The Addiction Progress Notes Planner. Группа авторов

2022).

      2 * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Addiction Treatment Planner, Sixth Edition, by Perkinson, Jongsma, & Bruce (Wiley, 2022).

CHILDHOOD TRAUMA

      CLIENT PRESENTATION

      1 Physical/Sexual/Emotional Abuse (1)*The client reported having a history of physical/sexual/emotional abuse in childhood.The client reported that painful memories of childhood abusive experiences are intrusive and unsettling.The client reported that nightmares and other disturbing thoughts related to childhood abuse interfere with sleep.The client was able to discuss childhood abusive experiences without being overwhelmed with negative emotions.The client reported that emotional reactions associated with the childhood abusive experiences have been resolved.

      2 Addiction Used to Escape Emotional Pain (2)The client reported a pattern of using mood-altering substances to escape emotional pain tied to childhood traumas.As the client has worked through emotional traumas, substance use has decreased.The client reported no longer engaging in any substance use.

      3 Neglect Experiences (3)The client reported a history of parents who were neglectful of the client's emotional and physical needs.The client's feelings of low self-esteem, lack of confidence, and vulnerability to depression are related to childhood experiences of neglect.The client stated that their parents were involved with substance abuse and this led to neglect of their child-rearing responsibilities.The client was able to discuss childhood experience of neglect without becoming overwhelmed with negative emotions.

      4 Unresolved Psychological Conflicts (4)The client described a pattern of emotional and psychological discord caused by childhood abuse or neglect.The client identified a pattern of interpersonal conflict related to unresolved psychological effects of childhood abuse or neglect.As the client has worked through the pattern of childhood abuse, there have been fewer psychological and relational conflicts.The client reports decreased psychological conflicts and an increased sense of serenity.

      5 Irrational Fears (5)The client's early traumatic life experiences have led to continuing irrational fears in the present.As the client has developed insight into conflicts related to childhood, irrational fears have begun to diminish.The client reported a greater sense of security and serenity and an absence of previously held irrational fears.The client reports decreased addiction behavior as irrational fears have decreased.

      6 Suppressed Rage (5)The client reported that early painful experiences have resulted in feelings of anger and unexpressed rage.The client has begun to express rage toward their parents for their treatment during childhood.The client's level of anger has diminished, and the client reported a greater sense of peace.As the client's level of anger has diminished, the client has decreased addictive behaviors.

      7 Depression and Low Self-Esteem (5)The client reported feelings of low self-esteem and depression related to painful experiences of childhood.As the client has shared pain related to childhood experiences, the feelings of low self-esteem and depression have diminished.The client reported increased feelings of positive self-esteem and a lifting of depression.As the client has progressed in therapy, decreased symptoms of depression and increased self-esteem have resulted in a reduction in addictive behaviors.

      8 Identity Conflicts/Anxious Insecurity (5)The client reported struggles with identity and feelings of insecurity because of painful childhood experiences.The client reported a clearer sense of identity and more self-confidence as painful childhood experiences were processed.As the client has processed painful childhood experiences, they have experienced a decrease in addictive behaviors.

      9 Intrusive Memories (6)The client described experiencing intrusive, distressing thoughts or images that recall the childhood traumas and their associated intensive emotional response.The client reported a sense of control over the intrusive, distressing thoughts of the traumatic event.The client reported no longer experiencing intrusive, distressing thoughts of the traumatic event.

      10 Guilt (6)The client described a pattern of guilty feelings related to a history of childhood trauma.The client reported that as they have worked through the childhood traumas, their sense of guilt has diminished.The client reported no longer experiencing feelings of guilt related to childhood trauma.

      11 Emotional Numbing (6)The client reported an inability to experience a full range of emotions.The client reported beginning to be in touch with feelings again.The client is able to experience a full range of emotions.

      12 Unresolved Emotions (7)The client described a pattern of unresolved emotional conflict because of a history of childhood trauma.The client described a gradual decrease in unresolved emotional conflict.As the client has worked through the childhood trauma, they described a decreased pattern of unresolved emotional conflict.

      13 Maladaptive Behaviors (7)The client described a pattern of maladaptive behaviors to deal with the emotional and psychological conflicts related to the childhood trauma.The client has gained insight into how their maladaptive behaviors are a result of the childhood trauma.The client reported a decreased pattern of maladaptive or unsuccessful behaviors that have resulted from the childhood trauma.

      14 Inability to Trust Others (8)The client reported a pattern of difficulty trusting others, poor bonding in relationships, and problematic communication in interpersonal relationships because of the early childhood neglect or abuse.As the client has worked through their reaction to the childhood traumas, there has been less conflict within personal relationships as well as an increased pattern of trusting others.The client's partner reported that the client is irritable, withdrawn, and preoccupied with childhood trauma.The client and partner reported increased communication and satisfaction with the interpersonal relationship.

INTERVENTIONS IMPLEMENTED

      1 Build Trust and Establish Rapport (1)*Caring was conveyed to the client through support, warmth, and empathy.The client was provided with nonjudgmental support and a level of trust was developed.The client was urged to feel safe in expressing experiences of childhood trauma.The client began to express feelings more freely as rapport and trust level have increased.The client has continued to experience difficulty being open and direct about the expression of painful feelings; the client was encouraged to use the safe haven of therapy to express these difficult issues.

      2 Focus on Strengthening Therapeutic Relationship (2)The relationship with the client was strengthened using empirically supported factors.The relationship with the client was strengthened through the implementation of a collaborative approach, agreement on goals, demonstration of empathy, verbalization of positive regard, and collection of client feedback.The client reacted positively to the relationship-strengthening measures taken.The client verbalized feeling supported and understood during therapy sessions.Despite attempts to strengthen the therapeutic relationship the client reports feeling distant and misunderstood.The client has indicated that sessions are not helpful and will be terminating therapy.

      3 Assign Step 1 Exercise for Addiction and Childhood Trauma (3)A 12-step recovery program's Step 1 was used to help the client see the powerlessness and unmanageability that have resulted from using addiction to deal with the negative feelings associated with childhood traumas.The client was assigned the Step 1 exercise from The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client displayed an understanding of the concept presented regarding powerlessness and unmanageability regarding addiction and the negative feelings associated with childhood trauma.The client was able to endorse the concept of powerlessness and unmanageability that have resulted from using addiction to deal with negative feelings associated with childhood trauma; this progress was reinforced.The client denied any sense of powerlessness or unmanageability in regard to the use of addiction to deal with negative feelings associated with childhood traumas; the client was provided with tentative examples of this concern.

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