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282 THE SEVERE AND PERSISTEN T MENTAL ILLNESS PRO GRESS NOTES PLANNER B. The client was assisted in identifying recreational areas in which he/she has had little experience due to severe and persistent mental illness. C. The client receiv ed positive feedback as he/she identified areas in which he/she has experienced limited involvement. D. The client has failed to identify recreation areas in which he/she has had little experience and was redirected to review this area. 6. Refer to a Phy sician (6) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic me dications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 7. Educa te about Psychotropic Medications ( 7) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indicat ions 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 with additional information and feedback regarding his/her medicat ions. 8. Monitor Medications ( 8) 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 possible side eff ects related to the client's medications were reviewed with the client. D. The client was monitored for the effectiveness and side effects of his/her prescribed medications. E. Concerns about the client's medication effectiveness and side effects were co mmunicated to the physician. F. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 9. Acknowledge/Consult about Medication Effects ( 9) A. The manner in which the side effects of the medications may i nhibit the client's involvement in some recreational activities was acknowledged. B. The client endorsed examples in which his/her medications have inhibited his/her involvement in recreational activities (e. g., slowed reaction time, decreased motor dexte rity), and this was processed. C. The client's physician was consulted regarding the possible change in the client's medication regimen to decrease side effects that inhibit involvement in recreational activities. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
RECREATIONAL DEFICIT S 283 D. The client's medications have been ad justed in order to increase his/her involvement in recreational activities. E. The client's medications have not been able to be adjusted in order to increase his/her involvement in recreational activities. 10. Refer to an Activity Therapist (1 0) A. The client was referred to an activity therapist for recommendations regarding current interests and abilities relative to recreational activities that are available in the community. B. The results of the activity therapist's review of the client's interest s and aptitudes were examined with him/her. C. The client was referred to community activities and other recreational programs. D. The client was reinforced for actively participating in community programs. E. The client has declined involvement in comm unity programs and was urged to consider this as he/she is able. 11. Contract for Interest Development (1 1) A. An agreement was made with the client to have him/her pursue a short-term involvement with a variety of activities. B. Emphasis was placed on the need for the client to explore several different activity areas to develop interests. C. The client was supported for committing to involvement in a variety of short-term activities in order to develop recreational interests. D. The client has declin ed involvement in short-term recreational activities and was redirected in this area. 12. Develop a Schedule (1 2) A. An activity schedule for the client was developed that samples a broad range of types of activities, settings, length of time, level of i nvolvement, cultural needs, and social contact. B. The client was provided with positive feedback regarding his/her participation in the schedule of activities. C. The client has not complied with his/her schedule of activities to help sample a broad ran ge of activities and was redirected to do so. 13. Review a Sample of Activities (1 3) A. The client's involvement in a sample of activities was reviewed on a regular basis. B. The client provided feedback about his/her involvement in activities, and this was processed. C. The client was requested to identify his/her preferences regarding the activities that he/she has experienced. D. The client has identified specific preferences, and these were accepted and processed. E. The client has not used the sa mpling of activities and was redirected to do so. 14. Explore Social Reactions (1 4) A. The client's reactions to difficult social situations in the past were explored. B. The client was assisted in identifying specific emotions regarding his/her previou s difficult social experiences. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
284 THE SEVERE AND PERSISTEN T MENTAL ILLNESS PRO GRESS NOTES PLANNER C. The client has identified difficult social experiences and the emotions that he/she has experienced relative to these social problems, and these experiences were processed. D. The client found it difficult to identify p roblematic social experiences and the emotions relative to these experiences and was provided with support and encouragement in this area. 15. Acknowledge Emotions ( 15) A. The emotions that the client may be experiencing, including fear, embarrassment, a nd uncertainty, were acknowledged. B. The effect of the client's emotions on limiting his/her willingness to be involved in new activities was acknowledged. C. As the client has worked through his/her emotions, he/she is more interested in recreational activities, and this was processed. D. The client tends to deny any feelings related to his/her involvement in activities and was provided with feedback in this area. 16. Request an Inventory of Community Activities ( 16) A. The client was requested to de velop an inventory of activities that are available in the community. B. The client was directed to review information from the local newspaper, telephone book, or magazines. C. The client was reinforced for developing an inventory of activities that are available in the community. D. The client has not developed his/her inventory of activities available in the community and was redirected to do so. 17. Obtain Additional Resources Regarding Available Activities (17) A. Additional resources were obtaine d for the client's review regarding the recreational activities that are available in the community (e. g., brochures from a local tourism board, current events calendar). B. Additional resources regarding recreational activities were reviewed with the cli ent. C. The client has identified additional interests, and these were processed. 18. Develop Income Sources ( 18) A. The client was assisted in obtaining, completing, and filing forms for Social Security Disability benefits or other public aid. B. The client was assisted in identifying ways to increase income through obtaining employment. C. The client has obtained regular income, and he/she is now able to afford the use of resources within the community and was provided with positive feedback for this progress. D. The client has not developed any regular sources of income and was redirected to do so. 19. Access Available Funding or Sponsors ( 19) A. The client was assisted in seeking access to funds that are available for assisting people with disabi lities in their recreational pursuits. B. The benefits of the use of funds for recreational activities were reviewed. C. Community recreational businesses were contacted to sponsor the client's involvement in recreational activities (e. g., free tickets o r supplies). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
RECREATIONAL DEFICIT S 285 D. The client has increased his/her involvement in recreational activities through the use of materials or other support from recreational businesses in the community, and the benefits of this were processed. E. The client has not accessed f unds from the agency or from sponsors/community organizations for assisting people with disabilities and was redirected to do so. F. The client has not used available resources from recreational businesses in the community and was redirected to do so. 20. Coordinate Ride Sharing and Public Transportation (2 0) A. Transportation to recreational events was coordinated through ride sharing with other clients or community members. B. The client was reinforced for increasing his/her involvement in recreationa l events through the use of ride sharing and public transportation. C. The client was assisted in identifying community-based transportation resources for his/her use in getting to recreational activities. D. The client was assisted in scheduling communi ty-based transportation resources for his/her use in recreational activities. E. The client has not taken advantage of ride sharing with other clients or community members or the use of public transportation in order to attend recreational events and was redirected to do so. 21. Refer to an Activity Therapist (2 1) A. The client was referred to an activity therapist for recommendations regarding basic skills necessary for involvement in recreational activities. B. The client was taught specific skills u seful in leisure or recreational activities (e. g., how to bowl or play bridge). C. The client was reinforced for displaying increased knowledge and ability in leisure and recreational activities. D. The client has declined to learn more or be involved in community recreational activities and was redirected to do so. 22. Increase Socialization Online (2 2) A. The client was provided with access to online services in order to increase his/her social contact in a safer setting. B. The client has identified an increased comfort level regarding social contact through his/her online social involvement, and this was processed. C. The client appears to be less social since accessing online services and was redirected in this area. D. The client has not used on line services as a way to increase social contact in a safer setting and was redirected in this area. 23. Incorporate Meals as a Training Incentive ( 23) A. During recreational skills training, cooking and meal preparation were incorporated as an added in centive for the completion of each training session. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
286 THE SEVERE AND PERSISTEN T MENTAL ILLNESS PRO GRESS NOTES PLANNER B. The client was supported for being more regular in his/her completion of training sessions through the use of cooking and meal preparation as an added incentive, and the benefits of this were reviewe d with him/her. C. The client has not been regularly involved in recreational skills training, despite added incentives, and was redirected to increase his/her involvement. 24. Refer to a Support Group ( 24) A. The client was referred to a support group for individuals with severe and persistent mental illness. B. The client has attended the support group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. C. The client reported that he/she ha s not experienced any positive benefit from the use of a support group, but was encouraged to continue to attend. D. The client has not used the support group for individuals with severe and persistent mental illness, and was redirected to do so. 25. Refer for Individual Therapy ( 25) A. The client was referred for individual therapy to a therapist who specializes in the treatment of the severely and persistently mentally ill and social skill development. B. The client was referred to a therapist who spe cializes in the treatment of the severely and persistently mentally ill for group therapy focused on social skill development. C. The client has followed up on the referral to therapy to develop social skills, and this treatment was reviewed. D. The clie nt has not followed up on the referral to therapy to develop social skills and was encouraged to make this contact. 26. Teach/Practice Social Skills ( 26) A. Role-playing, behavioral rehearsal, and role reversal techniques were used to help the client understand the use of social skills. B. Social skills were modeled to the client (e. g., assertiveness, clear communication, handling anger). C. The client was encouraged to use the modeled social skills on a regular basis. D. The client was provided with f eedback regarding his/her use of social skills. E. The client has not regularly used the social skills on which he/she has been educated and was provided with remedial information in this area. 27. Train Caregivers/Staff Members on Incidental Learning ( 27) A. The caregivers/staff members for the client were trained in the use of incidental learning techniques (e. g., teaching the client social and recreational skills during the course of everyday activities). B. The caregivers/staff members have regularl y used incidental learning techniques to assist the client in learning social and recreational skills, and the benefits of this teaching were reviewed with the caregivers/staff members and the client. C. The client's increased functioning regarding social and recreational skills was processed. D. The ongoing use of the incidental learning techniques by the caregivers/staff members was monitored to avoid “program drift. ” | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
RECREATIONAL DEFICIT S 287 E. Positive feedback was provided to the caregivers/staff members regarding their reg ular continued use of incidental learning techniques. F. The caregivers/staff members have not used the incidental learning techniques and were redirected to do so. 28. List Interesting Activities ( 28) A. The client was provided with a list of recreatio nal activities in which he/she has indicated some interest. B. The client was urged to use his/her list of interesting recreational activities to initiate activity during free times. C. The client received positive feedback regarding his/her use of his/h er list of recreational activities. D. The client has not used his/her list of recreational activities in order to initiate activity during his/her free time and was redirected to do so. 29. Chart Involvement in Activities ( 29) A. A chart was provided t o the client and his/her caretakers to monitor and track his/her involvement in various recreational activities. B. The chart of the client's involvement in recreational activities was reviewed. C. The chart of the client's involvement in recreational ac tivities indicated an increased pattern of involvement, and this was reflected to the client. D. The client was verbally reinforced for his/her involvement in recreational activities. E. The client was reinforced for identifying the positive effects of h is/her increased involvement in recreational activities. F. The chart of the client's involvement in recreational activities has indicated a limited amount of involvement in recreational activities, and this was reflected to him/her. G. The client denied any positive effect of his/her involvement in recreational activities, and contrary evidence was presented to him/her. 30. Shadow at Recreational Activities ( 30) A. As the client attended his/her chosen recreational activities, he/she was shadowed in or der to provide support and direction. B. To decrease stigma and increase independent functioning, the client was allowed to determine how closely the clinician was involved as the client was shadowed at his/her selected activity. C. As a result of the su pport and encouragement provided by the shadowing clinician, the client has been able to increase his/her involvement and comfort level at his/her chosen activities. D. The client declined to have the clinician shadow him/her at the chosen activities, and he/she was accepted for this position. 31. Solicit Volunteers to Accompany the Client ( 31) A. Volunteers were solicited from the client's family and peers to attend recreational activities with him/her. B. The family members and peers have volunteered to attend recreational activities with the client, and he/she described an increased comfort level. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
288 THE SEVERE AND PERSISTEN T MENTAL ILLNESS PRO GRESS NOTES PLANNER C. The client continues to feel uncomfortable, despite the use of family members and peers to accompany the client to recreational activities, and was prov ided with additional support in this area. 32. Refer for a Complete Physical ( 32) A. The client was referred to a physician for a complete physical examination to determine his/her ability to participate in physical activities. B. The client has complet ed the physical examination, and the physician has identified that he/she is able to participate in physical activities. C. The client has completed the physical examination, and specific limitations were identified regarding his/her ability to participat e in physical activities, and these were reviewed with him/her. D. The client has not submitted himself/herself for the physical examination and was redirected to do so. 33. Coordinate Exercising with Others ( 33) A. The client's physical exercise involv ement with others who have similar interests was coordinated. B. The client was assisted in locating and attending physical exercise with other individuals with severe and persistent mental illness. C. The client was assisted in locating and attending ph ysical exercise with the nondisabled population. D. The client was reinforced for increasing his/her physical exercise involvement with others. E. The client does not take advantage of physical exercise involvement with others and was redirected in this area. 34. Advise Nondisabled Peers on Coping with Mental Illness (34) A. An appropriate authorization to release confidential information was obtained in order to meet with the client's nondisabled peers. B. The client's nondisabled peers were provided with information about how best to cope with their friend's severe and persistent mental illness symptoms. C. The client's involvement in social relationships has increased as his/her nondisabled peers have developed better coping skills for his/her sever e and persistent mental illness symptoms. 35. Review Social Experiences Regularly (35) A. The client's successes and difficulties in social settings were reviewed. B. The client identified a variety of successes and difficulties in social settings and w as provided with support and feedback in this area. C. A specific time to reassess these concerns was identified with the client. 36. Teach Relaxation Techniques ( 36) A. The client was taught deep muscle relaxation and deep breathing techniques as ways to reduce muscle tension when feelings of stress are experienced. B. The Relaxation and Stress Reduction Workbook (Davis, Eshelman, and Mc Kay) was used to provide the client with examples of techniques to help himself/herself relax. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
RECREATIONAL DEFICIT S 289 C. The client was rei nforced for implementing the relaxation techniques and reporting decreased reactivity when experiencing stress. D. The client has not implemented the relaxation techniques presented to him/her and continues to feel quite stressed; use of relaxation proced ures was again encouraged. 37. Coordinate Respite Services (37) A. Access to funds was coordinated in order to obtain respite services. B. Respite services were coordinated for the client in order to provide short-term periods of relief from parenting i n order to engage in recreational activities. C. The client was encouraged to use respite funds and services in order to spend quality time alone with each child in their identified recreational pursuits. D. The client was encouraged for his/her use of r espite services in order to be involved in recreational activities and improve the overall relationship with the child. E. The client has not used the respite services and was encouraged to do so. 38. Incorporate Recreation in Other Programming (38) A. A recreational component was incorporated into the client's day program. B. A recreational component was incorporated into the client's supported employment program. C. A recreational component was incorporated into other programming for the client. D. The client was reinforced for increasing his/her recreational involvement through incorporating this into other types of programming. E. The client continues to struggle with his/her recreational involvement, despite the use of recreational activities in other types of programming. 39. Review Risks of Manipulation/Abuse ( 39) A. The possible situations in which an individual with severe and persistent mental illness might be manipulated or abused were reviewed. B. The client was provided with positive fe edback regarding his/her understanding of situations in which he/she might be manipulated or abused while participating in recreational activities. C. The client was reminded of the support system that he/she has and is able to use if uncertain about the treatment from others. D. The client was supported for contacting members of his/her support system that can help keep him/her from being manipulated or abused. E. The client continues to be at risk for being manipulated or abused, despite support, and f urther remediation of these concerns was implemented. 40. Emphasize Nonsubstance-Oriented Activities (40) A. The need for developing social and recreational activities that are not related to the use of mood-altering substances was reviewed. B. The clie nt was assisted in developing recreational activities that are not related to the use of mood-altering substances. C. As a result of the client's increased involvement in recreational activities, his/her use of mood-altering substances has decreased, and he/she was provided with positive feedback in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
290 SELF-DETERMINATION DEFICI TS CLIENT PRESENTATION 1. Lack of Choices (1) * A. The client identified a lack of involvement in making the choices related to his/her daily life, school, residence, or vocation. B. Others often take away from the client the res ponsibility for making choices. C. As self-determination techniques have been used, the client has experienced an increase in his/her freedom to choose in his/her daily life, school, residence, or vocational situation. 2. Limited Decision-Making Experien ce (2) A. The client described that he/she has often not been allowed to make important decisions for himself/herself. B. The client has limited experience with using decision-making techniques. C. As self-determination techniques have been used, the cl ient has increased his/her experience in making decisions. D. As the client has made more of his/her own decisions, he/she reported increased satisfaction and function. 3. Poor Planning for Transitions (3) A. The client often fails to plan for his/her n ear or distant future. B. The client often experiences difficult transitions regarding relationships, residence, vocational, or financial concerns due to his/her pattern of poor planning. C. The client has often abdicated his/her responsibility for plann ing and expected others to complete this for him/her. D. As the client has become more focused on taking responsibility for his/her own future, his/her planning has increased. E. The client described better transitions in his/her relationships and financ ial, residential, or vocational situations due to his/her implementation of positive planning. 4. Decreased Responsibilities (4) A. The client described a pattern of decreased responsibility due to his/her mental illness. B. Others often take responsibi lity for the client's needs due to his/her mental illness. C. The client often fails to take responsibility for those areas in which he/she is capable due to his/her mental illness and others' tendency to take responsibility for him/her. D. As the client has taken responsibility for his/her own needs, others have decreased taking responsibility for him/her. * The numbers in parentheses correlate to the number of the Behavioral Defini tion 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 |
SELF-DETERMINATION DEFICI TS 291 5. Decreased Opportunities (4) A. The client described decreased opportunities due to his/her mental illness. B. The client has often been prohibit ed from age-appropriate activities or other opportunities due to his/her mental illness. C. As the client has taken responsibility for his/her own needs, he/she has been more assertive in obtaining opportunities appropriate to his/her age and station, in spite of his/her mental illness, and he/she has reported increased satisfaction. 6. Agencies Limiting Freedom of Choice (5) A. The client described involvement in agencies that have consistently dictated the options/services that are available. B. The c lient has often been denied the assistance he/she desires due to agencies dictating the options/services that are available. C. As the client has been more responsible for determining his/her own needs and services, his/her choice of services has expanded. D. The client reports increased satisfaction with the services that he/she selects. 7. Lack of Independent Living Skills (6) A. The client displayed limited knowledge and lack of skills necessary for living in an independent setting. B. The client ha s been dependent on others for basic needs, limiting his/her ability to obtain independent living skills. C. As the client has obtained skills for living independently, he/she has become more independent and has increased his/her level of functioning. 8. Vocational/Residential Failures (7) A. The client described a pattern of vocational placement failures due to a lack of appropriate decision-making skills and an inability to adjust to changing situations. B. The client described a pattern of residenti al placement failures due to a lack of appropriate decision-making skills and an inability to adjust to changing situations. C. The client has begun to use appropriate decision-making skills to assist him/her in adjusting to changing situations. D. As tr eatment has progressed, the client displayed increased success in vocational and residential placements. 9. Lack of Assertiveness (8) A. The client displayed a lack of assertiveness. B. The client described that he/she has decreased his/her assertivenes s due to his/her caregivers' pattern of overprotecting him/her. C. As the client takes more responsibility for his/her own needs, he/she has increased in assertiveness. 10. Poor Decision Making and Problem Solving (8) A. The client described a pattern o f poor decision making and poor problem solving. B. The client is often overprotected by his/her caregiver, resulting in limited opportunities to solve problems and make decisions. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
292 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNE R C. As the client has become more involved in determining and meeting his/ her own needs, he/she has had increased experience in problem solving and decision making. D. The client displays an increased ability regarding solving problems and making decisions. 11. Choice Limited by Treatment Agency Structure (9) A. The agency pr oviding treatment to the client has limited his/her choice of services. B. The agency providing treatment to the client has limited his/her choice regarding which provider provides services to him/her. C. Agency structure tends to limit the client's choi ces. D. As the client has been allowed to have greater choice regarding his/her services and providers, he/she has been more motivated in treatment. 12. Limited Knowledge Regarding Self-Determination (10) A. The client, family, caregivers, and clinical staff lack knowledge or training in the concepts of self-determination. B. As the client, family, caregivers, and clinical staff have gained knowledge in the concepts of self-determination, the client has been given more responsibility for his/her own nee ds and choices. C. As the client, family, caregivers, and clinical staff have used self-determination techniques, the client has experienced increased functioning. INTERVENTIONS IMPLEM ENTED 1. Assess Understanding of Self-Determination (1) * A. The clien t's understanding of the concept of self-determination or person-centered planning was assessed. B. The client displayed a partial understanding of the concept of self-determination and person-centered planning and was provided with additional information in this area. C. The client was reinforced for displaying a complete understanding of the concepts related to self-determination and person-centered planning. D. The client described very little understanding of the concepts of self-determination or per son-centered planning and was provided with remedial information in this area. 2. Identify Examples of Self-Determination (2) A. The client was assisted in identifying examples of self-determination in his/her own life, as well as in the lives of others. B. The client's caregivers were assisted in identifying examples of self-determination in their own lives, as well as in the lives of others. C. Personal examples of how the clinician experiences self-determination were provided. D. Additional informat ion was provided in areas in which the client and caregivers have limited knowledge or experiences regarding self-determination. * The numbers in parentheses correlate to the number of the Therapeutic In tervention 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 |
SELF-DETERMINATION DEFICI TS 293 3. Invite to Training (3) A. The client and his/her caregivers were invited to agency trainings on person-centered planning and self-determination. B. The client and his/her caregivers have attended agency training on person-centered planning and self-determination, and the key points of this training were processed. C. The client and his/her caregivers have not attended agenc y training on person-centered planning and self-determination and were redirected to do so. 4. Encourage Discussion (4) A. The client and his/her caregivers were encouraged to discuss the use of self-determination principles relative to his/her treatment, dreams, and desires. B. Caregivers have discussed self-determination principles with the client, and their expectations in this area were reviewed. C. The client and his/her caregivers have not discussed the use of self-determination principles and wer e redirected to do so. 5. Assess Strengths and Weaknesses Regarding Self-Determination (5) A. The client was assessed for his/her strengths and weaknesses in the area of self-determination. B. Specific areas (e. g., the client's autonomy, self-regulation, psychological empowerment, and self-realization) were identified as strengths or weaknesses. C. Based on the assessment of the client's strengths and weaknesses in self-determination, a plan to promote his/her involvement in his/her future goals with th e support of his/her family was developed. D. The findings of the client's self-determination assessment were shared with him/her and his/her caregivers. E. The client's strengths related to self-determination were emphasized. 6. Facilitate Agenda Devel opment ( 6) A. The client's development of an agenda for a person-centered planning meeting was facilitated. B. The client was provided with examples of goals that he/she might like to achieve, but emphasis was placed on his/her input regarding goal areas. C. As the client has been provided with support in developing his/her agenda for the person-centered planning meeting, he/she has become more directive, and this was processed with him/her. 7. Assist with Invitations (7) A. The client was assisted wit h inviting all of the individuals whom he/she would like to have present during the person-centered planning meeting. B. The client was provided with minimal direction related to the clinicians, family members, peers, advocates, friends, and others that h e/she chooses to invite to the person-centered planning meeting. C. The client was allowed to choose how the members of his/her person-centered planning meeting were invited and where the meeting is held. D. A review was conducted with the client of thos e people whom he/she would prefer not to have at his/her person-centered planning meeting. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
294 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNE R E. The procedures were developed that the client wishes to use if those whom he/she would prefer not to have at the meeting indicate an interest in coming. F. The implications of not inviting specific individuals were reviewed. 8. Request Facilitator Choice ( 8) A. The client was requested to choose a facilitator for his/her person-centered planning meeting. B. Emphasis was placed on the idea that the client's fac ilitator does not have to be a clinical person. C. The client's request for a certain facilitator was honored. 9. Identify Off-Limits Topics ( 9) A. The client was encouraged to identify any off-limits topics (e. g., topics that he/she does not wish to be brought up at the person-centered planning meeting). B. The client identified off-limits topics, and this was accepted. C. The client was prompted to identify a setting in which he/she would be willing to discuss the off-limits topics. D. The client wa s reinforced for his/her willingness to review the off-limits topics in an alternative setting. E. The client has not been willing to review the off-limits topics in an alternative setting and was redirected to make sure that he/she covers these important areas. 10. Review Current Issues (10) A. The client was assisted in articulating his/her current concerns related to relationships, preferences, dreams, hopes and fears, community choices, and issues related to home, career, and health. B. The client w as supported as he/she identified a variety of issues and concerns in many different areas of his/her life. C. The client has failed to address many areas in his/her life in preparation for the person-centered planning meeting and was redirected to review these areas. 11. Identify Barriers and Supports (11) A. The client was asked to identify barriers that interfere with his/her stated desires. B. The client was supported as he/she identified a variety of barriers that interfere with his/her stated desi res. C. The client was assisted in identifying supports that are needed to attain future goals and dreams. D. The client has struggled to identify barriers and/or supports and was provided with additional feedback in this area. 12. Identify Areas for Im provement (12) A. The client was requested to identify areas in which he/she would like to improve (e. g., living situation, work setting, relationships). B. The client was reinforced for identifying areas in which he/she would like to improve. C. The cl ient has not identified areas in which he/she would like to improve 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 |
SELF-DETERMINATION DEFICI TS 295 13. Conduct Person-Centered Planning Meeting (1 3) A. The person-centered planning meeting was held, led by the client's chosen facilitator. B. Participants in the person-centered planning meeting were requested to direct their comments to the client. C. When comments were directed to the clinician or the facilitator, he/she consistently redirected those comments to the client. D. Participants in the person-centered planning meeting were reinforced for consistently directing their comments to the client. E. Participants in the person-centered planning meeting were encouraged to focus on the client and his/her desires and needs. F. Participants in the person-centered planning meeting did not focus on the client and his/her stated desires and needs, and they were redirected to do so. 14. Ask Client's and Others' Opinion (14) A. The client was asked to answer first, then the rest of the participants were aske d, “Who is ___?” B. The client was asked to answer first, then the rest of the participants were asked, “What are ___'s strengths and problems?” C. The client was asked to answer first, then the rest of the participants were asked, “What supports, accom modations, or barriers exist?” D. The client was asked to answer first, then the rest of the participants were asked, “What shall we put in the action plan for goals/objectives?” 15. List, Prioritize, and Coordinate Goals (1 5) A. The client was assisted in making a list of his/her short-and long-term goals. B. The client was requested to identify his/her favorite three goals. C. Continuity was ensured between the client's short-and long-term goals. D. The client's goals were written in a behaviorall y observable and attainable manner. E. The client failed to identify and prioritize his/her goals and was provided with additional feedback in this area. 16. Develop Conditions to Realize Goals ( 16) A. The client was assisted in identifying and creating conditions that will facilitate the realization of his/her goals and desires. B. Creative solutions were identified for breaking the existing barriers to identified goals. C. As the client has identified and created conditions to facilitate the realizat ion of his/her goals, he/she has experienced increased functioning, and this was reviewed. D. The client continues to struggle to develop conditions that will help him/her to realize his/her goals and desires and was provided with additional feedback. 17. Explore Participation in Activities ( 17) A. The client's desire to participate in a wide range of possible activities was explored. B. The client was encouraged to participate in activities that promote community integration (e. g., social contacts, ind ependent living, volunteer or work placement, service groups, church or recreational involvement). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
296 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNE R C. The client was reinforced for participating in a wide range of possible activities, and developing self-determination skills. D. The client continues to be quite limited in his/her involvement in community activities and was provided with additional assistance in this area. 18. Arrange Brainstorming and Commitment to Goals ( 18) A. The significant people in the client's life were encouraged to brainstorm regarding creative options to expand his/her personal choices. B. The significant people in the client's life were asked to commit to assist him/her in attaining the identified goals. C. As a result of brainstorming, a variety of creative options was id entified and processed. D. As a result of the assistance given by the significant people in the client's life, he/she has increased his/her involvement in chosen activities. E. Very few creative options were identified for helping the client attain his/h er identified goals, and the significant people in his/her life were encouraged to think more creatively. 19. Assess the Potential for Adverse Choices ( 19) A. The client's potential for making adverse choices was assessed. B. The risk of the client's ch oices was determined by talking with the client, his/her family, and professionals, as well as by direct observation. C. Those choices that have a low potential for resulting in physical and/or mental harm were identified and processed with the client. D. Those choices that have a high potential for resulting in physical and/or mental harm were identified and processed with the client. 20. Weigh Risks against Rights (2 0) A. The risk-of-harm level regarding the client's choices was weighed against his/he r right to make his/her own choices. B. A variety of factors was used to help weigh risks versus rights (e. g., the likelihood of short- or long-term harm, physical or psychological harm, direct or indirect harm, and predictable or unpredictable harm to th e client or others). C. The weight of the risk of harm versus the client's right to make his/her own choices was used to determine the degree of freedom of choice that is best suited for the client. D. The client was urged to identify his/her desired lev el of freedom of choice when factoring in his/her risk of harm and right to make own choices. E. Total independence with unrestricted choice was identified as a healthy option for the client. F. Limited independence with restricted options available from which to choose was identified as the best level of freedom for the client. 21. Remind about Service Choice (2 1) A. The client was reminded that he/she has a choice about the services to be provided, who provides them, and where he/she receives these se rvices. B. The client's guardian was reminded about the choice of services provided, who provides these services, and where the client receives the services. C. The client's choice of services, service providers, and locations was processed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SELF-DETERMINATION DEFICI TS 297 D. The clie nt's guardian was provided with feedback regarding the client's choice of services, service providers, and locations. 22. Develop a Provider Network (2 2) A. A network of providers was developed from which the client can choose to identify from whom he/sh e would like to receive services. B. The client's guardian was provided with a list of providers from which to choose someone to provide service to the client. C. Specific providers have been identified, and additional feedback was given regarding the choices of providers. 23. Select Services within Financial Boundaries (2 3) A. The costs of all the services that are currently being provided to the client were identified. B. The client was provided with the cost of each individual service/provider that is available and appropriate for meeting his/her needs. C. The client or guardian was allowed to choose whatever services and providers they see fit within their financial resources. D. The client or guardian was provided with feedback regarding the choi ces of services and providers within the financial resource pool. 24. Focus on Customer Service (2 4) A. Service providers were focused on the need to provide customer service. B. An emphasis was placed on the concept that the client has a choice of prov iders available. C. Providers were encouraged to adopt a “We need them!” philosophy rather than “They need us. ” 25. Identify Decision-Making Experience ( 25) A. The client was assisted in identifying actual examples from his/her life when he/she has used decision-making skills. B. The specific situations in which the client has used decision-making skills (e. g., gathering information, weighing pros and cons, consulting with others) were reviewed with him/her. C. The client was unable to identify specifi c situations in which he/she has used decision-making skills and was provided with additional feedback in this area. 26. Teach Assertive Self-Advocacy ( 26) A. The client was taught techniques for assertive self-advocacy. B. The client was taught specifi c self-advocacy techniques from The Self-Advocacy Manual for Consumers by the Michigan Protection and Advocacy Service, Inc., or The Self-Advocacy Workbook by Gardner. C. The client was provided with self-advocacy and leadership practice opportunities (e. g., with counselors, personal care support personnel, and residential supervisors). 27. Teach about Passiveness, Assertiveness, and Aggressiveness ( 27) A. The client was taught about the difference between passive, assertive, and aggressive behaviors. B. Assertive, aggressive, and passive responses to the same situation were modeled to the client, and he/she was requested to identify the most effective style. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
298 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNE R C. The client was reinforced for identifying an assertive style for dealing with a problem situation. D. The client has not identified the most assertive manner in which to respond to situations and was provided with additional feedback in this area. 28. Teach Problem-Solving and Logging Skills ( 28) A. The client was taught problem-solving techni ques via didactics, role-playing, and modeling. B. Specific problem-solving techniques were taught to the client as found in Thinking It Through: Teaching a Problem-Solving Strategy for Community Living by Foxx and Bittle. C. The client was reinforced as he/she displayed significant skills related to problem-solving techniques. D. The client was encouraged to keep a journal of his/her conflicts and problem solutions. E. The client's problem-solving journal entries were reviewed with him/her. F. The cli ent displays poor problem-solving techniques and was provided with additional information in this area. G. The client has failed to keep a problem-solving journal and was redirected to do so. 29. Identify Preferences ( 29) A. The client's responses to va rious activities and situations were assessed in order to understand his/her preferences better. B. The client's approach, verbalizations, gestures, and affect were reviewed to best understand his/her preferences. C. The client was provided with feedback regarding his/her preferences based on his/her responses to various activities. 30. Provide Choice Opportunities (3 0) A. The client was provided with opportunities to choose in all areas in his/her life (e. g., leisure, shopping, mealtime, lifestyle, or employment). B. The client was supported as he/she has made more independent choices. C. The client has not made independent choices, despite attempts to provide these opportunities to him/her and was provided with additional direction in this area D. The importance of the client being able to express his/her own choices and preferences and to have them honored was stressed with the family, caregivers, and support staff. E. Family, caregivers, and support staff were reinforced as they endorsed the impor tance of the client being able to express his/her own choices and preferences and to have them honored. F. Family, caregivers, and support staff have not allowed the client to express his/her own choices and preferences and were redirected to do so. 31. Generalize Self-Determination Skills (3 1) A. The client was provided with learning opportunities for self-determination skills. B. The client was assisted in generalizing his/her self-determination skills by processing his/her self-determination learning opportunities to a range of other situations. C. As the client has learned self-determination skills, he/she was supported for generalizing them into other areas. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SELF-DETERMINATION DEFICI TS 299 D. The client has failed to generalize self-determination skills from one area to another and was provided with remedial information in this area. 32. Review Goal-Oriented Decisions (32) A. The client was assisted in reviewing his/her decisions and evaluating the compatibility of the decisions with the identified goals. B. The client was sup ported as he/she identified his/her behavior as being consistent with his/her identified goals. C. The client does not see his/her behavior as being consistent with his/her identified goals and was assisted in changing these behaviors as needed. 33. Deve lop Reinforcers ( 33) A. The reinforcers that the client desires were identified. B. The client was focused on establishing his/her reinforcers as an attainable contingent of the occurrence of his/her own predetermined target behavior. C. The client was reinforced for using positive reinforcers to increase the frequency of his/her target behaviors. D. The client has not maintained the use of positive reinforcers and was redirected in this area. 34. Teach Social Skills ( 34) A. The client was taught soci al skills through didactic presentations and role playing. B. Specific social skills (e. g., basic conversational skills, self-assertion, honesty, truthfulness, and how to handle negative comments) were reviewed and role-played. C. The client was reinforc ed as he/she displayed mastery of the social skills that have been taught. D. The client has failed to learn and implement the social skills and was provided with additional encouragement in this area. 35. Arrange Social Skills Practice ( 35) A. Arrangem ents were made for the client to use social skills that he/she has identified as desirable. B. The client's practice of social skills has improved his/her functioning, and this was reflected to him/her. C. The client was urged to take risks to participat e in social situations with people who have disabilities and with those who do not. D. The client was reinforced for his/her increased attempts at participating in social situations. E. The client tends to limit his/her social involvement with other peop le who have disabilities and was urged to expand this involvement to those who do not have a disability. F. The client has not practiced social skills and was redirected to do so. 36. Advise Nondisabled Peers on Coping with Mental Illness ( 36) A. An appr opriate authorization to release confidential information was obtained in order to meet with the client's nondisabled peers. B. The client's nondisabled peers were provided with information about how best to cope with their friend's severe and persistent mental illness symptoms. C. The client's nondisabled peers were reinforced for implementing better coping skills for the client's severe and persistent mental illness symptoms. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
300 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLANNE R 37. Teach about Community Resources ( 37) A. The client was provided with inf ormation about the availability and use of community resources. B. The client was taught skills necessary for accessing entertainment, services, and other resources within the community. C. As the client has increased his/her community access, he/she was reinforced for reporting a greater sense of self-determination. D. The client was reinforced for displaying an increased understanding of the availability and use of community resources. E. The client has not developed an increased understanding of the use of community resources and was provided with additional information in this area. 38. Assist in Obtaining Employment ( 38) A. The client was assisted in obtaining employment. B. The client was referred to a supported employment program. C. The clien t was assisted with preparation of a resume, job application, and other needs for obtaining employment. D. The client has not obtained employment and was provided with additional support in this area. 39. Prompt Support Network to Plan for Self-Determina tion ( 39) A. The client's caregivers were encouraged to identify a plan of supporting lifelong learning opportunities and experiences for him/her. B. The client's support network was assisted in identifying specific steps to promote his/her decision-maki ng, problem-solving, goal-setting, and goal-attainment skills. C. Caregivers were supported in their attempts to develop self-awareness and knowledge for the client within the home setting. D. The client's caregivers have not supported ongoing steps towa rd self-determination and were provided with redirection in this area. 40. Demonstrate Opportunities for Identifying Preferences (4 0) A. The many opportunities throughout the day that the client can use for exerting choices and preferences were demonstra ted to the family. B. Opportunities for the client to exert his/her personal preference (e. g., meal choices, scheduling for the day, clothing choices) were identified with the family. C. The client's support network was encouraged to foster independence by helping him/her only when needed. D. The client's family was reinforced for encouraging and supporting him/her to exert his/her choices and preferences while he/she maximizes his/her abilities and independence. E. The client's family has not allowed h im/her to exert his/her choices and preferences and was redirected to do so. 41. Emphasize Freedom ( 41) A. An emphasis was placed on the client's freedom to make choices (even harmful choices) as a freedom that most people value. B. The client's family and support network were encouraged to allow him/her to assume responsibility for his/her own actions and the natural consequences of these actions. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SELF-DETERMINATION DEFICI TS 301 C. The family was reinforced for allowing the client to take responsibility for his/her own actions and to experience the natural consequences. D. The client's family and support system have not allowed him/her to assume the responsibility for his/her actions, and this was reviewed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
302 SEXUALITY CONCERNS CLIENT PRESENTATION 1. Sexual Victimization (1) * A. The client recalled a history of being victimized in a sexual manner due to the vulnerability that is caused by his/her severe and persistent mental illness symptoms. B. The client r ecalled specific memories of being sexually victimized. C. The client has experienced a variety of secondary symptoms due to his/her sexual victimization. D. As the client has stabilized his/her severe and persistent mental illness symptoms, he/she is less vulnerable to sexual victimization. 2. Bizarre Sexual Thoughts (2) A. The client's hallucinations, delusions, and other severe and persistent mental illness symptoms have caused him/her to experience bizarre sexual thoughts. B. The client's hallucina tions and delusions contain strong sexual themes. C. The client's support system has become alienated due to his/her expression of bizarre sexual thoughts. D. As the client has become more stable in regard to his/her hallucinations and delusions, his/her bizarre sexual thoughts have decreased as well. 3. High Risk for STDs (3) A. The client has reported engaging in high-risk behavior for sexually transmitted diseases (STDs). B. The client appears to lack an understanding about sexual behavior that puts him/her at a higher risk for STDs. C. As the client has gained understanding about safer sexual behavior, his/her risk for STDs has decreased. 4. Impulsive Sexual Acting Out (4) A. The client reported a behavior pattern that reflected a lack of normal inhibition and an increase in sexual impulsivity, without regard for potentially painful consequences. B. The client's impulsivity has been reflected in sexual acting out. C. The client has gained more control over his/her impulses and has returned to a normal level of inhibition and sexual propriety. 5. Hypersexuality (4) A. The client described a pervasive pattern of promiscuity and an increased focus on sexual matters. * 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 |
SEXUALITY CONCERNS 303 B. The client has a pattern of seduction and sexualization of relationships. C. The client acknowledged that he/she has developed an unhealthy sexualization of relationships. D. The client has terminated his/her pattern of sexual promiscuity and seduction. 6. Sexual Dysfunction (5) A. The client described a consistently very low de sire for or pleasurable anticipation of sexual activity. B. The client has experienced a recurrent lack of the usual physiological response of sexual excitement and arousal. C. The client reported a persistent delay in or absence of orgasm after achievin g arousal, in spite of sensitive sexual pleasuring by a caring partner. D. The client's sexual dysfunction appears to be due to the side effects of long-term psychotropic medication use. E. The client's sexual dysfunction has been ameliorated, and he/she reports increased pleasure and enjoyment in sexual activity. 7. Medical Problems Due to STDs (6) A. The client has a medical condition related to an STD that requires a physician's care. B. The client reported that he/she has tested positive for the hu man immunodeficiency virus (HIV). C. The client's HIV status has resulted in the development of acquired immunodeficiency syndrome (AIDS). D. As the client has received medical treatment for his/her STD, he/she reports better health functioning. 8. Inad equate Prenatal Care (7) A. The client reported that she is pregnant. B. The client has received inadequate prenatal care due to her homelessness, confusion, or other effects of severe mental illness. C. As the client has stabilized her mental illness c ondition, she has accessed more appropriate prenatal care. 9. Conflicts in Romantic Relationships (8) A. The client described conflicts in his/her sexual or romantic relationships due to his/her bizarre behavior or other severe mental illness symptoms. B. The client described a pattern of multiple lost romantic relationships due to his/her severe mental illness symptoms. C. As the client has stabilized his/her bizarre behavior and other severe mental illness symptoms, his/her romantic relationship has i mproved as well. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
304 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER INTERVENTIONS IMPLEM ENTED 1. Explore Sexual History (1) * A. The client's history of sexual abuse and vulnerability to sexual victimization was explored. B. The client's pattern of sexual dysfunction and deviant sexual practices was ex plored. C. The client was supported during his/her open and honest description of his/her history of sexuality concerns. D. The client appeared to be rather defensive and withholding regarding his/her history regarding sexuality concerns and was urged to be more open in this area. 2. Inquire in a Tentative, Open Manner ( 2) A. Inquiries regarding the client's sexuality issues were presented to him/her in a tentative, open manner, due to the highly personal and sensitive nature of such issues. B. The cli ent was focused on the voluntary nature of working on sexuality issues and that he/she will have the power to control how quickly or intensely these issues are addressed. C. As the client has felt more in control over how intensely the sexuality issues ar e worked on, he/she has been more capable of addressing these issues, and this was reflected to him/her. D. The client was reinforced for openly discussing matters of a sexual nature. E. Despite inquiries into sexuality issues being presented in a tentat ive, open manner, the client was very cautious and withholding regarding these issues; he/she was urged to address these issues as he/she is able. 3. Identify History of Sexuality Concerns (3) A. The client was requested to provide specific information r egarding his/her history of sexual difficulties, dysfunction, or confusion. B. The client's specific information regarding his/her history of sexual difficulties, dysfunction, or confusion was reviewed. C. The client has not provided more specific inform ation regarding his/her sexuality concerns and was redirected to do so. 4. Obtain Additional Sources of Information (4) A. A written consent to release information was obtained in order to procure additional information about the client's sexuality conce rns from outside sources. B. Specific information was obtained from the client's spouse, partner, or other family members regarding the client's sexuality concerns. C. The additional information regarding sexuality issues obtained from the client's spous e, partner, or other family members was reviewed with the client. D. The client's choice not to have others provide information regarding his/her sexuality concerns was respected. * 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 |
SEXUALITY CONCERNS 305 5. Prepare a Time line of Sexual Involvement ( 5) A. A graphic time line display was used to help the client chart his/her sexual history. B. The client noted patterns of sexual behavior, sexual abuse history, and other sexual history concerns, which were graphically displayed on a time line. C. The client was provided with s upport as he/she developed a greater understanding of his/her pattern of sexuality concerns. D. The client failed to gain insight into his/her pattern of sexuality concerns and was redirected in this area. 6. Focus on Reality (6) A. The client was encou raged to check out his/her beliefs regarding others by verifying his/her conclusions with others directly. B. The client was encouraged to identify respected individuals with whom he/she can check the reality of his/her delusional or paranoid thoughts. C. The client is beginning to verbalize a sense of trust in significant others, and this was processed within the session. D. The client has followed through on checking out his/her distrustful beliefs and has found that others do not share them; he/she wa s assisted in reexamining and processing his/her unreasonable beliefs. E. The client has attempted to use reality testing but has become more agitated when his/her beliefs are not supported, so he/she was encouraged to temporarily suspend this type of sel f-analysis. 7. Define Sexual Abuse ( 7) A. The client was provided with a definition of sexual abuse. B. The definition of sexual abuse was compared with the client's experience, and this was processed. 8. Explore Sexual Abuse History ( 8) A. The client was encouraged to tell the entire story of the sexual abuse, giving as many details as he/she felt comfortable with providing. B. The client was supported and encouraged as he/she appeared overwhelmed with feelings of sadness and shame due to talking abo ut his/her childhood sexual abuse. C. The client was supported as he/she spoke of the childhood sexual abuse without becoming emotionally overwhelmed. 9. Review Common Effects of Sexual Abuse ( 9) A. Common emotional, self-esteem, and relationship effect s of sexual abuse were reviewed with the client. B. It was noted that the client displayed understanding of the effects of sexual abuse but did not identify with any of these concerns. C. The client was supported as he/she identified emotional, self-esteem, and relationship effects that he/she has experienced due to his/her sexual abuse. 10. Assign Reading Regarding Sexual Abuse (1 0) A. The client was assigned to read information to assist in processing his/her feelings related to the sexual abuse. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
306 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was assigned specific readings from The Courage to Heal: A Guide for Women Survivors of Sexual Abuse by Bass and Davis or Reach for the Rainbow: Advanced Healing for Survivors of Sexual Abuse by Finney. C. The client was directed to complete as signments from the Courage to Heal Workbook: for Men and Women Survivors of Sexual Abuse (Davis); his/her assignments were processed. D. The client has read the assigned material regarding sexual abuse healing, and his/her reaction to this information was processed. E. The client has not read the assigned material regarding the sexual abuse and was redirected to do so. 11. Refer for Psychotherapy (1 1) A. The client was referred for individual psychotherapy to a therapist who specializes in the treatment of sexuality issues and severe mental illness. B. The client has followed up on the referral for psychotherapy, and this treatment was reviewed. C. The client has not followed up on the referral to psychotherapy and was encouraged to make this contact. 12. Inquire/Report about Current Abuse (1 2) A. The client was asked whether he/she is currently experiencing any sexual assault or abuse. B. Specific situations and individuals were identified as possible current sexual assault or abuse risks and were p rocessed with the client. C. The client identified specific sexual abuse/victimization that is currently occurring for him/her, and immediate steps were taken to protect him/her. D. Current sexual victimization was reported to the police and/or adult pro tective services agency in accordance with agency guidelines and local legal requirements. E. Based on agency guidelines and local legal requirements, no report was necessary regarding current sexual victimization F. The client denied any specific risk f actors or specific situations for sexual assault or abuse but was urged to remain vigilant about such risks. G. The client was informed of the report made to the police and/or adult protective services agency. 13. Advocate for Supports to End Abuse (13) A. Advocacy was provided for the client in order to assist him/her with obtaining the needed support that will remove him/her from an abusive situation (e. g., domestic violence shelter, protection order). B. The client has obtained the needed support and has used it to change his/her situation to end the abuse. C. The client has not been able to obtain the needed support to remove himself/herself from an abusive situation and was provided with additional advocacy and direction. 14. Stabilize Financial/R esidential Needs (1 4) A. The client was assisted in meeting financial and residential needs in order to decrease the likelihood of having to be dependent on a sexually or physically abusive partner. B. As the client's financial and residential needs have been met, he/she has become more independent, and the benefits of this were reviewed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SEXUALITY CONCERNS 307 C. As the client has become more independent, he/she has been able to terminate involvement with the sexually or physically abusive partner, and he/she was supported fo r this. D. The client continues to experience unmet financial and residential needs, which has continued his/her dependence on a sexually or physically abusive partner, and he/she was provided with additional encouragement to end this pattern. 15. Educat e about Self-Defense ( 15) A. The client was taught self-defense strategies to make him/her less vulnerable to abuse. B. The client was provided with specific techniques for self-defense, as described in Self-Defense: Steps to Success by Nelson. C. The c lient was provided with positive feedback as he/she displayed increased understanding of self-defense strategies. D. The client has not learned self-defense strategies and was provided with additional encouragement to do so. 16. Review Sexually Inappropr iate Behavior ( 16) A. The client was provided with feedback about his/her sexually inappropriate behavior. B. The client was provided with feedback about the illegality of his/her sexually inappropriate behavior. C. The client was reinforced for termina ting his/her sexually inappropriate behavior. D. The client continues to display sexually inappropriate behavior and was confronted more directly about these concerns. E. The client was referred to group therapy for sexual offenders. F. The client's exp erience in the sexual offender treatment group was processed. G. The client has not attended the sexual offender treatment group and was redirected to do so. 17. Educate about Human Sexuality ( 17) A. The client was provided with educational materials on human sexuality. B. The client was referred to books on human sexuality: All about Sex: A Family Resource on Sex and Sexuality by Moglia and Knowles and Sexual Health: Questions You Have, Answers You Need by Reitano and Ebel. C. The client has reviewed the information on human sexuality, and this was processed with him/her. D. The client has not reviewed the information on human sexuality and was redirected to do so. 18. Refer to a Sex Education Group ( 18) A. The client was referred to a sex education group. B. The client was referred to a sex education group based on Positive Partnerships: A Sexuality Education Curriculum for Persons with Serious Mental Illness by Caldwell and Reynolds. C. The client has attended the sex education group, and the inf ormation learned was processed. D. The client has not attended the sex education group and was redirected to do so. 19. Refer to a Physician ( 19) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
308 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declin ed evaluation by a physician for a prescription of psychotropic medication and was redirected to cooperate with this referral. 20. Educate about and Monitor Psychotropic Medications (2 0) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The client 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 psychotropic medication regimen. E. The cl ient was provided with positive feedback about his/her regular use of psychotropic medications. F. The client was monitored for the effectiveness and side effects of his/her prescribed medications; 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. 21. Advocate for Medications that Reduce Extrapyramidal Side Effects (EPSs) ( 21) A. Advocacy was provided for the client to his/her prescribing physician regarding the use of medications that reduce the likelihood of extrapyramidal side effects (EPSs). B. The client's prescribing physician has agreed to adjust medications to reduce EPSs, and this was told to the client. C. The client's prescribing physician has indicated that the client's medications cannot be adjusted to further decrease the likelihood of EPSs, and this was told to him/her. 22. Assist in Increasing ADLs ( 22) A. The client was enc ouraged to increase performance on his/her activities of daily living (ADLs). B. The client was reinforced for his/her improvement in personal appearance as a result of his/her increased focus on ADLs. C. The client was supported as he/she reported an en hanced self-image as a result of his/her improved ADLs and personal appearance. D. The client has not improved his/her performance on ADLs and was encouraged to do so. 23. Refer to a Support Group ( 23) A. The client was referred to a support group for i ndividuals with severe and persistent mental illness. B. The client has attended the support group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SEXUALITY CONCERNS 309 C. The client reported that he/she has not experienced any positive benefit from the use of a support group but was encouraged to continue to attend. D. The client has not used the support group for individuals with severe and persistent mental illness and was redirected to do so. 24. Teach Soci al Skills ( 24) A. The client was taught social skills that could be applied to a range of intimate relationships. B. The client was reinforced for using social skills to improve his/her intimate relationships. C. The client has not used social skills to increase his/her involvement in intimate relationships and was redirected to do so. 25. Educate the Partner Regarding Mental Illness ( 25) A. The client's partner was educated about the client's mental illness. B. The client's partner was assisted in id entifying how the client's mental illness symptoms impact on their intimacy and their relationship. C. The client's partner was reinforced for demonstrating more understanding of the client's mental illness symptoms and the impact on their intimacy. D. The client's partner has difficulty understanding the client's mental illness symptoms and accepting the impact on their pattern of intimacy and was given additional feedback in this area. 26. Resolve Family Needs ( 26) A. The client's partner was assisted in resolving family needs that are not directly related to the client's mental illness symptoms. B. Tension levels within the client's relationship have decreased as family needs have been met. 27. Engage Partner in Treatment ( 27) A. The client's partn er was encouraged to take an active role in the client's treatment (e. g., attend treatment meetings, provide feedback to the clinicians, or manage medications) as allowed by the client/partner. B. The client's partner has been active in the client's treat ment, and the benefits of this were reviewed. C. The client's partner has not been active in the client's treatment, despite encouragement, and was encouraged to increase that role in his/her treatment. D. The client has not allowed his/her partner to be very active in his/her treatment and was asked to consider this resource. 28. Refer for Marital Therapy ( 28) A. The client and his/her partner were referred for couple's therapy related to ongoing conflicts between them. B. The client and his/her partn er were reinforced for using the marital therapy to help inoculate the relationship from future troubles. C. The client and his/her partner have attended marital therapy, found it to be productive, and were encouraged to continue. D. The client and his/h er partner have attended marital therapy, have not found it helpful, and this was problem solved. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
310 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client and his/her partner have not followed through on the referral for marital therapy and were redirected to do so. 29. Review Sexual Needs and Dy sfunction ( 29) A. The client's typical sexual needs that may have been neglected due to his/her mental illness symptoms were reviewed. B. The client was supported as he/she acknowledged his/her own typical sexual needs that he/she has neglected due to hi s/her mental illness symptoms. C. The client was supported as he/she acknowledged his/her partner's sexual needs that have been neglected due to his/her mental illness symptoms. D. The client denied any pattern of sexual needs that have been neglected du e to his/her mental illness symptoms and was provided with feedback in this area. E. The client was asked about sexual dysfunction symptoms. F. The client identified specific sexual dysfunction symptoms and was provided with information about how to addr ess these problems. G. The client denied any sexual dysfunction symptoms, and this was accepted. 30. Review Side Effects of Medications ( 30) A. The client was taught about the sexual side effects of prescribed medications so that he/she can make an inf ormed decision about whether to use them. B. The client's decision against using medications due to their sexual side effects was processed. C. The client is aware of the sexual side effects of the medications but was supported in his/her decision to use them despite these problems. D. As the client continues to have a poor understanding of side effects of his/her medications, he/she was provided with additional information. E. The client identified significant side effects, and these were reported to t he medical staff. F. Possible side effects of the client's medications were reviewed, but he/she denied experiencing any side effects. 31. Refer for a Physical Evaluation of Sexual Dysfunction ( 31) A. The client was referred to a physician for a complet e physical to rule out any organic basis for his/her sexual dysfunction. B. The client was reinforced for cooperating with the referral for a physical evaluation to rule out any organic basis for his/her sexual dysfunction. C. The client's physical did i dentify medical conditions or medications that may have a harmful effect on his/her sexual functioning, and this finding was processed. D. An evaluation by a physician found no organic basis for the client's sexual dysfunction, and this conclusion was pro cessed. E. The client was supported in following up on the recommendations from the medical evaluation. F. The client has been following up on the recommendations from the medical evaluation, and he/she was encouraged for this. G. The client has not reg ularly followed up on his/her medical 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 |
SEXUALITY CONCERNS 311 32. Review Sexual Dysfunction with a Physician (32) A. The client's sexual dysfunction concerns were reviewed with his/her prescribing physician. B. The physic ian was urged to consider the sexual dysfunction concerns in the choice for the client's medication regimen. C. The client's physician has modified the client's medication regimen to minimize the impact on sexual libido and sexual functioning, and the imp act of this was reviewed. D. The client's physician has indicated an unwillingness to further modify the client's medications to minimize the impact on sexual libido and sexual functioning, and this was told to him/her. 33. Monitor for Decompensation (33 ) A. The client was carefully assessed for decompensation. B. The client's sexual dysfunction was interpreted as a precursor or a signal for a potential decompensation crisis. C. The client needs further intervention as he/she appears to be decompensati ng. D. The client does not appear to be otherwise decompensating, and this was reflected to him/her. 34. Educate about STDs (34) A. The client was educated about STDs and how to avoid them. B. The client was referred to read Sexually Transmitted Diseas es: A Physician Tells You What You Need to Know by Marr. C. The client has reviewed the assigned material on STDs, and key points were processed. D. The client was supported for implementing safer sex practices. E. The client has not read the assigned m aterial on STDs and was redirected to do so. F. The client does not display an accurate understanding of STDs and how to avoid them and was provided with remedial feedback in this area. 35. Refer for or Provide Free Condoms ( 35) A. The client was provid ed with free condoms. B. The client was referred to an agency that provides free condoms. C. The client was taught about the proper and timely use of condoms to decrease his/her risk for STDs. D. The client was reinforced for reporting regular use of co ndoms to decrease his/her risk of STDs. E. The client has not regularly used condoms and was redirected to do so. 36. Refer for an STD Test and Treatment, If Needed ( 36) A. The client was referred to a public health facility or to a physician to be test ed for HIV/AIDS or other STDs. B. The client has complied with the request to be tested for STDs, and the negative outcome of this test was reflected to him/her. C. The client has complied with the request to be tested for STDs, has been found to have an STD, and the implications of this were discussed. D. The client was supported in making arrangements for following up on his/her treatment for STDs. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
312 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client's follow-up on the recommendations for his/her STD was reviewed. F. The client was reinfo rced for following up on the recommendations for treatment for STDs. G. The client has not complied with the request to be evaluated for STDs or treatment recommendations and was redirected to do so. 37. Refer to an HIV-Positive Support Group ( 37) A. The client has tested positive for HIV and was referred to an appropriate support group. B. The client has attended the support group for individuals who are HIV-positive, and the benefits of this support group were reviewed. C. The client reported that he /she has not experienced any positive benefit from the use of a support group but was encouraged to continue to attend. D. The client has not used the HIV-positive support group and was redirected to do so. 38. Review Motivations for Parenthood ( 38) A. The possible motivations for the client's interest in parenthood (e. g., a redefinition of his/her self-concept from “mentally ill individual” to “parent” or a greater desire to maintain his/her psychological health) were reviewed. B. The client's specific motivations for parenthood related to his/her mental illness were reviewed. C. The client denied any specific motivations related to parenthood and was redirected to review this area. 39. Focus on Parenthood Stressors ( 39) A. The client was focused on stressors that are related to parenthood (e. g., financial burdens, increased responsibilities) and how these may exacerbate his/her mental illness symptoms. B. The client displayed an adequate understanding of the stressors related to parenthood, and the effects of these stressors on his/her mental illness symptoms were processed. C. The client displayed a poor understanding of the stressors related to parenthood, or how these may exacerbate his/her mental illness symptoms, and was provided with additiona l feedback in this area. 40. Teach about Birth Control ( 40) A. The client was taught about the correct and effective use of condoms, birth control pills, and other contraceptives. B. The client was praised as he/she displayed an adequate understanding o f the use of contraceptives. C. The client was reinforced for his/her report of regularly using contraceptives. D. The client displayed a poor understanding of the use of contraceptives and was provided with remedial information in this area. 41. Refer for Long-Lasting Birth Control ( 41) A. The client was referred for birth control measures that are less likely to fail due to human error (i. e., Depo-Provera shots). B. The client was reinforced for following through on the procurement of longer-lasting birth control measures. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SEXUALITY CONCERNS 313 C. The client has declined to use longer-lasting birth control measures, and his/her decision was accepted. 42. Provide Options Regarding Pregnancy ( 42) A. The client was provided with information regarding options that are avail able for reacting to a pregnancy (e. g., abortion, release for adoption, keeping the baby). B. The client was assisted in processing the effects of each option available regarding reacting to the pregnancy. C. The client has made a specific decision about how to react to the pregnancy and was provided with support and/or feedback in this area. D. The client is vacillating regarding options for reacting to the pregnancy and was provided with additional feedback in this area. 43. Emphasize Discontinuing Su bstances Due to Pregnancy ( 43) A. The client was taught about the need for discontinuing alcohol or street drug use if it is possible that she is pregnant. B. The client was taught about the effects of alcohol and street drug use during a pregnancy. C. The client has been provided with positive feedback regarding her discontinuation of substances due to her possible pregnancy. D. The client was provided with additional assistance and support, as she has struggled to discontinue substances during the pre gnancy. E. The client was referred to a substance abuse treatment program to assist in discontinuing her substance use due to the pregnancy. F. The client's physician was immediately informed when the client suspected that she might be pregnant. G. The client's physician's recommendations regarding a possible pregnancy were reviewed with the client. 44. Identify Atypical Sexual Behaviors ( 44) A. The client was assisted in identifying atypical sexual behavior that is related to psychosis, mania, or othe r severe and persistent mental illness symptoms. B. The client's atypical sexual behavior related to mental illness symptoms was compared with his/her typical sexual behavior or sexual orientation. C. The client identified his/her pattern of atypical sex ual behavior related to mental illness symptoms. D. The client has developed a response plan that he/she would prefer to be implemented if his/her mental illness symptoms cause atypical sexual behavior. 45. Validate the Experience of Stigmatization/Discr imination ( 45) A. Inquiries were made regarding the client's experience of stigmatization or discrimination due to being mentally ill and gay/lesbian. B. The client's stigmatization and discrimination experience due to his/her sexual orientation was processed. C. The client denies any stigmatization or discrimination related to his/her sexual orientation, and this was accepted. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
314 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. It was acknowledged that family and societal issues regarding sexual orientation may cause increased stress. E. The effects of increased stress on the client's symptoms were reviewed. F. The client's worth was affirmed regardless of his/her sexual identity. 46. Refer to a Support Group for Sexual Orientation/Mental Illness Concerns ( 46) A. The client was referred to a suppo rt group for those who are struggling with sexual orientation issues and severe and persistent mental illness concerns. B. The client has attended the support group for individuals with sexual orientation issues and severe and persistent mental illness, a nd the benefits of this support group were reviewed. C. The client reported that he/she has not experienced any positive benefit from the use of a support group, but he/she was encouraged to continue to attend. D. The client has not used the support grou p for individuals with sexual orientation issues and severe and persistent mental illness and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
315 SOCIAL ANXIETY CLIENT PRESENTATION 1. Social Anxiety/Shyness (1) * A. The client described a pattern of social anxiety and shyness that presents itself in almost any interpersonal situation. B. The client's social anxiety presents itself whenever he/she has to interact with people whom he/she does not know or must interact in a group situation. C. The client's social anxiety has diminished, and he/she is more confident in social situations. D. The client has begun to overcome his/her shyness and can ini tiate social contact with some degree of comfort and confidence. E. The client reported that he/she no longer experiences feelings of social anxiety or shyness when having to interact with new people or group situations. 2. Disapproval/Hypersensitivity ( 2) A. The client described a pattern of hypersensitivity to the criticism or disapproval of others. B. The client's insecurity and lack of confidence has resulted in an extreme sensitivity to any hint of disapproval from others. C. The client has acknow ledged that his/her sensitivity to criticism or disapproval is extreme and has begun to take steps to overcome it. D. The client reported increased tolerance for incidents of criticism or disapproval. 3. Social Isolation (3) A. The client has no close f riends or confidants outside of first-degree relatives. B. The client's social anxiety has prevented him/her from building and maintaining a social network of friends and acquaintances. C. The client has begun to reach out socially and to respond favorab ly to the overtures of others. D. The client reported enjoying contact with friends and sharing personal information with them. 4. Social Avoidance (4) A. The client reported a pattern of avoiding situations that require a degree of interpersonal contac t. B. The client's social anxiety has caused him/her to avoid social situations within work, family, and neighborhood settings. C. The client has shown some willingness to interact socially as he/she has overcome some of the social anxiety that was forme rly present. D. The client indicated that he/she feels free now to interact socially and does not go out of his/her way to avoid such situations. * The numbers in parentheses co rrelate 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 |
316 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 5. Fear of Social Mistakes (5) A. The client reported resisting involvement in social situations because of a fear of saying or doing something foolish or embarrassing in front of others. B. The client has been reluctant to involve himself/herself in social situations because he/she is fearful of his/her social anxiety becoming apparent to others. C. The clie nt has become more confident of his/her social skills and has begun to interact with more comfort. D. The client reported being able to interact socially without showing signs of social anxiety that would embarrass him/her. 6. Performance Anxiety (6) A. The client reported experiencing debilitating performance anxiety when expected to participate in required social performance demands. B. The client described himself/herself as unable to function when expected to complete typical social performance dema nds. C. The client avoids required social performance demands. D. As treatment has progressed, the client has become more at ease with typical social performance demands. E. The client reports no struggles with performance anxiety. 7. Physiological Anx iety Symptoms (7) A. The client has an increased heart rate and experiences sweating, dry mouth, muscle tension, and shakiness in most social situations. B. As the client has learned new social skills and developed more confidence in himself/herself, the intensity and frequency of physiological anxiety symptoms has diminished. C. The client reported engaging in social activities without experiencing any physiological anxiety symptoms. INTERVENTIONS IMPLEM ENTED 1. Build Rapport (1) * A. Consistent eye co ntact, active listening, unconditional positive regard, and warm acceptance were used to build rapport with the client. B. The client began to express feelings more freely as rapport and trust levels increased. C. The client has continued to experience d ifficulty being open and direct in his/her expression of painful feelings; he/she was encouraged to be more open as he/she feels safer. 2. Assess Nature of Social Discomfort Symptoms (2) A. The client was asked about the frequency, intensity, duration, a nd history of his/her social discomfort symptoms, fear, and avoidance. * 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 |
SOCIAL ANXIETY 317 B. The Anxiety Disorder's Interview Schedule for DSM-IV (Di Nardo, Brown, and Barlow) was used to assess the client's social discomfort symptoms. C. The assessment of the client's soci al discomfort symptoms indicated that his/her symptoms are extreme and severely interfere with his/her life. D. The assessment of the client's social discomfort symptoms indicates that these symptoms are moderate and occasionally interfere with his/her da ily functioning. E. The results of the assessment of the client's social discomfort 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 social discomfort sym ptoms were reviewed with the client. 3. Explore Social Discomfort Stimulus Situations (3) A. The client was assisted in identifying specific stimulus situations that precipitate social discomfort symptoms. B. The client was assigned “Monitoring My Panic Attack Experiences” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client could not identify any specific stimulus situations that produce social discomfort; he/she was helped to identify that they occur unexpectedly and without any pattern. D. The client was helped to identify that his/her social discomfort symptoms occur when he/she is expected to perform basic social interaction expectations. 4. Administer Social Anxiety Assessment (4) A. The client was administered a measu re of social anxiety to further assess the depth and breadth of his/her social fears and avoidance. B. The client was administered The Social Interaction Anxiety Scale and/or Social Phobia Scale (Mattick and Clarke). C. The result of the assessment of so cial anxiety indicated a high level of social fears and avoidance; this was reflected to the client. D. The result of the assessment of social anxiety indicated a medium level of social fears and avoidance; this was reflected to the client. E. The result of the assessment of social anxiety indicated a low level of social fears and avoidance; this was reflected to the client. F. The client declined to participate in an assessment of social anxiety; the focus of treatment was turned to this resistance. 5. Differentiate Anxiety Symptoms (5) A. The client was assisted in differentiating anxiety symptoms that are a direct affect of his/her severe and persistent mental illness, as opposed to a separate diagnosis of an anxiety disorder. B. The client was pro vided with feedback regarding his/her differentiation of symptoms that are related to his/her severe and persistent mental illness, as opposed to a separate diagnosis. C. The client has identified a specific anxiety disorder, which is freestanding from hi s/her severe and persistent mental illness, and this was reviewed within the session. D. The client has been unsuccessful in identifying ways in which his/her anxiety symptoms are related to his/her mental illness or a separate anxiety disorder; remedial feedback was provided. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
318 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 6. Acknowledge Anxiety Related to Delusional Experiences (6) A. It was acknowledged that both real and delusional experiences could cause anxiety. B. The client was provided with support regarding his/her anxieties and worries, wh ich are related to both the real experiences and delusional experiences. C. The client described a decreased pattern of anxiety due to the support provided to him/her. 7. Identify Diagnostic Classification (7) A. The client was assisted in identifying a specific diagnostic classification for his/her anxiety symptoms. B. Utilizing a description of anxiety symptoms such as that found in Bourne's The Anxiety and Phobia Workbook, the client was taken through a detailed review of his/her anxiety symptoms, diagnosis, and treatment needs. C. The client has failed to clearly understand and classify his/her anxiety symptoms and was given additional feedback in this area. 8. Refer for Medication Evaluation (8) A. Arrangements were made for the client to have a physician evaluation for the purpose of considering psychotropic medication to alleviate social discomfort symptoms. B. The client has followed through with seeing a physician for an evaluation of any organic causes for the anxiety and the need for psycho tropic medication to control the anxiety response. C. The client has not cooperated with the referral to a physician for a medication evaluation and was encouraged to do so. 9. Monitor Medication Compliance (9) A. The client reported that he/she has tak en the prescribed medication consistently and that it has helped to control the anxiety; this was relayed to the prescribing clinician. B. The client reported that he/she has not take the prescribed medication consistently and was encouraged to do so. C. The client reported taking the prescribed medication and stated that he/she has not noted any beneficial effect from it; this was reflected to the prescribing clinician. D. The client was evaluated but was not prescribed any psychotropic medication by th e physician. 10. Refer to Group Therapy (10) A. The client was referred to a small (closed enrollment) group for social anxiety. B. The client was enrolled in a social anxiety group as defined in The Group Therapy Treatment Planner, 2nd ed. (Paleg and Jo ngsma). C. The client was enrolled in a social anxiety group as defined in Social Anxiety Disorder (Turk, Heimberg, and Hope) and Clinical Handbook of Psychological Disorders (Barlow). D. The client has participated in the group therapy for social anxiet y; his/her experience was reviewed and processed. E. The client has not been involved in group therapy for social anxiety concerns 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 |
SOCIAL ANXIETY 319 11. Discuss Cognitive Biases (11) A. A discussion was held regarding how social anxiety derive s from cognitive biases that overestimate negative evaluation by others, undervalue the self, increase distress, and often lead to unnecessary avoidance. B. The client was provided with examples of cognitive biases that support social anxiety symptoms. C. The client was reinforced as he/she identified his/her own cognitive biases. D. The client was unable to identify any cognitive biases that support his/her anxiety symptoms and was provided with tentative examples in this area. 12. Assign Information on Social Anxiety, Avoidance, and Treatment (12) A. The client was assigned to read information on social anxiety that explains the cycle of social anxiety and avoidance and provides a rationale for treatment. B. The client was assigned information about s ocial anxiety, avoidance, and treatment from Overcoming Shyness and Social Phobia (Rapee). C. The client was assigned information about social anxiety, avoidance, and treatment from Overcoming Social Anxiety and Shyness (Butler). D. The client has read t he information on social anxiety, avoidance, and treatment, and key concepts were reviewed. E. The client has not read the assigned material on social anxiety, avoidance, and treatment and was redirected to do so. 13. Discuss Cognitive Restructuring (13) A. A discussion was held about how cognitive restructuring and exposure serve as an arena to desensitize learned fear, build social skills and confidence, and reality test biased thoughts. B. The client was reinforced as he/she displayed a clear understa nding of the use of cognitive restructuring and exposure to desensitize learned fear, build social skills and confidence, and reality test biased thoughts. C. The client did not display a clear understanding of the use of cognitive restructuring and expos ure and was provided with remedial feedback in this area. 14. Assign Information on Cognitive Restructuring and Exposure (14) A. The client was assigned to read about how cognitive restructuring and exposure-based therapy could be beneficial. B. The clie nt was assigned to read excerpts from Managing Social Anxiety (Hope, Heimberg, Juster, and Turk). C. The client was assigned to read portions of Dying of Embarrassment (Markaway, Carmin, Pollard, and Flynn). D. The client has read the assigned informatio n on cognitive restructuring and exposure-based therapy techniques, and key points were reviewed. E. The client has not read the assigned information on cognitive restructuring and exposure-based therapy techniques, and he/she was redirected to do so. 15. Teach Anxiety Management Skills (15) A. The client was taught anxiety management skills. B. The client was taught about staying focused on behavioral goals and riding the wave of anxiety. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
320 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. Techniques for muscular relaxation and paced diaphragmatic br eathing were taught to the client. D. The client was reinforced for his/her clear understanding and use of anxiety management skills. E. The client has not used his/her new anxiety management skills and was redirected to do so. 16. Assign Calming and Cop ing Strategy Information (16) A. The client was assigned to read about calming and coping strategies in books or treatment manuals on social anxiety. B. The client was assigned to read portions of Overcoming Shyness and Social Phobia (Rapee). C. The cli ent has read the assigned information on calming and coping strategies, and key points were reviewed. D. The client has not read the information on calming and coping strategies, and he/she was redirected to do so. 17. Identify Distorted Thoughts (17) A. The client was assisted in identifying the distorted schemas and related automatic thoughts that mediate social 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. 18. Assign Reading on Cognitive Restructuring (18) A. The client was assigned to read information about cognitive restructuring in books or treatment manuals on socia l anxiety. B. The client was assigned to read excerpts from The Shyness and Social Anxiety Workbook (Antony and Swinson). C. The client has read the assigned information on cognitive restructuring, and key points were reviewed. D. The client has not rea d the assigned information on cognitive restructuring and was redirected to do so. 19. Assign Exercises on Self-Talk (19) 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 “Bad Thoughts Lead to Depressed Feelings” from the Adolescent Psychotherapy Handbook Planner, 2nd ed. (Jongsma, Peterson, and Mc Innis). C. The client was directed to do assignments from The Shyness and Social Anxiety Workbook (Antony and Swinson). D. The client was directed to complete assignments from Overcoming Shyness and Social Phobia (Rapee). E. The client's replacement of fearful self-talk with reality-based alternatives was critiqued. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SOCIAL ANXIETY 321 F. The client was reinforced for his /her successes at replacing fearful self-talk reality-based alternatives. G. The client was provided with corrective feedback for his/her failures to replace fearful self-talk with reality-based alternatives. H. The client has not completed his/her assig nment homework regarding fearful self-talk and was redirected to do so. 20. Construct Anxiety Stimuli Hierarchy (20) A. The client was assisted in constructing a hierarchy of anxiety-producing situations associated with his/her phobic fear. B. It was di fficult for the client to develop a hierarchy of stimulus situations, as the causes of his/her fear remain quite vague; he/she was assisted in completing the hierarchy. C. The client was successful at completing a focused hierarchy of specific stimulus si tuations that provoke anxiety in a gradually increasing manner; this hierarchy was reviewed. 21. Select Exposures That Are Likely to Succeed (21) A. Initial in vivo or role-played exposures were selected, with a bias toward those that have a high likeliho od of being a successful experience for the client. B. Cognitive restructuring was done within and after the exposure using behavioral strategies (e. g., modeling, rehearsal, social reinforcement). C. In vivo or role-played exposures were patterned after those in “Social Anxiety Disorder” by Turk, Heimberg, and Hope in the Clinical Handbook of Psychological Disorders (Barlow). D. A review was conducted with the client about his/her use of in vivo or role-played exposure. E. The client was provided with p ositive feedback regarding his/her use of exposures. F. The client has not used in vivo or role-played exposures and was redirected to do so. 22. Assign Reading on Exposure (22) A. The client was assigned to read about exposure in books or treatment manu als on social anxiety. B. The client was assigned to read excerpts from The Shyness and Social Anxiety Workbook (Antony and Swinson). C. The client was assigned portions of Overcoming Shyness and Social Phobia (Rapee). D. The client's information about exposure was reviewed and processed. E. The client has not read the information on exposure and was redirected to do so. 23. Assign Homework on Exposure (23) A. The client was assigned homework exercises to perform sensation exposure and record his/her experience. B. The client was assigned “Gradually Reducing Your Phobic Fear” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client was assigned sensation exposure homework from The Shyness and Social Anxiety Workbook (Antony and Swinson). D. The client was directed to complete assignments from Overcoming Shyness and Social Phobia (Rapee). E. The client's use of sensation exposure techniques was reviewed and reinforced. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
322 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER F. The client has struggled in his/her implementation of se nsation exposure techniques and was provided with corrective feedback. G. The client has not attempted to use the sensation exposure techniques and was redirected to do so. 24. Build Social and Communication Skills (24) A. Instruction, modeling, and rol e-playing were used to build the client's general social and communication skills. B. Techniques from Social Effectiveness Therapy (Turner, Beidel, and Cooley) were used to teach social and communication skills. C. Positive feedback was provided to the c lient for his/her use of increased use of social and communication skills. D. Despite the instruction, modeling, and role-playing about social and communication skills, the client continues to struggle with these techniques and was provided with additiona l feedback in this area. 25. Assign Information on Social and Communication Skills (25) A. The client was assigned to read about general social and/or communication skills in books or treatment manuals on building social skills. B. The client was assigne d to read Your Perfect Right (Alberti and Emmons). C. The client was assigned to read Conversationally Speaking (Garner). D. The client has read the assigned information on social and communication skills, and key points were reviewed. E. The client has not read the information on social and communication skills and was redirected to do so. 26. Differentiate between Lapse and Relapse (26) A. A discussion was held with the client regarding the distinction between a lapse and a relapse. B. A lapse was as sociated 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 a n 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 he/she was provided with remedial feedback in this area. 27. Discuss Management of Lapse Risk Situatio ns (27) 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 was re inforced 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. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SOCIAL ANXIETY 323 28. Encourage Routine Use of Strategies (28) A. The client was instructed to routinely use the strateg ies 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 routine and life. 29. Develop a Coping Card (29) A. The client was provided with a coping ca rd 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 card when struggling with anxiety-producing situations. 30. Explore Rejection Experiences (30) A. The client was asked to identify childhood and adolescent experiences of social rejection and neglect that have contributed to his/her current feelings of social anxiety. B. Active listening was provided as the client described in detail many incidences of feeling rejected by peers, which has led to social anxiety and social withdrawal. C. The client denied any history of rejection experiences and was urged to speak about these if he/she should recall them in the future. 31. Assign Books on Shame (31) A. The client was directed to read books on shame. B. It was recommended to the client that he/she read Healing the Shame That Binds You (Bradshaw) and Facing Shame (Fossum and Mason). C. The cl ient has read the assigned books on shame and can now better identify how shame has affected his/her relating to others; key points from the reading material were reviewed. D. As the client has overcome his/her feelings of shame, he/she was asked to initi ate one social contact per day for increasing lengths of time. E. The client has failed to follow through on reading the recommended materials on shame and was urged to do so. 32. Identify Defense Mechanisms (32) A. The client was assisted in identifying the defense mechanisms that he/she uses to avoid close relationships. B. The client was assisted in reducing his/her defensiveness so as to be able to build social relationships and not alienate himself/herself from others. 33. Schedule a Booster Session (33) A. The client was scheduled for a booster session between one and three months after therapy ends. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
324 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was advised to contact the therapist if he/she needs to be seen prior to the booster session. C. The client's booster session was held, and he/she was reinforced for his/her successful implementation of therapy techniques. D. The client's booster session was held, and he/she was coordinated for further treatment as his/her progress has not been sustained. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
325 SOCIAL SKILLS DEFICI TS CLIENT PRESENTATION 1. Bizarre Behavior (1) * A. The client has demonstrated a repeated pattern of bizarre or other inappropriate social behavior. B. The client's social behavior appears to be disorganized and causes conflict in re lationships. C. The client's bizarre behavior has diminished in frequency and intensity. D. The client no longer displays bizarre or other inappropriate social behavior. 2. Broken/Conflicted Relationships (2) A. The client described a history of broken or conflicted relationships. B. The client has a history of problems in relationships due to personal deficiencies in problem solving. C. The client has found it difficult to maintain trust in relationships. D. The client tends to choose abusive/dysfun ctional partners/friends. E. As the client's severe and persistent mental illness symptoms have abated, his/her relationships have become more stable and healthy. 3. Social Anxiety (3) A. The client described a pattern of social anxiety, shyness, and ti midity that presents itself in almost any interpersonal situation. B. The client's social anxiety presents itself whenever he/she has to interact with others or in group situations with people whom he/she does not know well. C. The client's social anxiet y has diminished, and he/she is more confident in social situations. D. The client has begun to overcome his/her shyness and can initiate social contact with some degree of comfort and confidence. E. The client reported that he/she no longer experiences feelings of social anxiety or shyness when having to interact with new people or group situations. 4. Rude/Angry (4) A. The client presented in an angry, resentful, oppositional manner. B. The client was often rude and demanding in his/her comments towa rd peers and others. C. Anger predominated the client's mood. D. The client's overall manner was sullen and quiet, which covered a strong mood of anger and resentfulness. E. The client's general mood and presentation reflected a notable decrease in ange r and a general increase in pleasant, polite cooperation. * The numbers in parentheses correlate to the nu mber 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 |
326 THE SEVERE AN D PERSISTENT MENTAL ILLNESS PROGRESS NOT ES PLANNER 5. Inability to Establish and Maintain Relationships (5) A. The client described an inability to establish, nurture, and maintain meaningful, interpersonal relationships. B. The client's difficul ty in relationships is related to his/her failure to listen, support, communicate, or negotiate differences of opinion. C. The client often fails to work through problem situations within his/her relationships, often leading to a lost or diminished relati onship. D. As the client's severe and persistent mental illness symptoms have stabilized, he/she has learned to listen, support, communicate, and negotiate, which has helped him/her to maintain meaningful interpersonal relationships. 6. Estrangement Due to Mental Illness Symptoms (6) A. The client's psychotic symptoms (i. e., hallucinations, delusions, bizarre behavior, manic phases) have had a significant negative effect on his/her social interactions. B. The client tends to be estranged from others due to the negative impact of his/her psychotic symptoms. C. Others often avoid the client due to his/her mental illness symptoms. D. As the client has stabilized his/her mental illness symptoms, his/her social relationships have improved. 7. Loneliness (7 ) A. The client has no close friends or confidants outside of first-degree relatives. B. The client identified ongoing feelings of loneliness. C. The client's social anxiety has prevented him/her from building and maintaining a social network of friends and acquaintances. D. The client has begun to reach out socially and respond favorably to the overtures of others. E. The client reported enjoying contact with friends and sharing personal information with them. 8. Poor Support Network (7) A. The clie nt described a lack of friends to provide support during crises. B. The client sees all of his/her relationships as fair-weather friends. C. The client displayed a pattern of decompensation, which is exacerbated by the lack of a social network to provide support to him/her during these crises. D. As the client has developed better relationships, he/she has found more support and been more stable during crisis times. 9. Lack of Assertiveness (8) A. The client has difficulty saying no to other people whe n he/she is presented with a request for a favor. B. The client attempts to ingratiate himself/herself to others by being eager to meet their needs. C. The client often fails to be assertive in the appropriate situation. D. The client has been taken adv antage of by others because he/she fears rejection if he/she refuses to comply with others' requests. E. The client has begun to set limits in doing things for others and not complying with their requests. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SOCIAL SKILLS DEFICI TS 327 10. Lack of Experience in Social Activities (9) A. The client described that he/she has had little experience in recreational/leisure activities. B. The client is often unsure of the social aspects of recreational/leisure activities. C. The client's involvement in recreational/leisure activities has increased, as he/she has stabilized. D. The client reports an increased confidence in the social aspects of recreational/leisure activities. INTERVENTIONS IMPLEM ENTED 1. List Important Relationships (1) * A. The client was asked to prepare a list of all important relationships, including friends, family, and treatment providers. B. The client was provided with feedback regarding his/her list of important relationships, and important additions were made. C. The client has not completed his/her homework o f preparing a list of important relationships and was redirected to do so. 2. Develop a Genogram (2) A. The client was assisted in developing a family genogram. B. Important relationships within the family were identified through the use of the genogram. 3. Assess Social Skills Strengths and Weaknesses (3) A. The client's social skill strengths and weakness were assessed. B. Information from a variety of settings was used to assess the client's social skills. C. The client was assessed in settings th at demand a variety of different types of social involvement. D. The client's social skill strengths and weaknesses were reflected to him/her. 4. Conduct Semi-Structured Interview (4) A. An interview was conducted with the client and a person familiar w ith him/her in regard to the social skills that the client displays. B. The Social Behavior Schedule was used to conduct a semi-structured interview of social skills with a client and a person familiar with him/her. C. The Social Adjustment Scale was use d to conduct a semi-structured interview of social skills with the client and a person familiar with him/her. D. The client participated openly in the assessment of his/her social skills, and the results of this assessment were reflected to him/her. E. The client did not participate significantly in the assessment of his/her social skills and was redirected to do so. * 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 |
328 THE SEVERE AN D PERSISTENT MENTAL ILLNESS PROGRESS NOT ES PLANNER 5. Differentiate Etiology of Social Skill Deficits (5) A. An attempt was made to differentiate among the social skill deficits that the cl ient displays in regard to the etiological factors that create the deficits. B. Social skill deficits that were related to social anxiety were identified. C. Social skill deficits that are symptoms of a severe persistent mental disorder were identified. D. Social skill deficits were identified as a negative symptom of the client's schizophrenia. E. Social skill deficits were identified as a symptom of the client's manic episode. 6. Assess Cognitive Ability ( 6) A. The client was referred for an assess ment of cognitive abilities and deficits relative to social skills functioning. B. The client underwent objective psychological testing to assess his/her cognitive strengths and weaknesses. C. The client cooperated with the psychological testing, and fee dback about the results was given to him/her. D. The psychological testing confirmed the presence of specific cognitive abilities and deficits. E. The client was not compliant with taking the psychological evaluation and was encouraged to participate com pletely. 7. Educate about Mental Illness Symptoms ( 7) A. The client was educated about the expected or common symptoms of his/her mental illness that may negatively impact basic social skills. B. As the client's symptoms of mental illness were discussed, he/she displayed an understanding of how these symptoms may affect his/her social skills. C. The client struggled to identify how symptoms of his/her mental illness may negatively impact basic social skill functioning and was given additional feedback i n this area. 8. Refer to a Physician ( 8) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined an evaluation by a physician for a prescription of psychotropic medication and was redirected to cooper ate with this referral. 9. Monitor Medications ( 9) A. The client was monitored for compliance with his/her psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication effectiveness and side effects were communicated to the physician. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SOCIAL SKILLS DEFICI TS 329 E. Although the client was monitored for medicatio n side effects, he/she reported no concerns in this area. 10. Identify Positive Effects of the Medications (1 0) A. The client was assisted in recognizing the positive impact of his/her consistent use of the psychotropic medications on social interactions. B. The positive social effects of the client's consistent use of psychotropic medications were processed. C. The client was unable to identify the positive impact of his/her consistent use of psychotropic medications on social interactions and was give n feedback in this area. 11. Provide Rationale for Social Skills Training (11) A. A rationale for social skills training was provided to the client to help increase his/her commitment to the social skills training. B. An emphasis was placed on the improv ed social interactions that may occur from social skills training. C. An emphasis was placed on how social skills training may decrease negative social interactions. D. The client was reinforced for his/her increased commitment and motivation in social s kills training. E. The client has displayed indifference in regards to social skills training and was provided with additional motivation in this area. 12. Provide Social Skills Training (12) A. The client was provided with social skills training through the use of cognitive behavioral strategies. B. Individual social skills training was provided to the client. C. Group social skills training was provided to the client. D. The client was taught through education, modeling, role-play, practice, reinforc ement, and generalization techniques about new social skills. 13. Assign Social and Communication Information (13) A. The client was assigned to read about social skills. B. The client was assigned to read about communication skills. C. The client was a ssigned to read Your Perfect Right (Alberti and Emmons). D. The client was assigned to read Conversationally Speaking (Garner). E. The client has read the assigned information about social and communication skills and key points were reviewed. F. The cl ient has not read the assigned information on social and communication skills and was redirected to do so. 14. Refer for Conduct Assertiveness Training (1 4) A. Education, modeling, role-playing, practice, reinforcement, and generalization skills were use d to teach assertiveness skills. B. The client was referred to an assertiveness-training workshop. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
330 THE SEVERE AN D PERSISTENT MENTAL ILLNESS PROGRESS NOT ES PLANNER C. The client was educated in the concepts related to assertiveness skills through lectures, assignments, and role-playing within the assertiveness-trainin g group. D. The client has displayed increased assertiveness as a result of attending the assertiveness-training group. E. The client has not displayed an increased understanding of assertiveness, despite the use of assertiveness training, and was provid ed with additional feedback in this area. 15. Teach about Body Language ( 15) A. The client was asked to identify three different body language messages from preselected photographs. B. The client was reinforced as he/she correctly identified body langua ge messages from material (e. g., magazines, family photos). C. The client seemed to struggle with correctly identifying body language signals and was provided with feedback in this area. 16. Teach Accurate Interpretation of Body Language ( 16) A. Role-playing, modeling, and behavioral rehearsal were used to teach the client how to accurately interpret body language signals. B. In several practice situations, the client was able to correctly identify the body language signals that were being provided to h im/her. C. The client was given additional feedback as he/she failed to correctly identify the body language signals being provided to him/her. 17. Improve Eye Contact ( 17) A. The client was confronted for his/her pattern of poor eye contact. B. The cl ient was reinforced for his/her spontaneous use of positive eye contact with others. C. Subsequent to observing the client in social interactions, he/she was provided with feedback regarding his/her pattern of eye contact. D. The client continues to be q uite avoidant of eye contact with others and was urged to be more cognizant of these concerns. E. The client was reinforced for using more regular eye contact. 18. Practice Eye Contact ( 18) A. Role-playing and behavioral rehearsal were used to teach the client proper eye contact during social interactions. B. The client was provided with positive feedback regarding his/her socially appropriate use of eye contact during practice social interactions. C. The client was provided with feedback as he/she con tinued to display a pattern of poor eye contact during practice social interactions. 19. Develop Topics of Interest ( 19) A. The client was directed to develop a list of five topics in which he/she is interested. B. The client was directed to identify fi ve topics in which others seem to be interested. C. The client's list of topics of interest was processed. D. The client has not developed lists of interests 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 |
SOCIAL SKILLS DEFICI TS 331 20. Role-Play Inquiries about Interests (2 0) A. Role-playing tech niques were used to practice asking questions about others' areas of interest, modeling eye contact, noninterruptive listening, and assertiveness in the process. B. To facilitate the client's social skills, role-playing was used with him/her initiating conversation with others. C. The client was supported as he/she expressed more confidence in his/her social initiation ability after the role-playing experience. D. The client was reinforced for following through on implementing the initiation of social contact and reporting a feeling of success with this experience. E. The client has not followed through with the implementation of asking questions about others' interests and was redirected to do so. 21. Assign Skill Practice (2 1) A. The client was assig ned to practice the use of listening and speaking skills in three social situations. B. The client's experience of using social skills, including his/her successes and difficulties, was reviewed. C. The complexity of the client's social skill practice si tuations was gradually increased. D. The client has not followed through on practicing listening skills and was redirected to do so. 22. Refer to a Support Group (2 2) A. The client was referred to a support group for individuals with severe and persiste nt mental illness. B. The client has attended the support group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. C. The client reported that he/she has not experienced any positive benefit f rom the use of a support group but was encouraged to continue to attend. D. The client has not used the support group for individuals with severe and persistent mental illness and was redirected to do so. 23. Teach Calming and Intentional Focusing Skills (23) A. The client was taught calming and intentional focusing skills. B. The client was reminded to stay focused on external and behavioral goals. C. The client was taught physiological techniques to help calm his/her social anxiety, including muscular relaxation, evenly paced diaphragmatic breathing and “riding the wave of anxiety. ” D. The client was reinforced for his/her increased calm, focused management of his/her social anxiety symptoms. E. The client has not used calming and intentional focusin g skills to manage his/her social anxiety symptoms and was reminded about these helpful skills. 24. Identify Distorted Thoughts (24) A. The client was assisted in identifying the distorted schemas and related automatic thoughts that mediate problems with social skills. B. The client was taught the role of distorted thinking in precipitating emotional responses. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
332 THE SEVERE AN D PERSISTENT MENTAL ILLNESS PROGRESS NOT ES PLANNER C. The client was reinforced as he/she verbalized an understanding of the cognitive beliefs and messages that mediate his/her problem with social skills. 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 Exercise s 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. D. “Restoring Socialization Comfort” from Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was used to help identify fearful self-talk and create reality-based alternatives. E. The client was provided with corrective feedback for his/her failures to replace fearful self-talk with reality-based alternatives. F. The client has not completed his/her assigned homework regarding fearful self-talk and was redirected to do so. 26. Monitor Thought Process (2 6) A. The effect of the client's mental illness symptoms on his/her thought process was monitored. B. The client was provided with specific feedback about the areas in which his/her mental illn ess symptoms are currently affecting his/her thought process. C. The client was provided with general feedback regarding areas in which his/her mental illness symptoms may potentially affect his/her thought process. D. The client denied that his/her symp toms had any effect on his/her thought process and was provided with additional feedback in this area. 27. Develop Support and Feedback from Others ( 27) A. The client was encouraged to seek frequent reality testing to challenge his/her distorted beliefs. B. The client was provided with positive reinforcement for others' comparing his/her cognitions with the experience of trusted caregivers, friends, and family. C. The client has sought out emotional support from family and friends, and the benefits of t his were reviewed. D. The client was reinforced for demonstrating an increased reality orientation. E. The client failed to use reality testing from others to challenge his/her distorted beliefs and was encouraged to do so. 28. Assign Feedback Homework (28) A. The client was assigned the homework of gaining feedback from others in three social situations. B. The client completed the homework of obtaining feedback from others in social situations. C. The client was reinforced for displaying an increase d understanding of his/her social presentation as a result of the review of his/her feedback from others. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SOCIAL SKILLS DEFICI TS 333 D. The client has not participated in obtaining feedback from others in social situations and was redirected to do so. 29. Accept Praise Graciously (29) A. The client was assigned to focus on situations in which others provide praise and compliments to him/her. B. The client was urged to graciously acknowledge (without discounting) praise and compliments from others. C. The client's identified situ ations in which he/she received and responded to praise and compliments from others were processed. D. The client was unable to identify any situations in which he/she received praise and compliments from others and was urged to continue to search for the se areas. 30. Role-Play Requests for Group Involvement (3 0) A. Role-playing techniques were used to assist the client in practicing how to ask others to allow him/her to be included in a group activity. B. The client was supported as he/she practiced ap proaching others to increase his/her involvement in activities. C. The client failed to use socially appropriate means to assert himself/herself into others' activities, and he/she was provided with encouragement. 31. Identify Mutually Satisfying Activit ies (31) A. The client was assisted in identifying mutually satisfying social activities for himself/herself and friends/family members. B. The client was supported as he/she identified a wide variety of activities that were satisfying for both himself/h erself, as well as friends/family members. C. The client tended to identify activities in which he/she has interest, but which hold very little interest for his/her friends/family members and was provided with additional feedback in this area. 32. Encour age/Facilitate Involvement in Social/Recreational Opportunities (32) A. The client was encouraged to be involved in community-or agency-sponsored social/ recreational opportunities. B. The client's involvement in community-or agency-sponsored social/re creational opportunities was facilitated. C. The client was reinforced for selecting specific social/recreational opportunities in which he/she would like to be involved (e. g., bowling, exercise groups, church groups). D. The client was supported for inc reasing his/her involvement in social and recreational opportunities. E. The client has not increased his/her involvement in social/recreational opportunities and was provided with additional encouragement in this area. 33. Reframe Discrimination (3 3) A. The client was assisted in identifying instances in which he/she has experienced discrimination while trying to be more involved in the community. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
334 THE SEVERE AN D PERSISTENT MENTAL ILLNESS PROGRESS NOT ES PLANNER B. Instances of discrimination toward the client in his/her attempts to be involved in the community were reframed as a fault of the discriminating individual or group. C. The client's emotional pain experienced due to being discriminated against was acknowledged regardless of the fault of the discriminating person or group. 34. Identify/Process Rejection (3 4) A. The client was supported as he/she identified childhood and adolescent experiences of social rejection and neglect that contributed to his/her current feelings of social anxiety. B. A reciprocal relationship was identified between the client's expe rience of mental illness symptoms and the emotional pain from social rejection. C. The client tended to avoid any emotional content related to his/her history of social interaction or rejection, and this was accepted. 35. Teach Self-Affirmation Technique s (35) A. The client was taught positive self-affirmation techniques to increase his/her focus on positive characteristics that may draw others toward him/her. B. The client was instructed to write from 6 to 10 positive statements about himself/herself o n 3-by-5-inch cards and review them several times per day. C. The client has used positive self-affirmation techniques to increase his/her focus on positive characteristics, and the benefits of this were reviewed. D. The client has not used positive self-affirmation techniques and was redirected to do so. 36. Encourage Family Members' Venting ( 36) A. The client's family members were encouraged to vent their feelings about his/her past behavior and symptoms. B. The client's family members were cautioned about making disrespectful or dehumanizing remarks about him/her as they vented about his/her past behavior and symptoms. C. As the client's family members have been able to vent their emotions regarding his/her past behavior and symptoms, they have been able to increase their support for him/her. 37. Coordinate Family Therapy ( 37) A. Family therapy appointments were scheduled to allow the family to express concerns, emotions, and expectations directly to the client. B. The family's expressions of conc erns, emotions, and expectations directly to the client were processed within the family session. C. The client was supported as he/she accepted his/her family members' feedback. D. The client has significant difficulties accepting the feedback from his/ her family and was encouraged to allow them to vent their healthy emotions. 38. Answer Family Questions ( 38) A. An appropriate release of information was obtained to allow the clinician to answer the family's questions regarding the client's mental illne ss symptoms and abilities. B. Specific information was provided to the family regarding the client's mental illness symptoms, as well as his/her abilities. C. The client's family members were reinforced as they displayed an increased understanding of his/her overall level of functioning. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SOCIAL SKILLS DEFICI TS 335 D. The client's family continues to have a poor understanding of his/her mental illness symptoms, abilities, and needs and were provided with remedial information in this area. 39. Refer to a Family/Caregiver Support Gr oup ( 39) A. The client's family members/caregivers were referred to a support group for those who care for the chronically mentally ill. B. The client's family members/caregivers reported being helped by attending a support group for those who care for t he chronically mentally ill, and this attendance was reinforced. C. The client's family members/caregivers have not attended a support group and were encouraged to do so. 40. Review Relationships Damaged by Mental Illness (4 0) A. The client was requeste d to make a list of his/her important relationships, including those that have been damaged by his/her pattern of mental illness symptoms. B. The client's list of important relationships was reviewed, focusing on lost relationships that can be salvaged, d eveloped, or resurrected. C. The client's experience of the loss of these relationships was processed. D. The client has not developed a list of lost relationships and was redirected to do so. 41. Identify Individuals Hurt in Relationships (4 1) A. The client was assisted in identifying those who have been hurt in previous relationships. B. The client was assisted in identifying those to whom he must make amends. C. The client was assisted in identifying how to apologize to those whom he has hurt in pr evious relationships. 42. Coordinate Conjoint Session for Making Amends (4 2) A. A conjoint session was held to assist the client in making an apology or making amends to individuals whom he/she has harmed. B. The client was reinforced for making amends or providing apologies to those whom he/she has offended or hurt due to his/her mental illness symptoms. C. The client has denied any need for making amends to others and was encouraged to review this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
336 SPECIFIC FEARS AND A VOIDANCE CLIENT PRESENTATION 1. Unreasonable Fear of Object/Situation (1) * A. The client described a pattern of persistent and unreasonable phobic fear that promotes avoidance behaviors because an encounter with the phobic stimulus pr ovokes an immediate anxiety response. B. The client has shown a willingness to begin to encounter the phobic stimulus and endure some of the anxiety response that is precipitated. C. The client has been able to tolerate the previously phobic stimulus wit hout debilitating anxiety. D. The client verbalized that he/she no longer holds fearful beliefs or experiences anxiety during an encounter with the phobic stimulus. 2. Interference with Normal Routines (2) A. The client's avoidance of phobic stimulus si tuations is so severe as to interfere with normal functioning. B. The degree of the client's distrust associated with avoidance behaviors related to phobic experiences is such that he/she is not able to function normally. C. The client is beginning to ta ke on normal responsibilities and function with limited distress. D. The client has returned to normal functioning and reported that he/she is no longer troubled by avoidance behaviors and phobic fears. 3. Recognition That Fear Is Unreasonable (3) A. The client's phobic fear has persisted in spite of the fact that he/she acknowledges that the fear is unreasonable. B. The client has made many attempts to ignore or overcome his/her unreasonable fear, but has been unsuccessful. 4. Phobia without Panic (4) A. The client does not display panic attacks. B. Although the client feels anxious whenever leaving his/her constricted safety zone, he/she does not experience panic symptoms apart from the agoraphobia symptoms. * 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 Persist ent 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 |
SPECIFIC FEARS AND A VOIDANCE 337 INTERVENTIONS IMPLEM ENTED 1. Build Trust (1)* A. An initial trust level was established with the client through the use of unconditional positive regard. B. Warm acceptance and active-listening techniques were utilized to establish the basis for a trusting relationship. C. The client has form ed a trust-based relationship and was urged to begin to express his/her fearful thoughts and feelings. D. Despite the use of active listening, warm acceptance, and unconditional positive regard, the client remains hesitant to trust and to share his/her th oughts and feelings. 2. Administer Fear Survey (2) A. An objective fear survey was administered to the client to assess the depth and breadth of his/her phobic fear, including the focus of the fear, types of avoidance, development, and disability. B. The Anxiety Disorder's Interview Schedule for the DSM-IV (Di Nardo, Brown, and Barlow) was used to assess the client's phobia concerns. C. The fear survey results indicate that the client's phobic fear is extreme and severely interferes with his/her life. D. The fear survey results indicate that the client's phobic fear is moderate and occasionally interferes with his/her daily functioning. E. The fear survey results indicate that the client's phobic fear is mild and rarely interferes with his/her daily fun ctioning. F. The results of the fear survey were reviewed with the client. 3. Assess Cues (3) A. The client was assessed in regard to the stimuli that precipitate his/her specific fears and avoidance. B. The client was assessed in regard to the thought s that go along with his specific fears and avoidance. C. The client was assisted in identifying situations that seemed to precipitate his/her specific fears and avoidance. D. The client displayed significant insight into the precursors of his/her specif ic fears and avoidance and was provided with support and encouragement for being open about this. E. The client struggled to identify any stimuli, thoughts, or situations that precipitated his/her specific fears and avoidance and was provided with several possibilities in this area. 4. Administer Client-Report Measure (4) A. A client-report measure was used to further assess the depth and breadth of the client's phobic responses. * 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 P ersistent 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 |
338 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The Measures for Specific Phobias (Antony) was used to assess the depth and breadth of the client's phobic responses. C. The client-report measures indicated that the client's phobic fear is extreme and severely interferes with his/her life. D. The client-report measures indicated that the client's phobic fear is moderate a nd occasionally interferes with his/her life. E. The client-report measures indicated that the client's fear is mild and rarely interferes with his/her life. F. The client declined to complete the client-report measure and the focus of treatment was changed to this resistence. 5. Differentiate Anxiety Symptoms (5) A. The client was assisted in differentiating anxiety symptoms that are a direct affect of his/her severe and persistent mental illness, as opposed to a separate diagnosis of an anxiety disord er. B. The client was provided with feedback regarding his/her differentiation of symptoms that are related to his/her severe and persistent mental illness, as opposed to a separate diagnosis. C. The client has identified a specific anxiety disorder, whi ch is freestanding from his/her severe and persistent mental illness, and this was reviewed within the session. D. The client has been unsuccessful in identifying ways in which his/her anxiety symptoms are related to his/her mental illness or a separate a nxiety disorder. 6. Acknowledge Anxiety Related to Delusional Experiences (6) A. It was acknowledged that both real and delusional experiences could cause anxiety. B. The client was provided with support regarding his/her anxieties and worries, which ar e related to both the real experiences and delusional experiences. C. The client described a decreased pattern of anxiety due to the support provided to him/her. 7. Identify Diagnostic Classification (7) A. The client was assisted in identifying a speci fic diagnostic classification for his/her anxiety symptoms. B. Utilizing a description of anxiety symptoms such as that found in Bourne's The Anxiety and Phobia Workbook, the client was taken through a detailed review of his/her anxiety symptoms, diagnosi s, 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. 8. Refer to Physician (8) A. A referral to a physician was made for the purpose of evaluating th e client for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been pr escribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medication and was redirected to cooperate with this referral. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SPECIFIC FEARS AND A VOIDANCE 339 9. Monitor Medications (9) A. The client was monitored for compliance w ith his/her psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medication. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication compliance, 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. 10. Normalize Phobias (10) A. A discussion was held about how phobias are very common. B. The client was focused on how phobias are a natural, but irrational expression of our fight or flight response. C. It was emphasized to the client that phobias are not a sign of weakness, bu t cause unnecessary distress and disability. D. The client was reinforced as he/she displayed a better understanding of the natural facets of phobias. E. The client struggled to understand the natural aspects of phobias and was provided with remedial fee dback in this area. 11. Discuss Phobic Cycle (11) A. The client was taught about how phobic fears are maintained by a phobic 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 phobic cycle by encouraging positive, corrective experiences. C. The client was taught information from Mastery of Your Specific Phobia —Therapist Guide (Craske, Antony, and Barlow) regarding the phobic c ycle. D. The client was taught about the phobic cycle from information in Specific Phobias (Bruce and Sanderson). E. The client was reinforced as he/she displayed a better understanding of the phobic cycle of unwarranted fear and avoidance and how treatm ent breaks the cycle. F. The client displayed a poor understanding of the phobic cycle and was provided with remedial feedback in this area. 12. Assign Reading on Specific Phobias (12) A. The client was assigned to read psychoeducational chapters of book s or treatment manuals on specific phobias. B. The client was assigned information from Mastery of Your Specific Phobia —Client Manual (Antony, Craske, and Barlow). C. The client was directed to read information about specific phobias from The Anxiety and Phobic Workbook (Bourne). D. The client was assigned to read from Living with Fear (Marks). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
340 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client has read the assigned information on phobias, and key points were reviewed. F. The client has not read the assigned information on phobias and was redirected to do so. 13. Discuss Unrealistic Threats, Physical Fear, and Avoidance (13) A. A discussion was held about how phobias involve perceiving unrealistic threats, bodily expressions of fear, and avoidance of what is threatening that interact to maintain the problem. B. The client was taught about factors that interact to maintain the problem phobia from information in Mastery of Your Specific Phobia —Therapist Guide (Craske, Antony, and Barlow). C. The client was taught about factors that intera ct to maintain the problem phobia from information in Specific Phobias (Bruce and Sanderson). D. The client displayed a clear understanding of how unrealistic threats, bodily expression of fear, and avoidance combine to maintain the phobic problem; his/he r insight was reinforced. E. Despite specific information about factors that interact to maintain the problem, the client displayed a poor understanding of these issues; he/she was provided with remedial information in this area. 14. Discuss Benefits of E xposure (14) A. A discussion was held about how exposure serves as an arena to desensitize learned fear, build confidence, and make one feel safer by building a new history of success experiences. B. The client was taught about the benefits of exposure a s described in Mastery of Your Specific Phobia —Therapist Guide (Craske, Antony, and Barlow). C. The client was taught about the benefits of exposure as described in Specific Phobias (Bruce and Sanderson). D. The client displayed a clear understanding of how exposure serves to desensitize learned fear, build confidence, and make one feel safer by building a new history of success experiences; his/her insight was reinforced. E. Despite specific information about how exposure serves to desensitize learned f ear, build confidence, and make one feel safer by building a new history of success experiences, the client displayed a poor understanding of these issues; he/she was provided with remedial information in this area. 15. Teach Anxiety Management Skills (15) A. The client was taught anxiety management skills. B. The client was taught about staying focused on behavioral goals and positive self-talk. C. Techniques for muscular relaxation and paced diaphragmatic breathing were taught to the client. D. The cl ient was reinforced for his/her clear understanding and use of anxiety management skills. E. The client has not used new anxiety management skills and was redirected to do so. 16. Assign Reading about Calming Strategies (16) A. The client was assigned t o read psychoeducational chapters of books or treatment manuals describing calming strategies. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SPECIFIC FEARS AND A VOIDANCE 341 B. The client was assigned portions of Mastery of Your Specific Phobia —Client Manual (Antony, Craske, and Barlow). C. The client has read the assigned informat ion on calming strategies, and his/her favorite strategies were reviewed. D. The client has not read the assigned information on calming strategies, and he/she was redirected to do so. 17. Assign Calming Skills Exercises (17) A. The client was assigned a homework exercise in which he/she practices daily calming skills. B. The client's use of the exercises for practicing daily calming skills was closely monitored. C. The client's success at using daily calming skills was reinforced. D. The client was pr ovided with corrective feedback for his/her failures at practicing daily calming skills. 18. Use (Electromygraph) EMG Biofeedback (18) A. EMG biofeedback techniques were utilized to facilitate the client's relaxation skills. B. The client achieved deeper levels of relaxation from the EMG biofeedback experience. C. The client did not develop deep relaxation as a result of EMG biofeedback. 19. Teach Applied Tension Technique (19) A. The client was taught the applied tension technique to help prevent fain ting during encounters with phobic objects or situations. B. The client was taught to tense his/her neck and upper torso muscles to curtail blood flow out of the brain to help prevent fainting during encounters with phobic objects or situations involving blood, injection, or injury. C. The client was taught specific applied tension techniques as indicated in “Applied Tension, Exposure In Vivo, and Tension-Only in the Treatment of Blood Phobia” in Behavior Research and Therapy (Ost, Fellenius, and Sterner). D. The client was provided with positive feedback for his/her use of the applied tension technique. E. The client has struggled to appropriately use the applied tension technique and was provided with remedial feedback in this area. 20. Assign Daily A pplied Tension Practice (20) A. The client was assigned a homework exercise in which he/she practices daily use of the applied tension skills. B. The client's daily use of the applied tension technique was reviewed. C. The client was reinforced for his/ her success at using daily applied tension skills. D. The client was provided with corrective feedback for his/her failure to appropriately use daily applied tension skills. 21. Identify Distorted Thoughts (21) A. The client was assisted in identifying t he distorted schemas and related automatic thoughts that mediate anxiety responses. B. The client was taught the role of distorted thinking in precipitating emotional responses. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
342 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was reinforced as he/she verbalized an understanding of the co gnitive 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 provid ed with tentative examples in this area. 22. Assign Reading about Cognitive Restructuring (22) A. The client was assigned to read about cognitive restructuring in books or treatment manuals on Panic Disorder and Agoraphobia. B. The client was assigned to read Mastery of Your Specific Phobia —Client Manual (Antony, Craske, and Barlow). C. The client was assigned to read excerpts from The Anxiety and Phobia Workbook (Bourne). D. The client has read the assigned material on cognitive restructuring, and impo rtant concepts were reviewed within the session. E. The client has not read the assigned material on cognitive restructuring and was redirected to do so. 23. Assign Homework on Self-Talk (23) A. The client was assigned homework exercises to identify fear ful self-talk, create reality-based alternatives, and record his/her experiences. B. The client was assigned “Journal and Replace Self-Defeating Thoughts” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client's use of self-talk techniques was reviewed and reinforced. D. The client has struggled in his/her implementation of self-talk techniques and was provided with corrective feedback. E. The client has not attempted to use the self-talk techniques and was redirected to do so. 24. Model/Rehearse Self-Talk (24) A. Modeling and behavioral rehearsal were used to train the client in positive self-talk that reassured him/her of the ability to work through and endure anxiety symptoms without serious consequences. B. The client has i mplemented positive self-talk to reassure himself/herself of the ability to endure anxiety without serious consequences; he/she was reinforced for this progress. C. The client has not used positive self-talk to help endure anxiety and was provided with additional direction in this area. 25. Construct Anxiety Hierarchy (25) A. The client was directed and assisted in constructing a hierarchy of anxiety-producing situations. B. The client was successful in identifying a range of stimulus situations that pro duced increasingly greater amounts of anxiety, and this hierarchy was reviewed. C. The client found it difficult to identify a range of stimulus situations that produce increasingly greater amounts of anxiety and was provided with assistance in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SPECIFIC FEARS AND A VOIDANCE 343 26. Select Initial Exposures (26) A. Initial exposures were selected from the hierarchy of anxiety-producing situations, with a bias toward likelihood of being successful. B. A plan was developed with the client for managing the symptoms that may occur during the initial exposure. C. The client was assisted in rehearsing the plan for managing the exposure-related symptoms within his/her imagination. D. Positive feedback was provided for the client's helpful use of symptom management techniques. E. The client was redirected for ways to improve his/her symptom management techniques. 27. Assign Reading about Situational Exposure (27) A. The client was assigned to read about situational exposure. B. The client was assigned to read excerpts from Mastery of Your Specific Phobia —Client Manual (Antony, Craske, and Barlow). C. The client was assigned to read portions of Living with Fear (Marks). D. The information that the client has read regarding situational exposures was reviewed and processed within the session. E. The client has not read information about situational exposure and was redirected to do so. 28. Assign Homework on Situational Exposures (28) A. The client was assigned homework exercises to perform situational exposures and record his/her e xperience. B. The client was assigned “Gradually Facing a Phobic Fear” from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The client was assigned situational exposure homework from Mastery of Your Specific Phobia —Client Manual (Antony, Craske, and Barlow). D. The client was assigned situational exposure homework from Living with Fear (Marks). E. The client's use of situational exposure techniques was reviewed and reinforced. F. The client has struggled in his/her implementation of sit uational exposure techniques and was provided with corrective feedback. G. The client has not attempted to use the situational exposure techniques and was redirected to do so. 29. Differentiate between Lapse and Relapse (29) A. A discussion was held with the client regarding the distinction between a lapse and a relapse. B. A lapse was associated with a temporary and reversible return of symptoms, fear, or urges to avoid. C. A relapse was associated with the decision to return to fearful and avoidant pa tterns. 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 he/she was provided with remedial feedback in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
344 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 30. Discuss Management of Lapse Risk Situations (30) 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 was reinforced for his/her appropriate use of the lapse management skills. D. The client was redirected in regard to his/her poor use of lapse management skills. 31. Encoura ge Routine Use of Strategies (31) 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. 32. Develop a Coping Card (32) A. The client was provided with a coping card on which specif ic 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 card when struggling with anxiety-producing situations. 33. Explore Secondary Gain (33) A. Secondary gain was identified for the client's panic symptoms because of his/her tendency to escape or avoid certain situations. B. The client denied any role for secondary gain that results from his/her modification of life to accommodate panic; he/she was provided with tentative examples. C. The client was reinforced for accepting the role of secondary gain in promoting and maintaining the panic symptoms and encouraged to overcome this gain through living a more norma l life. 34. Differentiate Current Fear from Past Pain (34) A. The client was taught to verbalize the separate realities of the current fear and the emotionally painful experience from the past that has been evoked by the phobic stimulus. B. The client wa s reinforced when he/she expressed insight into the unresolved fear from the past that is linked to his/her current phobic fear. C. The irrational nature of the client's current phobic fear was emphasized and clarified. D. The client's unresolved emotion al issue from the past was clarified. 35. Encourage Sharing of Feelings (35) A. The client was encouraged to share the emotionally painful experience from the past that has been evoked by the phobic stimulus. B. The client was taught to separate the rea lities of the irrational feared object or situation and the painful experience from his/her past. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SPECIFIC FEARS AND A VOIDANCE 345 36. Reinforce Responsibility Acceptance (36) A. The client was supported and reinforced for following through with work, family, and social responsibilities rather than using escape and avoidance to focus on panic symptoms. B. The client reported performing responsibilities more consistently and being less preoccupied with panic symptoms or fear that panic symptoms might occur, his/her progress was highlight ed. 37. List Expectations for Improvement (37) A. The client was asked to list several ways that his/her life will become more satisfying or fulfilling as he/she manages his/her symptoms of panic and continues normal responsibilities. B. The client iden tified many ways in which his/her life will be more satisfying as his/her symptoms are managed and these changes were supported and reinforced. C. The client has struggled to identify ways in which his/her life may become more satisfying and fulfilling in the management of his/her symptoms of panic and was provided with tentative examples in this area. 38. Schedule a Booster Session (38) A. The client was scheduled for a booster session between 1 and 3 months after therapy ends. B. The client was advised to contact the therapist if he/she needs to be seen prior to the booster session. C. The client's booster session was held, and he/she was reinforced for his/her successful implementation on therapy techniques. D. The client's booster session was held, and he/she was coordinated for further treatment, as his/her progress has not been sustained. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
346 SUICIDAL IDEATION CLIENT PRESENTATION 1. Death Preoccupation (1) * A. The client reported recurrent thoughts of his/her own death. B. The intensity and frequency of the recurrent thoughts of death have diminished. C. The client reported no longer having thoughts of his/her own death. 2. Auditory Command Hallucinations (2) A. The client described his/her experience of auditory hallucinations that direct him/her to harm himself/herself. B. The client described difficulty resisting the command hallucinat ions to harm himself/herself. C. The client's reality orientation is significantly impaired, and he/she believes that he/she must act on the command hallucinations to harm himself/herself. D. As the client's severe and persistent mental illness symptoms have stabilized, his/her command hallucinations have decreased in intensity and frequency. E. The client no longer experiences suicide command hallucinations. 3. Suicidal Ideation without a Plan (3) A. The client reported experiencing recurrent suicidal ideation, but denied having any specific plan to implement suicidal urges. B. The frequency and intensity of the suicidal urges has diminished. C. The client stated that he/she has not experienced any recent suicidal ideation. D. The client stated that he/she no longer has any interest in causing harm to himself/herself. 4. Suicidal Ideation with a Plan (4) A. Although the client acknowledged that he/she has developed a suicide plan, he/she indicated that his/her suicidal urge is controllable, and he/ she promised not to implement such a plan. B. Because the client had a specific suicide plan and strong suicidal urges, he/she willingly submitted to a supervised psychiatric facility and more intensive treatment. C. The client stated that his/her suicid al urges have diminished, and he/she has no interest in implementing any specific plan for suicide. D. The client reported experiencing ongoing suicidal ideation and has developed a specific plan for suicide. E. The client reported no suicidal urges. 5. Recent Suicide Attempt (5) A. The client has made a suicide attempt within the last 24 hours. B. The client has made a suicide attempt within the last week. * The numbers in parentheses correlate to the number of t he 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 |
SUICIDAL IDEATION 347 C. The client has made a suicide attempt within the last month. D. The client denied any inter est in suicide currently and promised to engage in no self-harmful behavior. 6. Suicide Attempt History (6) A. The client reported a history of suicide attempts that have not been recent but did require professional and/or family/friend intervention to g uarantee safety. B. The client minimized his/her history of suicide attempts and treated the experience lightly. C. The client acknowledged the history of suicide attempts with appropriate affect and explained the depth of his/her depression at the time the suicide attempt occurred. D. The client indicated no current interest in or thoughts about suicidal behavior. 7. Family History of Depression (7) A. There is a positive family history of depression. B. There is a positive family history of suicide. C. The client acknowledged the positive family history of depression or suicide and indicated a concern as to the impact of this tendency on himself/herself. 8. Extreme Impulsivity (8) A. The client displayed an extreme level of impulsivity due to his/ her mania, psychosis, or other severe and persistent mental illness symptoms. B. The client displayed impulsive thoughts about committing suicide. C. The client has a history of acting on his/her impulsive thoughts due to mania, psychosis, or other sever e and persistent mental illness symptoms. D. As the client has stabilized his/her severe and persistent mental illness symptoms, he/she has decreased his/her level of impulsivity. 9. Increased Depression and Stress (9) A. The client displayed a signific ant increase in depressive symptoms, coupled with a recent increase of severe stressors. B. The client displayed a bleak, hopeless attitude toward life. C. The client has encountered significant losses, relationship problems, or other crises. D. As the client's depressive symptoms have stabilized, he/she has begun to cope with recent severe stressors. E. The client's severe depression has lifted, and he/she is no longer a suicide risk. INTERVENTIONS IMPLEM ENTED 1. Ask about Suicidal Ideation (1) * A. The client was asked to describe the frequency and intensity of his/her suicidal ideation, the details of any existing suicide plan, history of any previous suicidal attempts, and family history of depression or suicide. * The numbers in parentheses correlate to the number o f 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 |
348 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was encouraged to be forthright regarding the current strength of suicidal feelings and his/her ability to control such suicidal urges. 2. Perform a Risk Assessment (2) A. A suicide risk assessment was performed, including evaluating the nature of the client's suicidal state ments, specific plans, access to the means of suicide, and the degree of hope for the future. B. The impact of the client's other severe and persistent mental illness symptoms was considered as a risk assessment was performed. C. The risk assessment cond ucted regarding the client's suicidal ideation indicated no significant risk for suicide, and this was told to him/her. D. As the client's risk assessment has indicated a significant risk for suicide, additional intervention was warranted. 3. Arrange for Psychological Testing (3) A. The client underwent psychological testing to evaluate the depth of his/her depression and the degree of suicide risk. B. The Suicide Lethality Scale and the Beck Scale for Suicidal Ideation were administered to the client. C. The psychological test results were shared with the client, and the results indicate that his/her depression is severe and the suicide potential risk is high. D. The psychological test results were shared with the client, and the results indicate that his/her depression is moderate and the suicide potential risk is mild. E. The psychological test results were shared with the client, and the results indicate that his/her depression level has decreased significantly and the suicide risk is minimal. 4. Request Feedback from Support Network (4) A. The client's family members, friends, and caregivers were asked about his/her level of suicidal ideation and symptom intensity. B. The client's support network indicated significant suicidal ideation, and furt her steps to stabilize him/her were facilitated. C. Feedback from the client's support network indicated little concern regarding suicidal ideation and symptom intensity, and this was told to the client. 5. Obtain Clinical Supervision or Feedback (5) A. Clinical supervision was obtained regarding the necessary reaction to the client's current status. B. Clinical peers were contacted for feedback regarding the client's status and the necessary reaction. C. The use of clinical supervision or feedback has assisted in clarifying the most appropriate response to the client's suicidal ideation. 6. Obtain Emergency Medical Care (6) A. Emergency medical personnel were contacted regarding the client's suicide attempt in order to provide immediate care to him/h er. B. The client was assisted in obtaining emergency medical care for his/her suicide attempt. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SUICIDAL IDEATION 349 7. Arrange for Hospitalization (7) A. Because the client was judged to be uncontrollably harmful to himself/herself, arrangements were made for psychiatric h ospitalization. B. The client cooperated voluntarily with an admission to a psychiatric hospital. C. The client was referred to a crisis residential program with 24-hour trained staff. D. The client declined voluntary admission to a more secure setting, and he/she did not appear to qualify for involuntary commitment; the client was encouraged to use a crisis home or psychiatric unit. E. Contacts were made with the appropriate court or legal entity to involuntarily admit the client to a psychiatric unit until his/her suicidal crisis is alleviated. F. The appropriate court or legal entity has declined to involuntarily admit the client into a psychiatric unit, and this was told to him/her. G. The appropriate court or legal entity has decided that the clie nt is in need of involuntary hospitalization, and this was told to him/her. 8. Develop a Crisis Care Plan (8) A. A crisis care plan was developed, including supervision from caretakers, friends, and family. B. As the client appears to be in a suicidal c risis, his/her crisis care plan was implemented. C. The client was encouraged to voluntarily move forward with his/her crisis care plan. D. The client has declined the use of the crisis care plan, and closer monitoring of his/her safety was arranged. E. By using natural supports, such as the client's caretakers, friends, and family, his/her suicidal crisis has been averted. F. The client's natural supports do not appear capable of providing the level of safety that he/she needs, and a more structured en vironment was obtained. 9. Remove Lethal Weapons ( 9) A. Significant others were encouraged to remove firearms and other potentially lethal means of suicide from the client's easy access. B. Contact was made with significant others within the client's li fe to monitor his/her behavior and to remove potential means of suicide. 10. Recommend Medication Removal (1 0) A. It was recommended to the client's family and caregivers to limit the amount of available medication to a less-than-lethal or harmful dose. B. The client was advised that his/her medications have been removed from his/her access. C. The client's medications are being dispensed by others on a daily basis. 11. Develop a Suicide Prevention Contract (1 1) A. A suicide prevention contract was de veloped with the client that stipulated what he/she will and will not do when experiencing suicidal thoughts or impulses. B. The client was asked to make a commitment to agree to the terms of the suicide prevention contract and did make such a commitment. C. Verbal and written directions were provided to the client and his/her caregivers about where to call or go if the suicidal ideation persists or increases. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
350 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client was directed to contact the clinician or a 24-hour, professionally staffed crisis hotline if his/her suicidal ideation increases. E. The client declined to sign the suicide prevention contract and was told that arrangements would be made for commitment to a psychiatric facility or other supervised setting. F. The client was directed to go to an emergency room, local police unit, or other appropriate place should his/her suicidal ideation persist or increase. 12. Reinforce Positive Focus (1 2) A. The client was reinforced for his/her more positive focus and hopeful statements. B. As the client has been reinforced for his/her more positive focus and hopeful statements, he/she has been increasing such statements. C. It was noted that the client's suicidal ideation has decreased as he/she has continued to develop a more positive focus. D. The client did not display a very positive focus regarding his/her future and was provided with additional encouragement in this area. 13. Develop Structure (1 3) A. The client was directed to develop structure to his/her time, scheduling his/her acti vities for the next several hours or days. B. The client's specific plan for the next several hours or days was reviewed. C. The client has not developed structure to his/her time by the use of scheduling the next several hours or days and was redirected to do so. 14. Nurture Life-Affirming Part of Self (1 4) A. The client was reminded to focus on the portion of himself/herself that wants to go on living. B. The client's interaction with the clinician was noted as evidence that a part of him/her wants t o go on living. C. The client was supported as he/she focused on the part of himself/herself that wants to go on living. 15. Verbalize Context of Suicidal Ideation ( 15) A. The client's thoughts about suicide were identified as a common reaction to his/h er current problem areas. B. Emphasis was placed on the connection between the client's suicidal thoughts and emotional pain. C. The client acknowledged that his/her suicidal thoughts and comments are related to his/her emotional pain and began to proces s his/her emotional pain. D. The client was taught the importance of distinguishing between his/her thoughts of suicide and acting on those thoughts. 16. Talk Openly about Suicide Concerns ( 16) A. Concerns about the client's suicidal ideation were broug ht up in an open and honest manner. B. Emphasis was placed on the permanent nature of using suicide as a solution for a temporary problem or emotional state. C. The client was reinforced for his/her decreased focus on suicide as a solution for his/her temporary problems or emotional concerns. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SUICIDAL IDEATION 351 D. The client denied that his/her problems are temporary and does not see his/her way out of his/her current emotions; additional support, encouragement, and supervision were provided. 17. Discourage Denial of Suic idal Thoughts ( 17) A. The client was discouraged from disregarding or denying suicidal ideation. B. The client was reminded that disregarding or denying suicidal ideation generally leads to increased suicidal thoughts. C. The client was supported as he/ she talked openly and honestly about his/her suicidal ideation. D. It is suspected that the client is continuing to deny his/her suicidal ideation, and he/she was encouraged to be more open and honest. 18. Acknowledge Control of Suicidal Activity ( 18) A. The fact that the client is ultimately in control of his/her suicidal activity was acknowledged. B. The client's idea of suicide as an inadequate solution to stressors that he/she temporarily views as intolerable was reinforced. C. The client was suppo rted as he/she acknowledged that he/she is the one ultimately in control of his/her suicidal activity. D. The client tends to downplay his/her final responsibility for controlling his/her suicidal activity and was provided with additional direction in thi s area. 19. Provide Information about Treatment Options ( 19) A. The client's caregivers, friends, and family were provided with information about available treatment options. B. The client's family members were provided with feedback based on their conc erns for him/her. 20. Provide Information about Suicidal Ideation/Concerns (2 0) A. An appropriate authorization to release confidential information was obtained in order to advise the client's family, friends, and caregivers about his/her specific suicid al ideation/concerns. B. Because the client's crisis state meets the legal requirement for breaking confidentiality to preserve life, information was provided to the client's family, friends, or caretakers without a written release of information. C. The client's family members were reinforced for providing increased supervision and assistance to him/her as a result of being given additional information regarding his/her suicidal ideation. 21. Structure a Calm Environment (2 1) A. The client's family or caregivers were directed to structure his/her environment in order to reduce the level of stimulation. B. The agitated client was reassured about his/her safety and how the clinicians, family, and caregivers care about him/her. C. As the client was provi ded with a calm environment and reassurance that he/she will be cared for, his/her level of agitation and psychosis has decreased. D. Additional intervention was provided because the client remained quite agitated and continued to display symptoms of psyc hosis despite the more structured environment and support. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
352 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 22. Refer to a Physician (2 2) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychot ropic medications and was redirected to cooperate with this referral. 23. Educate about and Monitor Psychotropic Medications (2 3) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client' s psychotropic medications were reviewed, he/she 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 me dications and was provided with additional information and feedback regarding his/her medications. D. The client was monitored for compliance with, effectiveness of, and side effects from his/her psychotropic medication regimen. E. The client was provide d with positive feedback about his/her regular use of psychotropic medications. 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. 24. Review Side Effects of the Medications ( 24) A. The possible side effects related to the client's medications were reviewed with him/her. B. The client identified significant side effects, and these were rep orted to the medical staff. C. Possible side effects of the client's medications were reviewed, but he/she denied experiencing any side effects. 25. Identify Life Circumstances Contributing to Suicidal Ideation ( 25) A. The client was asked to identify l ife circumstances that have contributed to his/her suicidal ideation. B. The client was provided with support as he/she reviewed the life circumstances that have contributed to his/her suicidal ideation (e. g., the loss of a job or relationship, problems g etting along with others, or hallucinations/delusions). C. As the client has discussed his/her problematic life circumstances, he/she reported an increased hope for the future, and he/she was encouraged for this progress. D. As the client has discussed h is/her life circumstances, he/she continues to report suicidal ideation and was provided with additional support and supervision. 26. Inquire about Emotions ( 26) A. The client was probed about his/her feelings that may be contributing to suicidal ideatio n. B. The client was assisted in identifying how his/her feelings of hopelessness, anger, frustration, or sadness contribute to suicidal ideation. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SUICIDAL IDEATION 353 C. The client was encouraged to share his/her feelings in order to reduce their intensity. D. The client w as supported as he/she vented his/her emotions and reported decreased suicidal ideation. E. The client continues to be very cautious about expressing his/her emotions and was encouraged to do this at his/her own pace. 27. Identify the Emotional Effects o f Mental Illness Symptoms ( 27) A. The client was encouraged to identify the hallucinations and delusions that he/she experiences as a symptom of his/her mental illness. B. The client was reminded that the emotional reaction that he/she experiences due to the hallucinations and delusions is not reality-based. C. The client acknowledged that his/her hallucinations and delusions are symptoms of his/her mental illness, and the decreased emotional reaction that he/she experiences was processed. D. The client maintains his/her hallucinations and delusions as being based in reality, continues to experience severe emotional reactions, and was provided with additional feedback. 28. Label Suicidal Behavior as Avoidance of Transient Emotions ( 28) A. The client wa s presented with the concept of suicidal behavior as an avoidance of emotional pain. B. The client was focused on the passing nature and changing severity of his/her painful emotions. C. The client's experience was reviewed to identify his/her own use of suicidal behavior as an avoidance of emotional pain. D. The client accepted that his/her suicidal behavior was his/her technique to avoid emotional pain, and alternative options were developed. E. The client acknowledged that his/her negative emotions a re transient in nature, and he/she was urged to tolerate the pain of these passing negative emotions. F. The client denied his/her suicidal behavior as an avoidance of emotional pain and was given additional feedback regarding this concept. G. The client refused to accept that his/her negative emotions are transient in nature and was provided with additional feedback in this area. 29. Externalize Suicidal Ideation ( 29) A. The client was assisted in externalizing his/her suicidal ideation. B. Emphasis w as placed on the use of suicidal impulses as a warning sign that other issues need to be addressed. C. As the client identified his/her suicidal ideation as a warning sign, he/she has become more focused on the underlying issues and was provided with assi stance in processing these. D. The client tends to deny and avoid his/her underlying issues and was encouraged to address these as he/she is able to do so. 30. Provide Clear Directives (3 0) A. The client was provided with behavioral directives in a clea r, straightforward manner. B. The client was assisted in distinguishing between psychotic hallucinations/delusions and reality through the use of clear, straightforward information. C. Philosophical discussions or “why” questions were avoided. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
354 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. As the client has been provided with straightforward information, his/her ability to distinguish reality from psychosis has increased. E. The client continues to experience his/her hallucinations and delusions as reality-based despite significant information an d clear directives, and continued support and feedback were provided in this area. 31. Identify Hallucinations/Delusions ( 31) A. The client was assisted in identifying the hallucinations and delusions that tend to prompt his/her suicidal gestures. B. As the client discussed his/her hallucinations and delusions, he/she was provided with support and encouragement. C. The client was reminded about the unreality of his/her hallucinations and delusions. 32. Explore Coping Skills ( 32) A. The client's coping skills were explored that could assist him/her in decreasing psychotic thinking. B. The client was taught a variety of interventions to decrease his/her psychotic thinking (e. g., reducing external stressors, implementing distraction techniques, and seeki ng a reality check with caregivers). C. As the client has used his/her coping skills, it was noted that his/her psychotic thinking has decreased. D. The client's psychotic thinking persists, despite the use of coping skills and other interventions, and h e/she was provided with additional support in this area. 33. Identify Healthy Coping Practices ( 33) A. The client was assisted in identifying healthy coping practices that support optimistic, upbeat thinking patterns. B. The client was encouraged to imp lement his/her healthy coping practices (e. g., expressing emotions, social involvement, hobbies, or exercise). C. As the client has used his/her healthy coping practices, he/she has experienced a more positive, upbeat thinking pattern, and this was review ed with him/her. D. The client tends not to use healthy coping practices and was urged to do so. 34. Monitor Sudden Mood Shifts ( 34) A. The client's mood was monitored for sudden shifts from depressed and withdrawn to serene and at ease in spite of previ ously overwhelming problems. B. A significant mood shift was identified, indicating that the client may have decided to pursue a suicide attempt rather than to fight the stressors. C. The client seems to have decided to pursue the suicide attempt; theref ore, he/she was provided with more intensive supervision. 35. Assign a Positive Letter ( 35) A. During the client's period of stability, he/she was requested to write a letter to himself/herself regarding how positive and healthy his/her life could be. B. The client's letter to himself/herself regarding how positive his/her life can be was reviewed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SUICIDAL IDEATION 355 C. As the client has decompensated into a suicidal state, his/her letter about how positive and healthy his/her life can be was read to him/her. D. The clie nt was assisted in processing the letter from himself/herself in a more positive time, and his/her suicidal ideation has diminished. E. The client remains suicidal, despite the use of his/her own positive letter, and he/she was provided with additional su pport. 36. Develop Lists about Why to Go On ( 36) A. The client was asked to focus on the positive aspects of his/her life. B. The client was asked to develop a list of reasons why he/she should go on living. C. The client's list of positive aspects of his/her life and why he/she should go on living was processed. D. The client has failed to develop a list of positive aspects of his/her life and why he/she should go on living, and he/she was provided with additional feedback, support, and supervision. 37. Take the Reasons for Living Scale ( 37) A. The client was requested to take the Reasons for Staying Alive When You Are Thinking of Killing Yourself: Reasons for Living Scale (Linehan). B. The client's Reasons for Living Scale results were processed wi th him/her. C. The client has developed a more hopeful attitude as a result of taking the Reasons for Living Scale, and this was processed. D. The client has not developed a very hopeful attitude despite using the Reasons for Living Scale, and he/she was provided with additional feedback on this support and supervision. 38. Refer to a Support or Advocacy Group ( 38) A. The client was referred to a support group for individuals with severe and persistent mental illness. B. The client has attended the sup port group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. C. The client reported that he/she has not experienced any positive benefit from using a support group but was encouraged to contin ue to attend. D. The client was encouraged to become involved in local awareness and advocacy groups and functions. E. The client's involvement in local awareness and advocacy groups was processed. F. The client has not used the support group or advocac y group for individuals with severe and persistent mental illness and was redirected to do so. 39. Assess/Treat Substance Abuse ( 39) A. The client was evaluated for his/her use of substances, the severity of his/her substance abuse, and treatment needs a nd options. B. The client was referred to a clinician who is knowledgeable in both substance abuse and severe and persistent mental illness treatment in order to assess accurately his/her substance abuse concerns and treatment needs. C. The client was co mpliant with the substance abuse evaluation, and the results of the evaluation were discussed with him/her. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
356 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client was referred for substance abuse treatment. E. The client did not participate in the substance abuse evaluation and was encouraged to do so. 40. Teach Problem-Solving Skills ( 40) A. The client was taught problem-solving skills through modeling and didactic training. B. The client was taught specific problem-solving skills (e. g., focusing on the positive, negotiation, evaluating the pros and cons of alternatives, and practicing assertiveness). C. The client was provided with positive feedback as he/she displayed increased understanding regarding his/her use of problem-solving skills. D. The client continues to struggle with underst anding problem-solving skills and was provided with additional feedback in this area. 41. Teach Social Skills ( 41) A. The client was taught social skills through the use of modeling, role-playing, and behavioral rehearsal. B. The client was referred to a group training program for social skills. C. The client has developed increased social skills, and the benefits of this were reviewed. D. The client has not developed increased social skills, and he/she was urged to place more emphasis in this area. 42. Monitor Possible Crisis ( 42) A. The client was monitored more closely at possible crisis intervals (e. g., change in clinician, periods of loss). B. The client was provided with additional support and supervision as he/she is experiencing possible cris is periods. C. The client reported that he/she has been able to function well in his/her crisis situation due to the increased support that he/she has received. D. The client has decompensated, despite being more closely monitored and supported, and an increased level of service was provided. 43. Develop a Long-Term Plan ( 43) A. The client and his/her family were assisted in developing a long-term plan for dealing with stressors/symptoms contributing to his/her suicidal ideation. B. Specific long-term plans for monitoring and supporting the client were developed. C. The necessary portions of the client's long-term plan for support and coping with his/her stressors were coordinated. D. It was noted that as a result of the long-term plans, the client ha s decreased his/her pattern of suicidal ideation. E. A plan was developed to gradually taper the supervision of the client to a maintenance level. F. The client's other therapeutic needs are cared for; therefore, the level of contact with him/her has bee n tapered to a maintenance level. 44. Develop Personalized Crisis Cards ( 44) A. Personalized crisis cards were developed for the client, including a brief description of relapse prevention techniques, encouragement, and crisis contact numbers. B. The cl ient was provided with personalized crisis cards. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
SUICIDAL IDEATION 357 C. The client has used the personalized crisis cards and was encouraged to continue. D. The client has not used the personalized crisis cards and was redirected to do so. 45. Identify Suicidal Gestures I mpact ( 45) A. The powerful responses that others have to a suicidal gesture were reviewed with the client. B. The client was assisted in identifying and listing healthy ways in which he/she can have his/her need for attention and affirmation of caring me t, without eroding trust or acting in a dangerous, suicidal manner. C. The client received positive feedback as he/she has decreased his/her suicidal gesturing. D. The client was reinforced for identifying a variety of ways in which he/she can attempt positive attention. E. The client has not decreased his/her suicidal gestures, and was provided with additional feedback, support, and supervision. 46. Decrease Secondary Gain ( 46) A. A specialized treatment plan was developed to assist in decreasing seco ndary gain from suicidal gestures. B. An appropriate authorization to release confidential information was obtained in order to share the secondary gain treatment plan with other agencies that may be involved with the suicidal gestures (e. g., local emerge ncy room). C. The client's secondary gain for his/her suicidal gestures has been decreased, and he/she was focused on being more direct in order to meet his/her attentional and affirmational needs. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |