The Adult Psychotherapy Progress Notes Planner. David J. Berghuis

irritability is high.The client's level of tension has decreased, sleep has improved, and irritability has diminished as new anxiety-coping skills have been implemented.

INTERVENTIONS IMPLEMENTED

      1 Establishing Rapport (1)²Caring 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 his/her/their anxiety symptoms.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 his/her/their expression of painful feelings; he/she/they were 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 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 Assess Nature of Anxiety Symptoms (3)The client was asked about the frequency, intensity, duration, and history of his/her/their anxiety symptoms, fear, and avoidance.The Anxiety and Related Disorders Interview Schedule for DSM-5 (DiNardo, Brown, and Barlow) was used to assess the client's anxiety symptoms.The assessment of the client's anxiety symptoms indicated that his/her/their symptoms are extreme and severely interfere with his/her/their life.The assessment of the client's anxiety symptoms indicates that these symptoms are moderate and occasionally interfere with his/her/their daily functioning.The results of the assessment of the client's anxiety symptoms indicate that these symptoms are mild and rarely interfere with his/her/their daily functioning.The results of the assessment of the client's anxiety symptoms were reviewed with the client.

      4 Administer Client-Report Measure (4)A client-report measure was used to further assess the depth and breadth of the client's anxiety responses.The Penn State Worry Questionnaire (Meyer, Miller, Metzger, and Borkevec) was used to assess the depth and breadth of the client's anxiety responses.OQ-45.2 (Lambert and Burlingame) was used to assess the depth and breadth of the client's anxiety responses at the outset of treatment.The Symptom Checklist-90-R (Derogatis) was used to assess the client's level of anxiety.The client-report measure indicated that the client's anxiety is extreme and severely interferes with his/her/their life.The client-report measure indicated that the client's anxiety is moderate and occasionally interferes with his/her/their daily life.The client-report measure indicated that the client's anxiety is mild and rarely interferes with his/her/their daily life.

      5 Refer for Assessment Regarding Etiology (5)The client was referred for an assessment to rule out nonpsychiatric medical etiologies for his/her/their anxiety.The client was referred for an assessment to rule out substance-induced etiologies for his/her/their level of anxiety.The client has complied with the referral and the results of this evaluation were reviewed.The client has not complied with the referral for a medical evaluation and was redirected to do so.

      6 Assess Level of Insight (6)The client's level of insight toward the presenting problems was assessed.The client was assessed in regard to the syntonic versus dystonic nature of his/her/their insight about the presenting problems.The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.The client was noted to be in agreement with others' concerns and is motivated to work on change.The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.

      7 Assess for Correlated Disorders (7)The client was assessed for evidence of research-based correlated disorders.The client was assessed in regard to his/her/their level of vulnerability to suicide.The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.The client has been assessed for any correlated disorders, but none were found.

      8 Assess for Culturally Based Confounding Issues (8)The client was assessed for age-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for gender-related issues that could help to better understand his/her/their clinical presentation.The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand his/her/their clinical presentation.Alternative factors have been identified as contributing to the client's currently defined “problem behavior,” and these were taken into account in regard to his/her/their treatment.Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.

      9 Assess Severity of Impairment (9)The severity of the client's impairment was assessed to determine the appropriate level of care.The client was assessed in regard to his/her/their impairment in social, relational, vocational, and occupational endeavors.It was reflected to the client that his/her/their impairment appears to create mild to moderate effects on the client's functioning.It was reflected to the client that his/her/their impairment appears to create severe to very severe effects on the client's functioning.The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.

      10 Refer for Medication Evaluation (10)The client was referred to a prescribing clinician to evaluate him/her for psychotropic medication to reduce symptoms of anxiety.The client has completed an evaluation by the prescribing clinician and has begun taking antianxiety medications.The client has resisted the referral to a prescribing clinician and does not want to take any medication to reduce anxiety levels; his/her/their concerns were processed.

      11 Monitor Medication Adherence (11)The client's adherence with the clinician's prescription for psychotropic medication was monitored for the medication's effectiveness and side effects.The client reported that the medication has been beneficial to him/her/them in reducing his/her/their experience of anxiety symptoms; the benefits of this progress were reviewed.The client reported that the medication does not seem to be helpful in reducing anxiety experiences; this was reflected to the prescribing physician.The therapist conferred with the prescribing clinician to discuss the client's reaction to the psychotropic medication and adjustments were made to the prescription by the clinician.

      12 Discuss Anxiety Cycle (12)The client was taught about how anxious fears are maintained by a cycle of unwarranted fear and avoidance that precludes positive, corrective experiences with the feared object or situation.The client was taught about how treatment breaks the anxiety cycle by encouraging positive, corrective experiences.The client was taught information from Mastery of Your Anxiety and Worry—Therapist Guide (Craske, Barlow, and O'Leary) regarding the anxiety pattern.The client was taught information from the book Treating GAD (Rygh and Sanderson).The client was reinforced as he/she/they displayed a better understanding of the anxiety cycle of unwarranted fear and avoidance and how treatment breaks the cycle.The client displayed a poor understanding of the anxiety and was provided with remedial feedback in this area.

      13 Discuss Target of Treatment (13)A discussion was held about how treatment targets worry, anxiety symptoms, and avoidance to help the client manage worry effectively.The reduction of overarousal and unnecessary avoidance were emphasized as treatment targets.The client displayed a clear understanding of the target of treatment and was provided with positive feedback in this area.The client struggled to understand the target of treatment and was provided with specific examples in this area.

      14 Assign Reading on Anxiety (14)The client was assigned to read psychoeducational chapters of books or treatment manuals on anxiety.The client was assigned information from Mastery of Your Anxiety and Worry—Client Manual (Zinbarg, Craske, Barlow, and O'Leary).The client was assigned to gather information from the book The Anxiety and Worry Workbook