
The Adult Psychotherapy Progress Notes Planner
Description
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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 DSM 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
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Persons
ARTHUR E. JONGSMA, JR., PHD, is Series Editor for the bestselling PracticePlanners. He has provided professional mental health services to both inpatient and outpatient clients for approximately 50 years. He was the Founder and Director of Psychological Consultants, a group private practice in Michigan for 25 years.
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.
Content
PracticePlanners® Series Preface ix
Acknowledgments xi
Progress Notes Introduction 1
Anger Control Problems 3
Antisocial Behavior 18
Anxiety 34
Attention Deficit/Hyperactivity 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 Disorder (OCD) 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 Identity 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
ANGER CONTROL PROBLEMS
CLIENT PRESENTATION
- Episodic Excessive Anger (1)1
- The client described a history of loss of temper in response to specific situations.
- The client described a history of loss of temper that dates back many years, including verbal outbursts and property destruction, typically related to specific emotional themes.
- As treatment has progressed, the client has reported increased control of his/her/their situational episodic excessive anger.
- The client has had no recent incidents of episodic excessive anger.
- General Excessive Anger (2)
- The client shows a pattern of general, excessive anger across many situations.
- The client does not appear to be experiencing anger in response to specific issues, but as a general pattern.
- As treatment has progressed, the client has verbalized insight into his/her/their pattern of excessive anger.
- The client has made progress in controlling his/her/their pattern of excessive anger.
- Cognitive Biases Toward Anger (3)
- The client shows a pattern of cognitive biases commonly associated with anger.
- The client makes demanding expectations of others.
- The client tends to generalize labeling the targets of his/her/their anger.
- The client tends to have anger in reaction to perceived slights.
- As treatment has progressed, the subject displays decreased patterns of cognitive biases associated with anger.
- Evidence of Physiological Arousal (4)
- The client displayed direct evidence of physiological arousal in relation to his/her/their feelings of anger.
- The client displays indirect evidence of physiological arousal related to his/her/their feelings of anger.
- As treatment has progressed, the subject's level of physiological arousal has decreased as anger has become more managed.
- Explosive, Destructive Outbursts (5)
- The client described a history of loss of temper in which he/she/they have destroyed property during fits of rage.
- The client 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 client has reported increased control over his/her/their temper and a significant reduction in incidents of poor anger management.
- The client has had no recent incidents of explosive outbursts that have resulted in destruction of property or intimidating verbal assaults.
- Explosive, Assaultive Outbursts (5)
- The client described a history of loss of anger control to the point of physical assault on others who were the target of his/her/their anger.
- The client has been arrested for assaultive attacks on others when he/she/they have lost control of his/her/their temper.
- The client has used assaultive acts as well as threats and intimidation to control others.
- The client has made a commitment to control his/her/their temper and terminate all assaultive behavior.
- There have been no recent incidents of assaultive attacks on anyone, in spite of the client having experienced periods of anger.
- Overreactive Irritability (6)
- The client described a history of reacting too angrily to rather insignificant irritants in his/her/their daily life.
- The client indicated that he/she/they recognize that he/she/they become 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 client has made significant progress at increasing frustration tolerance and reducing explosive overreactivity to minor irritants.
- Physical/Emotional Abuse (7)
- The client reported physical encounters that have injured others or have threatened serious injury to others.
- The client showed little or no remorse for causing pain to others.
- The client projected blame for his/her/their aggressive encounters onto others.
- The client has a violent history and continues to interact with others in a very intimidating, aggressive style.
- The client has shown progress in controlling his/her/their aggressive patterns and seems to be trying to interact with more assertiveness rather than aggression.
- Harsh Judgment Statements (8)
- The client exhibited frequent incidents of being harshly critical of others.
- The client's family members reported that he/she/they react very quickly with angry, critical, and demeaning language toward them.
- The client reported that he/she/they have been more successful at controlling critical and intimidating statements made to or about others.
- The client reported that there have been no recent incidents of harsh, critical, and intimidating statements made to or about others.
- Angry/Tense Body Language (9)
- The client presented with verbalizations of anger as well as tense, rigid muscles and glaring facial expressions.
- The client expressed his/her/their anger with bodily signs of muscle tension, clenched fists, and refusal to make eye contact.
- The client appeared more relaxed, less angry, and did not exhibit physical signs of aggression.
- The client's family reported that he/she/they have been more relaxed within the home setting and has not shown glaring looks or pounded his/her/their fist on the table.
- Passive-Aggressive Behavior (10)
- The client described a history of passive-aggressive behavior in which he/she/they would not comply with directions, would complain about authority figures behind their backs, and would not meet expected behavioral norms.
- The client's family confirmed a pattern of the client's passive-aggressive behavior in which he/she/they would make promises of doing something, but not follow through.
- The client acknowledged that he/she/they tend to express anger indirectly through social withdrawal or uncooperative behavior, rather than using assertiveness to express feelings directly.
- The client has reported an increase in assertively expressing thoughts and feelings and terminating passive-aggressive behavior patterns.
- Time Bomb (11)
- The client tends to passively withhold feelings, and then explodes in a rage.
- The client seems to be "adding up" slights and irritations, waiting until enough have been "banked" and then explodes into a rage.
- The client appears to have rageful feelings under the surface, but presents in a passive manner.
- As treatment has progressed, the client has improved in regard to being able to express his/her/their feelings appropriately, and has decreased the reactive rage episodes.
- Overreaction to Perceived Negative Circumstances (12)
- The client seems to overreact to perceived disapproval, rejection, or criticism.
- The client can become angry even when no disapproval, rejection, or criticism exists.
- The client tends to have a bias toward his/her/their experience of disapproval, rejection, or criticism.
- As treatment has progressed, the client has decreased his/her/their pattern of overreaction to disapproval, rejection, or criticism.
- The client has decreased his/her/their angry overreaction to perceived disapproval, rejection, or criticism.
- Verbal Abuse (13)
- The client acknowledged that he/she/they frequently engage in verbal abuse of others as a means of expressing anger or frustration with them.
- Significant others in the client's family have indicated that they have been hurt by his/her/their frequent verbal abuse toward them.
- The client has shown little empathy toward others for the pain that he/she/they have caused because of his/her/their verbal abuse of them.
- The client has become more aware of his/her/their 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 client.
- Rationalization and Blaming (14)
- The client has a history of projecting blame for his/her/their angry outbursts or aggressive behaviors onto other people or outside circumstances.
- The client did not accept responsibility for his/her/their recent angry outbursts or aggressive behaviors.
- The client has begun to accept greater responsibility for his/her/their anger control problems and blame others less often for his/her/their angry outbursts or aggressive behaviors.
- The client verbalized an acceptance of responsibility for the poor control of his/her/their anger or aggressive impulses.
- The client expressed guilt about his/her/their anger control problems and apologized to significant others for his/her/their loss of control of anger.
- Aggression to Achieve Power and Control (15)
- The client appears to use aggression as a means to achieve power and control over others.
- The client uses veiled threats of aggression as a way to intimidate others.
- As treatment has progressed, the client has decreased aggression as mean of achieving power and control over others.
INTERVENTIONS...
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