clear, detailed memories of experiences of verbal, physical, and/or sexual abuse in his/her childhood or adultho od. C. The client displayed a pattern of overreaction to stress, due to his/her history of childhood abuse. D. The client has decreased his/her overreaction to stress as he/she has worked through his/her pattern of childhood verbal, physical, and/or sexu al abuse. 11. Self-Directed Anger (10) A. The client displayed self-directed anger, as evidenced by a history of multiple suicidal gestures and/or threats. B. The client has engaged in self-mutilating behavior as an expression of his/her anger toward himself/herself. C. The client has made a commitment to terminate suicidal gestures and threats. D. The client agreed to stop the pattern of self-mutilating behavior. E. There have been no recent reports of occurrences of suicidal gestures, threats, or se lf-mutilating behavior. INTERVENTIONS IMPLEM ENTED 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 acceptanc e. * 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

30 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 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 anger expression. 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 was accepted for this insight. 2. Assess Anger Dynamics (2) A. The client was assessed for various stimuli that have triggered his/her anger. B. The client was helped to identify situations, people, and thoughts that have triggered his/her anger. C. The client was assisted in identifying the thoughts, feelings, and actions that have characterized his/her anger responses. 3. Arrange More Restrictive Setting (3) A. The client was judged to be at imminent risk o f harm to himself/herself or others, and an admission to a more restrictive treatment setting was coordinated. B. The client declined voluntary admission to a more restrictive treatment setting and was petitioned to be involuntarily admitted. C. The clie nt has decreased his/her pattern of angry outbursts as a result of treatment in a more structured setting. D. The client reacted to the threat of an impending psychiatric hospitalization with a decrease in his/her anger outbursts. 4. Remove Anger-Provoki ng Stimuli (4) A. The client's environment was reviewed for possible anger-provoking stimuli. B. Specific anger-provoking stimuli were removed from the client's environment. 5. Physician Referral (5) A. The client was referred to a physician to undergo a thorough examination to rule out any organic contributors 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 ang er outbursts were reviewed. C. The client was supported as he/she is seeking out medical treatment that may decrease his/her anger outbursts. D. The client has followed 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 medications and was redirected to cooperate with this referral. 6. Review Substance Abuse (6) A. The client's use of street drugs o r alcohol as a contributing factor to anger control problems was reviewed.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANGER MANAGEMENT 31 B. The client identified that he/she often experiences his/her anger control problems in the context of using street drugs or alcohol, and this pattern was processed. C. The clien t denied any pattern of use of street drugs or alcohol as a contributing factor to his/her anger control problems and was directed to monitor this area. 7. Evaluate Substance Abuse (7) A. The client was evaluated for his/her use of substances, the severi ty 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 accurately assess his/her substance abuse concerns a nd 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. 8. Refer to a Physician for Psychotropic Medications (8) A. The client was assessed for the need for psychotropic medication. B. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. C. The client has followed through on a referral to a physician and has been assessed for a prescription of psychotropic medications, but none were prescribed. D. The client has been prescribed psychotropic medications. E. The client declined an evaluation by a physician for a pre scription of psychotropic medication and was redirected to do so. 9. Monitor Medications and Side Effects (9) A. The client was monitored for compliance with his/her psychotropic medication regimen, as well as possible side effects. B. The client was pr ovided 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. The client identified significant medication side effects, and t hese were reported to the medical staff. E. Possible side effects of the client's medications were reviewed, but he/she denied experiencing any side effects. F. Concerns about the client's medication effectiveness and side effects were communicated to the physician. G. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 10. Assign Anger Journal (10) A. The client was educated about triggers for anger. B. The client was assigned to keep a daily journa l in which he/she will document persons or situations that cause anger, irritation, or disappointment.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

32 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was assigned “Anger Journal” in the Adult Psychotherapy Homework Planner, Second Edition (Jongsma). D. The client has kept a journal of a nger-producing situations, and this material was processed within the session. E. The client has become more aware of the causes for and targets of his/her anger as a result of journaling these experiences on a daily basis; the benefits of this insight we re reflected to him/her. F. The client has not kept an anger journal and was redirected to do so. 11. List Targets of/Causes for Anger (11) A. The client was assigned to list as many of the causes for and targets of his/her anger that he/she is aware of. B. The client's list of targets of and causes for anger was processed in order to increase his/her awareness of anger management issues. C. The client has indicated a greater sensitivity to his/her anger feelings and the causes for them as a result of the focus on these issues. D. The client has not been able to develop a comprehensive list of causes for and targets of anger and was provided with tentative examples in this area. 12. Identify Anger (12) A. The client was assisted in becoming more awar e of the frequency with which he/she experiences anger and the signs of it in his/her life. B. Situations were reviewed in which the client experienced anger but refused to acknowledge it or minimized the experience. C. The client has acknowledged that h e/she is frequently angry and has problems with anger management and was provided with positive feedback about this process. 13. Identify Anger Expression Models (13) A. The client was assisted in identifying key figures in his/her life that have provide d examples to him/her of how to positively or negatively express anger. B. The client was reinforced as he/she identified several key figures who have been negative role models in expressing anger explosively and destructively. C. The client was supporte d and reinforced for acknowledging that he/she manages his/her anger in the same way that an explosive parent figure had done when he/she was growing up. D. The client was encouraged to identify positive role models throughout his/her life whom he/she cou ld respect for their management of anger feelings. E. The client was supported as he/she acknowledged that others have been influential in teaching him/her destructive patterns of anger management. F. The client failed to identify key figures in his/her life who have provided examples to him/her as to how to positively express his/her anger and was questioned more specifically in this area. 14. List Negative Anger Impact (14) A. The client was assisted in listing ways that his/her explosive expression o f anger has negatively impacted his/her life. B. The client was supported as he/she identified many negative consequences that have resulted from his/her poor anger management.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANGER MANAGEMENT 33 C. It was reflected to the client that his/her denial about the negative impa ct of his/her anger has decreased and he/she has verbalized an increased awareness of the negative impact of his/her behavior. D. The client has been guarded about identifying the negative impact of his/her anger and was provided with specific examples of how his/her anger has negatively impacted his/her life and relationships (e. g., injuring others or self, legal conflicts, loss of respect from self or others, destruction of property). 15. Identify Bodily Impact of Anger (15) A. The client was taught th e negative impact that anger can have on bodily functions and systems. B. The client indicated an increased awareness of the stress of his/her anger on such things as heart, brain, and blood pressure; this awareness was applied to his/her own functioning. C. The client was reinforced as he/she has tried to reduce the frequency with which he/she experiences anger in order to reduce the negative impact that anger has on bodily systems. 16. Reconceptualize Anger (16) A. The client was assisted in reconcept ualizing anger as involving different components that go through predictable phases. B. The client was taught about the different components of anger, including cognitive, physiological, affective, and behavioral components. C. The client was taught how to better discriminate between relaxation and tension. D. The client was taught about the predictable phases of anger, including demanding expectations that are not met, leading to increased arousal and anger, which leads to acting out. E. The client dis played a clear understanding of the ways to conceptualize anger and was provided with positive reinforcement. F. The client has struggled to understand the ways to conceptualize anger and was provided with remedial feedback in this area. 17. Identify Pos itive Consequences of Anger Management (17) A. The client was asked to identify the positive consequences he/she experienced in managing his/her anger. B. The client was assisted in identifying positive consequences of managing anger (e. g., respect from others and self, cooperation from others, improved physical health). C. The client was asked to agree to learn new ways to conceptualize and manage anger. 18. Teach Calming Techniques (18) A. The client was taught deep-muscle relaxation, rhythmic breath ing, and positive imagery as ways to reduce muscle tension when feelings of anger are experienced. B. The client has implemented the relaxation techniques and reported decreased reactivity when experiencing anger; the benefits of these techniques were und erscored. C. The client has not implemented the relaxation techniques and continues to feel quite stressed in the face of anger; he/she was encouraged to use the techniques. 19. Assign Use of Calming Techniques (19) A. The client was assigned implementa tion of calming techniques in his/her daily life when facing anger trigger situations.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

34 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client related situations in which he/she has appropriately used calming techniques when facing anger trigger situations; this progress was reinforced. C. The c lient described situations in which he/she has not used calming techniques and these failures were reviewed and redirected. 20. Explore Self-Talk (20) A. The client's self-talk that mediates his/her angry feelings was explored. B. The client was assesse d for self-talk, such as demanding expectations reflected in “should,” “must,” or “have to” statements. C. The client was assisted in identifying and challenging his/her biases and in generating alternative self-talk that correct for the biases. D. The c lient was taught about how to use correcting self-talk to facilitate a more flexible and temperate response to frustration. 21. Assign Self-Talk Homework (21) A. The client was assigned a homework exercise in which he/she identifies anger self-talk and generates alternatives that help moderate anger reactions. B. The client's use of self-talk alternatives was reviewed within the session. C. The client was reinforced for his/her success in changing angry self-talk to more moderated alternatives. D. The client was provided with corrective feedback to help improve his/her use of alternative self-talk to moderate his/her angry reactions. 22. Assign Thought-Stopping Technique (22) A. The client was directed to implement a thought-stopping technique on a da ily basis between sessions. B. The client was assigned “Making Use of the Thought-Stopping Technique” in the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client's use of the thought-stopping technique was reviewed. D. The client was p rovided with positive feedback for his/her helpful use of the thought-stopping technique. E. The client was provided with corrective feedback to help improve his/her use of the thought-stopping technique. 23. Teach Assertive Communication (23) A. The cl ient was taught about assertive communication through instruction, modeling, and role-playing. B. The client was referred to an assertiveness training class. C. The client displayed increased assertiveness and was provided with positive feedback in this area. D. The client has not increased his/her level of assertiveness and was provided with additional feedback in this area. 24. Teach Conflict Resolution Skills (24) A. The client was taught conflict resolution skills. B. The client was taught empathy and active listening skills.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANGER MANAGEMENT 35 C. “I messages” and respectful communication were taught via role modeling, role-playing, and instruction. D. Assertiveness without aggression and compromise were emphasized to the client. E. “Applying Problem-Solving to Per sonal Conflict” from Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was assigned to the client. F. The benefits, successes, and struggles of implementing conflict resolution skills were reviewed. 25. Teach Problem-Solving Skills (25) A. The clie nt was taught problem-solving skills (e. g., identify the problem, brainstorm all solutions, select best option, implement course of action, and evaluate results). B. Modeling, role-playing, and behavioral rehearsal were used to help the client use problem-solving skills to work through several current conflicts. C. The client was reinforced for his/her grasp of problem-solving skills. D. The client struggled to grasp the use of problem-solving skills and was provided with remedial feedback in this area. 26. Construct Strategy for Managing Anger (26) A. The client was assisted in constructing a client-tailored strategy for managing his/her anger. B. The client was encouraged to combine somatic, cognitive, communication, problem-solving, and conflict res olution skills relevant to his/her needs. C. The client was reinforced for his/her comprehensive anger management strategy. D. The client was redirected to develop a more comprehensive anger management strategy. 27. Select Challenging Situations for Mana ging Anger (27) A. The client was provided with situations in which he/she may be increasingly challenged to apply his/her new strategies for managing anger. B. The client was asked to identify his/her likely upcoming challenging situations for managing anger. C. The client was urged to use his/her strategies for managing anger in successively more difficult situations. 28. Consolidate Anger Management Skills (28) A. The client was assisted in consolidating his/her new anger management skills. B. Techn iques such as relaxation, imagery, behavioral rehearsal, modeling, role-playing, or vivo exposure/behavioral experiences were used to help the client consolidate the use of his/her new anger management skills. C. The client's use of techniques to consolid ate his/her anger management skills were reviewed and reinforced. 29. Monitor/Decrease Outbursts (29) A. The client's reports of angry outbursts were monitored, toward the goal of decreasing their frequency, intensity, and duration. B. The client was urg ed to use his/her new anger management skills to decrease the frequency, intensity, and duration of his/her anger outbursts. C. The client's progress in decreasing his/her angry outbursts was reviewed.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

36 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client was reinforced for his/her success at decreasing the frequency, intensity, and duration of his/her anger outbursts. E. The client has not decreased his/her frequency, intensity, or duration of anger outbursts and corrective feedback was provided. 30. Encourage Disclosure (30) A. The client w as encouraged to discuss his/her anger management goals with trusted persons who are likely to support his/her change. B. The client was assisted in identifying individuals who are likely to support his/her change. C. The client has reviewed his/her ange r management goals with trusted persons, and their responses were processed. D. The client has not discussed his/her anger management goals and was redirected to do so. 31. Educate Support System about Gains (31) A. The client's family, friends, and care givers were educated about anger management and the concepts that the client has learned in therapy. B. The client's family, friends, and caregivers were educated about the specific goals that the subject has developed in regard to his/her anger manageme nt needs and how the family can facilitate the client's therapeutic gains. C. The family members were reinforced for their understanding and support of the client's anger management concerns. D. Family members have not displayed support and understandin g for the client's anger management concerns and were redirected to provide this to the client. 32. Develop Support Network's Safety Plan (32) A. Members of the client's support network, including family, friends, and caregivers, were educated on how to manage the client's anger episodes. B. The family members, friends, and caregivers were assisted in developing an understanding of when to contact public safety officials. C. The client was informed about the support network's safety plan. D. The safet y plan has been used and has helped to contain the client's anger outbursts. E. The safety plan has not been helpful toward containing the client's anger outbursts, and additional plans were developed in this area. 33. Discuss Management of Lapse Risk Sit uations (33) 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. C. The client w as 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. 34. Encourage Routine Use of Strategies (34) A. The client was instructed to routinely use the st rategies that he/she has learned in therapy (e. g., calming, adaptive self-talk, assertion, and/or conflict resolution).

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANGER MANAGEMENT 37 B. The client was urged to find ways to build his/her strategies into his/her life as much as possible. C. The client was reinforced a s he/she reported ways in which he/she has incorporated copying 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. 35. Develop a Coping Card (35) A. The c lient was provided with a coping card on which specific coping strategies were 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 car d when struggling with anger-producing situations. 36. Schedule Maintenance Sessions (36) A. The client was assisted in scheduling maintenance sessions to help maintain therapeutic gains and adjust to life without anger outbursts. B. Positive feedback wa s provided to the client for his/her maintenance of therapeutic gains. C. The client has displayed an increase in anger symptoms and was provided with additional relapse prevention strategies. 37. Assign Reading Material (37) A. The client was assigned t o read material that educates him/her about anger and its management. B. The client was directed to read Overcoming Situational and General Anger: Client Manual (Deffenbacher and Mc Kay). C. The client was directed to read Of Course You're Angry (Rosselin i and Worden). D. The client was directed to read The Anger Control Workbook (Mc Kay). E. The client has read the assigned material on anger management, and key concepts were reviewed. F. The client has not read the assigned material on anger management and was redirected to do so 38. Teach Forgiveness (38) A. The client was taught about the process of forgiveness and encouraged to begin to implement this process as a means of letting go of his/her feelings of strong anger. B. The client focused on the perpetrators of pain from the past and he/she was encouraged to target them for forgiveness. C. The advantages of implementing forgiveness versus holding on to vengeful anger were processed with the client. D. Positive feedback was provided as the client has committed himself/herself to attempting to begin the process of forgiveness with the perpetrators of pain. E. The client has not been able to begin the process of forgiveness of the perpetrators of his/her pain and was urged to start this process as he/she feels able to. 39. Assign Books on Forgiveness (39) A. The client was assigned to read books on forgiveness. B. The client was assigned to read the book Forgive and Forget (Smedes) to increase his/her sensitivity to the process of forgiveness.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

38 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client has read the book Forgive and Forget, and key concepts were processed within the session. D. The client acknowledged that holding on to angry feelings has distinct disadvantages over his/her beginning the process of forgiveness; he/she was urg ed to start this process. E. The client has not followed through with completing the reading assignment of Forgive and Forget and was encouraged to do so. 40. Advocate within the Court System (40) A. Steps were taken to advocate for the client within th e court system to assist him/her in receiving assistance, legal representation, leniency, or sentencing that is commensurate with his/her mental illness status. B. Due to the advocacy provided on behalf of the client, the court has provided appropriate assistance, legal representation, leniency, or sentencing that is commensurate with his/her mental illness status. C. Although advocacy has been provided for the client within the court system, the court has not accommodated his/her mental illness status.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

39 ANXIETY CLIENT PRESENTATION 1. Apprehension Due to Severe and Persistent Mental Illness Symptoms (1) * A. The client identified a pattern of apprehension and nervousness in response to his/her severe and persistent mental illness symptoms. B. The client identified specific symptoms, such as frightening hallucinations or manic/racing thoughts, which have led to increased anxiety. C. The client described a general state of nervousness due to his/her severe and persistent mental illness symptoms. D. As tre atment has progressed, the client has reported a decrease in the severity of his/her mental illness symptoms and a decreased level of anxiety. 2. Excessive Worry (2) A. The client described preoccupation with worry that something dire would happen. B. The client showed some recognition that his/her excessive worry is beyond the scope of rationality, but he/she feels unable to control the anxiety. C. The client described that he/she worries about issues related to family, personal safety, health, and emp loyment, among other things. D. The client reported that his/her worry about life circumstances has diminished and that he/she is living with more of a sense of peace and confidence. 3. Motor Tension (3) A. The client described a history of restlessness, tiredness, muscle tension, and shaking. B. The client moved about in his/her chair frequently and sat stiffly. C. The client said that he/she is unable to relax and is always restless and stressed. D. The client reported that he/she has been successfu l in reducing levels of tension and increasing levels of relaxation. E. The client appeared more relaxed as he/she sat calmly during the clinical contact. 4. Fear Due to Persecutory Delusions (4) A. The client described a pattern of recurrent or persist ent fear due to persecutory delusions or other bizarre beliefs. B. The client described his/her delusions and bizarre beliefs, as well as the anxiety that he/she experiences due to these beliefs. C. The client has identified his/her delusions as not base d on reality and reports a decreased pattern of anxiety. * The numbers in parentheses correlate to the number of the Behavioral Definit ion 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

40 THE SEVERE AND PERSI STENT MENTAL ILLNESS PRO GRESS NOTES PLANNER D. As the client's persecutory delusions or other bizarre beliefs have decreased, he/she has also identified a decrease in his/her fear. 5. Hypervigilance (5) A. The client related that he/she is constantly feeling on edge, sleep is interrupted, and concentration is difficult. B. The client reported being irritable in interactions with others as his/her patience is thin and he/she worries about everything. C. The client's family members report th at he/she is difficult to get along with, as his/her irritability is high. D. As new anxiety/coping skills have been implemented, the client's level of tension has decreased, sleep has improved, and irritability has diminished. 6. Concentration Difficult ies (6) A. The client reported an inability to concentrate or maintain his/her train of thought due to anxious preoccupation. B. The client's lack of ability to concentrate has resulted in poor functioning in his/her social, vocational, and educational n eeds. C. The client's ability to concentrate seems to be increasing as he/she reports decreased anxious preoccupation. INTERVENTIONS IMPLEM ENTED 1. Develop Trust (1) * A. Today's clinical contact focused on building the level of trust with the client thr ough 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 ver bally 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 Anxiety Symptoms (2) A. The client was asked about the frequency, intensity, duration, and history of his/her anxiety 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 anxiety symptoms. C. The assessment of the client's anxiety sym ptoms indicated that his/her symptoms are extreme and severely interfere with his/her life. * The numbers in parentheses correlate to the number of the Therapeutic Int ervention 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

ANXIETY 41 D. The assessment of the client's anxiety symptoms indicates that these symptoms are moderate and occasionally interfere with his/her daily functioning. E. The re sults of the assessment of the client's anxiety 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 anxiety symptoms were reviewed with the client. 3. Develo p a Time Line (3) A. A graphic time line display was used to help the client chart his/her pattern of anxiety symptoms. B. The client identified his/her precursors, triggers, anxiety symptoms, and effects on a time line to review how he/she experiences a nd is affected by anxiety. C. The client displayed a greater understanding of his/her pattern of anxiety problems and was given support and feedback in this area. D. The client failed to adequately understand his/her pattern of anxiety symptoms and was redirected in this area. 4. Psychological Testing (4) A. A psychological evaluation was conducted to determine the extent and severity of the client's anxiety symptoms. B. The Penn State Worry Questionnaire was used to assess the client's level of worry. C. The client approached the psychological testing in an honest, straightforward manner and was cooperative with any requests presented to him/her. D. The client was uncooperative and resistant to engage during the evaluation process and was advised to use this testing to discover more about himself/herself. E. The results of the psychological evaluation were reviewed with the client. 5. Refer for a Physical Evaluation (5) 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 out medical treatment that may decrease his/her anger outbursts. D. The client has followed through on the physician evaluation referral, but no specific medical etiologies for anger outbursts have been ide ntified. E. The client declined evaluation by a physician and was redirected to cooperate with this referral. 6. Follow Up on Physical Evaluation Recommendations (6) 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. D. The client has not regularly followed up on his/her medi cal evaluation recommendations 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

42 THE SEVERE AND PERSI STENT MENTAL ILLNESS PRO GRESS NOTES PLANNER 7. Review Psychoactive Chemicals (7) A. The client's use of psychoactive chemicals (e. g., nicotine, caffeine, alcohol, street drugs) was reviewed. B. The client's pattern of psychoactive chemic al use was connected to his/her symptoms. C. The client was supported as he/she acknowledged that his/her psychoactive chemical use is affecting his/her anxiety symptoms. D. The client was reinforced for decreasing his/her psychoactive chemical use, lead ing to a decrease in anxiety symptoms. E. The client denies any connection between his/her psychoactive chemical use and his/her anxiety symptoms and has continued to use psychoactive chemicals, despite encouragement to discontinue this. 8. Recommend Sub stance Abuse Evaluation and/or Termination (8) A. It was recommended to the client that he/she terminate the consumption of mood-altering substances that could contribute to anxiety. B. The client was referred for a substance abuse evaluation to more com pletely 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 mood-altering substances. D. As the client has decreased his/her use of mood-altering 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. 9. Differentiate Anxiety Symptoms (9) A. The client was assisted in differentiating anxiety symptoms that are a direct effect of his/her severe and persistent mental illness, as opposed to a separate diagnosis of an anxiety disorder. B. The client was provi ded 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's specific anxiety disorder, which is freestanding from his/her severe and persistent mental illness, was reviewed. 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. 10. Differentiate Reality versus Hallucinations/Delus ions (1 0) A. The client was assisted in differentiating between actual life situations and those that appear real but are due to hallucinations or delusions. B. Positive feedback was provided to the client as he/she identified several situations that hav e appeared real but are actually due to hallucinations or delusions. C. Redirection was provided to the client as he/she continues to struggle with reality testing and is uncertain about the reality of his/her hallucinations or delusions. 11. Acknowledge Anxiety Related to Delusional Experiences (1 1) A. It was acknowledged that both real and delusional experiences could cause anxiety. B. The client was provided with support as he/she acknowledged his/her anxieties and worries, which are related to both the real experiences and delusional experiences.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANXIETY 43 12. Identify Diagnostic Classification (12) A. The client was assisted in identifying a specific diagnostic classification for his/her anxiety symptoms. B. Using a description of anxiety symptoms such as t hat 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 a Physician (13) 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 phys ician 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. 14. Educate about Psychotropic Medications (14) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications wer e 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 for and expected benefits of psychotropic medications and was provided wit h 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 client was provided with positive feedback about his/her re gular 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. 16. Review Side Effects of Medications (16) A. The possible side effects related to the client's medications were reviewed with him/her. B. The clie nt 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.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

44 THE SEVERE AND PERSI STENT MENTAL ILLNESS PRO GRESS NOTES PLANNER 17. Discuss Anxiety Cycle (17) A. The client was ta ught about how anxious fears are maintained by a cycle of unwarranted fear and avoidance that precludes positive, corrective experiences with the feared object or situation. B. The client was taught about how treatment breaks the anxiety cycle by encourag ing positive, corrective experiences. C. The client was taught information from Mastery of Your Anxiety and Worry —Therapist Guide (Craske, Barlow, and O'Leary) regarding the anxiety pattern. D. The client was reinforced as he/she displayed a better under standing of the anxiety cycle of unwarranted fear and avoidance and how treatment breaks the cycle. E. The client displayed a poor understanding of the anxiety and was provided with remedial feedback in this area. 18. Discuss Target of Treatment (18) A. A discussion was held about how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively. B. The reduction of overarousal and unnecessary avoidance were emphasized as treatment targets. C. The client displayed a clear understanding of the target of treatment and was provided with positive feedback in this area. D. The client struggled to understand the target of treatment and was provided with specific examples in this area. 19. Assign Reading on Anxiety (19) A. The client was assigned to read psychoeducational chapters of books or treatment manuals on anxiety. B. The client was assigned information from Mastery of Your Anxiety and Worry —Client Manual (Zinbarg, Craske, Barlow, and O'Leary). C. The client has read the assigned information on anxiety, and key points were reviewed. D. The client has not read the assigned information on anxiety and was redirected to do so. 20. Teach Relaxation Skills (20) A. The client was taught relaxation skills. B. The clie nt was taught progressive muscle relaxation, guided imagery, and slow diaphragmatic breathing. C. The client was taught how to discriminate better between relaxation and tension. D. The client was taught how to apply relaxation skills to his/her daily li fe. E. The client was taught relaxation skills as described in Progressive Relaxation Training (Bernstein and Borkovec). F. The client was taught relaxation skills as described in Treating GAD (Rygh and Sanderson). G. The client was provided with feedba ck about his/her use of relaxation skills. 21. Assign Relaxation Homework (21) A. The client was assigned to do homework exercises in which he/she practices relaxation on a daily basis.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANXIETY 45 B. The client has regularly used relaxation exercises, and the helpf ul benefits of these exercises were reviewed. C. The client has not regularly used relaxation exercises and was provided with corrective feedback in this area. D. The client has used some relaxation exercises, but does not find these to be helpful; he/sh e was assisted in brainstorming how to modify these exercises to be more helpful. 22. Assign Reading on Relaxation Calming Strategies (22) A. The client was assigned to read about progressive muscle relaxation and other calming strategies in relevant book s and treatment manuals. B. The client was directed to read about muscle relaxation and other calming strategies in Progressive Relaxation Training (Bernstein and Borkovec). C. The client was directed to read about muscle relaxation and other calming str ategies in Mastery of Your Anxiety and Worry —Client Guide (Zinbarg, Craske, Barlow, and O'Leary). D. The client has read the assigned information on progressive muscle relaxation, and key points were reviewed. E. The client has not read the assigned info rmation on progressive muscle relaxation and was redirected to do so. 23. Utilize Biofeedback (23) A. Electromyograph (EMG) biofeedback techniques were used to facilitate the client learning relaxation skills. B. The client reported that he/she has imple mented his/her use of relaxation skills in daily life to reduce levels of muscle tension and the experience of anxiety; the benefits of this technique were reviewed. C. The client reported that his/her level of anxiety has decreased since relaxation techn iques were implemented; he/she was encouraged to continue this technique. D. The client has not followed through on implementation of relaxation skills to reduce anxiety symptoms; he/she was redirected to do so. 24. Identify Distorted Thoughts (24) A. The client was assisted 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 understanding 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 cognitions and was provided with tentative examples in this area. 25. Assign Exercises on Self-Talk (25) A. The client was assigned homework exercises in which he/she identifies fearful self-talk and creates reality-based alternatives. B. The client's replacement of fearful self-talk with reality-based alternatives was critiqued. C. The client was reinforced for his/her successes at replacing fearful self-talk with reality-based alternatives.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

46 THE SEVERE AND PERSI STENT MENTAL ILLNESS PRO GRESS NOTES PLANNER D. The client was provided with corrective feedb ack for his/her failures to replace fearful self-talk with reality-based alternatives. E. The client has not completed his/her assigned homework regarding fearful self-talk and was redirected to do so. 26. Teach Thought Stopping (26) A. The client was ta ught thought-stopping techniques that involve thinking of a stop sign and replacing negative thoughts with a pleasant scene. B. The client was assigned “Making Use of the Thought-Stopping Technique” form the Adult Psychotherapy Homework Planner, 2nd ed. ( Jongsma). C. The client's implementation of the thought-stopping technique was monitored and his/her success with this technique was reinforced. D. The client reported that the thought-stopping technique has been beneficial in reducing his/her preoccupat ion with anxiety-producing cognitions; he/she was encouraged to continue this technique. E. The client has failed to use the thought-stopping techniques and his/her attempts to use these techniques were reviewed and problem-solved. 27. Read about Cognitiv e Restructuring of Fears (27) A. The client was assigned to read about cognitive restructuring of fears or worries in books or treatment manuals. B. Mastery of Your Anxiety and Worry —Client Guide (Zinbarg, Craske, Barlow, and O'Leary) was assigned to the client to help teach him/her about cognitive restructuring. C. Key components of cognitive restructuring were reviewed. D. The client and parents have not done the assigned reading on cognitive restructuring, and they were redirected to do so. 28. Assig n Reading on Worry Exposure (28) A. The client was assigned to read about worry exposure in relevant books or treatment manuals. B. The client was assigned Mastery of Your Anxiety and Worry —Client Guide (Zinbarg, Craske, Barlow, and O'Leary) to learn abo ut worry exposure. C. Key concepts related to worry exposure were reviewed and processed within the session. D. The client has not done the reading on worry exposure, and he/she was redirected to do so. 29. Construct Anxiety Stimulus Hierarchy (29) 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 hierarchy of stimulus situations, as the causes of his/her anxiety remain qui te 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. 30. Select Initial E xposures (30) A. Initial exposures were selected from the hierarchy of anxiety-producing situations, with a bias toward the likelihood of being successful.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANXIETY 47 B. A plan was developed with the client for managing the symptoms that may occur during the initia l 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 client's helpful use of symptom management techniques. E. The client was redir ected for ways to improve his/her symptom management techniques. 31. Assign Homework on Situational Exposures (31) A. The client was assigned homework exercises to perform worry exposures and record his/her experience. B. The client was assigned situatio nal exposures homework from Mastery of Your Anxiety and Worry —Client Guide (Zinbarg, Craske, Barlow, and O'Leary). C. The client was assigned situational exposures homework from Generalized Anxiety Disorder (Brown, O'Leary, and Barlow). D. The client's use of worry exposure techniques was reviewed and reinforced. E. The client has struggled in his/her implementation of worry exposure techniques and was provided with corrective feedback. F. The client has not attempted to use the worry exposure techniqu es and was redirected to do so. 32. Assign Imagination Exercises (32) A. The client was asked to vividly imagine worse-case consequences of worries, holding them in mind until the anxiety associated with them weakens. B. The client was asked to imagine c onsequences of his/her worries as described in Mastery of Your Anxiety and Worry —Therapist Guide (Craske, Barlow, and O'Leary). C. The client was supported as he/she has maintained a focus on the worst-case consequences of his/her worry until the anxiety weakened. D. The client was assisted in generating reality-based alternatives to the worst-case scenarios, and these were processed within the session. 33. Teach Problem-Solving Strategies (33) A. The client was taught a specific problem-solving strategy. B. The client was taught problem-solving strategies including specifically defining a problem, generating options for addressing it, implementing a plan, evaluating options, and reevaluating and refining the plan. C. The client was provided feedback on his/her use of the problem-solving strategies. 34. Assign Problem-Solving Exercise (34) A. The client was assigned a homework exercise in which he/she problem solves a current problem. B. The client was assigned a problem to solve as described in Master y of Your Anxiety and Worry —Client Guide (Zinbarg, Craske, Barlow, and O'Leary). C. The client was assigned a problem to solve as described in Generalized Anxiety Disorder (Brown, O'Leary, and Barlow).

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

48 THE SEVERE AND PERSI STENT MENTAL ILLNESS PRO GRESS NOTES PLANNER D. “Applying Problem-Solving to Interpersonal Confl ict” from Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was assigned to the client. E. The client was provided with feedback about his/her use of the problem-solving assignment. 35. Differentiate between Lapse and Relapse (35) A. A discussion w as 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. 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 identifying future situations or circumstances in which lapses could occur. B. The session focused on rehearsing the manageme nt of future situations or circumstances in which lapses could occur. 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. 37. Encourag e 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 into his/her life and routine. D. The client was redirected about ways to incorporate his/her new strategies into his/her ro utine and life. 38. Apply Secondary Gain ( 38) A. The possible secondary gain associated with anxiety symptoms was reviewed. B. The client identified specific secondary gains that he/she has attained related to anxiety symptoms, such as less involvement i n potentially difficult social situations, and these were reviewed. C. The client denied any pattern of secondary gain related to decreased functioning due to his/her anxiety and was provided with hypothetical examples of the secondary gains. 39. Encoura ge Daily Routines ( 39) A. The client was encouraged to develop a routine daily pattern as a means of reducing stress. B. The client was assisted in setting a routine daily pattern, including his/her regular waking and resting times, mealtimes, and routin ely performing daily chores. C. The client was reinforced for implementing a regular daily routine, which has increased his/her emotional stability.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

ANXIETY 49 D. The client has not maintained his/her regular daily routine and was provided with redirection in this area. 40. Enlist the Client's Support System (40) A. The help of the client's support system was enlisted in his/her implementation of specific stress reduction techniques. B. The client's support system was enthusiastic and supportive of his/her stress reduction techniques, and he/she was encouraged to use this support on a regular basis. C. The client's support system has declined significant involvement in helping him/her to implement specific stress reduction techniques, so alternative means of deve lopment of support for stress reduction were developed. D. The client has declined support from his/her family, friends, and caretakers and was again urged to use this support.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

50 BORDERLINE PERSONALI TY CLIENT PRESENTATION 1. Emotional Reactivity (1 )* A. The client described a history of extreme emotional reactivity when minor stresses occur in his/her life. B. The client's emotional reactivity is usually quite short lived, as he /she returns to a calm state after demonstrating strong feelings of anger, anxiety, or depression. C. The client's emotional liability has been reduced, and he/she reported less frequent incidents of emotional reactivity. 2. Chaotic Interpersonal Relatio nships (2) A. The client has a pattern of intense, but chaotic, interpersonal relationships as he/she puts high expectations on others and is easily threatened that the relationship might be in jeopardy. B. The client has had many relationships that have ended because of the intensity and demands that he/she placed on the relationship. C. The client reported incidents that have occurred recently with friends, whereby he/she continued placing inappropriately intense demands on the relationship. D. The cl ient has made progress in stabilizing his/her relationship with others by diminishing the degree of demands that he/she places on the relationship and reducing the dependency on it. 3. Identify Disturbance (3) A. The client has a history of being confuse d as to who he/she is and what his/her goals are in life. B. The client has become very intense about questioning his/her identity. C. The client has become more assured about his/her identity and is less reactive to this issue. 4. Impulsivity (4) A. The client described a history of engaging in impulsive behaviors that have the potential for producing harmful consequences for himself/herself. B. The client has engaged in impulsive behaviors that compromise his/her reputation with others. C. The clien t has established improved control over impulsivity and considers the consequences of his/her actions more deliberately before engaging in behavior. 5. Suicidal/Self-Mutilating Behavior (5) A. The client reported a history of multiple suicidal gestures a nd/or threats. B. The client has engaged in self-mutilating behavior on several occasions. C. The client made a commitment to terminate suicidal gestures and threats. D. The client agreed to stop the pattern of self-mutilating behaviors. * 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

BORDERLINE PERSONALI TY 51 E. There have been no recent reports of occurrences of suicidal gestures, threats, or self-mutilating behavior. 6. Feelings of Emptiness (6) A. The client reported a chronic history of feeling empty and bored with life. B. The client's frequent complaints of feeling bored and that life had no meaning had alienated him/her from others. C. The client has not complained recently about feeling empty or bored, but appears to be more challenged and at peace with life. 7. Intense Anger Eruptions (7) A. The client frequent ly has eruptions of intense and inappropriate anger triggered by seemingly insignificant stressors. B. The client seems to live in a state of chronic anger and displeasure with others. C. The client's eruptions of intense and inappropriate anger have dim inished in their frequency and intensity. D. The client reported that there have been no incidents of recent eruptions of anger. 8. Feels Others Are Unfair (8) A. The client made frequent complaints about the unfair treatment he/she believes that others have given him/her. B. The client frequently verbalized distrust of others and questioned their motives. C. The client has demonstrated increased trust of others and has not complained about unfair treatment from them recently. 9. Black-or-White Thinki ng (9) A. The client demonstrated a pattern of analyzing issues in simple terms of right or wrong, black or white, trustworthy versus deceitful, without regard for extenuating circumstances before considering the complexity of the situations. B. The clie nt's black-or-white thinking has caused him/her to be quite judgmental of others. C. The client finds it difficult to consider the complexity of situations, but prefers to think in simple terms of right versus wrong. D. The client has shown some progress in allowing for the complexity of some situations and extenuating circumstances, which might contribute to some other people's actions. 10. Abandonment Fears (10) A. The client described a history of becoming very anxious whenever there is any hint of abandonment present in an established relationship. B. The client's hypersensitivity to abandonment has caused him/her to place excessive demands of loyalty and proof of commitment on relationships. C. The client has begun to acknowledge his/her fear of ab andonment as being excessive and irrational. D. Conflicts within a relationship have been reported by the client, but he/she has not automatically assumed that abandonment will be the result.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

52 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER INTERVENTIONS IMPLEM ENTED 1. Assess Behavior, Affect, and Cogn itions (1) * A. The client's experience of distress and disability was assessed to identify targets of therapy. B. The client's pattern of behaviors (e. g., parasuicidal acts, angry outbursts, overattachment) was assessed to help identify targets for thera py. C. The client's affect was assessed, including emotional overractions and painful emptiness, in regard to targets for therapy. D. The client's cognitions were assessed, including biases such as dichotomous thinking, overgeneralization, and catastroph izing, to assist in identifying targets for therapy. E. Specific targets for therapy were identified. 2. Explore Childhood Abuse/Abandonment (2) A. Experiences of childhood physical or emotional abuse, neglect, or abandonment were explored. B. As the c lient identified instances of abuse and neglect, the feelings surrounding these experiences were processed. C. The client's experiences with perceived abandonment were highlighted and related to his/her current fears of this experience occurring in the pr esent. D. As the client's experience of abuse and abandonment in his/her childhood was processed, he/she denied any emotional impact of these experiences on himself/herself. E. The client denied any experience of abuse and abandonment in his/her childhoo d, and he/she was urged to talk about these types of concerns as he/she deems it necessary in the future. 3. Validate Distress and Difficulties (3) A. The client's experience of distress and subsequent difficulties were validated as understandable, given his/her particular circumstances, thoughts, and feelings. B. It was reflected to the client that most people would experience the same distress and difficulties, given the same circumstances, thoughts, and feelings. C. The client was noted to accept the validation about his/her level of distress 4. Orient to Dialectical Behavioral Therapy (DBT) (4) A. The client was oriented to DBT. B. The multiple facets of DBT were highlighted, including support, collaboration, challenge, problem solving, and skill building. C. The biosocial view related to Borderline Personality Disorder was emphasized, including the constitutional and social influences. D. The concept of dialectics was reviewed with the client. E. Information from Cognitive-Behavioral Treatment of Borderline Personality (Linehan) was reviewed with the client. * The numbers in parentheses correlate to the number of the Therapeutic Inte rvenion 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.

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BORDERLINE PERSONALI TY 53 5. Assign Reading on Borderline Personality Disorder (5) A. The client was asked to read selected sections of books or manuals that reinforce therapeutic interventions. B. Portions of Skills Training Manual for Treating Borderline Personality Disorder (Linehan) were assigned to the client. C. The client has read assigned information from books or manuals, and key concepts were reinforced. D. The client has not read assigned portions of b ooks or manuals that reinforce therapeutic interventions and was redirected to do so. 6. Solicit Agreement for DBT (6) A. An agreement was solicited from the client to work collaboratively within the parameters of the DBT approach. B. A written agreemen t was developed with the client to work collaboratively within the parameters of the DBT approach. C. The client has agreed to work within the DBT approach to overcome the behaviors, emotions, and cognitions that have been identified as causing problems i n his/her life. D. The client was reinforced for his/her commitment to working within the DBT program. E. The client has not agreed to work within the DBT program and was referred back to “Treatment as Usual. ” 7. Explore Self-Mutilating Behavior (7) A. The client's history and nature of self-mutilating behavior were explored thoroughly. B. The client recalled a pattern of self-mutilating behavior that has dated back several years. C. The client's self-mutilating behavior was identified as being associ ated with feelings of depression, fear, and anger, as well as a lack of self-identity. 8. Assess Suicidal Behavior (8) A. The client's history and current status regarding suicidal gestures were assessed. B. The secondary gain associated with suicidal g estures was identified. C. Triggers for suicidal thoughts were identified, and alternative responses to these trigger situations were proposed. 9. Arrange Hospitalization (9) A. As the client was judged to be harmful of self, arrangements were made for voluntary psychiatric hospitalization. B. As the client refused a necessary psychiatric hospitalization, the proper steps to involuntary hospitalize the client were initiated. C. The client has been psychiatrically hospitalized. D. Ongoing contact with the psychiatric hospital has been maintained in order to coordinate the most helpful treatment while in the hospital. 10. Refer to Emergency Helpline (10) A. The client was provided with an emergency helpline telephone number that is available 24 hours a day.

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54 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. Positive feedback was provided as the client promised to utilize the emergency helpline telephone number rather than engaging in any self-harm behaviors. C. The client has not used the emergency helpline telephone system in place of engaging in s elf-harm behaviors and was reminded about this useful resource. 11. Interpret Self-Mutilating Behavior (11) A. The client's self-mutilation was interpreted as an expression of the rage and helplessness that could not be expressed as a child victim of emot ional abandonment and abuse. B. The client accepted the interpretation of his/her self-mutilation and more directly expressed his/her feelings of hurt and anger associated with childhood abuse experiences. C. The client rejected the interpretation of sel f-mutilating behavior as an expression of rage associated with childhood abandonment or neglect experiences. D. An expectation that the client will be able to control his/her urge for self-mutilation was expressed. 12. Elicit Nonsuicide Contract (12) A. A promise was elicited from the client that he/she will initiate contact with the therapist or an emergency helpline if the suicidal urge becomes strong and before any self-injurious behavior is enacted. B. The client was reinforced as he/she promised to terminate self-mutilation behavior and to contact emergency personnel if urges for such behavior arise. C. The client has followed through on the nonself-harm contract by contacting emergency service personnel rather than enacting any suicidal gestures or self-mutilating behavior; he/she was reinforced for this healthy use of support. D. The client's potential for suicide was consistently assessed despite the suicide prevention contract. 13. Resolve Therapy-Interfering Behaviors (13) A. The client's patt ern of therapy-interfering behavior (e. g., missing appointments, noncompliance, abruptly leaving therapy) was consistently monitored. B. The client was confronted for his/her therapy-interfering behaviors. C. The clinician took appropriate responsibility for the clinician's own therapy-interfering behaviors. D. Therapy-interfering behaviors were problem-solved. 14. Refer for Medication Evaluation (14) A. The client was assessed in regard to the need for psychotropic medication. B. The client was referr ed to a physician to be evaluated for psychotropic medications to stabilize his/her mood. C. The client has cooperated with a referral to a physician and has attended the evaluation for psychotropic medications. D. The client has refused to attend a phys ician evaluation for psychotropic medications 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

BORDERLINE PERSONALI TY 55 15. Monitor Medication Compliance (15) A. The client's compliance with prescribed medications was monitored, and effectiveness of the medication on his/her level of functioning was noted. B. The client reported that the medication has been beneficial in stabilizing his/her mood, and he/she was encouraged to continue its use. C. The client reported that the medication has not been beneficial in stabilizing his/her mood; this was re flected to the prescribing clinician. D. The client reported side effects of the medication that he/she found intolerable; these side effects were relayed to the physician. 16. Use Strategies to Manage Maladaptive Behaviors, Thoughts, and Feelings (16) A. Validation, dialectical strategies, and problem-solving strategies were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings. B. Therapeutic techniques as described in Cognitive-Behavioral Treatment of Borde rline Personality (Linehan) were used to help the client manage his/her symptoms. C. Validation was consistently used to help the client manage, reduce, and stabilize maladaptive behaviors, thoughts, and feelings. D. Dialectical strategies, such as metap hor or devil's advocacy, were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feeling. E. Problem-solving strategies, such as behavioral analysis, cognitive restructuring, skills training, and exposure, were used to help the client manage, reduce, or stabilize his/her maladaptive behaviors, thoughts, and feelings. F. It was noted that the client has decreased maladaptive behaviors (e. g., angry outbursts, binge drinking, abusive relationships, high-risk sex, uncont rolled spending), maladaptive thought patterns (e. g., all-or-nothing thinking, catastrophizing, personalizing), and maladaptive feelings (e. g., rage, hopelessness, abandonment). 17. Conduct Skills Training (17) A. Group skills training was used to teach r esponses to identified problem behaviors. B. Individual skills training was used to teach the client responses to identified behavioral problem patterns. C. The client was taught assertiveness for use in abusive relationships. D. The client was taught c ognitive strategies for identifying and controlling financial, sexual, and other impulsivity. E. The client has participated in skills training for specific behavioral problems, and the benefit of this treatment was reviewed. F. The client has not partic ipated in group skills training and was redirected to do so. 18. Teach Skills for Regular Use (18) A. Behavioral strategies were taught to the client via instruction, modeling, and advising. B. Role-playing and exposure exercises were used to strengthen the client's use of behavioral strategies. C. The client was provided with regular homework assignments to help incorporate the behavioral strategies into his/her everyday life. D. The client was reinforced for his/her regular use and understanding of be havioral strategies.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

56 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client has struggled to understand the behavioral strategies and was provided with remedial information in this area. 19. Conduct Trauma Work (19) A. As the client's adaptive behavior patterns have been evident, work on rememb ering and accepting the facts of previous trauma was initiated. B. The client was assisted in using his/her new adaptive behavior patterns and emotional regulation skills to reduce denial and increase insight into the effects of previous trauma. C. The c lient was helped to reduce maladaptive emotional and/or behavioral responses to trauma-related stimuli through the regular use of adaptive behavioral patterns and emotional skills. D. The client was assisted in tolerating the distress of remembering and a ccepting the facts of previous trauma and in reducing self-blame. E. The client has been noted to be successful in using his/her adaptive behavioral patterns and emotional regulation skills in managing the effects of previous trauma. F. The client has be come more emotionally disregulated due to the trauma work and was redirected to use behavioral and emotional regulation skills. 20. Explore Schema and Self-Talk (20) A. The client was assisted in exploring how his/her schema and self-talk mediate his/her trauma-related and other fears. B. The client's distorted schema and self-talk were reviewed. C. The client was reinforced for his/her insight into his/her self-talk and schema that support his/her trauma-related and other fears. D. The client struggled to develop insight into his/her own self-talk and schema and was provided with tentative examples of these concepts. 21. Assign Exercises on Self-Talk (21) A. The client was assigned homework exercises in which he/she identifies fearful self-talk and creates reality-based alternatives. B. The client was assigned the homework exercise “Journal and Replace Self-Defeating Thoughts” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client was directed to complete the “Daily Record of Dysfunctional Thoughts” from Cognitive-Behavioral Therapy of Depression (Beck, Rush, Shaw, and Emery). D. The client's replacement of fearful self-talk with reality-based alternatives was critiqued. E. The client was reinforced for his/her successes at r eplacing fearful self-talk with reality-based alternatives. 22. Reinforce Positive Self-Talk (22) A. The client was reinforced for implementing positive, realistic self-talk that enhances self-confidence and increases adaptive action. B. The client noted several instances from his/her daily life that reflected the implementation of positive self-talk, and these successful experiences were reinforced. 23. Develop Hierarchy of Triggers (23) A. The client was directed to develop a hierarchy of feared and av oided trauma-related stimuli. B. The client was helped to list many of the feared and avoided trauma-related stimuli.

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BORDERLINE PERSONALI TY 57 C. The client was assisted in developing a hierarchy of feared and avoided trauma-related stimuli. D. The client's journaling was used to assist in developing a hierarchy of feared and avoided trauma-related stimuli. 24. Direct Imaginal Exposure (24) A. Imaginal Exposure was directed by having the client describe a chosen traumatic experience at an increasing, but client-chosen, level of detail. B. Cognitive restructuring techniques were integrated and repeated until the associated anxiety regarding childhood trauma was reduced and stabilized. C. The session was recorded and provided to the client to listen to between sessions. D. “Sha re the Painful Memory” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was assigned to help direct the client's imaginal exposure. E. Techniques from Posttraumatic Stress Disorder (Resick and Calhoun) were used to direct the client's imag inal exposure. F. The client's progress was reviewed, reinforced, and problem solved. 25. Assign Homework on Exposure (25) A. The client was assigned homework exercises to perform exposure to feared stimuli and record his/her experience. B. The client w as directed to listen to the taped exposure session to consolidate his/her skills for exposure to feared stimuli. C. The client was assigned situational exposure homework from Posttraumatic Stress Disorder (Resick and Calhoun). D. The client's use of exp osure techniques was reviewed and reinforced. E. The client has struggled in his/her implementation of exposure techniques and was provided with corrective feedback. F. The client has not attempted to use the exposure techniques and was redirected to do so. 26. Encourage Trust in Own Evaluations (26) A. The client was encouraged to value, believe, and trust in his/her evaluations of himself/herself, others, and situations. B. The client was encouraged to examine situations in a nondefensive manner, inde pendent of others' opinions. C. The client was encouraged to build self-reliance through trusting his/her own evaluations. D. The client was reinforced for his/her value, belief, and trust in his/her own evaluations of himself/herself, others, and situat ions. E. The client was redirected when he/she tended to devalue, disbelieve and distrust his/her own evaluations. 27. Encourage Positive Experiences (27) A. The client was encouraged to facilitate his/her personal growth by choosing experiences that strengthen self-awareness, personal values, and appreciation of life. B. The client was encouraged to use spiritual practices and other relative life experiences to help increase his/her positive experiences.

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58 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 28. Use Multiple Family Group Treatment (28) A. The client was referred for multiple family group treatment. B. The client was enrolled in a multiple family group treatment program. C. The client's family has participated in a multiple family group treatment program, gaining insight into family dynami cs and how to cope with the client's symptoms. D. The family is not enrolled in the multiple family group treatment program, and the reasons for this resistance were reviewed.

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59 CHEMICAL DEPENDENCE CLIENT PRESENTATION 1. Consistent Abuse of Alcohol (1) * A. The client described a history of alcohol abuse on a frequent basis, often until intoxicated or passed out. B. Family members confirmed a pattern of chronic alcohol abuse by the client. C. The client acknowledged that his/her alcohol use began in adolescence and has continued into adulthood. D. The client has committed himself/herself to a plan of abstinence from alcohol and participation in a recovery program. E. The clien t has maintained total abstinence, which is confirmed by his/her family. 2. Consistent Drug Abuse (1) A. The client described a history of mood-altering illicit drug abuse on a frequent basis. B. Family members confirmed a pattern of chronic drug abuse by the client. C. The client acknowledged that his/her drug abuse began in adolescence and has continued into adulthood. D. The client has committed himself/herself to a plan of abstinence from mood-altering drugs and participation in a recovery program. E. The client has maintained total abstinence, which is confirmed by his/her family. 3. Exacerbation of Primary Symptoms (2) A. The client displayed an increase in his/her primary psychosis symptoms (e. g., hallucinations, delusions, mania) as a result of abuse of mood-altering illicit substances. B. The client has displayed a compromised reality orientation due to the abuse of mood-altering illicit substances. C. Due to the client's withdrawal from mood-altering illicit substances, he/she has displaye d an increase in primary psychosis symptoms. D. As the client has terminated his/her use of mood-altering illicit substances, his/her experience of primary psychosis symptoms has decreased significantly. 4. Exacerbation of Secondary Symptoms (2) A. The client has displayed an exacerbation of secondary psychosis symptoms (e. g., anxiety, unstable affect, disorganization) as a result of abuse of mood-altering illicit substances. * The numbers in parentheses correlate to the n umber 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

60 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client has displayed increased anxiety, unstable affect, and disorganiz ation as a result of withdrawal from mood-altering illicit substances. C. As the client has terminated his/her use of mood-altering illicit substances, his/her experience of secondary psychosis symptoms has decreased significantly. 5. Inability to Reduce Alcohol/Drug Abuse (3) A. The client acknowledged that he/she frequently has attempted to terminate or reduce his/her use of mood-altering substances but found that he/she has been unable to follow through. B. The client acknowledged that in spite of ne gative consequences and a desire to reduce or terminate the mood-altering substances, he/she has been unable to do so. C. As the client has participated in a total recovery program, he/she has been able to maintain abstinence from mood-altering drug use. 6. Negative Blood Effects (4) A. The client's blood work results reflect a pattern of heavy substance use in that his/her liver enzymes are elevated. B. The client's blood work results indicate that mood-altering drugs have been used. C. As the client has participated in the recovery program and has been able to maintain abstinence from mood-altering substances, his/her blood work has shown no evidence of ongoing substance abuse. 7. Denial (5) A. The client presented with denial regarding the negative consequences of his/her substance abuse, in spite of direct feedback from others about its negative impact. B. The client's denial is beginning to break down as he/she is acknowledging that substance abuse has created problems in his/her life. C. The cl ient now openly admits to the severe negative consequences brought on by his/her substance abuse. 8. Persistent Alcohol/Drug Abuse Despite Problems (6) A. The client has continued to abuse alcohol and/or drugs in spite of recurring physical, legal, vocat ional, social, or relationship problems that were directly caused by the substance use. B. The client has denied that the many problems in his/her life are directly caused by substance abuse. C. The client acknowledged that substance abuse has been the c ause of multiple problems in his/her life, and he/she verbalized a strong desire to maintain a life free from using all mood-altering substances. D. As the client has maintained sobriety, some of the direct negative consequences of substance abuse have di minished. E. The client is now able to face resolution of significant problems in his/her life as he/she has begun to establish sobriety.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

CHEMICAL DEPENDENCE 61 9. Diversion of Resources (7) A. The client displayed a pattern of diverting limited financial or personal resource s into obtaining the substance, using the substance, or recovering from the effects of the substance. B. The client's basic needs have gone unfulfilled due to his/her diverting financial and personal resources into substance use and abuse. C. As the clie nt has decreased or discontinued his/her substance use, he/she has used financial and personal resources in a more prudent, self-sustaining manner. 10. Medical Warnings (8) A. The client acknowledged that a physician has warned him/her about the negative consequences of substance abuse. B. The client has received specific warnings about the interactions of his/her psychotropic medications and illicit substances. C. The client is suffering from poor health due to his/her substance abuse, but this substan ce abuse continues in spite of significant negative consequences. D. The client's physical health has stabilized, and some of the negative consequences have begun to reverse as he/she has maintained a life free of mood-altering substances. E. The client' s psychiatric status has improved as his/her substance abuse has decreased due to the increased potency of his/her psychotropic medication and decreased negative interactions of illicit substances. 11. Increased Tolerance (9) A. The client described a pa ttern of increasing tolerance for the mood-altering substance, as he/she needed to use more of it to obtain the desired effect. B. The client described the steady increase in the amount and frequency of the substance abuse as his/her tolerance for it has increased. 12. Physical Withdrawal (10) A. The client acknowledged that he/she has experienced physical withdrawal symptoms (e. g., shaking, seizures, nausea, headaches, sweating, insomnia) as he/she withdrew from the substance abuse. B. The client's phy sical symptoms of withdrawal have eased as he/she stabilized and maintained abstinence from the mood-altering substance. C. There is no further evidence of physical withdrawal symptoms associated with chemical dependence. 13. Relapse after Substantial So briety (11) A. The client has relapsed after having been free from substance abuse for several years. B. The client presented with low self-esteem and feelings of hopelessness and helplessness subsequent to reverting to substance abuse after a substantia l period of sobriety. C. The client is confident that he/she can return to clean and sober living after having relapsed briefly following a period of substantial sobriety.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

62 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER INTERVENTIONS IMPLEM ENTED 1. Remove Substances (1) * A. After obtaining permission from the client, illicit substances were removed from his/her immediate access and disposed of. B. The client was assisted with disposing of his/her available illicit mood-altering substances. C. The client refused to dispose of or give permission for r emoval of his/her illicit mood-altering substance despite being urged to do so. 2. Refer to an Emergency Room (2) A. The client was referred to an emergency room for immediate medical assessment and care relative to present substance use and intoxication. B. Transportation to an emergency room was provided for the client for immediate medical assessment and care. C. The client required an ambulance to assist him/her in obtaining emergency medical care. D. The client declined to submit to emergency medi cal care or assessment relative to his/her present substance use and intoxication. 3. Assess Intoxication (3) A. The client's current level of intoxication was assessed by subjective means (e. g., reviewing his/her behavior or speech). B. Based on subjec tive means, the client is identified as being significantly intoxicated. C. The client's level of intoxication was reviewed through objective means, such as a Breathalyzer or blood test. D. Based on objective assessment, the client meets the legal standa rd for intoxication. E. Based on the results of both a subjective and objective evaluation, the client is not intoxicated. 4. Refer to Detoxification (4) A. The client was referred to an acute detoxification unit within a substance abuse treatment progr am. B. The client was referred to a hospital-based acute detoxification unit. C. The client was supported as he/she willingly admitted himself/herself to an acute detoxification unit. D. The client declined to admit himself/herself to an acute detoxific ation unit, despite being urged to do so. * The numbers in parentheses correlate to th e 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

CHEMICAL DEPENDENCE 63 5. Assess Suicide Risk (5) A. The client was asked to describe the frequency and intensity of his/her suicidal ideation, the details of any suicide plan, the history of any previous suicide attempts, and any fami ly history of depression or suicide. B. The client was asked to promise to be forthright regarding the current and future strength of his/her suicidal feelings and the ability to control such suicidal urges. C. The client was monitored on an ongoing basi s for his/her suicide potential. D. The client denied any pattern of suicidal ideation and was assessed to be not at risk for harming himself/herself. 6. Refer to Medical Staff for Immediate Physical Needs (6) A. An immediate physical examination was ar ranged for the client, and the medical staff was encouraged to identify rehabilitation programs to aid the client in recovering from chemical dependence. B. Medical staff examined the client, and specific negative medical effects of chemical dependence were identified. C. The medical staff has identified specific recommendations to help remediate the immediate effects of the client's chemical dependence. D. The physician has not identified any physical effects related to the client's chemical dependence. E. Specific chemical dependence remediation behaviors were reviewed with the client. 7. Encourage Healthy Nutrition (7) A. The client was encouraged to maintain healthy nutritional practices. B. Education was provided to the client regarding his/her n utrition needs. C. The client was provided with positive feedback regarding his/her pattern of healthy nutrition. D. The client has not been maintaining healthy nutritional practices and was urged to modify this pattern. 8. Refer to a Dietician or Nutri tionist (8) A. The client was referred to a dietician for an assessment regarding basic nutritional knowledge and skills, usual diet, and nutritional deficiencies. B. The client has met with the dietician, and the results of his/her assessment were revie wed. C. The client displayed an understanding of his/her nutritional functioning as the assessment was reviewed. D. The client displayed a lack of understanding about the information contained in the nutritional assessment and was provided with additiona l feedback in this area. E. The client has not followed through on his/her referral to a dietician and was redirected to do so. 9. Identify Residential Needs (9) A. The client was assisted in identifying his/her residential needs that will be most condu cive to his/her sobriety and mental health stabilization.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

64 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was provided with feedback as he/she described aspects of his/her current residential needs. C. The client identified that he/she needs a place to live that will be supportive of his /her abstinence from substance abuse and was praised for his/her understanding. D. The client was referred to a local crisis residential program. E. The client was accompanied to a local crisis housing program and advocated for regarding his/her need to be admitted to the program. F. The client has been admitted to a crisis housing setting. G. The client refused any involvement in the crisis housing and was redirected to the benefits of this type of service. 10. Facilitate an Agreement with the Landlor d or Home Provider (1 0) A. An agreement was facilitated between the client and the landlord or home provider regarding expectations for the client to remain in that residential setting. B. The client's pattern of symptoms and behaviors related to his/her psychiatric status and substance abuse were reviewed and incorporated into the agreement with the landlord or home provider. C. The client's landlord or home provider was supported for demonstrating an understanding of the client's specific needs within the residential setting. D. The client continues to be at risk for removal from his/her current residential situation due to his/her exacerbated psychiatric symptoms and substance abuse. 11. Explore Victimization ( 11) A. The client was asked about any re cent history of having experienced sexual, physical, or other types of victimization. B. The client identified recent experiences of victimization, and this was reviewed within the session. C. The client was provided with empathetic support regarding his /her reports of victimization. D. The client denied any recent experience of sexual, physical, or other types of victimization. 12. Contact Adult Protective Services (12) A. The local adult protective services agency was contacted regarding abuse that h as been occurring to client. B. Advocacy was provided on behalf of the client regarding the need for intervention by the adult protective services unit due to the client being abused. C. Adult protective services staff has not followed up on possible abu se, and further advocacy was provided. 13. Provide Information to Legal Authorities (13) A. After obtaining a proper authorization to release confidential information, information regarding the client's mental illness and its effect on his/her behavior w as provided to legal authorities.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

CHEMICAL DEPENDENCE 65 B. Legal authorities were provided with feedback regarding the impact of the client's mental illness on his/her behavior, and this assisted in the appropriate adjudication of his/her legal concerns. C. Legal authorities appear to be disinterested in the client's mental illness issues, and further advocacy was provided in this area. D. The client refused to provide an authorization to release information, so no information was provided to the police/prosecutor. 14. Urge Personal Responsibility (1 4) A. The client was urged to accept personal responsibility for his/her substance abuse and the consequences of his/her erratic behavior. B. As the client accepted his/her responsibility for his/her substance abuse and erratic behavior, he/she was provided with positive feedback. C. The client tends to minimize and deny his/her substance abuse and consequent erratic behavior and was given additional feedback in this area. 15. Facilitate Involvement with Legal Needs (15) A. The client was encouraged to attend legal appointments, court dates, and other legal needs. B. Transportation to the client's legal appointments, court dates, and other legal needs was provided. C. The client was accompanied to his/her legal appointments. D. Despite providing support to help the client keep his/her legal appointments and court dates, he/she continues to be sporadic in his/her attendance. 16. Coordinate Support System Confrontation (16) A. Family members, friends, and colleagues were coord inated to confront the client about the negative effects that his/her substance abuse has had on their lives and on their relationships with him/her. B. The client's friends and family were supported in gathering to confront the client about his/her subst ance abuse and the negative effects it has had on their relationships with the client. C. The client received positive feedback for his/her ability to accept the confrontation from his/her support system and described an increased determination to discont inue his/her substance use. D. The client reacted negatively to the confrontation from his/her support system and was urged to review their concerns. 17. Conduct Motivational Interviewing (17) A. Motivational Interviewing techniques were used to help as sess the client's preparation for change. B. The client 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 cli ent was assisted in strengthening his/her commitment to change. E. The client was noted to be participating actively in treatment.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

66 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 18. Gather Drug/Alcohol History (18) A. The client was asked to describe his/her substance abuse in terms of the amount a nd pattern of use, symptoms of abuse, and negative life consequences that have resulted from chemical dependence. B. The client was reinforced for openly discussing his/her substance abuse history and giving complete data regarding its nature and extent. C. The client was confronted for minimizing his/her substance abuse and not giving reliable data regarding the nature and extent of his/her chemical dependence problem. 19. Gather Drug/Alcohol Abuse Information from Support Network (19) A. Family member s, peers, and other treatment staff were requested to provide additional information regarding the client's substance use history. B. Family members have not given reliable data regarding the nature and extent of the client's chemical dependence problems and were confronted on minimizing the client's substance abuse. 20. Administer Objective Test of Drug/Alcohol Abuse (20) A. The Alcohol Severity Index was administered to the client. B. The Michigan Alcohol Screening Test (MAST) was administered to the client. C. The results of the objective test of drug/alcohol abuse, which indicated a significant substance abuse problem, were processed with the client. D. The results of the objective test of drug/alcohol abuse indicated that the client's problem with chemical dependence is relatively minor, and this was shared with the client. 21. Refer to a Physician (21) A. The client was referred to a physician/psychiatrist who is familiar with both mental illness and chemical dependence issues for an evaluation f or 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 p sychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medication and was redirected to cooperate with this referral. 22. Monitor Medications (22) 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. Concer ns 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.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf

CHEMICAL DEPENDENCE 67 23. List Reasons Why Substance Abuse Is Attrac tive (2 3) A. Today's clinical contact focused on developing a list of reasons why the client finds substance abuse attractive. B. The client was assisted in identifying specific reasons why he/she finds substance abuse to be attractive (e. g., self-medica tion of mental illness symptoms, novelty seeking, euphoria). C. The client's list of reasons why substance abuse is attractive was processed with the clinician. D. The client has not developed a list of why substance abuse is attractive for him/her and w as redirected to do so. 24. List Negative Impact of Substance Abuse (24) A. The client was asked to list all of the negative consequences that have resulted from his/her substance abuse. B. The client's list of the ways substance abuse has had a negativ e impact was processed, and each negative impact was reinforced with him/her. C. The client's list of the negative impact of his/her substance abuse was processed, and the shortness of the list was confronted as denial on his/her part. D. The client has not completed his/her list of the negative impact of his/her substance abuse and was redirected to do so. 25. Assign First Step Paper (25) A. The client was assigned to complete an Alcoholics Anonymous First Step paper and to share it with a group and the therapist. B. The client has completed a First Step paper; it was reviewed and noted to reflect that chemical dependence has dominated and controlled his/her life. C. The client has failed to complete a First Step paper and was redirected to do so. 26. Reinforce Breakdown of Denial (26) A. The client was reinforced for any statement that reflected acceptance of his/her chemical dependence and acknowledgment of the destructive consequences that it has had on his/her life. B. The client was noted to have decreased his/her level of denial as evidenced by fewer statements that minimize the amount of his/her alcohol/drug abuse and its negative impact on his/her life. 27. Require More Learning about Chemical Dependence (27) A. The client was required to lear n more about chemical dependence and the recovery process. B. The client was asked to attend didactic lectures, read, or view films related to chemical dependence and the process of recovery. C. The client was asked to identify in writing several key poi nts attained from his/her media about chemical dependence. D. Key points from the media that were noted by the client were processed in individual sessions. E. The client has become more open in acknowledging and accepting his/her chemical dependence; th is openness was noted and reinforced.

Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf