Procedure Note
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Responsive To Open Ended Questions
Resistant To CareResistant
Receptive To Intervention
Explored Responsive To Attentive Listening
Engaged
Endorses

Endorsed/Discussed The Following Problems

Displayed The Following Behaviors In Session
Described
Continuing To Reflect On
Agreed To
Began To Express Feelings More Freely As Rapport /The Trust Level Increased
Responsive to Cognitive Restructuring
Discussed
Pessimistic
Participated In TraumaParticipated In
Identified Feeling
Expresses Envy Anger At Other Individuals' Comparatively Better Performance
Completed Exercises From A Workbook
Endorses
Appears To Be Developing Greater Insight As
Shared Disclosed
Process Key Ideas



complete an in vivo exposure today,
address negative thought distortion,
practiced re-framing.
Patient practiced normalizing their feelings and using alternative reactions.
Discussed ??.
Practiced using thought diffusion and self soothing.

Acknowledges intellectual understanding but emotionally struggles


Pt discussed pros and cons of


Continues to struggle with strongly held schemas/interpersonal conflicts

Patient participated in CBT.
Patient participated in Trauma-Based CBT


Continues to...
Endorse
Continuing To
Grieve The Loss Of
Struggle W
Self-Criticism
Sensitivity To Others' Perceptions
Feel Stress Related To Dealing With
Strongly Held Schemas/Interpersonal Conflicts
Understanding Relational Cues
Make Progress In Therapy
Continuing To Engage In Coping Efforts
Continuing To Reflect On


continues to struggle with understanding relational cues.
expresses envy and anger at other individuals' comparatively better performance.
has been struggling with tolerating feelings of loneliness.
has been struggling with feelings of dysphoria;
has been having problems motivating him/herself into meaningful action.
has been struggling with recognizing the physiological and affective cues of her/his affective states.
has been struggling maintaining a regular schedule, especially in face of persisting amotivation and fatigue associated with dysphoria/depression.
continues to struggle with self-criticism; continues to evince tendency to engage in self-blame.
continues to struggle with sensitivity to others' perceptions; reporting feelings of hurt and disappointment.
Symptoms:NormalTearfulnessChange in AppetiteMotivationSleep ChangeEnergy Level ChangeInterest Level ChangeChange in Sex DriveObsessions/CompulsionsAnxiety:NormalHigh-StrungPanic AttacksStage FrightPhobiaScared to leave the house
Somatic Symptoms (Palpitation, Hyperventilation, Sweating)Other


Response:

Symptoms:
Mild
Moderate
Severe

Neutral


Favorable

Unfavorable

Maintaining Baseline
Improvement of mental health symptoms
Improvement of mood/affect
Improvement of thought process/content
Improved coping skills
Reduced coping skills
Worsening of mental health symptoms
Worsening of mood/affect
Worsening of thought process/content
PROGRESS TOWARD GOALS (SINCE LAST MEETING)
PROGRESS:
No Progress
pt has made no progress.
No change in mental status
Small Progress
Increasing
Exceptional
Variable
Steady
Moderate Progress
Slow
Regressing
Decreasing
Deterioration
Stable
Significant Progress
Maintaining
Discharge Plan

continues to make progress in therapy.
Improved
necessary adjustments to the treatment planCognitive impairment not observed in this interactionCognitive impairment concern expressed by family members, care givers and/or friends: ??
No change in mental statusImprovement of mental health symptomsImprovement of mood/affectImprovement of thought process/contentImproved coping skillsWorsening of mental health symptomsWorsening of mood/affectWorsening of thought process/contentReduced coping skills
New issues/Stressors Presented today: Participation:None reportedSYMPTOMS/SEVERITY:NOTES:
continues to make progress in therapy


Reviewed developmental, family, psychosocial, psychiatric, medical, academic, and occupational history
Reviewed symptoms and functioning in life domains. Treatment planning
Session Content: ??
Patient reports positive change in stressors: ??
Patient reports negative change in stressors: ??
Suicidality not present
Homicidality not present
Patient denies suicidal ideation
Patient denies homicidal ideation
Patient reports suicidal ideation: ?? Intent: ?? Plan: ??
Patient reports homicidal ideation: ?? Intent: ?? Plan: ??
Patient reports drug/alcohol use/abuse: ??
Patient reports medication compliance
Patient reports medication noncompliance: ??
Strengths/limitations affecting progress: ??
Patient stated: ??
Patient described: ??
Session addressed treatment goals specific to DSM diagnosis
Session addressed impact and mitigation of symptoms as related to physical health and/or medical conditions(s)


Subjective Summary of Family Session: ??

Goals of Session:


Discussion:


Level of participation: [] High [] Medium [] Low [] None :

Goal Achieved:

Clinician Comments/ Recomendations: ??
Strengths identified: ??
Barriers identified: ??


Self Care
Consistently Not Sleeping Well
Low/Lacking
Met Unmet
Maintaining
Intensity
Less Severe
More Severe
Moderate/Severe
Moderate
Stressors
Unfavorable
Support
Steady
Unable To Sleep
Variable
Solving Strategies
Resolved
Remains Rather
Remains
Regressing
Psychosocial Environmental Issues Addressed
Improved
Identified His/ Her Distorted
Future Goals/Plan
Functioning
Frequency
Favorable
Experiencing Difficulty
Continuing To Reflect On
Much Worse
Negative For
New Issues/StressorsYes No
More Physical Exercise
Sad Feelings Surrounding Those Experiences Have Diminished
To Help Manage
Small
Skills Training
Session Addressed Treatment Goals Specific To Dxs
Talking To Someone
The Skills Practiced Since The Last Session
Solving Attempts Discuss New Alternatives That Are AvailableSolving
Positive For
Maintaining Baseline
Initially
Increased Social Involvement
Improved Necessary Adjustments To The Treatment Plan
Impairments
Doing Something That Is DistractingDoing Something Physical Like Walking
Efficacy
Distress Tolerance Appropriate Behaviors When In Her Presence
Displays A Significant Interest Engagement In Activities
Disruption
Decreasing
Concerns Decline/Function
Better
Approach To Overcome The Behaviors
Deterioration
Analyze Goals To Make Sure They Are Realistic/Attainable
The Same As It Has Been
Somewhat Worse Than It Has Been
Significantly Worse Than It Has Been
Much Worse
Significantly Worse Than It Has Been
Better
Has Progressed In Therapy Goals To The Level That Session Frequency Will Be Reduced
Has Gained Some Insight Into How These Traumatic Experiences Impact Current Functioning
Progress Toward Goals Since Last Meeting
Has Made No Progress
Continues To Make Progress In Therapy
Less Able
Much Less Able
Able
Steady
Small
Slow
Significant
More Severe
Moderate
Decrease In Disturbing Persistent Thoughts
Continued
Decrease In
Decrease In Excessive Worry
More Control
Occurring More Days Than Not
Decrease In Hypervigilance Fear That Something Bad Is Going To Happen
Decrease In Motor Tension Such As Restlessness
Drug/Alcohol Use/Abuse
Experiencing
Feeling
Feeling Lonely
Increase in Ability To Identify Express Feelings
Increase In Previously Avoided Activities
Medication Compliance
Medication Noncompliance
Negative Change In
No Change
No Change In Mental Status
No Distress Related To The Targeted Memory
None Reported
Positive Change In Stressors
Reduction Overall Frequency
Reported
Reported Experiencing The Following Sx
Reported Increase In Personal Hygiene Self
Reported Positive Traits Talents About Self
Shows Motivation To Change
Has Been Struggling Maintaining A Regular Schedule
Has Been Having Problems Motivating Him/Herself Into Meaningful Action
Reduced Coping Skills
Inability To Enact Coping
Improved Coping Skills
Continuing To Engage In Coping Efforts
Change In Coping Ability/Skills
Pain Experiences Gained Insight As To This Has Contributed To Depression
Has Begun To Open Up About His/Her Childhood Experiences

Has Been Feeling This Way For


Responded Appropriately


Learned Calming Coping Skills
Agreed To Implementation To Reduce Overall Anxiety Manage

Identified Painful Childhood Experiences That Have Continued To Foster Feelings

Focused On
Coping Skills
Sleep Disturbance/Sleep Problems
Coping

Using Positive Self Talk
Coping

Continues To Evidence Tendency To Engage In Self-Criticism
Continues To Endorse

Agreed To Utilize Coping Strategies
Continues To Struggle W



Able To Explore
Able To Describe

The Skills Practiced Since The Last Session
Talking To Someone


More Consistent Eating Sleeping Pattern
Talkative
Regressing




Reduce

Moderate Severe Response

Minutes
Minimal
Mild
Met Unmet
Maintaining Baseline
Maintaining
Less Severe
Less Internal Focus
Increasing
Increased Social Involvement
Improved
Impairments
Impairment
Improved Necessary Adjustments To The Treatment Plan
Functioning
Action
Active

Abruptly Leaving Therapy

Stressors

Also Changes Anxiety SpecificConsistently Not Sleeping WellContinuedDecrease InDecrease In Disturbing Persistent ThoughtsDecrease In Excessive Worry More Control Occurring More Days Than NotDecrease In Hypervigilance Fear That Something Bad Is Going To HappenDecrease In Motor Tension Such As RestlessnessDrug/Alcohol Use/AbuseExperiencingFeelingFeeling LonelyHis/ Her Ability To Identify Express FeelingsIncrease In Previously Avoided ActivitiesMedication ComplianceMedication NoncomplianceNegative Change In ReNo ChangeNo Change In Mental StatusNo Distress Related To The Targeted MemoryNone ReportedPositive Change In StressorsReduction Overall FrequencyReportedReported Experiencing The Following SxReported Increase In Personal Hygiene SelfReported Positive Traits Talents About SelfShows Motivation To ChangeThat
Less SevereLess Internal Focus
Moderate Severe Response
ModerateMinutesMinimalMild
SteadyMore Consistent Eating Sleeping PatternStableStabilize Maladaptive Behaviors
Identified His/ Her DistortedIdentified Goals Accomplishments That Would Improve Self
New Issues/StressorsNew Issues Presented Today? Yes NoNeutral




Less Internal Focus
Minutes
Minimal
Mild
More Consistent Eating Sleeping Pattern
Stable
Stabilize Maladaptive Behaviors
Reduce
Identified Goals Accomplishments That Would Improve Self
Neutral
Slow
Increasing
Impairment
Images
Verbalized A Plan To Achieve Those Goals
Decrease In

Constipation
Copd
Fatigue
Headaches
Hallucinations
Vomiting
Upset Stomach
Tremors
Nausea
Memory
alcohol/Drugs
Medical


REVIEW OF SYSTEMS


Positive for:


Negative for:
blunt affect.
disorganized thought process.


dizziness.


flat affect.
inappropriate affect.
incoherence.
agitation
emotional lability
rapid speech.
sweating.
tremors.
vomiting.
REVIEW OF SYSTEMS
Positive for:
Negative for:
blunt affect.
disorganized thought process.
dizziness.
flat affect.
inappropriate affect.
incoherence.
agitation
emotional lability
rapid speech.
sweating.
tremors.
vomiting.


Endorsed/Discussed The Following Problems
Endorses
Discussed The Following Topics
Discussed


Treatment Planning
Traumatic Stress Disorder Its Treatment
Uncontrolled Spending
Thoughts Feelings
Social Conflict/Stressors
Social Activities
Social Isolation
Social Discomfort
Sleep Disturbance
Sexual Activity
Self-talk Messages Used To Reinforce Low Self Esteem
Self-Talk Messages To Build Self
Self Care
Sadness
Relationships
Relationship Problems
Stressors
Sexual Problems
Seasonal Affective Disorder
Recreational
Recurring Disturbing Memories
Psychosocial Environmental Issues Addressed
Problems W Peers/Roommate
Problems Related To
Personal Problems
Personal History Relationship
Personal History
Peer Intimate Relationship Problems
Peers/Roommate
Peer Intimate Relationships
Participation In Activities Financial Issues Housing Problems
Participation In Activities
Participated In
Participation
Parenting
Parenting Problems
Paranoia
Panic Attacks
Panic Disorder
Pain
Others Taking Over Responsibilities
Onset
Occupational History
Nothing Thinking
Nothing All
Noncompliance
Negative Beliefs About Self The World
Motivation
Medical
Marriage/Spouse/Divorce
Low/Lacking Self
Low Self Worth
Low Energy
Loss
Loneliness
Limited Social Supports
Irritability Irritability/Anger
Intrusive Thoughts
Interpersonal Conflict
Intense Unstable Personal Relationships
Frequent Arguments
Family History
Failure To
Dysfunctional Interpersonal Relationships
Abuse
abusive Relationships
Academic
Acceptance

Addiction
Adjustment
Adjustment/Situational


Uncontrolled Spending
Discussed The Following Topics
Discussions Related To The Traumatic Event
Content Or Topics Discussed
Social Isolation
Self-talk Messages Used To Reinforce Low Self Esteem | Self-Talk Messages To Build Self Esteem
Secondary Gain
SeasonalSadness
RelationshipsRelationship Problems
Recurring Disturbing Memories
Problems W Peers/RoommateProblems Related To
Pornography
Phobia Extreme Anxiety/Panic
Personal Problems/Personal History
Personality Disorder
Noncompliance
Others Taking Over Responsibilities
Pain
Low/Lacking SelfLow Self WorthLow EnergyLossLonelinessLimited Social Supports
Verbalize Emotions & Express Needs
TirednessThoughts FeelingsThoughts
Socially IsolatedSocialSleep DisturbanceSleepPsychosocial
Parenting ProblemsParentingPanic DisorderPanic AttacksOnsetOcdOccupational HistoryObsessive Thoughts ParanoiaObsessive ThoughtsNightmaresNegative SelfNegative Beliefs About Self The WorldMotivationMarriage/Spouse/DivorceMajor Depressive DisorderLability Sadness/Depression
How They Have Impacted His/ Her Feelings About Himself/ Herself
Traumatic EventHopelessness
HelplessnessGuiltgrief/Frequent Arguments
Emotions
Blame
Diet Exercise
Divorce
Couple Relationship Issues
Control
Conflict/Stressors
Conflict/Conflict Resolution
Communication
Cognitions That Have Been Identified As Causing Problems In His/ Her Life
Chronic Illness
Cbt
Flashbacks
Death/Dying
Depression
Avoidance
Appetite Disturbance
Autism Spectrum Disorder
Binge Drinking
Being Alone
Behavior Therapy
Chronic
Childhood
Catastrophizing
Caregivers /Or Friends
Caregiver Burden
Care
Cancer Diagnosis
Cancer
Computer Addiction
Compulsive Behavior
Consequences
Crying Spells
Descriptive Statements
Criticism
Dialectical Strategies
Devil’s Advocate
Emotional Experience Related To Diagnosis
Dysfunctional Interpersonal Relationships
Feelings
Fearfulness
Family History
Family
Failure To
Exposure
Impulsive/Impulse
Intense Unstable Personal Relationships
Intense Fear
Irritability Irritability/AngerIntrusive Thoughts
Interpersonal Conflict
Peer Intimate Relationships
Peer Intimate Relationship Problems
Participation In Activities Financial Issues Housing Problems
Participation In Activities/Participation
Recreational
Personal Relationship
Seasonal Affective Disorder
Social Discomfort
Social Conflict/Stressors
Social Activities
Achievements In His/ Her Life
FUNCTIONING

Acceptance
Adjustment/Situational Concerns
Decline/Function
Decrease in Participation in Activities
Financial Issues
housing problems
Identification Of Coping Mechanisms
inability to enact coping
Lack Of Coping Skills
Lack Of Motivation


Medical
Alcohol/Drugs
Caregiver Burden
Coping with Chemotherapy
Current Emotional Distress Of Recent Cancer Diagnosis
Diagnosis Of Copd
Fatigue
Headaches
Memory
Nausea
Pain
Personal History
Resistant to Care
Sleep
Death/Dying


nutrition history
hx of Eating Disorder
Constipation
Appetite Disturbance
Diet Exercise


SOCIAL
Abuse
Assertiveness
Dysfunctional Interpersonal Relationships
Family Problems
Failure to Verbalize Emotions & Express Needs
interpersonal conflict
Marriage/Spouse/Divorce
Marital or Couple Relationship Issues
Peer and intimate relationship problems
Problems w Peers/Roommate
social conflict/stressors
Social Discomfort
Social Isolation
Unrealistic Expectations


psych
Impulse Control
Chronic PTSD
intrusive thoughts associated with traumatic event
Emotional Experience Related To Diagnosis
Nightmares
Frequent Arguments
Wide Mood Swings
Recurring, Disturbing Memories


DEPRESSION
depression
emotional blunting
Feelings of Worthlessness
Guilt
Grief/Loss
Low/Lacking Self-Esteem
Mood Lability
Feelings Of Guilt Or Worthlessness
Seasonal Mood Changes


ANXIETY
Specific Phobia
extreme anxiety/panic
Obsessive Thoughts
Flashbacks
Unable To Sleep
Autism Spectrum Disorder
Fearfulness
Impulsive/Impulsivity
Thoughts Of Death
self-harm/suicidal ideation


ADDICTION
Computer Addiction
Cognitive Impairment
Paranoia
Compulsive Behavior
Gambling Problems
Problems With Pornography

psych symptoms/diagnoses
Anhedonia (Loss Of Interest)
Chronic PTSD Major Depressive Disorder, Anxiety, Panic Disorder Major Depressive Disorder, Seasonal Affective Disorder Panic Attacks Panic Attacks, General Anxiety, Insomnia



Psychosis
Auditory HallucinationsHearing voices
Racing ThoughtsRapid Or Pressured SpeechNightmaresNightmares/Recurrent And Intrusive Memories Of A Traumatic ExperienceObsessive ThoughtsparanoiaParanoid Personality Disorderintrusive thoughts intrusive thoughts associated with traumatic eventHypervigilance And Scanning



personal problems
Computer Addiction



Mood
BoredomMood InstabilityMood LabilitySadness/depression Seasonal mood changes
IrritabilityIrritability/anger



Anxiety
Anxiety/worry Apprehensive Expectation
OCD Heightened Anxiety Panic Disorder
Avoidance



depression

Coping Skills
Sleep Disturbance/Sleep problems
skills
Recreational
Acceptance
Adjustment
inability to enact coping
Identification Of Coping Mechanisms
Depressed Mood
Crying spells
negative self-talk
Self-Esteem
Loss of pleasure/interest
Low self worth
Major Depressive Disorder
Hopelessness


progress with depression is as follows:
identified and understands behavioral and thinking triggers associated with an increase in emotional distress and depressed mood.
identified cognitive distortions and thinking errors associated with depression and low self-esteem.
was able to describe experiences of depression for the signs and symptoms that are present in his/her daily living.
listed several factors that he/she believes contribute to his/her feelings of hopelessness and sadness.
was able to identify distorted cognitive messages that contribute to the patient's feelings of depression.
made progress related to childhood experiences related to current depression as follows:
The pt was able to explore Childhood Pain and experiences and gained insight as to this has contributed to the patient's depression. Experiences from the patient's childhood that contribute to his/her current depressed state were explored.The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance. . The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance. .As the patient has described his/her childhood experiences within an understanding atmosphere, sad feelings surrounding those experiences have diminished. The pt began to express feelings more freely as rapport and the trust level increased. The pt has continued to experience difficulty being open and direct in his/her expression of painful feelings. The patient explained what it was like to grow up in the home environment, focusing on the abusive/neglectful experiences that he/she endured. The patient has begun to open up about his/her childhood experiences, but still remains rather guarded.The patient described, in detail, the facts and feelings associated with his/her painful childhood experiences.The patient reported struggles with his/her identity and feelings of insecurity due to painful childhood experiences.The patient reported a clearer sense of identity and more self-confidence as his/her painful childhood experiences were processed.The pt progress in regards to low self-esteem is as follows:As this therapist explored, through therapy session, the pt's sense of self compared to others, the pt acknowledged feeling less competent than most others.The pt was able to actively begin to build a level of trust with this therapist in individual sessions through consistent eye contact, active listening, unconditional positive regard.The pt reports his/ her ability to identify and express feelings. Explored the pt’s assessment of himself/ herself regarding self worth. The pt reported and increase insight into the historical and current sources of low self-esteem. The pt has become aware of his/ her fear of rejection and its connection with past rejection or abandonment experiences. The pt, through the session was able to discuss incidents of abuse. Through therapeutic interaction, the pt was able to again insight into incidents of abuse (emotional, physical, and sexual) and how they have impacted his/ her feelings about himself/ herself. The pt reported decreasing the frequency of negative self-descriptive statements and an increase in the frequency of positive self-descriptive statements. The pt is becoming aware of how he/ she expresses or acts out negative feelings about himself/ herself. Assisted the pt in developing self-talk as a way of boosting his/ her confidence and positive self-image. Discussed with pt the goal to Identify negative self-talk messages used to reinforce low self-esteem. The pt identified his/ her distorted, negative beliefs about self and the world. Asked the pt to complete and process an exercise in the book Ten Days to Self Esteem! (Burns). Discussed with pt the possibility of any secondary gain that is received by speaking negatively about self and refusing to take any risks. Helped the pt by teaching the meaning and power of secondary gain in maintaining negative behavior patterns.Assisted the pt in identifying how self-disparagement and avoidance of risk taking could bring secondary gain (e.g., praise from others, others taking over responsibilities). The pt gained insight into perceived fear of rejection and was able to indentify need need to increase statements of self-acceptance. This therapist asked the pt to make one positive statement about self daily and record it on a chart or in a journal. Verbally reinforced the pt’s use of positive statements of confidence and accomplishments.The pt identified goals and accomplishments that would improve self-image and verbalized a plan to achieve those goals. In the therapy session, the pt was able to analyze his/ her goals to make sure they are realistic and attainable. Assigned self-esteem-building exercises from a workbook (e.g., The Six Pillars of Self-Esteem by Branden, or Ten Days to Self Esteem! by Burns);The pt was receptive to how self esteem can be increased by improving eye contact with others. Assigned the pt to make eye contact with whomever he/ she is speaking to; process the feelings associated with eye contact. Confronted the pt when he/ she is observed avoiding eye contact with others. The pt reported increase in personal hygeine and self-care.The pt reported positive traits and talents about self. Reinforced the pt’s positive self-descriptive statements. Discussed with pt the goal of helping pt demonstrate an increased ability to identify and express personal feelings. Assigned the pt to keep a journal of feelings on a daily basis. Assisted the pt in identifying and labeling emotions.Discussed with pt the goal of articulating a plan to be proactive in trying to get identified needs met. Assisted the pt in identifying and verbalizing his/ her needs, met and unmet. Conducted a conjoint or family therapy session in which the pt is supported in expression of unmet needs. Assisted the pt in developing a specific action plan to get each need met. Discussed with pt ways to improve self-esteem by positively acknowledging compliments from others. Assigned the pt to be aware of and acknowledge graciously (without discounting) praise and compliments from others. Discussed with pt the need to form realistic, appropriate, and attainable goals for self in all areas of life. Helped the pt analyze his/ her goals to make sure they are realistic and attainable. Assigned the pt to make a list of goals for various areas of life and a plan for steps toward goal attainment.Discussed with pt the need to take verbal responsibility for accomplishments without discounting. Asked the pt to list accomplishments; process the integration of these into his/ her self-image. Discussed and educated pt of positive self-talk messages to build self-esteem. Assigned the pt to read What to Say When You Talk to Yourself (Helmstetter); process key ideas. Reinforced the pt’s use of more realistic, positive messages to himself/ herself in interpreting life events. Discussed with pt the goal to Increase the frequency of speaking up with confidence in social situations. Used role-playing and behavioral rehearsal to improve the pt’s social skills in greeting people and carrying a conversation.The pt acknowledged feeling less competent than most others.This therapist actively continues to build the level of trust with the pt in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/ her ability to identify and express feelings. The pt has made progress with borderline personality disorder behaviors and thinking identified as:The pt was open to exploration of his/her the history of abuse and/ or abandonment particularly in childhood years. This therapist gave validation the the pt's distress and difficulties as understandable given his/her particular circumstances, thoughts and feelings.The pt was oriented to behavior therapy highlighting its multiple facets (e.g., support, collaboration, challenge, problem-solving, skill-building) and discuss dialectical/ biosocial view of borderline personality, emphasizing constitutional and social influences on its features. Solicitted from the pt an agreement to work collaboratively within the parameters of the CBT approach to overcome the behaviors, emotions, and cognitions that have been identified as causing problems in his/ her life. Discussed the pt’s suicidal gestures as to triggers, frequency, seriousness, secondary gain, and onset. Provided the pt with an emergency helpline telephone number that is available 24 hours a day. Elicited a promise (as part of a self-mutilation and suicide prevention contract) from the pt that he/ she will initiate contact with support system or a helpline if a suicidal urge becomes strong and before any self-injurious behavior occurs; This therapist provided monitoring, confrontation, and problem-solving for the pt actions that threaten to interfere with the continuation of therapy such as missing appointments, noncompliance, and/ or abruptly leaving therapy. Used validation, dialectical strategies (e.g., metaphor, devil’s advocate), and problem-solving strategies (e.g., behavioral and solution analysis, cognitive restructuring, skills training, exposure) to help the pt manage, reduce, or stabilize maladaptive behaviors (e.g., angry outbursts, binge drinking, abusive relationships, high-risk sex, uncontrolled spending), thoughts (e.g., all-or-nothing all-or-nothing thinking, catastrophizing, personalizing), and feelings.The pt has made progress in area of suicidal ideation as follows:Assisted the pt to identify how previous attempts to solve interpersonal problems have failed, leading to feelings of abject loneliness and rejection. Assisted the pt in becoming aware of life factors that were significant precursors to the beginning of his/ her suicidal ideation. 3. Encouraged the pt to share feelings of grief related to broken close relationships.Reviewed with the pt previous problem-solving attempts and discuss new alternatives that are available. Assisted the pt in developing coping strategies for suicidal ideation (e.g., more physical exercise, less internal focus, increased social involvement, more expression of feelings). The pt agreed to utilize coping strategies.The pt states a more consistent eating and sleeping pattern. The pt verbally reports no longer feeling the impulse to take own life and demonstrate an increased sense of hope for self. This therapist will continue to assist and monitor the pt’s suicidal potential on an ongoing basis. Assisted the pt in finding positive, hopeful things in his/ her life at the present time. The pt was able to identify the positive aspects, relationships, and achievements in his/ her life.Reviewed with the pt the success he/ she has had and the sources of love and concern that exist in his/ her life; ask him/ her to write a list of positive aspects of his/ her life. Through the therapy session the pt was able to Identify and replace negative thinking patterns that mediate feelings of hopelessness and helplessness. The pt has made progress in symptoms of anxiety in the following area:The pt was able to describe in the therapy session current and past experiences with the worry and anxiety symptoms, complete with their impact on functioning and attempts to resolve it. The pt reports a decrease in excessive worry and more control occurring more days than not. The pt reports a decrease in motor tension such as restlessness, tiredness, shakiness and muscle tension. The pt has gained insight into factors that have contributed to anxiety symptoms.The pt reports a reduction overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.The pt reports decrease in hypervigilence and fear that something bad is going to happen.The pt reports a resolution oth the core conflict that is the source of anxiety. The pt reports more effectively being able to cope with life's daily stressors and anxieties.The pt agreed and is willing to learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.The pt agreed to cooperate with evaluation with psychiatrist for psychotropic medication.The pt verbalized an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage anxiety symptoms.The pt has made progress in the area of Post Traumatic Stress Disorder as follows:The pt verbalized an understanding of the cognitive, physiological, and behavioral components of post-traumatic stress disorder and its treatment.. The pt was able to verbalize traumatic incident or incidents and has gained some insight into how these traumatic experiences impact current functioning.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage PTSD symptoms..Reports decrease in intense fear, helplessness, or horror to the traumatic event. The pt reports a decrease in disturbing and persistent thoughts, images, and/or perceptions of the traumatic event. The pt reports a decrease in the frequency of nightmares. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. The pt reports no distress related to the targeted memory, (s)he is asked to think of the preferred positive belief that was identified at the beginning of the session. At this time, the pt may adjust the positive belief if necessary, and then focus on it during the next set of distressing events.. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. New issues/Stressors Presented today: Participation:None reportedSYMPTOMS/SEVERITY:NOTES:


Experiences from the patient's childhood that contribute to his/her current depressed state were explored.
The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance.
. The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance.
.As the patient has described his/her childhood experiences within an understanding atmosphere, sad feelings surrounding those experiences have diminished.
The pt began to express feelings more freely as rapport and the trust level increased. The pt has continued to experience difficulty being open and direct in his/her expression of painful feelings.
The patient explained what it was like to grow up in the home environment, focusing on the abusive/neglectful experiences that he/she endured.
The patient has begun to open up about his/her childhood experiences, but still remains rather guarded.
The patient described, in detail, the facts and feelings associated with his/her painful childhood experiences.
The patient reported struggles with his/her identity and feelings of insecurity due to painful childhood experiences.
The patient reported a clearer sense of identity and more self-confidence as his/her painful childhood experiences were processed.
The pt progress in regards to low self-esteem is as follows:As this therapist explored, through therapy session, the pt's sense of self compared to others, the pt acknowledged feeling less competent than most others.
The pt was able to actively begin to build a level of trust with this therapist in individual sessions through consistent eye contact, active listening, unconditional positive regard.
The pt reports his/ her ability to identify and express feelings.
Explored the pt’s assessment of himself/ herself regarding self worth.
The pt has become aware of his/ her fear of rejection and its connection with past rejection or abandonment experiences.
The pt, through the session was able to discuss incidents of abuse. Through therapeutic interaction, the pt was able to again insight into incidents of abuse (emotional, physical, and sexual) and how they have impacted his/ her feelings about himself/ herself.
The pt reported decreasing the frequency of negative self-descriptive statements and an increase in the frequency of positive self-descriptive statements.
The pt is becoming aware of how he/ she expresses or acts out negative feelings about himself/ herself. Assisted the pt in developing self-talk as a way of boosting his/ her confidence and positive self-image.
Discussed with pt the goal to Identify negative self-talk messages used to reinforce low self-esteem.
The pt identified his/ her distorted, negative beliefs about self and the world.
Asked the pt to complete and process an exercise in the book Ten Days to Self Esteem! (Burns).
Discussed with pt the possibility of any secondary gain that is received by speaking negatively about self and refusing to take any risks.
Helped the pt by teaching the meaning and power of secondary gain in maintaining negative behavior patterns.
Assisted the pt in identifying how self-disparagement and avoidance of risk taking could bring secondary gain (e.g., praise from others, others taking over responsibilities).
The pt gained insight into perceived fear of rejection and was able to indentify need need to increase statements of self-acceptance.
This therapist asked the pt to make one positive statement about self daily and record it on a chart or in a journal. Verbally reinforced the pt’s use of positive statements of confidence and accomplishments.The pt identified goals and accomplishments that would improve self-image and verbalized a plan to achieve those goals. In the therapy session, the pt was able to analyze his/ her goals to make sure they are realistic and attainable. Assigned self-esteem-building exercises from a workbook (e.g., The Six Pillars of Self-Esteem by Branden, or Ten Days to Self Esteem! by Burns);The pt was receptive to how self esteem can be increased by improving eye contact with others. Assigned the pt to make eye contact with whomever he/ she is speaking to; process the feelings associated with eye contact. Confronted the pt when he/ she is observed avoiding eye contact with others. The pt reported increase in personal hygeine and self-care.The pt reported positive traits and talents about self. Reinforced the pt’s positive self-descriptive statements. Discussed with pt the goal of helping pt demonstrate an increased ability to identify and express personal feelings. Assigned the pt to keep a journal of feelings on a daily basis. Assisted the pt in identifying and labeling emotions.Discussed with pt the goal of articulating a plan to be proactive in trying to get identified needs met. Assisted the pt in identifying and verbalizing his/ her needs, met and unmet. Conducted a conjoint or family therapy session in which the pt is supported in expression of unmet needs. Assisted the pt in developing a specific action plan to get each need met. Discussed with pt ways to improve self-esteem by positively acknowledging compliments from others. Assigned the pt to be aware of and acknowledge graciously (without discounting) praise and compliments from others. Discussed with pt the need to form realistic, appropriate, and attainable goals for self in all areas of life. Helped the pt analyze his/ her goals to make sure they are realistic and attainable. Assigned the pt to make a list of goals for various areas of life and a plan for steps toward goal attainment.Discussed with pt the need to take verbal responsibility for accomplishments without discounting. Asked the pt to list accomplishments; process the integration of these into his/ her self-image. Discussed and educated pt of positive self-talk messages to build self-esteem. Assigned the pt to read What to Say When You Talk to Yourself (Helmstetter); process key ideas. Reinforced the pt’s use of more realistic, positive messages to himself/ herself in interpreting life events. Discussed with pt the goal to Increase the frequency of speaking up with confidence in social situations. Used role-playing and behavioral rehearsal to improve the pt’s social skills in greeting people and carrying a conversation.The pt acknowledged feeling less competent than most others.This therapist actively continues to build the level of trust with the pt in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/ her ability to identify and express feelings. The pt has made progress with borderline personality disorder behaviors and thinking identified as:The pt was open to exploration of his/her the history of abuse and/ or abandonment particularly in childhood years. This therapist gave validation the the pt's distress and difficulties as understandable given his/her particular circumstances, thoughts and feelings.The pt was oriented to behavior therapy highlighting its multiple facets (e.g., support, collaboration, challenge, problem-solving, skill-building) and discuss dialectical/ biosocial view of borderline personality, emphasizing constitutional and social influences on its features. Solicitted from the pt an agreement to work collaboratively within the parameters of the CBT approach to overcome the behaviors, emotions, and cognitions that have been identified as causing problems in his/ her life. Discussed the pt’s suicidal gestures as to triggers, frequency, seriousness, secondary gain, and onset. Provided the pt with an emergency helpline telephone number that is available 24 hours a day. Elicited a promise (as part of a self-mutilation and suicide prevention contract) from the pt that he/ she will initiate contact with support system or a helpline if a suicidal urge becomes strong and before any self-injurious behavior occurs; This therapist provided monitoring, confrontation, and problem-solving for the pt actions that threaten to interfere with the continuation of therapy such as missing appointments, noncompliance, and/ or abruptly leaving therapy. Used validation, dialectical strategies (e.g., metaphor, devil’s advocate), and problem-solving strategies (e.g., behavioral and solution analysis, cognitive restructuring, skills training, exposure) to help the pt manage, reduce, or stabilize maladaptive behaviors (e.g., angry outbursts, binge drinking, abusive relationships, high-risk sex, uncontrolled spending), thoughts (e.g., all-or-nothing all-or-nothing thinking, catastrophizing, personalizing), and feelings.The pt has made progress in area of suicidal ideation as follows:Assisted the pt to identify how previous attempts to solve interpersonal problems have failed, leading to feelings of abject loneliness and rejection. Assisted the pt in becoming aware of life factors that were significant precursors to the beginning of his/ her suicidal ideation. 3. Encouraged the pt to share feelings of grief related to broken close relationships.Reviewed with the pt previous problem-solving attempts and discuss new alternatives that are available. Assisted the pt in developing coping strategies for suicidal ideation (e.g., more physical exercise, less internal focus, increased social involvement, more expression of feelings). The pt agreed to utilize coping strategies.The pt states a more consistent eating and sleeping pattern. The pt verbally reports no longer feeling the impulse to take own life and demonstrate an increased sense of hope for self. This therapist will continue to assist and monitor the pt’s suicidal potential on an ongoing basis. Assisted the pt in finding positive, hopeful things in his/ her life at the present time. The pt was able to identify the positive aspects, relationships, and achievements in his/ her life.Reviewed with the pt the success he/ she has had and the sources of love and concern that exist in his/ her life; ask him/ her to write a list of positive aspects of his/ her life. Through the therapy session the pt was able to Identify and replace negative thinking patterns that mediate feelings of hopelessness and helplessness. The pt has made progress in symptoms of anxiety in the following area:The pt was able to describe in the therapy session current and past experiences with the worry and anxiety symptoms, complete with their impact on functioning and attempts to resolve it. The pt reports a decrease in excessive worry and more control occurring more days than not. The pt reports a decrease in motor tension such as restlessness, tiredness, shakiness and muscle tension. The pt has gained insight into factors that have contributed to anxiety symptoms.The pt reports a reduction overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.The pt reports decrease in hypervigilence and fear that something bad is going to happen.The pt reports a resolution oth the core conflict that is the source of anxiety. The pt reports more effectively being able to cope with life's daily stressors and anxieties.The pt agreed and is willing to learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.The pt agreed to cooperate with evaluation with psychiatrist for psychotropic medication.The pt verbalized an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage anxiety symptoms.The pt has made progress in the area of Post Traumatic Stress Disorder as follows:The pt verbalized an understanding of the cognitive, physiological, and behavioral components of post-traumatic stress disorder and its treatment.. The pt was able to verbalize traumatic incident or incidents and has gained some insight into how these traumatic experiences impact current functioning.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage PTSD symptoms..Reports decrease in intense fear, helplessness, or horror to the traumatic event. The pt reports a decrease in disturbing and persistent thoughts, images, and/or perceptions of the traumatic event. The pt reports a decrease in the frequency of nightmares. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. The pt reports no distress related to the targeted memory, (s)he is asked to think of the preferred positive belief that was identified at the beginning of the session. At this time, the pt may adjust the positive belief if necessary, and then focus on it during the next set of distressing events.. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. New issues/Stressors Presented today: Participation:None reportedSYMPTOMS/SEVERITY:NOTES:
The pt gained insight and awareness into the importance of daily structure.


Relative Changes to condition (Reported/Observed):


None reported


Behavior/Functioning


Orientation


Mood/affect


New issues/Stressors Presented today:
No Significant Change
Notable
If notable, please comment

Homicidal/Suicidal:


NO


YES


Type of risk:


Ideation.


Plan


Attempt


Directed to:


Self


Others


Property


Intervention details/Other Therapeutic Interventions Provided:


Reviewed current and past functioning


Developed treatment plan


Assessed risk of harm


Contracted for safety


Discussed barrier’s to progress


Introduced parenting strategies


Evaluated progress toward treatment goals.


Provided referral or linkage


Provided Education and Information


Discussed alternative behaviors


Other:

Response to intervention/progress toward Goals/Objectives:







Plan:





Continue therapy




Terminate therapy.



Increase frequency.


Medication consult


Medication Compliant:


[ ] YES [ ] NO [ ] NA

Other notes: ______
Responsive To Open Ended Questions
Resistant To CareResistant
Receptive To Intervention
Explored Responsive To Attentive Listening
Engaged
Endorses

Endorsed/Discussed The Following Problems

Displayed The Following Behaviors In Session
Described
Continuing To Reflect On
Agreed To
Began To Express Feelings More Freely As Rapport /The Trust Level Increased
Responsive to Cognitive Restructuring
Discussed
Pessimistic
Participated In TraumaParticipated In
Identified Feeling
Expresses Envy Anger At Other Individuals' Comparatively Better Performance
Completed Exercises From A Workbook
Endorses
Appears To Be Developing Greater Insight As
Shared Disclosed
Process Key Ideas



complete an in vivo exposure today,
address negative thought distortion,
practiced re-framing.
Patient practiced normalizing their feelings and using alternative reactions.
Discussed ??.
Practiced using thought diffusion and self soothing.

Acknowledges intellectual understanding but emotionally struggles


Pt discussed pros and cons of


Continues to struggle with strongly held schemas/interpersonal conflicts

Patient participated in CBT.
Patient participated in Trauma-Based CBT


Continues to...
Endorse
Continuing To
Grieve The Loss Of
Struggle W
Self-Criticism
Sensitivity To Others' Perceptions
Feel Stress Related To Dealing With
Strongly Held Schemas/Interpersonal Conflicts
Understanding Relational Cues
Make Progress In Therapy
Continuing To Engage In Coping Efforts
Continuing To Reflect On


continues to struggle with understanding relational cues.
expresses envy and anger at other individuals' comparatively better performance.
has been struggling with tolerating feelings of loneliness.
has been struggling with feelings of dysphoria;
has been having problems motivating him/herself into meaningful action.
has been struggling with recognizing the physiological and affective cues of her/his affective states.
has been struggling maintaining a regular schedule, especially in face of persisting amotivation and fatigue associated with dysphoria/depression.
continues to struggle with self-criticism; continues to evince tendency to engage in self-blame.
continues to struggle with sensitivity to others' perceptions; reporting feelings of hurt and disappointment.
Symptoms:NormalTearfulnessChange in AppetiteMotivationSleep ChangeEnergy Level ChangeInterest Level ChangeChange in Sex DriveObsessions/CompulsionsAnxiety:NormalHigh-StrungPanic AttacksStage FrightPhobiaScared to leave the house
Somatic Symptoms (Palpitation, Hyperventilation, Sweating)Other


Response:

Symptoms:
Mild
Moderate
Severe

Neutral


Favorable

Unfavorable

Maintaining Baseline
Improvement of mental health symptoms
Improvement of mood/affect
Improvement of thought process/content
Improved coping skills
Reduced coping skills
Worsening of mental health symptoms
Worsening of mood/affect
Worsening of thought process/content
PROGRESS TOWARD GOALS (SINCE LAST MEETING)
PROGRESS:
No Progress
pt has made no progress.
No change in mental status
Small Progress
Increasing
Exceptional
Variable
Steady
Moderate Progress
Slow
Regressing
Decreasing
Deterioration
Stable
Significant Progress
Maintaining
Discharge Plan

continues to make progress in therapy.
Improved
necessary adjustments to the treatment planCognitive impairment not observed in this interactionCognitive impairment concern expressed by family members, care givers and/or friends: ??
No change in mental statusImprovement of mental health symptomsImprovement of mood/affectImprovement of thought process/contentImproved coping skillsWorsening of mental health symptomsWorsening of mood/affectWorsening of thought process/contentReduced coping skills
New issues/Stressors Presented today: Participation:None reportedSYMPTOMS/SEVERITY:NOTES:
continues to make progress in therapy


Reviewed developmental, family, psychosocial, psychiatric, medical, academic, and occupational history
Reviewed symptoms and functioning in life domains. Treatment planning
Session Content: ??
Patient reports positive change in stressors: ??
Patient reports negative change in stressors: ??
Suicidality not present
Homicidality not present
Patient denies suicidal ideation
Patient denies homicidal ideation
Patient reports suicidal ideation: ?? Intent: ?? Plan: ??
Patient reports homicidal ideation: ?? Intent: ?? Plan: ??
Patient reports drug/alcohol use/abuse: ??
Patient reports medication compliance
Patient reports medication noncompliance: ??
Strengths/limitations affecting progress: ??
Patient stated: ??
Patient described: ??
Session addressed treatment goals specific to DSM diagnosis
Session addressed impact and mitigation of symptoms as related to physical health and/or medical conditions(s)


Subjective Summary of Family Session: ??

Goals of Session:


Discussion:


Level of participation: [] High [] Medium [] Low [] None :

Goal Achieved:

Clinician Comments/ Recomendations: ??
Strengths identified: ??
Barriers identified: ??


Self Care
Consistently Not Sleeping Well
Low/Lacking
Met Unmet
Maintaining
Intensity
Less Severe
More Severe
Moderate/Severe
Moderate
Stressors
Unfavorable
Support
Steady
Unable To Sleep
Variable
Solving Strategies
Resolved
Remains Rather
Remains
Regressing
Psychosocial Environmental Issues Addressed
Improved
Identified His/ Her Distorted
Future Goals/Plan
Functioning
Frequency
Favorable
Experiencing Difficulty
Continuing To Reflect On
Much Worse
Negative For
New Issues/StressorsYes No
More Physical Exercise
Sad Feelings Surrounding Those Experiences Have Diminished
To Help Manage
Small
Skills Training
Session Addressed Treatment Goals Specific To Dxs
Talking To Someone
The Skills Practiced Since The Last Session
Solving Attempts Discuss New Alternatives That Are AvailableSolving
Positive For
Maintaining Baseline
Initially
Increased Social Involvement
Improved Necessary Adjustments To The Treatment Plan
Impairments
Doing Something That Is DistractingDoing Something Physical Like Walking
Efficacy
Distress Tolerance Appropriate Behaviors When In Her Presence
Displays A Significant Interest Engagement In Activities
Disruption
Decreasing
Concerns Decline/Function
Better
Approach To Overcome The Behaviors
Deterioration
Analyze Goals To Make Sure They Are Realistic/Attainable
The Same As It Has Been
Somewhat Worse Than It Has Been
Significantly Worse Than It Has Been
Much Worse
Significantly Worse Than It Has Been
Better
Has Progressed In Therapy Goals To The Level That Session Frequency Will Be Reduced
Has Gained Some Insight Into How These Traumatic Experiences Impact Current Functioning
Progress Toward Goals Since Last Meeting
Has Made No Progress
Continues To Make Progress In Therapy
Less Able
Much Less Able
Able
Steady
Small
Slow
Significant
More Severe
Moderate
Decrease In Disturbing Persistent Thoughts
Continued
Decrease In
Decrease In Excessive Worry
More Control
Occurring More Days Than Not
Decrease In Hypervigilance Fear That Something Bad Is Going To Happen
Decrease In Motor Tension Such As Restlessness
Drug/Alcohol Use/Abuse
Experiencing
Feeling
Feeling Lonely
Increase in Ability To Identify Express Feelings
Increase In Previously Avoided Activities
Medication Compliance
Medication Noncompliance
Negative Change In
No Change
No Change In Mental Status
No Distress Related To The Targeted Memory
None Reported
Positive Change In Stressors
Reduction Overall Frequency
Reported
Reported Experiencing The Following Sx
Reported Increase In Personal Hygiene Self
Reported Positive Traits Talents About Self
Shows Motivation To Change
Has Been Struggling Maintaining A Regular Schedule
Has Been Having Problems Motivating Him/Herself Into Meaningful Action
Reduced Coping Skills
Inability To Enact Coping
Improved Coping Skills
Continuing To Engage In Coping Efforts
Change In Coping Ability/Skills
Pain Experiences Gained Insight As To This Has Contributed To Depression
Has Begun To Open Up About His/Her Childhood Experiences

Has Been Feeling This Way For


Responded Appropriately


Learned Calming Coping Skills
Agreed To Implementation To Reduce Overall Anxiety Manage

Identified Painful Childhood Experiences That Have Continued To Foster Feelings

Focused On
Coping Skills
Sleep Disturbance/Sleep Problems
Coping

Using Positive Self Talk
Coping

Continues To Evidence Tendency To Engage In Self-Criticism
Continues To Endorse

Agreed To Utilize Coping Strategies
Continues To Struggle W



Able To Explore
Able To Describe

The Skills Practiced Since The Last Session
Talking To Someone


More Consistent Eating Sleeping Pattern
Talkative
Regressing




Reduce

Moderate Severe Response

Minutes
Minimal
Mild
Met Unmet
Maintaining Baseline
Maintaining
Less Severe
Less Internal Focus
Increasing
Increased Social Involvement
Improved
Impairments
Impairment
Improved Necessary Adjustments To The Treatment Plan
Functioning
Action
Active

Abruptly Leaving Therapy

Stressors

Also Changes Anxiety SpecificConsistently Not Sleeping WellContinuedDecrease InDecrease In Disturbing Persistent ThoughtsDecrease In Excessive Worry More Control Occurring More Days Than NotDecrease In Hypervigilance Fear That Something Bad Is Going To HappenDecrease In Motor Tension Such As RestlessnessDrug/Alcohol Use/AbuseExperiencingFeelingFeeling LonelyHis/ Her Ability To Identify Express FeelingsIncrease In Previously Avoided ActivitiesMedication ComplianceMedication NoncomplianceNegative Change In ReNo ChangeNo Change In Mental StatusNo Distress Related To The Targeted MemoryNone ReportedPositive Change In StressorsReduction Overall FrequencyReportedReported Experiencing The Following SxReported Increase In Personal Hygiene SelfReported Positive Traits Talents About SelfShows Motivation To ChangeThat
Less SevereLess Internal Focus
Moderate Severe Response
ModerateMinutesMinimalMild
SteadyMore Consistent Eating Sleeping PatternStableStabilize Maladaptive Behaviors
Identified His/ Her DistortedIdentified Goals Accomplishments That Would Improve Self
New Issues/StressorsNew Issues Presented Today? Yes NoNeutral




Less Internal Focus
Minutes
Minimal
Mild
More Consistent Eating Sleeping Pattern
Stable
Stabilize Maladaptive Behaviors
Reduce
Identified Goals Accomplishments That Would Improve Self
Neutral
Slow
Increasing
Impairment
Images
Verbalized A Plan To Achieve Those Goals
Decrease In

Constipation
Copd
Fatigue
Headaches
Hallucinations
Vomiting
Upset Stomach
Tremors
Nausea
Memory
alcohol/Drugs
Medical


REVIEW OF SYSTEMS


Positive for:


Negative for:
blunt affect.
disorganized thought process.


dizziness.


flat affect.
inappropriate affect.
incoherence.
agitation
emotional lability
rapid speech.
sweating.
tremors.
vomiting.
REVIEW OF SYSTEMS
Positive for:
Negative for:
blunt affect.
disorganized thought process.
dizziness.
flat affect.
inappropriate affect.
incoherence.
agitation
emotional lability
rapid speech.
sweating.
tremors.
vomiting.


Endorsed/Discussed The Following Problems
Endorses
Discussed The Following Topics
Discussed


Treatment Planning
Traumatic Stress Disorder Its Treatment
Uncontrolled Spending
Thoughts Feelings
Social Conflict/Stressors
Social Activities
Social Isolation
Social Discomfort
Sleep Disturbance
Sexual Activity
Self-talk Messages Used To Reinforce Low Self Esteem
Self-Talk Messages To Build Self
Self Care
Sadness
Relationships
Relationship Problems
Stressors
Sexual Problems
Seasonal Affective Disorder
Recreational
Recurring Disturbing Memories
Psychosocial Environmental Issues Addressed
Problems W Peers/Roommate
Problems Related To
Personal Problems
Personal History Relationship
Personal History
Peer Intimate Relationship Problems
Peers/Roommate
Peer Intimate Relationships
Participation In Activities Financial Issues Housing Problems
Participation In Activities
Participated In
Participation
Parenting
Parenting Problems
Paranoia
Panic Attacks
Panic Disorder
Pain
Others Taking Over Responsibilities
Onset
Occupational History
Nothing Thinking
Nothing All
Noncompliance
Negative Beliefs About Self The World
Motivation
Medical
Marriage/Spouse/Divorce
Low/Lacking Self
Low Self Worth
Low Energy
Loss
Loneliness
Limited Social Supports
Irritability Irritability/Anger
Intrusive Thoughts
Interpersonal Conflict
Intense Unstable Personal Relationships
Frequent Arguments
Family History
Failure To
Dysfunctional Interpersonal Relationships
Abuse
abusive Relationships
Academic
Acceptance

Addiction
Adjustment
Adjustment/Situational


Uncontrolled Spending
Discussed The Following Topics
Discussions Related To The Traumatic Event
Content Or Topics Discussed
Social Isolation
Self-talk Messages Used To Reinforce Low Self Esteem | Self-Talk Messages To Build Self Esteem
Secondary Gain
SeasonalSadness
RelationshipsRelationship Problems
Recurring Disturbing Memories
Problems W Peers/RoommateProblems Related To
Pornography
Phobia Extreme Anxiety/Panic
Personal Problems/Personal History
Personality Disorder
Noncompliance
Others Taking Over Responsibilities
Pain
Low/Lacking SelfLow Self WorthLow EnergyLossLonelinessLimited Social Supports
Verbalize Emotions & Express Needs
TirednessThoughts FeelingsThoughts
Socially IsolatedSocialSleep DisturbanceSleepPsychosocial
Parenting ProblemsParentingPanic DisorderPanic AttacksOnsetOcdOccupational HistoryObsessive Thoughts ParanoiaObsessive ThoughtsNightmaresNegative SelfNegative Beliefs About Self The WorldMotivationMarriage/Spouse/DivorceMajor Depressive DisorderLability Sadness/Depression
How They Have Impacted His/ Her Feelings About Himself/ Herself
Traumatic EventHopelessness
HelplessnessGuiltgrief/Frequent Arguments
Emotions
Blame
Diet Exercise
Divorce
Couple Relationship Issues
Control
Conflict/Stressors
Conflict/Conflict Resolution
Communication
Cognitions That Have Been Identified As Causing Problems In His/ Her Life
Chronic Illness
Cbt
Flashbacks
Death/Dying
Depression
Avoidance
Appetite Disturbance
Autism Spectrum Disorder
Binge Drinking
Being Alone
Behavior Therapy
Chronic
Childhood
Catastrophizing
Caregivers /Or Friends
Caregiver Burden
Care
Cancer Diagnosis
Cancer
Computer Addiction
Compulsive Behavior
Consequences
Crying Spells
Descriptive Statements
Criticism
Dialectical Strategies
Devil’s Advocate
Emotional Experience Related To Diagnosis
Dysfunctional Interpersonal Relationships
Feelings
Fearfulness
Family History
Family
Failure To
Exposure
Impulsive/Impulse
Intense Unstable Personal Relationships
Intense Fear
Irritability Irritability/AngerIntrusive Thoughts
Interpersonal Conflict
Peer Intimate Relationships
Peer Intimate Relationship Problems
Participation In Activities Financial Issues Housing Problems
Participation In Activities/Participation
Recreational
Personal Relationship
Seasonal Affective Disorder
Social Discomfort
Social Conflict/Stressors
Social Activities
Achievements In His/ Her Life
FUNCTIONING

Acceptance
Adjustment/Situational Concerns
Decline/Function
Decrease in Participation in Activities
Financial Issues
housing problems
Identification Of Coping Mechanisms
inability to enact coping
Lack Of Coping Skills
Lack Of Motivation


Medical
Alcohol/Drugs
Caregiver Burden
Coping with Chemotherapy
Current Emotional Distress Of Recent Cancer Diagnosis
Diagnosis Of Copd
Fatigue
Headaches
Memory
Nausea
Pain
Personal History
Resistant to Care
Sleep
Death/Dying


nutrition history
hx of Eating Disorder
Constipation
Appetite Disturbance
Diet Exercise


SOCIAL
Abuse
Assertiveness
Dysfunctional Interpersonal Relationships
Family Problems
Failure to Verbalize Emotions & Express Needs
interpersonal conflict
Marriage/Spouse/Divorce
Marital or Couple Relationship Issues
Peer and intimate relationship problems
Problems w Peers/Roommate
social conflict/stressors
Social Discomfort
Social Isolation
Unrealistic Expectations


psych
Impulse Control
Chronic PTSD
intrusive thoughts associated with traumatic event
Emotional Experience Related To Diagnosis
Nightmares
Frequent Arguments
Wide Mood Swings
Recurring, Disturbing Memories


DEPRESSION
depression
emotional blunting
Feelings of Worthlessness
Guilt
Grief/Loss
Low/Lacking Self-Esteem
Mood Lability
Feelings Of Guilt Or Worthlessness
Seasonal Mood Changes


ANXIETY
Specific Phobia
extreme anxiety/panic
Obsessive Thoughts
Flashbacks
Unable To Sleep
Autism Spectrum Disorder
Fearfulness
Impulsive/Impulsivity
Thoughts Of Death
self-harm/suicidal ideation


ADDICTION
Computer Addiction
Cognitive Impairment
Paranoia
Compulsive Behavior
Gambling Problems
Problems With Pornography

psych symptoms/diagnoses
Anhedonia (Loss Of Interest)
Chronic PTSD Major Depressive Disorder, Anxiety, Panic Disorder Major Depressive Disorder, Seasonal Affective Disorder Panic Attacks Panic Attacks, General Anxiety, Insomnia



Psychosis
Auditory HallucinationsHearing voices
Racing ThoughtsRapid Or Pressured SpeechNightmaresNightmares/Recurrent And Intrusive Memories Of A Traumatic ExperienceObsessive ThoughtsparanoiaParanoid Personality Disorderintrusive thoughts intrusive thoughts associated with traumatic eventHypervigilance And Scanning



personal problems
Computer Addiction



Mood
BoredomMood InstabilityMood LabilitySadness/depression Seasonal mood changes
IrritabilityIrritability/anger



Anxiety
Anxiety/worry Apprehensive Expectation
OCD Heightened Anxiety Panic Disorder
Avoidance



depression

Coping Skills
Sleep Disturbance/Sleep problems
skills
Recreational
Acceptance
Adjustment
inability to enact coping
Identification Of Coping Mechanisms
Depressed Mood
Crying spells
negative self-talk
Self-Esteem
Loss of pleasure/interest
Low self worth
Major Depressive Disorder
Hopelessness


progress with depression is as follows:
identified and understands behavioral and thinking triggers associated with an increase in emotional distress and depressed mood.
identified cognitive distortions and thinking errors associated with depression and low self-esteem.
was able to describe experiences of depression for the signs and symptoms that are present in his/her daily living.
listed several factors that he/she believes contribute to his/her feelings of hopelessness and sadness.
was able to identify distorted cognitive messages that contribute to the patient's feelings of depression.
made progress related to childhood experiences related to current depression as follows:
The pt was able to explore Childhood Pain and experiences and gained insight as to this has contributed to the patient's depression. Experiences from the patient's childhood that contribute to his/her current depressed state were explored.The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance. . The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance. .As the patient has described his/her childhood experiences within an understanding atmosphere, sad feelings surrounding those experiences have diminished. The pt began to express feelings more freely as rapport and the trust level increased. The pt has continued to experience difficulty being open and direct in his/her expression of painful feelings. The patient explained what it was like to grow up in the home environment, focusing on the abusive/neglectful experiences that he/she endured. The patient has begun to open up about his/her childhood experiences, but still remains rather guarded.The patient described, in detail, the facts and feelings associated with his/her painful childhood experiences.The patient reported struggles with his/her identity and feelings of insecurity due to painful childhood experiences.The patient reported a clearer sense of identity and more self-confidence as his/her painful childhood experiences were processed.The pt progress in regards to low self-esteem is as follows:As this therapist explored, through therapy session, the pt's sense of self compared to others, the pt acknowledged feeling less competent than most others.The pt was able to actively begin to build a level of trust with this therapist in individual sessions through consistent eye contact, active listening, unconditional positive regard.The pt reports his/ her ability to identify and express feelings. Explored the pt’s assessment of himself/ herself regarding self worth. The pt reported and increase insight into the historical and current sources of low self-esteem. The pt has become aware of his/ her fear of rejection and its connection with past rejection or abandonment experiences. The pt, through the session was able to discuss incidents of abuse. Through therapeutic interaction, the pt was able to again insight into incidents of abuse (emotional, physical, and sexual) and how they have impacted his/ her feelings about himself/ herself. The pt reported decreasing the frequency of negative self-descriptive statements and an increase in the frequency of positive self-descriptive statements. The pt is becoming aware of how he/ she expresses or acts out negative feelings about himself/ herself. Assisted the pt in developing self-talk as a way of boosting his/ her confidence and positive self-image. Discussed with pt the goal to Identify negative self-talk messages used to reinforce low self-esteem. The pt identified his/ her distorted, negative beliefs about self and the world. Asked the pt to complete and process an exercise in the book Ten Days to Self Esteem! (Burns). Discussed with pt the possibility of any secondary gain that is received by speaking negatively about self and refusing to take any risks. Helped the pt by teaching the meaning and power of secondary gain in maintaining negative behavior patterns.Assisted the pt in identifying how self-disparagement and avoidance of risk taking could bring secondary gain (e.g., praise from others, others taking over responsibilities). The pt gained insight into perceived fear of rejection and was able to indentify need need to increase statements of self-acceptance. This therapist asked the pt to make one positive statement about self daily and record it on a chart or in a journal. Verbally reinforced the pt’s use of positive statements of confidence and accomplishments.The pt identified goals and accomplishments that would improve self-image and verbalized a plan to achieve those goals. In the therapy session, the pt was able to analyze his/ her goals to make sure they are realistic and attainable. Assigned self-esteem-building exercises from a workbook (e.g., The Six Pillars of Self-Esteem by Branden, or Ten Days to Self Esteem! by Burns);The pt was receptive to how self esteem can be increased by improving eye contact with others. Assigned the pt to make eye contact with whomever he/ she is speaking to; process the feelings associated with eye contact. Confronted the pt when he/ she is observed avoiding eye contact with others. The pt reported increase in personal hygeine and self-care.The pt reported positive traits and talents about self. Reinforced the pt’s positive self-descriptive statements. Discussed with pt the goal of helping pt demonstrate an increased ability to identify and express personal feelings. Assigned the pt to keep a journal of feelings on a daily basis. Assisted the pt in identifying and labeling emotions.Discussed with pt the goal of articulating a plan to be proactive in trying to get identified needs met. Assisted the pt in identifying and verbalizing his/ her needs, met and unmet. Conducted a conjoint or family therapy session in which the pt is supported in expression of unmet needs. Assisted the pt in developing a specific action plan to get each need met. Discussed with pt ways to improve self-esteem by positively acknowledging compliments from others. Assigned the pt to be aware of and acknowledge graciously (without discounting) praise and compliments from others. Discussed with pt the need to form realistic, appropriate, and attainable goals for self in all areas of life. Helped the pt analyze his/ her goals to make sure they are realistic and attainable. Assigned the pt to make a list of goals for various areas of life and a plan for steps toward goal attainment.Discussed with pt the need to take verbal responsibility for accomplishments without discounting. Asked the pt to list accomplishments; process the integration of these into his/ her self-image. Discussed and educated pt of positive self-talk messages to build self-esteem. Assigned the pt to read What to Say When You Talk to Yourself (Helmstetter); process key ideas. Reinforced the pt’s use of more realistic, positive messages to himself/ herself in interpreting life events. Discussed with pt the goal to Increase the frequency of speaking up with confidence in social situations. Used role-playing and behavioral rehearsal to improve the pt’s social skills in greeting people and carrying a conversation.The pt acknowledged feeling less competent than most others.This therapist actively continues to build the level of trust with the pt in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/ her ability to identify and express feelings. The pt has made progress with borderline personality disorder behaviors and thinking identified as:The pt was open to exploration of his/her the history of abuse and/ or abandonment particularly in childhood years. This therapist gave validation the the pt's distress and difficulties as understandable given his/her particular circumstances, thoughts and feelings.The pt was oriented to behavior therapy highlighting its multiple facets (e.g., support, collaboration, challenge, problem-solving, skill-building) and discuss dialectical/ biosocial view of borderline personality, emphasizing constitutional and social influences on its features. Solicitted from the pt an agreement to work collaboratively within the parameters of the CBT approach to overcome the behaviors, emotions, and cognitions that have been identified as causing problems in his/ her life. Discussed the pt’s suicidal gestures as to triggers, frequency, seriousness, secondary gain, and onset. Provided the pt with an emergency helpline telephone number that is available 24 hours a day. Elicited a promise (as part of a self-mutilation and suicide prevention contract) from the pt that he/ she will initiate contact with support system or a helpline if a suicidal urge becomes strong and before any self-injurious behavior occurs; This therapist provided monitoring, confrontation, and problem-solving for the pt actions that threaten to interfere with the continuation of therapy such as missing appointments, noncompliance, and/ or abruptly leaving therapy. Used validation, dialectical strategies (e.g., metaphor, devil’s advocate), and problem-solving strategies (e.g., behavioral and solution analysis, cognitive restructuring, skills training, exposure) to help the pt manage, reduce, or stabilize maladaptive behaviors (e.g., angry outbursts, binge drinking, abusive relationships, high-risk sex, uncontrolled spending), thoughts (e.g., all-or-nothing all-or-nothing thinking, catastrophizing, personalizing), and feelings.The pt has made progress in area of suicidal ideation as follows:Assisted the pt to identify how previous attempts to solve interpersonal problems have failed, leading to feelings of abject loneliness and rejection. Assisted the pt in becoming aware of life factors that were significant precursors to the beginning of his/ her suicidal ideation. 3. Encouraged the pt to share feelings of grief related to broken close relationships.Reviewed with the pt previous problem-solving attempts and discuss new alternatives that are available. Assisted the pt in developing coping strategies for suicidal ideation (e.g., more physical exercise, less internal focus, increased social involvement, more expression of feelings). The pt agreed to utilize coping strategies.The pt states a more consistent eating and sleeping pattern. The pt verbally reports no longer feeling the impulse to take own life and demonstrate an increased sense of hope for self. This therapist will continue to assist and monitor the pt’s suicidal potential on an ongoing basis. Assisted the pt in finding positive, hopeful things in his/ her life at the present time. The pt was able to identify the positive aspects, relationships, and achievements in his/ her life.Reviewed with the pt the success he/ she has had and the sources of love and concern that exist in his/ her life; ask him/ her to write a list of positive aspects of his/ her life. Through the therapy session the pt was able to Identify and replace negative thinking patterns that mediate feelings of hopelessness and helplessness. The pt has made progress in symptoms of anxiety in the following area:The pt was able to describe in the therapy session current and past experiences with the worry and anxiety symptoms, complete with their impact on functioning and attempts to resolve it. The pt reports a decrease in excessive worry and more control occurring more days than not. The pt reports a decrease in motor tension such as restlessness, tiredness, shakiness and muscle tension. The pt has gained insight into factors that have contributed to anxiety symptoms.The pt reports a reduction overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.The pt reports decrease in hypervigilence and fear that something bad is going to happen.The pt reports a resolution oth the core conflict that is the source of anxiety. The pt reports more effectively being able to cope with life's daily stressors and anxieties.The pt agreed and is willing to learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.The pt agreed to cooperate with evaluation with psychiatrist for psychotropic medication.The pt verbalized an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage anxiety symptoms.The pt has made progress in the area of Post Traumatic Stress Disorder as follows:The pt verbalized an understanding of the cognitive, physiological, and behavioral components of post-traumatic stress disorder and its treatment.. The pt was able to verbalize traumatic incident or incidents and has gained some insight into how these traumatic experiences impact current functioning.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage PTSD symptoms..Reports decrease in intense fear, helplessness, or horror to the traumatic event. The pt reports a decrease in disturbing and persistent thoughts, images, and/or perceptions of the traumatic event. The pt reports a decrease in the frequency of nightmares. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. The pt reports no distress related to the targeted memory, (s)he is asked to think of the preferred positive belief that was identified at the beginning of the session. At this time, the pt may adjust the positive belief if necessary, and then focus on it during the next set of distressing events.. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. New issues/Stressors Presented today: Participation:None reportedSYMPTOMS/SEVERITY:NOTES:


Experiences from the patient's childhood that contribute to his/her current depressed state were explored.
The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance.
. The pt identified painful childhood experiences that have continued to foster feelings of low self-esteem, sadness, and sleep disturbance.
.As the patient has described his/her childhood experiences within an understanding atmosphere, sad feelings surrounding those experiences have diminished.
The pt began to express feelings more freely as rapport and the trust level increased. The pt has continued to experience difficulty being open and direct in his/her expression of painful feelings.
The patient explained what it was like to grow up in the home environment, focusing on the abusive/neglectful experiences that he/she endured.
The patient has begun to open up about his/her childhood experiences, but still remains rather guarded.
The patient described, in detail, the facts and feelings associated with his/her painful childhood experiences.
The patient reported struggles with his/her identity and feelings of insecurity due to painful childhood experiences.
The patient reported a clearer sense of identity and more self-confidence as his/her painful childhood experiences were processed.
The pt progress in regards to low self-esteem is as follows:As this therapist explored, through therapy session, the pt's sense of self compared to others, the pt acknowledged feeling less competent than most others.
The pt was able to actively begin to build a level of trust with this therapist in individual sessions through consistent eye contact, active listening, unconditional positive regard.
The pt reports his/ her ability to identify and express feelings.
Explored the pt’s assessment of himself/ herself regarding self worth.
The pt has become aware of his/ her fear of rejection and its connection with past rejection or abandonment experiences.
The pt, through the session was able to discuss incidents of abuse. Through therapeutic interaction, the pt was able to again insight into incidents of abuse (emotional, physical, and sexual) and how they have impacted his/ her feelings about himself/ herself.
The pt reported decreasing the frequency of negative self-descriptive statements and an increase in the frequency of positive self-descriptive statements.
The pt is becoming aware of how he/ she expresses or acts out negative feelings about himself/ herself. Assisted the pt in developing self-talk as a way of boosting his/ her confidence and positive self-image.
Discussed with pt the goal to Identify negative self-talk messages used to reinforce low self-esteem.
The pt identified his/ her distorted, negative beliefs about self and the world.
Asked the pt to complete and process an exercise in the book Ten Days to Self Esteem! (Burns).
Discussed with pt the possibility of any secondary gain that is received by speaking negatively about self and refusing to take any risks.
Helped the pt by teaching the meaning and power of secondary gain in maintaining negative behavior patterns.
Assisted the pt in identifying how self-disparagement and avoidance of risk taking could bring secondary gain (e.g., praise from others, others taking over responsibilities).
The pt gained insight into perceived fear of rejection and was able to indentify need need to increase statements of self-acceptance.
This therapist asked the pt to make one positive statement about self daily and record it on a chart or in a journal. Verbally reinforced the pt’s use of positive statements of confidence and accomplishments.The pt identified goals and accomplishments that would improve self-image and verbalized a plan to achieve those goals. In the therapy session, the pt was able to analyze his/ her goals to make sure they are realistic and attainable. Assigned self-esteem-building exercises from a workbook (e.g., The Six Pillars of Self-Esteem by Branden, or Ten Days to Self Esteem! by Burns);The pt was receptive to how self esteem can be increased by improving eye contact with others. Assigned the pt to make eye contact with whomever he/ she is speaking to; process the feelings associated with eye contact. Confronted the pt when he/ she is observed avoiding eye contact with others. The pt reported increase in personal hygeine and self-care.The pt reported positive traits and talents about self. Reinforced the pt’s positive self-descriptive statements. Discussed with pt the goal of helping pt demonstrate an increased ability to identify and express personal feelings. Assigned the pt to keep a journal of feelings on a daily basis. Assisted the pt in identifying and labeling emotions.Discussed with pt the goal of articulating a plan to be proactive in trying to get identified needs met. Assisted the pt in identifying and verbalizing his/ her needs, met and unmet. Conducted a conjoint or family therapy session in which the pt is supported in expression of unmet needs. Assisted the pt in developing a specific action plan to get each need met. Discussed with pt ways to improve self-esteem by positively acknowledging compliments from others. Assigned the pt to be aware of and acknowledge graciously (without discounting) praise and compliments from others. Discussed with pt the need to form realistic, appropriate, and attainable goals for self in all areas of life. Helped the pt analyze his/ her goals to make sure they are realistic and attainable. Assigned the pt to make a list of goals for various areas of life and a plan for steps toward goal attainment.Discussed with pt the need to take verbal responsibility for accomplishments without discounting. Asked the pt to list accomplishments; process the integration of these into his/ her self-image. Discussed and educated pt of positive self-talk messages to build self-esteem. Assigned the pt to read What to Say When You Talk to Yourself (Helmstetter); process key ideas. Reinforced the pt’s use of more realistic, positive messages to himself/ herself in interpreting life events. Discussed with pt the goal to Increase the frequency of speaking up with confidence in social situations. Used role-playing and behavioral rehearsal to improve the pt’s social skills in greeting people and carrying a conversation.The pt acknowledged feeling less competent than most others.This therapist actively continues to build the level of trust with the pt in individual sessions through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/ her ability to identify and express feelings. The pt has made progress with borderline personality disorder behaviors and thinking identified as:The pt was open to exploration of his/her the history of abuse and/ or abandonment particularly in childhood years. This therapist gave validation the the pt's distress and difficulties as understandable given his/her particular circumstances, thoughts and feelings.The pt was oriented to behavior therapy highlighting its multiple facets (e.g., support, collaboration, challenge, problem-solving, skill-building) and discuss dialectical/ biosocial view of borderline personality, emphasizing constitutional and social influences on its features. Solicitted from the pt an agreement to work collaboratively within the parameters of the CBT approach to overcome the behaviors, emotions, and cognitions that have been identified as causing problems in his/ her life. Discussed the pt’s suicidal gestures as to triggers, frequency, seriousness, secondary gain, and onset. Provided the pt with an emergency helpline telephone number that is available 24 hours a day. Elicited a promise (as part of a self-mutilation and suicide prevention contract) from the pt that he/ she will initiate contact with support system or a helpline if a suicidal urge becomes strong and before any self-injurious behavior occurs; This therapist provided monitoring, confrontation, and problem-solving for the pt actions that threaten to interfere with the continuation of therapy such as missing appointments, noncompliance, and/ or abruptly leaving therapy. Used validation, dialectical strategies (e.g., metaphor, devil’s advocate), and problem-solving strategies (e.g., behavioral and solution analysis, cognitive restructuring, skills training, exposure) to help the pt manage, reduce, or stabilize maladaptive behaviors (e.g., angry outbursts, binge drinking, abusive relationships, high-risk sex, uncontrolled spending), thoughts (e.g., all-or-nothing all-or-nothing thinking, catastrophizing, personalizing), and feelings.The pt has made progress in area of suicidal ideation as follows:Assisted the pt to identify how previous attempts to solve interpersonal problems have failed, leading to feelings of abject loneliness and rejection. Assisted the pt in becoming aware of life factors that were significant precursors to the beginning of his/ her suicidal ideation. 3. Encouraged the pt to share feelings of grief related to broken close relationships.Reviewed with the pt previous problem-solving attempts and discuss new alternatives that are available. Assisted the pt in developing coping strategies for suicidal ideation (e.g., more physical exercise, less internal focus, increased social involvement, more expression of feelings). The pt agreed to utilize coping strategies.The pt states a more consistent eating and sleeping pattern. The pt verbally reports no longer feeling the impulse to take own life and demonstrate an increased sense of hope for self. This therapist will continue to assist and monitor the pt’s suicidal potential on an ongoing basis. Assisted the pt in finding positive, hopeful things in his/ her life at the present time. The pt was able to identify the positive aspects, relationships, and achievements in his/ her life.Reviewed with the pt the success he/ she has had and the sources of love and concern that exist in his/ her life; ask him/ her to write a list of positive aspects of his/ her life. Through the therapy session the pt was able to Identify and replace negative thinking patterns that mediate feelings of hopelessness and helplessness. The pt has made progress in symptoms of anxiety in the following area:The pt was able to describe in the therapy session current and past experiences with the worry and anxiety symptoms, complete with their impact on functioning and attempts to resolve it. The pt reports a decrease in excessive worry and more control occurring more days than not. The pt reports a decrease in motor tension such as restlessness, tiredness, shakiness and muscle tension. The pt has gained insight into factors that have contributed to anxiety symptoms.The pt reports a reduction overall frequency, intensity, and duration of the anxiety so that daily functioning is not impaired.The pt reports decrease in hypervigilence and fear that something bad is going to happen.The pt reports a resolution oth the core conflict that is the source of anxiety. The pt reports more effectively being able to cope with life's daily stressors and anxieties.The pt agreed and is willing to learn and implement calming skills to reduce overall anxiety and manage anxiety symptoms.The pt agreed to cooperate with evaluation with psychiatrist for psychotropic medication.The pt verbalized an understanding of the cognitive, physiological, and behavioral components of anxiety and its treatment.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage anxiety symptoms.The pt has made progress in the area of Post Traumatic Stress Disorder as follows:The pt verbalized an understanding of the cognitive, physiological, and behavioral components of post-traumatic stress disorder and its treatment.. The pt was able to verbalize traumatic incident or incidents and has gained some insight into how these traumatic experiences impact current functioning.The pt learned calming and coping skills and agreed to implementaion to reduce overall anxiety and manage PTSD symptoms..Reports decrease in intense fear, helplessness, or horror to the traumatic event. The pt reports a decrease in disturbing and persistent thoughts, images, and/or perceptions of the traumatic event. The pt reports a decrease in the frequency of nightmares. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. The pt reports no distress related to the targeted memory, (s)he is asked to think of the preferred positive belief that was identified at the beginning of the session. At this time, the pt may adjust the positive belief if necessary, and then focus on it during the next set of distressing events.. The pt reported a decrease in experiences of the reliving of the event, particularly through dissociation flashbacks. The pt reported decrease in avoidance of thoughts, feelings, or discussions related to the traumatic event. The pt reports an increase in previously avoided activities, places, people, or objects that evoke memories of the event. Displays a significant interest and engagement in activities. New issues/Stressors Presented today: Participation:None reportedSYMPTOMS/SEVERITY:NOTES:
The pt gained insight and awareness into the importance of daily structure.


Relative Changes to condition (Reported/Observed):


None reported


Behavior/Functioning


Orientation


Mood/affect


New issues/Stressors Presented today:
No Significant Change
Notable
If notable, please comment

Homicidal/Suicidal:


NO


YES


Type of risk:


Ideation.


Plan


Attempt


Directed to:


Self


Others


Property


Intervention details/Other Therapeutic Interventions Provided:


Reviewed current and past functioning


Developed treatment plan


Assessed risk of harm


Contracted for safety


Discussed barrier’s to progress


Introduced parenting strategies


Evaluated progress toward treatment goals.


Provided referral or linkage


Provided Education and Information


Discussed alternative behaviors


Other:

Response to intervention/progress toward Goals/Objectives:







Plan:





Continue therapy




Terminate therapy.



Increase frequency.


Medication consult


Medication Compliant:


[ ] YES [ ] NO [ ] NA

Other notes: ______

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