The Adult Psychotherapy Progress Notes Planner
576
The Adult Psychotherapy Progress Notes Planner
576Paperback(6th ed.)
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Overview
PracticePlanners® THE BESTSELLING TREATMENT PLANNING SYSTEM FOR MENTAL HEALTH PROFESSIONALS
Fully revised and updated throughout, The Adult Psychotherapy Progress Notes Planner, Sixth Edition enables practitioners to quickly and easily create progress notes that completely integrate with a client’s treatment plan. Each of the more than 1,000 prewritten session and patient presentation descriptions directly link to the corresponding behavioral problem contained in The Complete Adult Psychotherapy Treatment Planner, Sixth Edition. Organized around 44 behaviorally-based problems aligned with DSM-V diagnostic categories, the Progress Notes Planner covers an extensive range of treatment approaches for anxiety, bipolar disorders, attention-deficit/hyperactivity disorder (ADHD), dependency, trauma, cognitive deficiency, and more.
Part of the market-leading Wiley PracticePlanners® series, The Adult Psychotherapy Progress Notes Planner will save you hours of time by allowing you to rapidly adapt your notes to each individual patient’s behavioral definitions, symptom presentations, or therapeutic interventions. An essential resource for psychologists, therapists, counselors, social workers, psychiatrists, and other mental health professionals working with adult clients, The Adult Psychotherapy Progress Notes Planner:
- Provides more than 8,000 prewritten, easy-to-modify progress notes summarizing patient presentation and the interventions implemented within the session
- Features sample progress notes conforming to the requirements of most third-party health care payors and accrediting agencies, including CARF, The Joint Commission (TJC), COA, and the NCQA
- Include a brand-new chapter that coordinates with the Treatment Planner’s chapter on loneliness
Additional resources in the PracticePlanners® series:
Treatment Planners cover all the necessary elements for developing formal treatment plans, including detailed problem definitions, long-term goals, short-term objectives, therapeutic interventions, and DSMTM diagnoses.
Homework Planners feature behaviorally based, ready-to-use assignments to speed treatment and keep clients engaged between sessions.
For more information on our PracticePlanners®, including our full line of Treatment Planners, visit us on the Web at:
www.wiley.com/practiceplanners
Product Details
| ISBN-13: | 9781119691181 |
|---|---|
| Publisher: | Wiley |
| Publication date: | 05/11/2021 |
| Series: | PracticePlanners |
| Edition description: | 6th ed. |
| Pages: | 576 |
| Sales rank: | 672,539 |
| Product dimensions: | 8.40(w) x 10.80(h) x 1.30(d) |
About the Author
DAVID J. BERGHUIS, MA, LLP, is President and Clinical Director for Berghuis Psychological Services, a leading provider of treatment for individuals with sexual behavior problems. He is President of the Michigan Chapter of the Association for Treatment of Sexual Abusers.
KATY PASTOOR, is a Limited Licensed Psychologist at Berghuis Psychological Services, working with patients with demonstrated sexual behavior problems. Her work includes the completion of risk assessments, the running of treatment groups, and conducting individual therapy with clients.
Read an Excerpt
ANGER MANAGEMENT
(The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Complete Adult Psychotherapy Treatment Planner, second edition [Jongsma and Peterson] by John Wiley & Sons, 1999.)
PATIENT PRESENTATION
1. Explosive, Destructive Outbursts
(1)The patient described a history of loss of temper in which he/she has destroyed property during fits of rage.The patient described a history of loss of temper that dates back to childhood, involving verbal outbursts as well as property destruction.As therapy has progressed, the patient has reported increased control over his/her temper and a significant reduction in incidents of poor anger management.The patient has no recent incidents of explosive outbursts that have resulted in destruction of any property or intimidating verbal assaults
2. Explosive, Assaultive Outbursts
(1)The patient described a history of loss of anger control to the point of physical assault on others who were the target of his/her anger.The patient has been arrested for assaultive attacks on others when he/she has lost control of his/her temper.The patient has used assaultive acts as well as threats and intimidation to control others.The patient has made a commitment to control his/her temper and terminate all assaultive behavior.There have been no recent incidents of assaultive attacks on anyone, in spite of the patient having experienced periods of anger.
3. Overreactive Irritability
(2)The patient described a history of reacting too angrily to rather insignificant irritants in his/her daily life.The patient indicated that he/she recognizes that he/she becomes too angry in the face of rather minor frustrations and irritants.Minor irritants have resulted in explosive, angry outbursts that have led to destruction of property and/ or striking out physically at others.The patient has made significant progress at increasing frustration tolerance and reducing explosive overreactivity to minor irritants.
4. Harsh Judgment Statements
(3)The patient exhibited frequent incidents of being harshly critical of others.The patient's family members reported that he/she reacts very quickly with angry, critical, and demeaning language toward them.The patient reported that he/she has been more successful at controlling critical and intimidating statements made to or about others.The patient reported that there have been no recent incidents of harsh, critical, and intimidating statements made to or about others.
5. Angry/Tense Body Language
(4) The patient presented with verbalizations of anger as well as tense, rigid muscles and glaring facial expressions.The patient expressed his/her anger with bodily signs of muscle tension, clenched fists, and refusal to make eye contact.The patient appeared more relaxed, less angry, and did not exhibit physical signs of aggression.The patient's family reported that he/she has been more relaxed within the home setting and has not shown glaring looks or pounded his/her fists on the table.
6. Passive/ Aggressive Behavior
(5) The patient described a history of passive-aggressive behavior in which he/she would not comply with directions, would complain about authority figures behind their backs, and would not meet expected behavioral norms.The patient's family confirmed a pattern of the patient's passive-aggressive behavior in which he/she would make promises of doing something, but not follow through. The patient acknowledged that he/she tends to express anger indirectly through social withdrawal or uncooperative behavior, rather than using assertiveness to express feelings directly.The patient has reported an increase in assertively expressing thoughts and feelings and terminating passive-aggressive behavior patterns.
7. Challenging Authority
(6)The patient's history shows a consistent pattern of challenging or disrespectful treatment of authority figures. The patient acknowledged that he/she becomes angry quickly when someone in authority gives direction to him/her.The patient's disrespectful treatment of authority has often erupted in explosive, aggressive outbursts.The patient has made progress in controlling his/her overreactivity to taking direction from those in authority and is responding with more acts of cooperation.
8. Verbal Abuse
(7)The patient acknowledged that he/she frequently engages in verbal abuse of others as a means of expressing anger or frustration with them.Significant others in the patient's family have indicated that they have been hurt by his/her frequent verbal abuse toward them.The patient has shown little empathy toward others for the pain that he/she has caused because of his/her verbal abuse of them.The patient has become more aware of his/her pattern of verbal abuse of others and is becoming more sensitive to the negative impact of this behavior on them.There have been no recent incidents of verbal abuse of others by the patient.
INTERVENTIONS IMPLEMENTED
1. Identify Anger
(1)The patient was assisted in becoming more aware of the frequency with which he/she experiences anger and the signs of it in his/her life.Situations were reviewed in which the patient experienced anger but refused to acknowledge it or minimized the experience.The patient has acknowledged that he/she is frequently angry and has problems with anger management.
2. Assign Books on Anger
(2)The patient was asked to read Of Course You're Angry(Rosellini and Worden) or The Angry Book (Rubin) to increase his/her understanding and experiencing of anger.The patient followed through and read the assigned material on anger, and key ideas from this material were processed within the session.The patient has not followed through on reading the assigned material and was encouraged to do so.The patient reported learning a lot from the material that was assigned, and he/she stated that he/she is more aware of the causes for and targets of his/her anger.
3. Assign Anger Journal
(3) The patient was assigned to keep a daily journal in which he/she would document persons or situations that cause anger, irritation, or disappointment.The patient has kept a journal of anger-producing situations, and this material was processed within the session.The patient has become more aware of the causes for and targets of his/her anger as a result of journaling these experiences on a daily basis.
4. List Targets of/Causes for Anger
(4)The patient was assigned to list as many of the causes for and targets of his/her anger that he/she is aware of.The patient's list of targets for and causes of anger was processed in order to increase his/her awareness of anger management issues.The patient has indicated a greater sensitivity to his/her angry feelings and the causes for them as a result of focusing his/her attention on these issues.
5. Confront Session Anger
(5)When the patient seemed to be experiencing anger during the session, but would minimize or deny it, he/she was confronted.The patient reacted with increased denial, minimization, and rationalization when confronted about his/her feelings of anger.The patient has become more accepting of his/her feelings of anger being confronted.The patient's anger, reflected back to him/her, has increased his/her awareness of feelings of anger.
6. Anger Management Group Referral
(6) The patient was referred to a group that teaches anger management and sensitivity to the feelings of others.The patient has followed through with the referral to an anger management group and has attended consistently.The patient has refused to follow the recommendation to attend an anger management class.The patient has developed, through attending an anger management group, an increased awareness of his/her anger expression patterns and a means of anger control.
7. Identify Anger Expression Models (7) The patient was assisted in identifying key figures in his/her life that have provided examples to him/her as to how to positively or negatively express anger.The patient identified several key figures who have been negative role models in expressing anger explosively and destructively.The patient acknowledged that he/she manages his/her anger in the same way that an explosive parent figure had done when he/she was growing up.The patient was encouraged to identify positive role models throughout his/her life that he/she could respect for their management of angry feelings. The patient acknowledged that others have been influential in teaching him/her destructive patterns of anger management.
8. List Own Hurtful Experiences
(8)The patient was assisted in identifying those painful and hurtful experiences from his/her past that have led to feelings of anger and revenge.The patient reported a significant history of verbal and physical abuse, which fueled his/her anger toward others.As the patient has shared experiences of pain and hurt from the past, he/she has become less reactive with anger in the present.
9. Empathize with Hurtful Feelings
(9)The therapist empathized with the patient's pain from past hurtful experiences and assisted him/her in clarifying reasons for this pain and the other feelings that were triggered by the pain. The patient's traumas of the past were explored to help him/her clarify his/her feelings of hurt, disappointment, and suppressed rage.As the patient has gained understanding and empathy within the therapy sessions regarding his/her feelings of pain from past traumas, his/her expressions of anger have diminished.
10. Assign Assertiveness Classes
(10)The patient was assigned to attend assertiveness training classes to gain a greater understanding of ways to express feelings directly, constructively, and in a controlled fashion.The patient has followed through with attendance at assertiveness training classes and has learned more adaptive ways to express thoughts and feelings.The patient has not followed through on the recommendation to attend assertiveness classes and was encouraged to do so.The patient's attendance at assertiveness training has taught him/her increased skills at expressing himself/herself with control.
11. Process Recent Anger Outbursts
(11)Incidents of recent anger outbursts by the patient were processed, and alternative adaptive ways to express that anger were reviewed.The patient has begun to implement alternative, positive ways to express anger in a controlled fashion. The patient expressed feeling good about the fact that he/she was capable of expressing anger in a more controlled, assertive way that did not negatively impact others.
12. Role-Play Anger Control
(12)Role-playing techniques were used to teach the patient non-self-defeating ways of managing angry feelings.The patient has learned to utilize assertive methods versus aggressive methods to express anger.The patient has implemented assertive methods learned through the role-playing techniques and has reported success at managing anger more adaptively.
13. Assign Anger Management Exercise
(13)The patient was assigned an anger management exercise from a workbook. The patient completed the assigned anger management exercise, and the material produced was processed.The patient has learned to decrease the number and duration of his/her angry outbursts as a result of completing the workbook exercise.The patient has not followed through with completing the assigned workbook exercise on anger management and was encouraged to do so.
14. Teach Relaxation Techniques
(14)The patient was taught deep-muscle relaxation, rhythmic breathing, and positive imagery as ways to reduce muscle tension when feelings of anger are experienceThe patient has implemented the relaxation techniques and reported decreased reactivity when experiencing anger. The patient has not implemented the relaxation techniques and continues to feel quite stressed in the face of anger.
15. List Negative Anger Impact
(15)The patient was assisted in listing ways that his/her explosive expression of anger has negatively impacted his/her life.The patient identified many negative consequences that have resulted from his/her poor anger management.The patient's denial about the negative impact of his/her anger has decreased, and he/she has verbalized an increased awareness of the negative impact of his/her behavior.
16. Identify Bodily Impact of Anger
(16)The patient was taught the negative impact that anger can have on bodily functions and systems.The patient indicated an increased awareness of the stress of his/her anger on such things as heart, brain, and blood pressure.The patient has tried to reduce the frequency with which he/she experiences anger in order to reduce the negative impact that anger has on bodily systems.
17. Empty-Chair Technique
(17)The empty-chair technique was used to approach the patient in expressing angry feelings in a constructive, non-self-defeating manner.The patient identified several instances in his/her daily life in which the adaptive means of expressing anger, learned through the empty-chair technique, were able to be used.The patient reported success at implementing constructive ways of expressing anger and terminating verbal and physical abusive ways of expressing anger.
18. Identify Anger Triggers
(18)The patient was assisted in increasing his/her ability to recognize triggers that lead to explosive expressions of anger.The triggers for anger experience were listed, and coping mechanisms for each trigger were identified.The patient has implemented effective coping mechanisms for his/her hot buttons for anger, and this has reduced aggressive anger expression.
19. Utilize Rational Emotive Therapy Techniques
(19)The patient was trained in the use of rational emotive therapy (RET) techniques for coping with feelings of anger, frustration, and rage.The patient has implemented the techniques that he/she learned in managing anger.The patient has successfully implemented rational emotive therapy techniques to reduce aggressive reaction to anger triggers.
20. Assign Anger Letter
(20)The patient was asked to write a letter expressing his/her feelings of anger toward the targets of those feelings, focusing on the reasons for his/her anger toward that person.The patient has written an anger letter and his/her reasons for feeling anger were processed.The patient reported that his/her feelings of anger have diminished since he/she wrote the anger letter and processed the causes for his/her anger.
21. Encourage Anger Expression
(21) The patient was encouraged to express and release his/her feelings of rage and violent urges that are felt toward others.The patient was cautioned to exercise control over these feelings even though he/she was encouraged to express such angry feelings within the session.The patient showed a high degree of rage and seemed to indicate little interest in trying to control it.The processing of the patient's feelings of anger and rage have diminished these feelings and increased his/her sense of control over them.
22. Teach Forgiveness
(22)The patient was taught about the process of forgiveness and encouraged to begin to implement this process as a means of letting go of his/her feelings of strong anger.>The patient focused on the perpetrators of pain from the past, and he/she was encouraged to target them for forgiveness.The advantages of implementing forgiveness versus holding onto vengeful anger were processed with the patient.The patient has committed himself/herself to attempting to begin the process of forgiveness with the perpetrators of pain.
23. Assign Forgive and Forget
(23)The patient was assigned to read the book Forgive and Forget (Smedes) to increase his/her sensitivity to the process of forgiveness.
24. Assign Forgiveness Letter
(24)The patient was asked to write a letter of forgiveness to the target of his/her anger as a step toward letting go of that anger.The patient has followed through with writing a letter of forgiveness to the perpetrator of pain from his/her past, and this was processed within the session.The patient has not followed through with writing the forgiveness letter and is very resistive to letting go of his/her feelings of angry revenge.Writing and processing the letter of forgiveness have reduced the patient's feelings of anger and increased his/her capacity to control its expression.
Table of Contents
PracticePlanners® Series Preface ix
Acknowledgments xi
Progress Notes Introduction 1
Anger Control Problems 3
Antisocial Behavior 18
Anxiety 34
Attention Deficit Disorder (ADHD)-Adult 47
Bipolar Disorder-Depression 61
Bipolar Disorder-Mania 76
Borderline Personality 90
Childhood Trauma 103
Chronic Pain 113
Cognitive Deficits 128
Dependency 139
Depression-Unipolar 152
Dissociation 167
Eating Disorders and Obesity 175
Educational Deficits 190
Family Conflict 200
Female Sexual Dysfunction 212
Financial Stress 226
Grief/Loss Unresolved 236
Impulse Control Disorder 248
Intimate Relationship Conflicts 260
Legal Conflicts 272
Loneliness 280
Low Self-Esteem 293
Male Sexual Dysfunction 304
Medical Issues 317
Obsessive-Compulsive and Related Disorders 330
Opioid Use Disorder 343
Panic/Agoraphobia 358
Paranoid Ideation 371
Parenting 380
Phase of Life Problems 395
Phobia 405
Posttraumatic Stress Disorder (PTSD) 416
Psychoticism 431
Sexual Abuse Victim 443
Sexual Orientation Confusion 454
Sleep Disturbance 464
Social Anxiety 475
Somatization 488
Spiritual Confusion 501
Substance Use 510
Suicidal Ideation 525
Type A Behavior 540
Vocational Stress 553
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