The Adult Psychotherapy Progress Notes Planner. David J. Berghuis

gained more control over his/her/their impulses and has returned to a normal level of inhibition and social propriety.

      12 Bizarre Dress/Grooming (11)The client's grooming and style of dress were outlandish.The client showed little comprehension of the impact of his/her/their outlandish and bizarre dress and grooming practices.The client has shown better judgment in dress and has become more conventional in grooming habits.

      13 Expansive Moods/Irritability (12)The client gave evidence of a very expansive mood that can easily turn to impatience and irritability if his/her/their behavior is blocked or confronted.The client related instances of feeling angry when others tried to control his/her/their expansive, grandiose ideas and mood.As the client's expansive mood has been controlled, his/her/their impatience and irritable anger have diminished.

      14 Lack of Follow-Through (13)The client described a behavior pattern that reflects a lack of follow-through on many projects, even though his/her/their energy level is high, due to distractibility and impairment in discipline and goal directedness.The client's lack of follow-through on projects has resulted in frustration on the part of others.The client has begun to exercise more discipline and goal directedness in his/her/their behavior, resulting in the completion of projects.

INTERVENTIONS IMPLEMENTED

      1 Establish 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 bipolar mania 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 expression of painful feelings; he/she 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 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 Mania Intensity (3)The client was assessed for whether he/she/they were or have been hypomanic, manic, or manic with psychotic features.The client was assessed with the Young Mania Rating Scale (Young et al.).The client was assessed with the Clinical Monitoring Form (Sachs et al.).The client was assessed to be hypomanic.The client was assessed to be manic.The client's mania was noted to be so severe as to evolve into periods of psychosis.

      4 Assess Family Communication Patterns (4)Objective instruments were used to assess the family communication patterns.The level of expressed emotions within the family was specifically assessed.The Perceived Criticism Scale (Hooley and Teasdale) was used to assess family communication problems.The family was provided with feedback about their pattern of communication.The family has not been involved in the assessment of communication patterns, and the focus of treatment was diverted to this resistance.

      5 Refer for Physician Assessment Regarding Etiology (5)The client was referred to a physician to rule out nonpsychiatric medical etiologies (e.g. thyroid dysregulation, sedative use) for his/her/their bipolar disorder.The client was referred to a physician to rule out substance-induced etiologies for his/her/their bipolar disorder.The client has complied with the referral to a physician 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 Arrange Substance Abuse Evaluation (6)The client's use of alcohol and other mood-altering substances was assessed.The client was assessed to have a pattern of mild substance use.The client was assessed to have a pattern of moderate substance use.The client was assessed to have a pattern of severe substance use.The client was referred for a substance use treatment.The client was found to not have any substance use concerns.

      7 Assess Level of Insight (7)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.

      8 Assess for Correlated Disorders (8)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.

      9 Assess for Culturally Based Confounding Issues (9)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.

      10 Assess Severity of Impairment (10)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.

      11 Explore Suicide Potential (11)The client's experience of suicidal urges and his/her history of suicidal behavior were explored.Because the client's suicidal urges were assessed to be very serious, immediate referral to a more intensive supervised level of care was made.Due to the client's suicidal urges, and his/her/their unwillingness to voluntarily self-admit to a more intensive, supervised level of care, involuntary commitment procedures were begun.The client identified suicidal urges as being present but contracted to contact others if the urges became strong.It was noted that the client has stated that he/she/they do experience suicidal urges but feel that they are clearly under his/her/their control and that there is no risk of engagement in suicidal behavior.

      12 Monitor Ongoing Suicide Potential (12)The client was asked to report any suicidal urges or increase in the strength of these urges.The client stated that suicidal urges are diminishing and that they are under his/her/their control; he/she/they were praised for this progress.The client stated that he/she/they have no longer experienced thoughts of self-harm; he/she/they will continue to be monitored.The client stated that his/her/their suicide urges are strong and present a threat; a transfer to a more supervised setting was coordinated.

      13 Arrange Hospitalization (13)Arrangements were made for the client to be hospitalized in a psychiatric setting based on the fact that his/her/their mania is so intense that he/she/they could be harmful to self or others or unable to care for his/her/their own basic needs.The client acknowledged the need for the recommended hospitalization and voluntarily self-admitted to the psychiatric facility.The client was not willing to voluntarily submit to hospitalization; therefore, commitment procedures were initiated.

      14 Refer