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82 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication effectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 17. Monitor Symptom Increase Due to an Antidepressant (17) A. The client's pattern of severe and persistent mental illness symp toms was monitored due to the possibility of these being exacerbated by the introduction of an antidepressant medication. B. The client's severe and persistent mental illness symptoms appear to have increased subsequent to the introduction of an antidepre ssant, and this information was reflected to the prescribing physician. C. Medication adjustments have been implemented in order to decrease the negative effects of the antidepressant medication on the client's severe and persistent mental illness symptom s. D. No exacerbation of severe and persistent mental illness symptoms has been identified subsequent to the introduction of antidepressants. 18. Discuss Depression Development, Maintenance, and Changes (18) A. Factors that were related to the developmen t and maintenance of the client's depression were discussed. B. The focus was placed on how treatment will target specific factors that develop and maintain the client's depression. C. The client has been able to disclose factors that develop and maintai n his/her depression and is accepting of the ways in which treatment will target these factors for change. D. The client has been uncertain about the factors that develop and maintain his/her depression and was provided with remedial feedback in this area. 19. Identify Depressogenic Schemata (19) A. The client was assisted in developing an awareness of his/her automatic thoughts that reflect depressogenic schemata. B. The client was assisted in developing an awareness of his/her distorted cognitive mess ages that reinforce hopelessness and helplessness. C. The client was helped to identify several cognitive messages that occur on a regular basis and feed feelings of depression. D. The client recalled several instances of engaging in negative self-talk t hat precipitated feelings of helplessness, hopelessness, and depression; these were processed. 20. Assign Dysfunctional-Thinking Journal (20) A. The client was requested to keep a daily journal that lists each situation associated with depressed feelings and the dysfunctional thinking that triggered the depression. B. The client was assigned to use the “Daily Record of Dysfunctional Thoughts,” as described in Cognitive Therapy of Depression (Beck, Rush, Shaw, and Emery). C. The client was directed to co mplete the “Negative Thoughts Trigger Negative Feelings” assignment from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
DEPRESSION 83 D. The Socratic method was used to challenge the client's dysfunctional thoughts and to replace them with positive, reali ty-based thoughts. E. The client was reinforced for instances of successful replacement of negative thoughts with more realistic positive thinking. F. The client has not kept his/her record of automatic thoughts and was redirected to do so. 21. Conduct Behavioral Experiments (21) A. The client was encouraged to do “behavioral experiments” in which depressive automatic thoughts are treated as hypotheses/predictions and are tested against reality-based alternative hypothesis. B. The client's automatic de pressive thoughts were tested against the client's past, present, and/or future experiences. C. The client was assisted in processing the outcome of his/her behavioral experiences. D. The client was encouraged by his/her experience of the more reality-based hypothesis/ predictions; this progress was reinforced. E. The client continues to focus on depressive automatic thoughts and was redirected toward the behavioral evidence of the more reality-based alternative hypotheses. 22. Reinforce Positive Self-Talk (22) A. The client was reinforced for any successful replacement of distorted negative thinking with positive, reality-based cognitive messages. B. It was noted that the client has been engaging in positive,, reality-based thinking that has enhanced his/her self-confidence and increased adaptive action. C. The client was assigned to complete the “Positive Self-Talk” assignment from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). 23. Teach Behavioral Coping Strategies (23) A. The client was taught behavioral coping strategies such as physical exercise, increased social involvement, sharing of feelings, and increased assertiveness as ways to reduce feelings of depression. B. The client has implemented behavioral coping strategies to redu ce feelings of depression and was reinforced for doing so. C. The client reported that the utilization of behavioral coping strategies has been successful at reducing feelings of depression; the benefits of this progress were reviewed. D. The client was assisted in identifying several instances in which behavioral coping strategies were helpful in reducing depressive feelings. E. The client has not used behavioral coping strategies and was redirected to use this important resource. 24. Engage in Behavi oral Activation (24) A. The client was engaged in “behavioral activation” by scheduling activities that have a high likelihood for pleasure and mastery. B. The client was directed to complete tasks from the “Identify and Schedule Pleasant Events” assignm ent from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. Rehearsal, role-playing, role reversal, and other techniques were used to engage the client in behavioral activation. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
84 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client was reinforced for his/her successes in schedulin g activities that have a high likelihood for pleasure and mastery. E. The client has not engaged in pleasurable activities and was redirected to do so. 25. Employ Self-Reliance Training (25) A. Self-reliance training was used to help the client assume i ncreased responsibility for routine activities (e. g., cleaning, cooking, shopping). B. The client was urged to take responsibility for routine activities in order to overcome depression symptoms. C. The client was reinforced for his/her increased self-reliance. D. The client has not assumed increased responsibility for routine activities and his/her struggles in this area were redirected. 26. Assess the Interpersonal Inventory (26) A. The client was asked to develop an “interpersonal inventory” of impo rtant past and present relationships. B. The client's interpersonal inventory was assessed for potentially depressive themes (e. g., grief, interpersonal disputes, role transitions, interpersonal deficits). C. The client's interpersonal inventory was foun d to have significant depressive themes, and this was reflected to the client. D. The client's interpersonal inventory was found to have minimal depressive themes, and this was reflected to the client. 27. Explore Unresolved Grief (27) A. The client's h istory of losses that have triggered feelings of grief were explored. B. The client was assisted in identifying losses that have contributed to feelings of grief that have not been resolved. C. The client's unresolved feelings of grief are noted to be co ntributing to current feelings of depression and were provided a special focus. 28. Teach Assertiveness (28) A. The client was referred to an assertiveness training group that will educate and facilitate assertiveness skills. B. Role-playing, modeling, a nd behavioral rehearsal were used to train the client in assertive ness skills. C. The client has demonstrated a clearer understanding of the difference between assertiveness, passivity, and aggressiveness; he/she was urged to use these skills. D. The cl ient displayed a poor understanding of assertiveness skills and was provided with remedial training in this area. 29. Teach Conflict Resolution Skills (29) A. The client was taught conflict resolution skills such as practicing empathy, active listening, respectful communication, assertiveness, and compromise. B. Using role-playing, modeling, and behavioral rehearsal, the client was taught implementation of conflict resolution skills. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
DEPRESSION 85 C. The client reported implementation of conflict resolution skills i n his/her daily life and was reinforced for this utilization. D. The client reported that resolving interpersonal conflicts has contributed to a lifting of his/her depression; the benefits of this progress were emphasized. E. The client has not used the conflict-resolution skills that he/she has been taught and was provided with specific examples of when to use these skills. 30. Help Resolve Interpersonal Problems (30) A. The client was assisted in resolving interpersonal problems through the use of re assurance and support. B. The “Applying Problem-Solving to Interpersonal Conflict” assignment from the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma) was used to help resolve interpersonal problems. C. The client was helped to clarify cognitive and affective triggers that ignite conflicts. D. The client was taught active problem-solving techniques to help him/her resolve interpersonal problems. E. It was reflected to the client that he/she has significantly reduced his/her interpersonal problem s. F. The client continues to have significant interpersonal problems, and he/she was provided with remedial assistance in this area. 31. Address Interpersonal Conflict through Conjoint Sessions (31) A. A conjoint session was held to assist the client in resolving interpersonal conflicts with his/her partner. B. The client reported that the conjoint sessions have been helpful in resolving interpersonal conflicts with his/her partner, and this has contributed to a lifting of his/her depression. C. It was reflected that ongoing conflicts with a partner have fostered feelings of depression and hopelessness. 32. Teach Decision-Making Strategy (32) A. The client was taught specific decision-making strategies. B. The client was encouraged to identify one pro blem at a time, break the decision down into relevant parts, examine the pros and cons of relevant choices, and develop a decision based on that procedure. C. The client was reinforced for his/her successful use of decision-making skills. D. The client g ave specific examples of his/her use of decision-making strategies. E. The client has not used appropriate decision-making strategies and was redirected to do so. 33. Discourage Major Decisions While Depressed (33) A. The client was discouraged from ma king major life decisions until after his/her mood disorder improves. B. The client acknowledges the need to improve his/her mood before making major life decisions and was commended for this restraint. C. The client continues to attempt to make major li fe changes despite the presence of his/her mood disorder and was provided with additional feedback in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
86 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 34. Reinforce Physical Exercise (34) A. A plan for routine physical exercise was developed with the client, and a rational for including this in his/her daily routine was made. B. The client and therapist agreed to make a commitment toward implementing daily exercise as a depression reduction technique. C. The client has performed routine daily exercise, and he/she reports that it has been ben eficial; these benefits were reinforced. D. The client has not followed through on maintaining a routine of physical exercise and was redirected to do so. 35. Recommend Exercising Your Way to Better Mental Health (35) A. The client was encouraged to read Exercising Your Way to Better Mental Health (Leith) to introduce him/her to the concept of combating stress, depression, and anxiety with exercise. B. The client has followed through with reading the recommended book on exercise and mental health and rep orted that it was beneficial; key points were reviewed. C. The client has implemented a regular exercise regimen as a depression reduction technique and reported successful results; he/she was verbally reinforced for this progress. D. The client has not followed through with reading the recommended material on the effect of exercise on mental health and was encouraged to do so. 36. Build Relapse Prevention Skills (36) A. The client was assisted in building relapse prevention skills through the identifica tion of early warning signs of relapse. B. The client was directed to consistently review skills learned during therapy. C. The client was assisted in developing an ongoing plan for managing his/her routine challenges. 37. Connect Repressed Emotions wit h Depression (37) A. The client was taught about the possible connection between previously unexpressed feelings and his/her current state of depression. B. As the client has been assisted in gaining insight into his/her suppressed feelings from the past, his/her current feelings of depression have diminished. C. The client verbalized an understanding of the relationship between his/her current depressed mood and the repression of anger, hurt, and sadness, and this was processed. D. The client was unabl e to connect his/her repressed feelings and his/her current state of depression and was provided with additional feedback in this area. 38. Teach Expression of Repressed Emotions ( 38) A. The client was taught about healthy ways in which he/she can expres s his/her repressed emotions. B. To help the client express repressed emotions, specific techniques were modeled. C. Physical techniques for expressing emotions (e. g., beating a pillow) were reviewed. D. Verbal and written expressions of emotions (e. g., writing a letter) were reviewed. E. Specific rituals for expressing repressed emotions were reviewed (e. g., writing the emotion down, then tearing it up, and tossing it into the wind). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
DEPRESSION 87 F. The client was reinforced for his/her use of healthy techniques t o express his/her repressed emotions and reports decreased feelings of depression. G. The client continues to struggle with depressed feelings despite having been assisted in expressing his/her repressed emotions. 39. Refer to an Activity Therapist ( 39) A. The client was referred to an activity therapist for recommendations regarding physical fitness activities that are available in the community. B. The client was referred to community physical fitness resources (e. g., health clubs and other recreationa l programs). C. The client has been actively participating in community physical fitness programs and was reinforced for this. D. The client has declined involvement in community physical fitness programs and was redirected to do so. 40. Educate the Fam ily (40) A. The client's family was educated about his/her mental illness concerns. B. The client's family was referred to What to Do When Someone You Love Is Depressed: A Practical and Helpful Guide by Golant and Golant. C. Family members were praised for displaying an increased understanding of the client's mental illness concerns. 41. Teach Support Changes (41) A. The family members were taught about how to support the changes the client has made through treatment. B. Specific examples were listed from the family members regarding the ways in which the client's changes may affect the family functioning. C. Family members were reinforced for their positive support of the client's changes within treatment. D. Family members have sought a return to the previous status quo and have not supported the client through his/her treatment; this pattern was reflected to the family members. 42. Educate about Maintenance Treatment ( 42) A. The client was educated about the ongoing need for maintenance treatmen t (e. g., following up on appointments, continuing to take medications, or attending support groups) despite the lack of identifiable symptoms. B. The client acknowledged his/her need for maintenance treatment despite the lack of identifiable symptoms and was reinforced for this understanding. C. The client continues to use maintenance treatment despite the lack of identifiable symptoms and was provided with positive feedback in this area. D. The client has not used maintenance treatment and was redirecte d to do so. 43. Identify Symptom Indicators of Depression ( 43) A. The client was requested to identify a list of symptom triggers and indicators of his/her depression deepening. B. The client has developed a list of symptom triggers and indicators, and this was reviewed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
88 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was urged to share information about symptom indicators with his/her support network to assist them in monitoring his/her symptoms. D. The client has not developed a list of symptom triggers or indicators and was redirec ted in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
89 EMPLOYMENT PROBLEMS CLIENT PRESENTATION 1. Chronic Unemployment (1) * A. The client described a history of unemployment and underemployment. B. Although the client has attempted to work on a regular basis, he/she has been unable to sustain regular period s of employment. C. The client has little motivation to maintain regular patterns of work. D. Although the client has been working on a regular basis, his/her employment is in a setting that is less than his/her capability. E. As treatment has progresse d, the client has been more regularly involved in work activity. 2. History of Job Loss (2) A. The client reported that he/she has often been terminated from his/her occupational setting due to interpersonal conflicts or an inability to control his/her p rimary psychosis symptoms. B. The client described that he/she has been fired due to psychotic symptoms. C. The client reported that his/her current job is at risk due to his/her severe mental illness symptoms. D. As the client's severe and persistent m ental illness symptoms have stabilized, he/she has been able to be more regular in employment. 3. Decreased Desire for Employment (3) A. The client reported a low pattern of motivation to seek employment. B. The client reported a lack of desire to maint ain his/her current employment position. C. The client's low energy level has placed his/her current work setting in jeopardy. D. As the client has stabilized his/her mood, he/she reports an increased desire to actively seek and maintain employment. 4. Lack of Training (4) A. The client's lack of training has contributed to his/her failure to obtain employment. B. The client has not received formal or on-the-job training to assist in securing employment. C. As the client has developed specific trainin g and job skills, he/she has been able to obtain and maintain employment. 5. Failure to Achieve Expected Success (5) A. The client reports a pattern of failure to achieve or maintain expected levels of occupational involvement, duration, and success. B. The client described his/her pattern of employment as functioning below the age-appropriate level of occupational involvement, duration, and success. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
90 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. As the client's severe and persistent mental illness symptoms have stabilized, he/she has reported an increase in his/her level of occupational involvement, duration, and success. 6. Conflicts Due to Paranoia (6) A. The client described his/her pattern of conflict with authority figures due to unfounded suspiciousness or paranoia. B. The client describ ed that he/she has often rebelled against authority figures due to his/her unfounded suspiciousness or paranoia. C. As the client's pattern of suspiciousness and paranoia have been reduced, he/she reports decreased conflicts with authority figures. D. The client does not experience conflicts with authority figures due to any suspiciousness or paranoia. 7. Psychiatric Destabilization Due to Job Loss (7) A. The client described feelings of anxiety, depression, or other psychiatric destabilization secondar y to being fired or laid off. B. The client describes fears, feelings of worthlessness, and bizarre thoughts as a reaction to the stress of being fired or laid off. C. As treatment has progressed, the client reports increased psychiatric stability despit e employment problems. D. The client's employment problems have stabilized with a commensurate stabilization in his/her psychiatric functioning. 8. Fears Returning to Work (8) A. The client is fearful, due to his/her history of employment problems and f ailures, about returning to the workplace. B. The client's fears of returning to the workplace have exacerbated his/her employment problems. C. The client was able to identify and verbalize his/her fears about returning to the workplace. D. As the clien t has worked through his/her fears about returning to the workplace, he/she has shown more interest in employment. 9. Emotional Reaction to Job Placement (9) A. The client identified specific negative emotions that he/she experiences due to the nature of his/her job placement. B. The client described that his/her anxiety symptoms have increased due to the menial or repetitive nature of his/her job placement. C. The client identified depressed thoughts and feelings due to the nature of his/her job placem ent. D. As the client has worked through his/her feelings of depression and anxiety, he/she has become more emotionally stable. E. The client reports that he/she is content in his/her job placement. 10. Symptom Exacerbation Due to Increased Expectations (10) A. The client described that he/she has been anxious due to his/her increased job expectations. B. The client has experienced an increase in his/her primary mental illness symptoms due to his/her anxiety related to job tasks and expectations. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
EMPLOYMENT PROBLEMS 91 C. As the client has adjusted to his/her increased job expectations, he/she has experienced a decrease in his/her primary psychosis symptoms. INTERVENTIONS IMPLEM ENTED 1. Outline Employment History (1) * A. The client was asked to prepare a chronological outl ine of his/her previous employment. B. The client was assisted in preparing a chronological outline of his/her previous employment. C. The client's employment history was reviewed. D. Specific incidents of the client's employment success and failure wer e identified and processed within the session. E. The client has not prepared a chronological outline of his/her previous employment and was redirected to do so. 2. Identify Successful and Unsuccessful Employment Experiences ( 2) A. The client was asked to describe his/her previous successful employment situations. B. The client was asked to describe his/her negative job experiences. C. Attentive listening and encouragement were used to support the client as he/she reviewed his/her previous successful a nd unsuccessful employment situations. D. The client was unable to identify any previous successful employment situations and was given feedback in this area. 3. Relate Symptom Pattern to Employment Difficulties ( 3) A. The client was requested to identi fy situations in which the primary symptoms of his/her mental illness have negatively affected his/her job performance. B. The client was asked to identify situations in which his/her primary symptoms of mental illness have affected his/her social interac tions at work. C. The client's job performance and social interaction difficulties were processed within the clinical contact. D. The client was unable to identify ways in which his/her primary symptoms have affected his/her job performance or social int eraction and was given additional feedback in this area. 4. Educate about Mental Illness ( 4) A. The client was educated about the expected or common symptoms of his/her mental illness that may negatively impact his/her employment. B. As his/her symptoms of mental illness were discussed, the client displayed an understanding of how these symptoms may affect his/her level of employment. C. The client struggled to identify how symptoms of his/her mental illness may negatively impact his/her employment and was given additional feedback in this area. 5. Identify and Evaluate Reasons against Employment (5) A. The client was assisted in identifying possible reasons for not obtaining employment. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statem ent in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Johnsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
92 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client identified specific reasons why he/she is hesitant to obtain employment (e. g., his/her loss of disability payments or fear of increased responsibility or expectations), and this was accepted as an important factor. C. The client's reasons for not wishing to obtain employment were evaluated, reviewed, and processed. D. The client has been unable to identify any reasons why he/she would not desire to gain employment and was challenged to pursue employment. E. As the client has worked through his/her reasons for not wishing to obtain or maintain employment, he/she was assisted in acknowledging his/her tendency to sabotage his/her employment. F. As the client has processed his/her reasons for not obtaining or maintaining employment, he/she has rejected them and is noted to have an increased commitment to ob taining and maintaining employment. 6. Identify Positive Reasons for Employment (6) A. The client was asked to identify positive reasons for obtaining or maintaining employment. B. The client was assisted in developing positive reasons for obtaining or maintaining employment C. As the client has developed his/her positive reasons for obtaining or maintaining employment, he/she has been provided with feedback and support. D. The client has struggled to identify positive reasons for obtaining or maintain ing employment and was given additional support in this area. 7. Arrange Psychiatric Evaluation ( 7) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client has followed through on a refe rral to a physician and has been assessed for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychot ropic medication and was redirected to do so. 8. Encourage Consistent Use of Medications ( 8) A. The client was encouraged to take his/her medications on a consistent basis. B. The client was provided with positive reinforcement for his/her regular use o f psychiatric medications. C. The client has been erratic with his/her use of psychiatric medications and was provided with feedback in this area. 9. Coordinate Privacy at Work Site ( 9) A. The availability of a secure, private area where the client can keep and take his/her medications was coordinated at his/her work site. B. The client's employer has provided a secure, private area where the client can store and take his/her medications, and the benefits of this accommodation were reviewed. C. The cli ent has been able to regularly take his/her medications in a secure, private area at his/her work site, and the benefits of this were reviewed within the session. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
EMPLOYMENT PROBLEMS 93 D. The client has not taken advantage of using a secure, private area to keep and take his/h er medications and has continued to be erratic with the use of his/her medications. The effects of this were reviewed within the clinical contact. 10. Monitor Medications ( 10) A. The client was monitored for compliance with his/her psychotropic medicatio n regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medi cation effectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 11. Educate about Psychotropic Medications ( 11) A. The client was taugh t about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The cli ent displayed a lack of understanding of the indications for and expected benefits of psychotropic medications and was provided with additional information regarding his/her medications. 12. Educate Regarding Medication Effect on Employment (1 2) A. The c lient was educated about the expected positive effect of his/her psychiatric medications on his/her employment functioning. B. The client identified that his/her functioning in the employment situation has significantly improved as he/she has been more st able on his/her medication, and this was processed within the session. C. The client continues to struggle with his/her employment setting despite his/her improved functioning subsequent to the use of psychiatric medications, and this was reviewed. 13. Encourage Employment as Central to Recovery (1 3) A. The client was advised about how employment is a central goal in the recovery process. B. The personal, social, financial, and other revelant benefits of employment were discussed with the client. C. The client was reinforced in his/her motivation to obtain employment as a central goal in recovery. D. The client has not developed employment as a central goal for recovery, and was redirected to do so. 14. Refer to Supported Employment (1 4) A. The client was referred to a supported employment program. B. The client has engaged in the support employment program and the benefits of this program were reviewed. C. The client has not utilized the supported employment program and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
94 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 15. Identify Target Social Behaviors (1 5) A. The client was asked to identify three social behaviors that will promote better interpersonal functioning in the work situation. B. The client was assisted in identifying three social behaviors that will promote his/her better interpersonal functioning in the work situation. C. The client was reinforced for making a commitment to work on specific social behaviors (e. g., eye contact, dress, and politeness) to promote better interpersonal functioning in the work situation. D. The client has failed to identify his/her needs regarding increased social behaviors and was provided with additional feedback in this area. 16. Identify Setting for New Social Behaviors (16) A. The client was assisted in identifying employm ent situations in which his/her new prosocial behaviors could be used. B. The client was given positive feedback regarding the situations in which he/she has been using his/her new, prosocial behaviors in the work setting. 17. Practice Target Social Beha viors (17) A. Behavioral rehearsal, role playing, and role reversal were used to help the client practice targeted interpersonal behaviors. B. The client was praised for displaying a good understanding of how to use his/her targeted interpersonal behavio rs. C. The client was urged to implement his/her targeted interpersonal behaviors in real-life settings. D. The client has continued to struggle with his/her targeted interpersonal behaviors and was given additional practice in this area. 18. Teach Asse rtiveness (1 8) A. The client was taught assertiveness skills. B. The client was referred to written material regarding how to implement assertiveness. C. The client was referred to The Assertiveness Workbook by Pfeiffer or Assert Yourself by Lindenfield to learn more about assertiveness skills. D. Role modeling, role playing, modeling, and behavioral rehearsal were used to train the client in assertiveness skills. E. The client has demonstrated a clearer understanding of the difference between assertiv eness, passivity, and aggressiveness and was commended for this success. 19. Refer to an Assertiveness-Training Workshop (1 9) A. The client was referred to an assertiveness-training workshop to assist in his/her education regarding assertiveness skills. B. The client was reinforced for attending lectures, completing assignments, and cooperating with role-playing situations to help learn more about his/her assertiveness through the training workshop. C. The client failed to demonstrate an understanding o f assertiveness and was provided with additional feedback in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
EMPLOYMENT PROBLEMS 95 20. Identify Marketable Skills (20) A. The client was asked to identify marketable skills for which he/she has displayed mastery and could form a basis for employment search. B. The client was provided with feedback about his/her marketable skills. C. As the client's marketable skills have been reviewed, he/she has become more positive about his/her ability to obtain employment. 21. Refer to a Skill Program (21) A. The client was referred for employment skill assessment and training (e. g., community education, technical center training, vocational rehabilitation, or occupational therapy). B. The client has attended an employment skill assessment and training program, and his/her n ew vocational skills were reviewed. C. The client has been sporadic in his/her attendance at the employment skill assessment and training program and was urged to be more regular. D. The client has declined to be involved in the employment skill assessme nt and training program and was given additional encouragement in this area. 22. Monitor Progress in Educational/Rehabilitation Program (2 2) A. The client's ongoing attendance, functioning, and progress in the educational or employment rehabilitation pro gram was monitored. B. The client was accompanied to the employment training program to assist in increasing his/her functioning within the program. C. The client was provided feedback about his/her attendance, functioning, and progress in the employment educational or rehabilitation program. 23. Identify Occupational Interests (23) A. Interest testing was administered to identify specific types of occupations in which the client has interest. B. The client has participated in interest testing, and occ upations in which he/she has shown interest were reviewed. C. The client's interest testing has been completed, and he/she has been given feedback in this area. D. The client refused to cooperate with the interest testing and was urged to do so. 24. Review Testing to Identify Occupational Placement (2 4) A. The client's interest testing was reviewed with him/her to help brainstorm specific jobs in which he/she would be interested. B. The client has been able to identify a variety of jobs in which he/she has an interest, and this was noted to be consistent with his/her interest testing. C. The client has struggled to identify occupational interests that are consistent with his/her interest testing. 25. Develop a Resume (2 5) A. The client was assisted i n developing his/her resume. B. Resources from 101 Quick Tips for a Dynamite Resume by Fein or Resumes for the First Time Job Hunter by VGM Career Horizons editors were used to assist the client in developing his/her resume. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
96 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client has completed h is/her resume and was given helpful feedback. D. The client has not completed his/her resume and was redirected to do so. 26. Obtain Letters of Reference (2 6) A. The client was requested to identify family, friends, teachers, former employers, or other clinicians from whom letters of reference for employment may be requested. B. The client was assigned to procure letters of reference from family, friends, teachers, former employers, or other clinicians. C. The client has obtained his/her letters of ref erence, and these were reviewed. D. The client has not obtained his/her letters of reference and was redirected to do so. 27. Review Classified Ads ( 27) A. The local classified advertisements for job placements were reviewed with the client. B. Feedbac k was shared with the client about specific job advertisements. C. The client identified specific jobs for which he/she would like to apply and was given feedback about these selections. D. The client has neglected to identify jobs from the classified ad vertisements for which he/she would like to apply and was redirected to do so. 28. Assign Interviewing Techniques Material ( 28) A. The client was assigned to read material related to interviewing techniques. B. The client was assigned to read from selec tions from What Color Is Your Parachute? by Bowles or 10 Minute Guide to Job Interviews by Morgan. C. The client has read specific material on job interview techniques, and this was processed. D. The client has not reviewed the information regarding job interview techniques and was redirected to do so. 29. Practice Job Interviews ( 29) A. Role-playing, behavioral rehearsal, and role reversal were used to help increase the client's confidence and skill in the interview process. B. As the client practiced his/her interview techniques, he/she was provided with feedback and support. 30. Assist in Planning and Coordinating Interview Appointment ( 30) A. The client was assisted in planning his/her interview appointment. B. As the client developed specific pl ans for his/her interview appointment, he/she was monitored and provided feedback to make sure that he/she had covered all areas. C. The client has developed a comprehensive plan for his/her interview appointment and was provided with positive feedback in this area. D. Transportation to the client's interview was coordinated for him/her. E. The client indicated that he/she had transportation to the job interview but was reminded about other resources as a backup plan. F. The client was assisted in ident ifying public modes of transportation. G. The client has not developed a comprehensive plan for his/her interview appointment and was redirected in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
EMPLOYMENT PROBLEMS 97 31. Process Interview/Decide about Job (3 1) A. Subsequent to the interview, the client's overa ll interview experience was processed, identifying positive and negative aspects of his/her performance. B. The client has been offered a job position, and he/she was assisted in making decisions about whether to accept the job offer. C. The client has m ade a decision about accepting the job offered to him/her and was provided with feedback and support in this area. 32. Secure Reliable Transportation (3 2) A. The client was assisted in planning for reliable transportation to and from work. B. The client secured reliable transportation to and from work, and he/she was reinforced for planning ahead in this manner. C. The client has not developed reliable options for transportation to and from work, and was redirected to do so. 33. Arrange for a Job Coach (33) A. It was arranged for a job coach to meet regularly with the client in the job setting to review job needs, skills, and problem areas. B. The client was supported for cooperating with the job coach, who has assisted in helping the client coordinate all needs, skills, and problem resolution to maintain his/her position. C. The client has been stable in his/her job setting, and the services of the job coach have been discontinued. 34. Educate the Employer (3 4) A. After obtaining the proper authoriz ation for release of information, the client's mental illness symptoms were reviewed with his/her employer. B. The employer was supported for verbalizing a better understanding of the client's needs within the employment setting. C. The employer reacted negatively to the information regarding the client's mental illness, and this was reviewed with the client. 35. Educate Fellow Employees (35) A. After obtaining the proper authorization to release confidential information, specific information was provid ed to the client's fellow employees regarding his/her mental illness concerns. B. Sensitivity training regarding the client's mental illness and his/her needs were provided to his/her fellow employees. C. The client reports increased support in the workp lace due to his/her fellow employees being aware of his/her mental illness concerns, and this was discussed. D. The client reported that his/her fellow employees have reacted negatively to the disclosure about his/her mental illness, and this was processe d within the session. 36. Develop Crisis Intervention Plan with Employer (36) A. The client assisted in developing an agreed-upon intervention plan with his/her employer related to symptom exacerbation. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
98 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client and his/her employer have utilized th e crisis plan and were provided with feedback about how useful this has been. C. The client and his/her employer have not used the agreed upon intervention plan and were redirected to do so. 37. Provide Feedback (37) A. The client was visited at the job site and provided with feedback about his/her hygiene, dress, behavior, and technical skills. B. The client has improved his/her hygiene, dress, behavior, and technical skills as a result of the feedback provided for him/her. C. The client continues to struggle with basic hygiene, dress, behavior, and technical skills and was provided with additional feedback in this area. 38. Review Rules and Etiquette ( 38) A. A review of the workplace rules for the client was completed. B. The client was informed re garding basic etiquette expectations within the workplace. C. The client reports his/her employment functioning has increased as he/she regularly adheres to workplace rules and etiquette, and this success was reflected back to him/her. D. The client cont inues to not comply with basic workplace rules and etiquette and was provided with additional feedback in this area. 39. Meet with the Employer ( 39) A. A meeting was held with the employer to review the client's functioning and needs. B. Specific issues related to the client's functioning and needs within the employment setting were identified, and specific techniques to ameliorate these needs were developed. C. As the employer has indicated ongoing satisfaction with the client's functioning, the freque ncy of the meetings with the employer has been reduced. D. The client is no longer in need of outside coordination or review of his/her employment functioning. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
99 FAMILY CONFLICTS CLIENT PRESENTATION 1. Estranged Relationships (1) * A. The client described an atmosphere of frequent conflict with parents and siblings. B. Family members have little contact with the client and are not seen as a positive influence or source of support. C. The client has taken the initiative to increase the closeness he/she experiences with family members. D. The client indicated that he/she feels more a part of a family unit and is supported by his/her family members. 2. Abuse towar d Family (2) A. A series of incidents have occurred in which the client was abusive toward family members. B. The client tends to project the blame for his/her aggressive or abusive behaviors onto other people. C. The client has begun to take steps to c ontrol his/her abusive behavior. D. The client has recently demonstrated good self-control and not engaged in any abusive or aggressive behaviors toward family members. 3. Manipulation/Intimidation (2) A. The client described a pattern of incidents in w hich he/she has been manipulative or attempted to intimidate family members. B. Family members reported that the client has displayed a pattern of threatening behavior to manipulate or intimidate them, without becoming physically abusive. C. The client h as recently become more cooperative and respectful, rather than being manipulative or intimidating. D. The client has been supportive and respectful toward family members on a consistent basis. 4. Overcontrol by Family (3) A. The client displayed a patt ern of lower-than-expected functioning in a variety of areas due to overcontrol of his/her basic needs and decisions by the family. B. The client described a pattern of his/her family members making basic choices for him/her despite his/her ability to tak e care of these basic needs. C. The client has begun to take control of some of his/her own basic needs. D. The client has become more independent and displayed the ability to care for many of his/her needs despite his/her mental illness concerns. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
100 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 5. Family Denial/Rejection (4) A. Family members have often demonstrated rejection toward the client due to his/her mental illness. B. The family members have often denied the client's diagnosis of mental illness. C. The client described family conflicts due to his/her family's difficulty accepting him/her and his/her diagnosis. D. The client reported that he/she has begun to feel more accepted by family members despite his/her mental illness concerns. E. The client described a consistent pattern of his/her family members accepting him/her despite his/her mental illness. 6. Lack of Prodromal Knowledge (5) A. Family members displayed a consistent pattern of ignorance about the client's chronic mental illness symptoms and indicators of decompensation. B. Family members have often been slow to assist the decompensating client due to their lack of knowledge about his/her chronic mental illness symptoms and indicators of decompensation. C. Family members have begun to learn about the client's mental illness sy mptoms and indicators of decompensation. D. Family members have been more supportive as they have learned about the client's pattern of symptoms and indicators of decompensation. 7. Lack of Treatment Knowledge (6) A. Family members displayed a poor unde rstanding of the treatment options available to the client. B. Family members have not accessed helpful treatment for the client due to their lack of knowledge or understanding of treatment options. C. Family members have inadvertently thwarted treatment due to their lack of understanding of the treatment options available to the client. D. As family members have become knowledgeable about treatment options, they have been more supportive of the client's treatment. 8. Embarrassment (7) A. Family member s described a feeling of embarrassment and a tendency to hide the client because of his/her erratic behaviors related to his/her severe mental illness symptoms. B. The client feels rejected when his/her family members display embarrassment and a tendency to hide him/her because of his/her mental illness symptoms. C. Family members have begun to support the client and accept his/her pattern of symptoms. D. The client reports that he/she feels more accepted and has experienced decreased family conflicts du e to his/her family members being more open about his/her symptoms and needs. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FAMILY C ONFLICTS 101 INTERVENTIONS IMPLEM ENTED 1. Explore Family Relationships (1) * A. The client was asked to describe his/her experiences in family relationships. B. The client was probed as to the nature, frequency, and intensity of the family conflict. C. Causes for conflict within family relationships were explored. D. The client outlined the nature of the family conflicts and his/her perspective on the causes for them, and these data were p rocessed. 2. Describe Specific Family Interactions (2) A. The client was requested to provide examples of positive family experiences. B. The client's identification of positive family experiences was reviewed and processed. C. The client was requested to provide examples of negative family experiences. D. The client's description of negative family experiences was reviewed and processed. E. The client struggled to identify examples of positive and negative family experiences, and was urged to develop this information more fully. 3. Create a Family Genogram (3) A. The client's description of family members, patterns of interaction, rules, and secrets was translated into a graphical genogram. B. A family session was conducted in which a genogram was developed that was complete, denoting family members, patterns of interaction, rules, and secrets. C. The dysfunctional communication patterns between nuclear and extended family members were highlighted. D. Family members were supported as they acknowle dged the lack of healthy communication that permeates the extended family. E. The client displayed increased understanding of his/her family's pattern of unhealthy communication and was encouraged for this progress. F. The client failed to develop insigh t into family interactions and was given tentative interpretations of these patterns. 4. Describe Problematic Relationships (4) A. The client was requested to list and describe his/her problematic relationships. B. The client's description of his/her pr oblematic relationships was processed. C. The client has failed to develop a comprehensive list of his/her problematic relationships and was redirected to do so. 5. Clarify Impact on Relationships ( 5) A. The client's specific behaviors that contribute t o positive relationships and interactions were highlighted and clarified. B. Specific behaviors in which the client engages that have a negative impact on relationships were highlighted and clarified. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the com panion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
102 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client was given positive feedback as he/she d isplayed insight into the positive and negative effects that his/her behavior has on relationships. D. The client failed to connect his/her behavior with the positive or negative impact on relationships and was given additional feedback in this area. 6. Identify Past Positive Interactions ( 6) A. Solution-focused techniques were used to assist the client in identifying how he/she has facilitated positive social interaction in the past. B. The client identified specific situations in which he/she has been able to facilitate some positive social interactions in the past, and these were processed. C. Solution-focused techniques were used to help the client generate a list of additional situations in which he/she could use his/her positive social skills. D. The client struggled to identify positive interactions from the past and was provided with additional feedback and support in this area. 7. Facilitate Family Emotional Expression ( 7) A. Family members were assisted in identifying and expressing emotions regarding the client's mental illness. B. Family members were supported as they expressed their emotions regarding the client's mental illness concerns. C. Family members expressed multiple emotions regarding the client's mental illness, which were processed within the session. D. Family members have been reluctant to express emotions relating to the client's mental illness concerns and were encouraged to do so when they felt more comfortable with it. 8. Use Magical Question ( 8) A. A magical question (i. e., “What would happen in your family if the client did not have any mental illness symptoms?”) was used to help the family members identify the impact of the mental illness symptoms on the family. B. Family members identified specific ways in which th e client's mental illness symptoms have impacted the family, and these were reviewed and clarified. C. Family members displayed a greater understanding of the impact on the family relative to the client's mental illness symptoms and were reinforced for th is increased understanding. 9. Use Multiple Family Group Treatment (9) A. The client was referred for multiple family group treatment. B. The client was enrolled in a multiple family group treatment program. C. The client's family has participated in a multiple family group treatment program, gaining insight into family dynamics and how to cope with the client's symptoms. D. The family is not enrolled in the multiple family group treatment program, and the reasons for this resistance were reviewed. 10. Conduct Family-Focused Treatment (10) A. The client and significant others were included in the family-focused treatment model. B. Family-focused treatment was used with the client and significant others as indicated in Bipolar Disorder: A Family Appr oach (Miklowitz and Goldstein). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FAMILY C ONFLICTS 103 C. As family members were not available to participate in therapy, the family-focused treatment model was adapted to individual therapy. 11. Refer to a Lending Library (11) A. The client and his/her family were referred t o a lending library within the agency to access books or tapes on the topic of severe mental illness. B. The client and his/her family were referred to the community library resources to access books or tapes on severe mental illness. C. The client and h is/her family's increased understanding of severe mental illness symptoms through the use of the educational materials was reviewed and noted. D. The client and his/her family have not sought out available reading materials and were redirected to do so. 12. Teach Family Members about Severe and Persistent Mental Illness (12) A. The client's family members were referred to a didactic session on the topic of severe and persistent mental illness. B. The client's family members were provided with didactic i nformation about the topic of severe and persistent mental illness. C. The client's family members were reinforced for displaying new knowledge about his/her mental illness symptoms. D. The client's family members have not attended didactic sessions on p sychosis and were redirected to do so. 13. Educate about Mood Episodes (13) A. A variety of modalities were used to teach the family about signs and symptoms of the client's mood episodes. B. The phasic relapsing nature of the client's mood episodes was emphasized. C. The client's mood episode concerns were normalized. D. The client's mood episodes were destigmatized. 14. Teach Stress Diathesis Model (14) A. The client was taught a stress diathesis model of Bipolar Disorder. B. The biological predispo sition to mood episodes was emphasized. C. The client was taught about how stress can make him/her more vulnerable to mood episodes. D. The manageability of mood episodes was emphasized. E. The client was reinforced for his/her clear understanding of th e stress diathesis model of Bipolar Disorder. F. The client struggled to display a clear understanding of the stress diathesis model of Bipolar Disorder and was provided with additional remedial information in this area. 15. Provide Rational for Treatment (15) A. The client was provided with the rationale for treatment involving ongoing medication and psychosocial treatment. B. The focus of treatment was emphasized, including recognizing, managing, and reducing biological and psychological vulnerabilitie s that could precipitate relapse. C. A discussion was held about the rationale for treatment. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
104 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client was reinforced for his/her understanding of the appropriate rational for treatment. E. The client was redirected when he/she displayed a poor und erstanding of the rationale for treatment. 16. Identify Relapse Triggers (16) A. Sources of the client's stress and triggers of potential relapse were identified. B. Negative events, cognitive interpretations, aversive communication, poor sleep hygiene, and medication noncompliance were investigated as potential stressors or triggers of potential relapse. C. Cognitive-behavioral techniques were used to address the sources of stress and triggers for potential relapse. 17. Enhance Engagement in Medication Use (17) A. Motivational interviewing approaches were used to help enhance the client's level of engagement in his/her medication use and compliance to the medication regimen. B. Modeling, role-playing, and behavioral rehearsal were used to help the clie nt use problem-solving skills to work through several current conflicts. C. The client was taught about the risk for relapse when medication is discontinued. D. Commitment was obtained to continuous prescription adherence. E. As a result of motivational interviewing approaches for medication compliance, the subject's use of medication has significantly improved. F. The client continues to be medication noncompliant despite use of motivational interviewing approaches; the client was refocused onto this t ask. 18. Assess Prescription Noncompliance Factors (18) A. Factors that have precipitated the client's prescription noncompliance were assessed. B. The client was checked for specific thoughts, feelings, and stressors that might contribute to his/her pre scription noncompliance. C. A plan was developed for recognizing and addressing the factors that have precipitated the client's prescription noncompliance. 19. Educate about Lab Work (19) A. The client was educated about the need to stay compliant with n ecessary lab work involved in regulating his/her medication levels. B. The client was encouraged to stay compliant with necessary lab work. C. The client was reinforced for his/her compliance to completing necessary lab work to help regulate his/her medi cation levels. D. The client has not been regular in his/her compliance to lab work for regulating his/her medication levels and was redirected to do so. 20. Assess Potential Crises (20) A. The client was assisted in assessing potential crises, including his/her most likely route to decompensation. B. The client was assisted in problem solving how to manage his/her potential crises. C. Family members were engaged in discussing the client's likely potential crises and how to manage them. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FAMILY C ONFLICTS 105 D. Family me mbers have been assisted in developing a comprehensive plan for managing the client's potential crises. E. The family members are not in agreement on how to manage the client's potential crises and were provided with additional coordination in this area. 21. Develop Relapse Drill (21) A. The client and family were assisted in drawing up a relapse drill, detailing roles and responsibilities. B. Family members were asked to take responsibility for specific roles (e. g., who will call a meeting of the famil y to problem solve potential relapse; who will call physician, schedule a serum level, or contact emergency services, if needed). C. Obstacles to providing family support to the client's potential relapse were reviewed and problem solved. D. The family w as asked to make a commitment to adherence to the relapse response plan. E. The family was reinforced for their commitment to the adherence to the relapse response plan. F. The family has not developed a clear commitment to the relapse prevention plan an d was redirected in this area. 22. Assess and Educate about Aversive Communication (22) A. The family was assessed for the role of aversive communication in family distress and in the risk for the client's manic relapse. B. The family was educated about the role of aversive communication (e. g., highly expressed emotion) in developing greater family stress and in increasing the client's risk for manic relapse. C. The family displayed a clear understanding of the effects of aversive communication, and this was reinforced. D. The family was provided with remedial feedback, as they did not display a clear understanding of the risk for relapse due to aversive communication. 23. Teach Communication Skills (23) A. Behavioral techniques were used to teach commu nication skills. B. Communication skills such as offering positive feedback, active listening, making positive requests for behavioral change, and giving negative feedback in an honest, respectful manner were taught to the client and family. C. Behaviora l techniques were used to teach the family healthy communication skills. D. Education, modeling, role-playing, corrective feedback, and positive reinforcement were used to teach communication skills. 24. Assign Communication Skills Homework (24) A. The c lient and family were assigned homework exercises to use and record newly learned communication skills. B. Family members have used newly learned communication skills, and the results were processed within the session. C. Family members have not used the newly learned communication skills and were redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
106 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 25. Increase Sensitivity to Effects of Behavior (25) A. Role-playing, role reversal, and behavioral rehearsal were used to increase the client's sensitivity to the negative effects of his/h er impulsive behavior. B. The client was reinforced for his/her increased sensitivity to the negative effects of his/her impulsive behavior on others. 26. Confront Mania and Enforce Rules (26) A. Unhealthy, impulsive, or manic behaviors that occur during contacts with the clinician were identified and confronted. B. Clear rules and roles in the relationship were identified and enforced with immediate, short-term consequences for breaking such boundaries. C. The client's unhealthy, impulsive, or manic be haviors have diminished in response to limit setting within the session. 27. Address Problem Solving (27) A. The client was asked to identify conflicts that can be addressed through problem-solving techniques. B. The family members were asked to give inp ut about conflicts that could be addressed with problem-solving techniques. C. The client and family arrived at a list of conflicts that could be addressed with problem-solving techniques. 28. Teach Problem-Solving Skills (28) A. Behavioral techniques su ch as education, modeling, role-playing, corrective feedback, and positive reinforcement were used to teach the client and family problem-solving skills. B. Specific problem-solving skills were taught to the family, including defining the problem construc tively and specifically, brainstorming options, evaluating options, choosing options, implementing a plan, evaluating results, and reevaluating the plan. C. Family members were asked to use the problem-solving skills on specific situations. D. The family was reinforced for positive use of problem-solving skills. E. The family was redirected for failures to properly use problem-solving skills. 29. Assign Problem-Solving Homework (29) A. The client and family were assigned to use newly learned problem-solving skills and record their use. B. The client and family were assigned “Applying Problem-Solving to Interpersonal Conflict” in the Adult Psychotherapy Homework Planner, 2nd ed. (Jongsma). C. The results of the family members' use of problem-solving ski lls were reviewed within the session. 30. Assess Family Support Network ( 30) A. The family was assessed for the extent to which it has a support network. B. The family was encouraged to use extended family, neighbors, church friends, social relationship s, and other portions of their support network to provide diversion, emotional support, and/or respite care for the client. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FAMILY C ONFLICTS 107 C. The family has limited support to assist in diversion, emotional support, or respite care for the client and was encouraged to d evelop more supports. 31. Refer the Family to Respite Services (3 1) A. The family was referred to a community-based respite care service. B. Respite services have assisted in providing supervision or taking responsibility for the client on a short-term basis. C. The family was supported for using respite services and reporting less stress and strain on the family. D. The family has not used respite services and was encouraged to do so. 32. Acknowledge Family Frustration Regarding Services ( 32) A. The family was facilitated in expressing their frustration and anger regarding not having received services that they desired in the past. B. The family's experience of not having received services that they desired in the past was acknowledged. C. The fami ly reported feeling validated about having experienced past service difficulties and are being redirected to current available services. D. The family's frustration and anger regarding past service failures has caused decreased desire to attempt current s ervices, and they were encouraged to attempt these resources again. 33. Refer Family Members to Support Group (33) A. The client's family members were referred to a support group for families of the mentally ill. B. The client's family members have used the support group for families of the mentally ill, and their positive experience was reviewed. C. The client's family members have attended a support group for families of the mentally ill but did not find this a helpful experience; this was reviewed in order to help problem solve obstacles to gaining benefits from this resource. D. The client's family members have not attended the support group for families of the mentally ill and were redirected to do so. 34. Schedule Maintenance Sessions (34) A. The client was scheduled for a maintenance session between one and three months after therapy ends. B. The client was advised to contact the therapist if he/she needs to be seen prior to the maintenance session. C. The client's maintenance session was held, and he/she was reinforced for his/her successful implementation of therapy techniques. D. The client's maintenance session was held, and he/she was coordinated for further treatment, as his/her progress has not been sustained. 35. Identify Social Activi ties (3 5) A. The client was assisted in identifying mutually satisfying social activities for himself/herself and his/her family. B. The client was supported for identifying mutually satisfying social activities for himself/herself and his/her family. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
108 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client and his/her family have participated in mutually satisfying social activities, and this was reviewed and supported. D. The client has not identified helpful social activities and was redirected to do so. 36. Refer to an Activity or Recreatio nal Therapist (3 6) A. The client was referred to an activity or recreational therapist for assistance in developing leisure skills or activities to share with family members. B. The client has met with the activity or recreational therapist and is develo ping leisure skills to share with family members. C. The client was reinforced for developing more leisure skills and reporting better relationships with family members. D. The client has not followed through on the referral to an activity or recreationa l therapist and was redirected to do so. 37. Identify Family Patterns That Limit the Client's Functioning (3 7) A. Family roles and behavioral patterns that have developed as a result of the family's reaction to the client's mental illness were identified. B. An analysis of family roles and behavioral patterns focused on how the client's independent functioning has been limited and dependence has been encouraged. C. The client was reinforced for displaying insight into his/her family's reaction to his/he r mental illness symptoms and how this affects his/her functioning. D. The client's family members were supported for displaying insight into their reaction to his/her severe and persistent mental illness symptoms and how this affects his/her functioning. E. The client and his/her family members did not display any insight into their family patterns of behavior, so they were given feedback in this area. 38. Encourage Independence (3 8) A. The client was encouraged to make all possible choices and demonst rate maximum independence in daily events. B. The client's family members were encouraged to allow him/her to make all possible choices and demonstrate maximum independence in daily events. C. The client's growing pattern of independence and ability to m ake his/her own choices were reviewed within the session. D. The client was given positive feedback for his/her increase in independence. E. The client reported that he/she has not focused on making his/her own choices and maximizing independence, and th is resistance was reviewed. 39. Review Backup Caregiver/Advocate (39) A. The options available for backup to the primary caregiver/advocate were reviewed. B. A specific plan was developed for the client's care and advocacy should the primary caregiver/a dvocate be unable to care for the client. C. The client and his/her family have developed a comprehensive plan in the event that the primary caregiver/advocate is unable to care for the client, and they received positive feedback for this. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FAMILY C ONFLICTS 109 D. The client and his/her family reported minimal resources for his/her care and advocacy should the primary caregiver be unable to care for him/her, and they were referred to community resources. 40. Encourage Sibling Involvement (40) A. The client's siblings were en couraged to be regularly involved in his/her treatment and social contacts. B. The client reported increased involvement with his/her siblings, and this was reviewed and supported. C. The client's siblings have developed a more involved relationship with him/her, and this development was reinforced. D. The client's siblings continue to avoid involvement with him/her, and this pattern was reviewed and confronted. 41. Encourage Religious Involvement ( 41) A. Family members were encouraged to continue regu lar involvement of the client in church or other religious practices. B. Family members have worked to include the client in the family's regular religious practices and were provided with reinforcement for this. C. Family members continue to exclude the client from the family's religious activities and were encouraged to involve him/her in this area. 42. Monitor Religiously Themed Symptoms/Issues ( 42) A. The potency of the client's religious interest was assessed. B. The client was assisted in differe ntiating between religiously oriented mental illness symptoms and legitimate spiritual issues. C. The client was reinforced for displaying a clear understanding of legitimate spiritual issues versus his/her religiously oriented mental illness symptoms, an d this was noted to be helpful in his/her involvement in family religious practices. D. The client displayed confusion regarding his/her religiously oriented mental illness symptoms and legitimate spiritual issues and was provided with additional feedback in this area. 43. Provide Symptom Information to Religious Leaders ( 43) A. A release of information was obtained to allow information to be provided to the clergy or other church leaders regarding assistance that the client may need in accessing spiritu al practices and programs. B. Specific information was provided to the clergy and other church leaders regarding the client's special needs related to spiritual practices and programs. C. Church leaders were supported for responding positively to informa tion about the client's specific needs related to spiritual practices and programs. D. The client reported ongoing difficulty engaging in family-oriented spiritual practices and was provided with additional feedback in this area. 44. Resolve Family Self-Blame (44) A. Family members were assisted in identifying feelings of responsibility and self-blame for the client's mental illness. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
110 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. Family members were provided with information regarding the etiology of the client's severe and persistent mental illn ess. C. Family members were assisted in resolving any unrealistic feelings of responsibility and self-blame regarding the client's mental illness. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
111 FINANCIAL NEEDS CLIENT PRESENTATION 1. Low Income (1) * A. The client described a history of low income due to the effects of psychotic and other severe mental illness symptoms. B. The client is on a limited, state-supported income. C. The client report ed that his/her psychosis and other severe mental illness symptoms have resulted in a significant loss of income. D. As the client has stabilized, he/she reports increased financial stability. 2. Chronic Homelessness (2) A. The client described a patter n of chronic homelessness. B. The client described that he/she often uses supported transitional living services (e. g., homeless shelters or adult foster care placements). C. The client described a pattern of financial difficulty, which has contributed t o his/her homelessness. D. As treatment has progressed, the client has become more financially stable and is able to sustain his/her living situation. 3. Unemployment (3) A. The client has become unemployed and has no source of income. B. The client de scribed a consistent pattern of unemployment or underemployment and is not capable of providing sufficient funds to meet his/her basic needs. C. The client has developed a plan to obtain emergency financial relief through community services. D. The clien t has developed a plan to seek employment. E. The client has become employed again, and income has been restored. 4. Impulsive Spending (4) A. The client described a pattern of his/her impulsive spending that does not consider the eventual financial con sequences of such actions. B. The client was in defensive denial regarding his/her pattern of impulsive spending. C. The client acknowledged his/her impulsive spending and has begun to develop a plan to help cope with this problem. D. The client identif ied that his/her impulsive spending often occurs in relation to psychotic or manic episodes. E. The client has established a pattern of delaying any purchase until the financial consequences of the purchase can be planned for and met. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
112 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 5. Failure to Budge t (5) A. The client described a long-term lack of discipline and money management that has led to a failure to budget for basic financial responsibilities. B. The client described that his/her financial information is poorly organized, which results in unpaid bills and greater financial liability. C. The client has never established a budget with spending guidelines and savings goals that would allow for prompt payment of bills. D. The client has developed a budget and has begun to live within it, makin g timely payments of bills. 6. Lack of Entitlements (6) A. The client described a history of not applying for or accessing monetary entitlements or other available welfare benefits. B. The client displayed a lack of knowledge of the available monetary e ntitlements or other available welfare benefits. C. The client has been reluctant to access monetary entitlements or other welfare benefits due to his/her perceived stigma regarding these resources. D. The client has applied for and accessed monetary ent itlements or other available welfare benefits. 7. Illegal Activity (7) A. The client described a pattern of illegal activity used to meet his/her financial needs. B. The client described legal concerns due to his/her illegal activity. C. As the client has become more financially stable, he/she has discontinued his/her illegal activity. 8. Bad Credit (8) A. The client described his/her poor credit history. B. The client has attempted to qualify for credit but has been turned down. C. The client descr ibed a pattern of unpaid bills and outstanding debts, which have negatively affected his/her credit history. D. As the client has become more financially secure, he/she has taken responsibility for his/her bad debts and is improving his/her credit. INTERV ENTIONS IMPLEMENTED 1. Request Financial History (1) * A. The client was requested to relate his/her history or pattern of financial problems. B. The client was assisted in developing an understanding of his/her pattern of financial problems. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FINANCIAL NEEDS 113 C. The cli ent displayed an increased understanding of his/her syndrome of financial difficulties and how they relate to his/her severe and persistent mental illness symptoms; he/she was provided with positive feedback about this insight. D. The client has little un derstanding of his/her pattern of financial problems and was provided with additional feedback in this area. 2. Provide Support and Decrease Blame (2) A. The client was provided with support and empathy regarding his/her financial difficulties. B. An em phasis was placed on decreasing the client's sense of guilt and blame for his/her financial difficulties. C. The client reports, due to the increased support, diminished feelings of guilt or being overwhelmed by his/her financial difficulties. D. The cli ent reported ongoing feelings of guilt for his/her financial problems and was provided with additional feedback in this area. 3. Identify Beneficial Financial Practices (3) A. The client was requested to identify at least two financial practices that he/ she uses that are beneficial or that add stability. B. The client identified specific financial practices that are helpful (e. g., saving, budgeting, and comparison shopping) and was provided with positive feedback for these. C. The client could not ident ify any positive financial practices and was provided with prompts to assist in identifying beneficial financial practices. 4. Identify Negative Financial Practices (4) A. The client was asked to identify at least two financial practices that have led to his/her financial difficulty. B. The client was assisted in identifying specific patterns of financial behavior that have led to financial difficulty (e. g., unstable work history, impulsive spending, failure to pay on commitments). C. The client could n ot identify his/her pattern of negative financial practices and was provided with specific examples in this area. 5. Process Financial Patterns (5) A. The client's financial successes and failures were processed, focusing on patterns, triggers, and conse quences of successes and failures. B. The client received positive feedback for his/her identification of patterns, triggers, and consequences of his/her financial decisions. C. The client found it difficult to identify patterns, triggers, and consequenc es of his/her financial successes and failures and was given additional feedback about these areas. 6. List Current Financial Obligations (6) A. The client was directed to write out a list of all current financial obligations. B. The client's list of cu rrent financial obligations was reviewed for accuracy and completeness. C. The client has not written out a complete list of all current financial obligations and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
114 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 7. Review Financial Obligations (7) A. The client's list of finan cial obligations was compared with normally expected obligations (e. g., those listed on the budgeting worksheet in Personal Budget Planner: A Guide for Financial Success by Gelb). B. The client's list of financial obligations appears to be complete when c ompared with normally expected obligations, and this was processed with him/her. C. The client has omitted many typical financial obligations and was provided with feedback in this area. 8. Educate about Mental Illness (8) A. The client was educated abo ut the expected or common symptoms of his/her mental illness that may negatively impact his/her financial functioning. B. As his/her symptoms of mental illness were discussed, the client displayed an understanding of how these symptoms may affect his/her financial stability. C. The client did not understand how symptoms of his/her mental illness may negatively impact basic financial functioning and was given additional feedback in this area. 9. Relate Symptom Pattern to Financial Difficulties (9) A. The client was requested to identify situations in which the primary symptoms of his/her mental illness have negatively affected his/her financial stability. B. The client's financial difficulties related to mental illness symptoms were processed. C. The cl ient was unable to identify ways in which his/her primary symptoms have affected his/her financial functioning and was given additional feedback in this area. 10. Suggest a Payee (10) A. It was suggested to the client that he/she use a payee to receive p ublic aid funds on his/her behalf. B. The client was directed to consider allowing someone else to exercise general control over his/her finances. C. The client agreed with the suggestion to obtain a payee and allow outside control over his/her finances in order to decrease his/her erratic, impulsive spending; the effects of this decision were processed. D. The client declined using a payee or allowing other control over his/her finances and was provided with additional encouragement in this area. 11. Coordinate a Payee (11) A. The client was assisted in initiating the procedures for obtaining a payee for benefits. B. The client was given instructions about what steps to take to obtain a payee. C. A payee was obtained for administration of the client' s benefits. 12. Coordinate a Cosigner (12) A. The client was assisted in requiring a cosigner to be necessary for all bank withdrawal transactions. B. The client was reinforced for obtaining a cosigner to be necessary for all bank withdrawal transaction s, which has helped to limit his/her erratic, impulsive spending. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FINANCIAL NEEDS 115 C. The client refused to allow a cosigner to be required for any bank withdrawal transactions; additional encouragement was given to him/her to reconsider. 13. Pursue Involuntary Legal Con trol (13) A. Involuntary legal control over the client's finances was pursued through the guard ianship process. B. Involuntary legal control over the client's finances was obtained through the guard ianship process. C. Although involuntary legal contro l has been sought, the legal process did not allow for outside control of the client's finances. 14. Refer to a Physician (14) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a p hysician for a prescription of psychotropic medications and was redirected to cooperate with this referral. E. The client's medications were coordinated. 15. Educate about Psychotropic Medications (15) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The client displayed a lack of unde rstanding of the indications for and expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. 16. Monitor Medications (16) A. The client was monitored for compliance with his/h er psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concern s about the client's medication effectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 17. Coordinate Adult Foster Care Placement (17) A. The client was placed in an adult foster care placement to create a stable residence that is not dependent on financial management skills. B. The client was supported for accepting adult foster care placement, which has helped him/her to obtain a sta ble residence regardless of his/her personal financial management. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
116 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client has declined involvement in the adult foster care placement and is continuing to have an unstable living situation due to his/her financial mismanagement; additional encourag ement to reconsider this decision was given. 18. Coordinate Placement within the Support System (18) A. The client was assisted in coordinating placement with family or friends to create a stable residence that is not dependent on financial management sk ills. B. The client was supported for accepting placement with family or friends, which has helped him/her to obtain a stable residence regardless of his/her personal financial management. C. The client has declined placement with family or friends and i s continuing to have an unstable living situation due to his/her financial mismanagement; he/she was urged to reconsider this decision. 19. Provide Support for Independent Living Situation (19) A. The client was assisted in developing an independent or s emi-independent living situation. B. The client received guidance for obtaining financial assistance related to developing an independent or semi-independent living situation. C. The client has been able to successfully develop, after obtaining assistanc e on the financial aspects, an independent or semi-independent living situation; he/she was given support for this step. D. The client has not created a more independent living situation and was provided with additional direction in this area. 20. Review Financial Needs and Management (20) A. The client's financial needs and money management practices were reviewed. B. The client was supported as he/she reviewed his/her financial needs and management practices. C. The client refused to provide data reg arding how he/she manages his/her money and was urged to do so. 21. File for Benefits (21) A. The client was assisted in obtaining, completing, and filing forms for Social Security Disability benefits or other public aid. B. The client has completed all necessary documentation for filing for Social Security Disability benefits or other public aid, and this material was reviewed. C. The client's application for Social Security Disability benefits and other public aid was incomplete, and he/she received a ssistance in completing these applications. 22. Coordinate Transportation (22) A. Transportation was coordinated for the client to all necessary appointments related to obtaining financial assistance benefits. B. The client was praised for attending all necessary appointments related to obtaining benefits. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FINANCIAL NEEDS 117 23. Assign Social Security Readings (23) A. The client was assigned to read information about maximizing his/her Social Security benefits. B. The client was assigned to read specific portions in How to Get Every Penny You're Entitled to from Social Security by Bosley and Gurwitz. C. The client has read important information regarding how to obtain benefits from Social Security, and this information was processed. D. The client has not done approp riate reading from Social Security information and was redirected to do so. 24. Provide Agency as an Address (24) A. The client was directed to use the agency address as a mail drop for his/her benefit checks. B. The client has regularly obtained his/he r government check by having it sent to the agency address, which has stabilized his/her financial concerns; this procedure was supported. C. The client refused to allow the agency to receive his/her mailed benefit checks; additional urging to reconsider this decision was given. 25. Provide Financial Assistance Lists (25) A. The client received a list of available and relevant financial assistance resources. B. The client was advised about financial assistance resources in his/her area (e. g., home heati ng assistance, scholarships, or housing funds). C. The client has accessed relevant financial assistance resources, which has helped to stabilize his/her financial concerns, and this assistance was reviewed. 26. Help with Assistance Programs (26) A. The client was assisted in coordinating appointments and filling out forms to obtain assistance from area programs. B. The client has accessed area assistance programs, and the benefits of these programs were reviewed. C. The client has not attempted to obt ain assistance from area programs and was provided with additional direction to do so. 27. Coordinate Health Insurance Application (27) A. The client was assisted in making his/her application for the appropriate public health insurance program. B. The client has successfully obtained health insurance, and the benefits of this were reviewed with him/her. C. The client has failed to complete the necessary documentation for applicable public insurance and was provided with additional assistance in this ar ea. 28. Educate about Budgeting Skills (28) A. The client was educated about basic budgeting procedures. B. Specific budget information, contained in Personal Budget Planner: A Guide for Financial Success by Gelb, was reviewed. C. The client was suppor ted for displaying a mastery of the basic budgeting skills that he/she has been taught. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
118 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client has failed to master basic budgeting skills and was provided with additional information and guidance in this area. 29. Develop a Budget (29) A. The cl ient was requested to develop a basic budget, including income, necessary expenses, additional spending, and savings plans. B. The client has developed a basic budget, and this material was reviewed. C. The client was given positive feedback for his/her comprehensive, realistic budget. D. The client has not developed a basic budget and was redirected to do so. 30. Refer to Budgeting Classes (30) A. The client was referred to a community education class related to managing personal finances. B. The cli ent has attended the community education class related to managing personal finances, and the concepts learned were reviewed. C. The client has not obtained any benefit from his/her community education class on personal finances, but was encouraged to con tinue. D. The client has not attended the community education class regarding personal finances and was redirected to do so. 31. Develop Long-Term Financial Plans (31) A. The client was requested to identify his/her realistic, long-term financial plans. B. The client was provided with feedback regarding his/her long-term financial plans. C. The client has not developed a long-term financial plan and was redirected to do so. 32. Teach Banking Procedures (32) A. The client was taught about typical bank ing procedures. B. The client received positive feedback as he/she displayed mastery of how to complete basic banking procedures. C. The client displayed a poor understanding of typical banking procedures and was provided with additional training in this area. 33. Tour a Bank (3 3) A. A tour of a bank was arranged for the client. B. The client was supported for participating in the bank tour, with a focus on becoming more comfortable with the procedures and security measures expected within the bank. C. As the client has become more comfortable with the procedures and security measures within the bank, he/she has been able to more appropriately use the bank; this process was reviewed. D. The client did not attend the bank tour, and this resistance was processed. 34. Practice Banking Procedures (34) A. The client was assisted in practicing typical banking procedures within the session (e. g., check writing or check cashing) using imitation supplies or forms. B. The client was reinforced for displaying the skills necessary to do basic banking procedures. C. The client continues to display a poor understanding of basic banking procedures and was provided with additional education in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
FINANCIAL NEEDS 119 35. Obtain Proper Identification (3 5) A. The client was assi sted in obtaining proper identification necessary for banking functions. B. The client was assisted in obtaining a state identification card. C. The client was reinforced for completing necessary banking functions after obtaining proper identification. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
120 GRIEF AND LOSS CLIENT PRESENTATION 1. Death of Significant Other (1) * A. The client presented as visibly upset and distressed over the recent loss of his/her significant other. B. The client displayed symptoms of depression, confusion, and feelings of i nsecurity regarding the future. C. The client reported severe emotional reactions and uncertainty due to his/her grief and loss. D. The client revealed that feelings of being alone and hopeless have been overwhelming for him/her since the death of his/he r significant other. E. The client has started to talk about the loss of his/her significant other and has begun to accept consolation, support, and encouragement from others. F. The client has resolved the debilitating grief over the death of his/her si gnificant other. 2. Preoccupation with Loss (2) A. The client's thoughts have been dominated by the loss experienced, and he/she has not been able to maintain normal concentration on other tasks. B. The client reported a reduction in his/her preoccupati on with the experience of loss and slightly improved concentration. C. The client's concentration has improved significantly, and his/her thoughts are no longer dominated by the loss he/she has experienced. 3. Exacerbation of Mental Illness Symptoms (2) A. The client's recent loss has caused an emotional upheaval, which has caused an exacerbation of his/her mental illness symptoms. B. The client has not regularly maintained his/her medications or monitored his/her prodromals due to his/her preoccupation by the loss, which has resulted in an exacerbation of his/her primary mental illness symptoms. C. The client has regressed due to his/her recent loss. D. As the client has worked through his/her feelings related to the loss, his/her primary mental illness symptoms have decreased. 4. Depression Symptoms (3) A. The client described a lack of appetite, sad affect, low energy, and a disturbance of his/her sleep, as well as other depression signs that have occurred since the experience of the loss. B. The client has experienced thoughts of suicide, crying, or depressed mood since the experience of the loss. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
GRIEF AND LOSS 121 C. The client's depression symptoms have diminished as he/she has begun to resolve the feelings of grief. D. The client's depression symptoms have lif ted. 5. Hopelessness/Worthlessness (4) A. The client verbalized feelings of hopelessness and worthlessness subsequent to his/her experience of the loss of the significant other. B. The client verbalized an unreasonable pattern of feeling hopeless and wo rthless as he/she struggles to meet the needs previously met by the lost significant other. C. The client reports that his/her feelings of hopelessness and worthlessness have diminished. D. The client reports a pattern of feeling hopeful and worthwhile d espite the loss. 6. Inappropriate Guilt (4) A. The client expressed feelings of guilt about having acted in some way to cause the death of his/her significant other. B. The client has continued to hold onto the unreasonable belief that he/she behaved in some manner that either caused the death of the significant other or failed to prevent it from occurring. C. The client has started to work through his/her feelings of guilt about the death of the significant other. D. The client verbalized that he/she is not responsible for the death of the significant other. E. The client has successfully worked through his/her feelings of guilt and no longer blames himself/herself for the death of the significant other. 7. Fear of Abandonment (4) A. The client repo rted that he/she fears being abandoned by all significant others due to his/her experience of multiple losses. B. The client reported being confused about what the future of his/her life would be like due to his/her traumatic loss. C. The client is begin ning to talk about his/her future and reports a decreased fear of abandonment as he/she struggles to resolve the experience of loss. D. The client has begun to return to a more normal, hopeful outlook on his/her life, and he/she does not fear being abando ned by others who care for him/her. 8. Grief Avoidance (5) A. The client has shown a pattern of avoidance of talking about the loss except on a very superficial level. B. The client's feelings of grief are coming more to the surface as he/she faces the loss issue more directly. C. The client is able to talk about the loss more directly without being overwhelmed by feelings of grief. 9. Loss Due to the Effects of Mental Illness (6) A. The client described a pattern of loss of ability, status, relations hips, and competence due to his/her incapacitating effects of psychosis and other severe mental illness symptoms. B. The client described his/her pattern of grief-related emotions due to the personal losses he/she has experienced subsequent to his/her sev ere mental illness symptoms. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
122 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. As the client has stabilized, he/she has regained some abilities, status, and competence and reports less of a sense of loss. D. The client has become more at ease with the incapacitating effects of his/her severe mental illness symptoms. 10. Low Self-Esteem (7) A. The client stated that he/she has a very negative perception of himself/herself. B. The client's low self-esteem was evident within the session as he/she made many self-disparaging remarks and maintained very little eye contact. C. The client related his/her low self-esteem to his/her history of losses. D. The client's self-esteem has increased as he/she is beginning to find reasons to affirm his/her self-worth. E. The client verbalized positive feelings tow ard himself/herself. 11. Childhood Trauma (8) A. The client reported that he/she had a history of childhood traumas that includes abuse. B. The client reported that painful memories of his/her abusive childhood experiences are intrusive and unsettling. C. The client reported that nightmares and other disturbing thoughts related to childhood abuse have interfered with his/her sleep. D. The client reported that his/her emotional reactions associated with the childhood abusive experiences have been resolv ed. E. The client was able to discuss his/her childhood abusive experience without being overwhelmed with negative emotions. 12. Abusive Parent Figures (8) A. The client described his/her parents as rigid, perfectionist, and hypercritical, resulting in consistent feelings of inadequacy. B. The client reported that his/her parents were threatening and demeaning, resulting in feelings of low self-esteem. C. The client reported that his/her parents were hyperreligious, resulting in rigid, high expectation s of behavior and harsh discipline. D. The client described an emotionally repressive atmosphere at home during his/her childhood as a result of his/her parents' lack of nurturance, encouragement, and positive reinforcement. E. The client is able to affi rm himself/herself now, in spite of a history of parental rejection. 13. Dissociative Phenomena (9) A. The client described a pattern of dissociative experiences. B. The client displayed periods of lost time, depersonalization, and other dissociative ph enomena. C. The client's dissociative experiences have diminished in frequency and intensity. D. The client no longer experiences dissociative phenomena. 14. Paranoia (9) A. The client's speech and thought patterns displayed paranoid ideation. B. The client is distrustful and reactive subsequent to his/her experience of significant losses. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
GRIEF AND LOSS 123 C. The client's paranoid thoughts and speech have become less frequent. D. The client no longer gives evidence of paranoia. 15. Spiritual Conflicts (10) A. The client described confusing and conflicting thoughts and feelings regarding his/her spiritual understanding of the losses he/she has experienced. B. The client described that he/she is angry with God for the losses that he/she has experienced. C. The clie nt has begun to work through his/her spiritual conflicts. D. The client has become more settled regarding his/her spiritual conflicts and made his/her peace with God. 16. Loss of Support Network (11) A. The client expressed grief over having lost import ant portions of his/her support network due to his/her psychotic or other severe mental illness symptoms. B. The client's support network members have identified their inability to continue supporting him/her due to the effects of his/her severe mental il lness symptoms. C. As the client has stabilized, his/her support network has become more available to him/her, and his/her grief has resolved. INTERVENTIONS IMPLEM ENTED 1. Provide Emotional Support (1) * A. Active and empathic listening, consistent eye c ontact, unconditional positive regard, and warm acceptance were used to help provide direct emotional support to the client. B. The client was supported as he/she began to express feelings more freely as rapport and trust levels increased. C. The client has continued to experience difficulties being open and direct in his/her expression of painful feelings and was encouraged to discuss these as he/she feels safe to do so. 2. Assess Suicidal Intent (2) A. The client was asked to describe the frequency an d intensity of his/her suicidal ideation, the details of any existing suicidal plan, the history of any previous suicide attempts, and any family history of depression or suicide. B. The client was encouraged to be forthright regarding the current strengt hs of his/her suicidal feelings and his/her ability to control such suicidal urges. C. The client was provided with positive feedback and support as he/she described his/her thoughts and feelings regarding suicide. D. The client was assessed to have a lo w potential for suicide and was advised that suicide monitoring will continue. E. The client was assessed to have a high potential for suicide and was referred for a more intensive level of supervision. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
124 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 3. Arrange for Hospitalization/Crisis Residential P lacement (3) A. The client was judged to be uncontrollably harmful to himself/herself and psychiatrically unstable; therefore, arrangements were made for psychiatric hospitalization. B. The client was judged to be at risk for harm to himself/herself; the refore, arrangements were made for a crisis residential admission. C. The client was reinforced for cooperating voluntarily with admission to a more intensive level of treatment. D. The client refused to cooperate voluntarily with admission to a psychiat ric facility, and therefore commitment procedures were indicated. 4. List Relationship Losses (4) A. The client was asked to elaborate on the circumstances, feelings, and effects of the loss or losses in his/her life. B. The client was supported as he/s he identified the losses that have been experienced in his/her life and shared the feelings of pain and grief associated with these losses. C. The client talked about the losses experienced, but the feelings associated with these losses were not shared; c ontinued efforts to explore these feelings were implemented. 5. Resolve Relationship Problems (5) A. The client was assisted in resolving specific relationship problems. B. The client was provided with specific examples of how to resolve relationship pr oblems. C. The client was provided with feedback as he/she explained his/her attempts at resolving his/her relationship problems. D. As the client has resolved relationship problems, he/she has improved his/her overall functioning and was provided with p ositive feedback in this area. 6. Explore Losses Due to Mental Illness (6) A. The client was asked to describe his/her experience of job losses and other losses related to his/her mental illness symptoms. B. The client was provided with feedback and sup port as he/she described the losses that he/she has experienced due to the loss of occupational and other functional abilities. C. The client avoided providing meaningful feedback about the losses that he/she has experienced related to mental illness conc erns and was given further encouragement to focus on these losses. 7. Resolve Occupational Problems (7) A. The client was assisted in resolving specific occupational problems. B. The client was provided with specific examples of how to resolve occupatio nal problems. C. The client was provided with feedback as he/she explained his/her attempts at resolving his/her occupational problems. D. As the client has resolved occupational problems, he/she has improved his/her overall functioning and was provided with positive feedback in this area. 8. Vent Emotions (8) A. The client was assisted in identifying, clarifying, and expressing feelings associated with his/her losses. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
GRIEF AND LOSS 125 B. The client was praised as he/she has become more open in expressing feelings of g rief. C. The client minimizes and denies feelings of grief associated with the loss and was encouraged to be more open about these feelings. 9. Refer to a Physician (9) A. The client was referred to a physician for an evaluation for a prescription of ps ychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined an evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 10. Educate about Psychotropic Medications (10) A. The client was taught about the indications for a nd the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The client displayed a lack of under standing of the indications for and expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. 11. Monitor Medications (11) A. The client was monitored for compliance with his/he r psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psycho tropic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concern s about the client's medication effectiveness and side effects were communicated to the physician. E. Although the client was monitored for medication side effects, he/she reported no concerns in this area. 12. Reinforce Medication Compliance (12) A. The client was urged to continue his/her strict compliance with his/her prescription medications. B. The client was assessed for refusal to take his/her psychotropic medications as prescribed. C. The client was reinforced for his/her regular use and strict compliance with medication prescriptions. D. The client has not regularly used his/her prescription medications in the manner in which it was ordered and was redirected to comply with these directions. 13. Assign Grief Books (13) A. Several books on th e grieving process were recommended to the client. B. The client was assigned specific readings from The Grief Recovery Handbook: The Action Program for Moving Beyond Death (James and Friedman). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
126 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client has read the material on the grieving process, and content from that material was processed. D. The client was reinforced for showing an increased understanding of the steps of the grieving process as a result of reading the recommended grief material. E. The client has not followed through on read ing any of the grief material and was encouraged to do so. 14. Teach Grief Stages (14) A. The client was educated regarding the stages of the grieving process. B. The client verbalized an increased understanding of the steps of the grieving process and identified the stages that he/she has experienced personally, and this was processed. C. The client could not apply the grief stages to his/her own experience and was provided with additional support and feedback in this area. 15. Educate about Mental Il lness (15) A. The client was educated about the expected or common symptoms of his/her mental illness that may contribute to his/her grief and loss issues. B. As the client's symptoms of mental illness were discussed, he/she displayed an understanding of how these symptoms may affect his/her grief process. C. The client did not understand how symptoms of his/her mental illness may negatively impact his/her grief process and was given additional feedback in this area. 16. Apply Knowledge of Mental Illnes s to Symptoms (16) A. The client's specific symptoms were reviewed. B. The client's pattern of mental illness symptoms was reviewed relative to the impact that his/her symptoms have had on his/her pattern of personal losses. C. The client was provided w ith positive feedback as he/she displayed insight into his/her pattern of mental illness symptoms and his/her symptoms' impact on his/her losses. D. The client continued to struggle with his/her understanding of how his/her symptoms have contributed to gr ief and loss issues and was provided with additional feedback in this area. 17. Refer to a Support Group (17) A. The client was referred to a support group for individuals with severe and persistent mental illness. B. The client has attended the support group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. C. The client reported that he/she has not experienced any positive benefit from the use of a support group but was encouraged to conti nue attending. D. The client has not used the support group for individuals with severe and persistent mental illness and was redirected to do so. 18. Teach about Defense Mechanisms (18) A. The client was taught about the common tendency for people to u se defense mechanisms. B. The client was provided with specific examples of the use of defense mechanisms regarding mental illness concerns (e. g., some people deny problems rather than face the reality of a chronic mental illness). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
GRIEF AND LOSS 127 C. The client's descri ption of his/her own pattern of defense mechanisms was processed within the session. D. The client denied any pattern of defense mechanisms, and this was processed as a defense mechanism itself. 19. Identify Defense Mechanisms (19) A. The client was ass isted in identifying ways in which he/she uses defense mechanisms to delay or avoid facing grief and loss issues. B. The client accepted his/her pattern of defense mechanisms to delay or avoid facing grief and loss issues, and this was processed within th e session. C. The client denied any use of defense mechanisms and was urged to apply this more appropriately to himself/herself. 20. Assign Reading on Grieving Mental Illness (20) A. The client was assigned to read material on the process of grief ass ociated with accepting his/her mental illness. B. The client was referred to sections of Grieving Mental Illness: A Guide for Patients and Their Caregivers by Lafond. C. The client has read the material on grief and mental illness issues, and the content o n that material was processed. D. The client has shown an increase in understanding of his/her losses related to his/her mental illness, and this was reviewed. E. The client has not followed through on the reading material related to grief associated wit h mental illness and was encouraged to do so. 21. List the Effects of Mental Illness (21) A. The client was requested to develop a list of ways in which his/her mental illness symptoms have affected him/her. B. The client has developed a list of the eff ects of his/her mental illness on his/her life, and these were processed. C. The client was assisted in clarifying and identifying those feelings of grief associated with the effect of mental illness, and he/she began to resolve them. D. The client has n ot followed through on listing ways in which his/her mental illness symptoms have affected him/her and was redirected to do so. 22. Review Basic Emotions (22) A. The client was assisted in reviewing a list of basic emotions. B. The client was helped to identify the social, verbal, and body language cues used to identify basic emotions. C. As the client has developed an increased understanding of basic emotions, he/she was assisted in applying this to his/her own pattern of feelings. D. The client was r einforced for improving his/her pattern of functioning as he/she has begun to express his/her emotions. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
128 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 23. Review Emotion Identification (23) A. The client was assisted in identifying ways in which he/she labels specific emotions that he/she has experie nced. B. As the client has identified his/her pattern of emotions and how he/she identifies and labels them, he/she was provided with positive feedback in this area. C. The client was not able to identify how to label specific emotions and was provided w ith remedial information in this area. 24. Clarify Unidentified Emotional States (24) A. The client was probed for emotional states that he/she has previously been unable to identify. B. The client was assisted in uncovering previously unidentified emot ional states that have contributed to his/her pattern of symptoms. 25. Assign a Grief Journal/Tape (25) A. It was recommended that the client keep a daily grief journal to be shared in future sessions. B. The client has limited writing skills; therefore, he/she was assigned to record grief feelings on an audiotape to be shared in future sessions. C. The client has kept a grief journal/tape on a daily basis and verbalized the feelings of grief that he/she has experienced, and these were reviewed. D. The client was provided with positive feedback for using a grief journal to help clarify and identify feelings of grief, and he/she is beginning to resolve them. 26. Journal/Tape Acceptance of Feelings (26) A. It was recommended to the client that he/she ke ep a daily journal of his/her feelings of acceptance of the losses. B. It was recommended to the client that he/she use an audiotape to describe his/her feelings of acceptance of his/her losses. C. The client's record of his/her feelings of acceptance of losses was shared with the clinician. D. As the client has kept a record of his/her feelings of acceptance of his/her losses, he/she has begun to resolve his/her grief issues, and he/she was encouraged for this progress. 27. Assign Forgiveness Readings (27) A. The client was assigned to read information on the process of forgiveness. B. The client was referred to read portions of Forgive and Forget: Healing the Hurts We Don't Deserve by Smedes. C. Portions of the written material on forgiveness were r eviewed to help the client overcome his/her feelings of resentment. D. The client has failed to read any of the recommended grief material and was redirected to do so. 28. Encourage Mourning Events (28) A. The client was encouraged to use typical mourn ing events (e. g., visit the grave site of a deceased relative or write a good-bye letter to someone who is deceased). B. The client has followed through on implementing the grieving ritual, and his/her experience was processed. C. The client's involvemen t in an appropriate grieving ritual was coordinated. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
GRIEF AND LOSS 129 D. The client has not followed through on development of a grieving ritual and was encouraged to do so. 29. Develop a Meaningful Release (29) A. The client was assisted in developing and safely carryi ng out a meaningful ritual for letting go of the loss. B. The client was provided with specific examples of meaningful personal rituals for letting go of the loss (e. g., tying a journal entry, letter, or picture to a helium balloon and letting it go). C. The client has selected his/her own personalized, meaningful ritual for letting go of the loss and was assisted in completing this. D. The client has not developed his/her own meaningful ritual for letting go of the loss and was provided with additional encouragement in this area. 30. Develop Meaningful Activities (30) A. The client was assisted in developing meaningful activities that assist in resolving grief issues (e. g., volunteering to help in a support group that focuses on his/her loss issue). B. The client has identified his/her own meaningful activities to assist in resolving grief issues and was assisted in implementing these activities. C. The client's experience of involvement in meaningful activities to assist in resolving grief issues was processed. D. The client has not instituted the use of meaningful activities to assist in resolving grief issues and was redirected to do so. 31. Encourage Increased Activities (31) A. The client was encouraged to increase his/her involvement in social activities, hobbies, or volunteer placements. B. The client's increased involvement in social activities, hobbies, or volunteer placements was coordinated. C. As the client has increased his/her involvement in social activities, hobbies, or volunteer placements, he/she has reported increased emotional stability, and this progress was processed. D. The client has not become more involved in social activities, hobbies, or volunteer placements and was encouraged to do so. 32. Explore or Refer Spiritual Iss ues (3 2) A. The client's spiritual struggles were explored. B. The client was referred to an appropriate clergy person to allow for further discussion of the client's spiritual struggles. C. The client was reinforced for resolving his/her spiritual stru ggles and demonstrating an increased pattern of functioning. D. The client has not focused on his/her spiritual struggles and was redirected to do so. 33. Suggest Faith Readings (3 3) A. The client was urged to read spiritual material suitable to his/her faith. B. The client was urged to read How Could It Be All Right When Everything Is All Wrong? by Smedes. C. The client was urged to read When Bad Things Happen to Good People by Kushner. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
130 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client has read material appropriate to his/her faith, an d pertinent issues were reviewed. E. The client has not read faith-related material and was encouraged to do so. 34. Coordinate a Family Session (34) A. A family therapy session was conducted with all members of the family expressing their experience re lated to the history of losses. B. Each family member was supported as he/she expressed his/her feelings of grief and related how he/she is coping with the losses. C. Family members displayed an increased understanding of the client's history of losses a nd were encouraged to provide additional support to him/her. D. Family members were confronted regarding not being supportive of the client despite their increased understanding of his/her history. 35. Facilitate Support from Others (35) A. The client wa s assisted in identifying other people who are struggling with similar issues. B. The client was directed to develop supportive relationships with people outside his/her family who are dealing with grief and loss. C. The client has developed mutually sup portive relationships with people outside of his/her family, and the benefits of these relationships were reviewed. D. The client has failed to develop better relationships with people outside of his/her family that are struggling with similar loss issues, and such a relationship was facilitated for the client. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
131 HEALTH ISSUES CLIENT PRESENTATION 1. Serious Medical Condition (1) * A. The client presented with serious medical problems. B. The client's medical problems cause serious impact on his/her daily living. C. The client's severe and persistent mental illne ss symptoms are exacerbated by his/her medical problems. D. The client's medical condition has improved. 2. Receiving Treatment (2) A. The client has pursued treatment for his/her medical condition. B. The client has refused treatment for his/her medic al condition. C. The client has not sought treatment for his/her medical condition because of a lack of insurance and financial resources. D. The client's physical health concerns have improved due to his/her medical treatment. 3. HIV-Positive (3) A. The client has tested positive for the human immunodeficiency virus (HIV). B. The client has been HIV-positive for an extended period of time but has had no serious deterioration in his/her condition. C. The client is obtaining consistent medical care for his/her HIV status. D. The client has refused medical care for his/her HIV-positive status and tends to be in denial about the seriousness of the situation. 4. AIDS (3) A. The client's HIV-positive status has resulted in the development of acquired imm une deficiency syndrome (AIDS). B. The client's medical condition resulting from AIDS has deteriorated, and his/her severe and persistent mental illness symptoms have increased. C. Although the client has serious AIDS complications, he/she remains at pea ce and is getting good medical care. 5. Poor Understanding of Medical Issues (4) A. The client displayed a poor understanding of his/her medical needs. B. The client is uncertain about his/her available treatment options and medical services for his/her medical concerns. C. As the client has obtained more specific information related to his/her medical needs, he/she has stabilized his/her medical condition. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and J ongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
132 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 6. Barriers to Treatment (5) A. The client described difficulties with gaining access to medica l facilities or health care providers. B. Health care providers have discriminated against the client due to his/her severe and persistent mental illness symptoms. C. The client has failed to make his/her medical needs known due to the effects of his/her severe and persistent mental illness symptoms. D. As the client has gained better access to medical facilities and health care providers, his/her overall level of functioning has increased. 7. Failure to Access Medical Treatment (6) A. The client has f ailed to access appropriate medical treatment due to his/her severe and persistent mental illness symptoms. B. The client's health status has suffered due to his/her failure to access appropriate medical treatment. C. As the client's severe and persisten t mental illness symptoms have been stabilized, his/her medical treatment has been more easily accessed. D. The client's medical status has improved due to his/her accessing appropriate medical treatment. 8. Poor Health Habits (7) A. The client displaye d poor oral hygiene. B. The client bathes infrequently and has significant body odor on a consistent basis. C. The client lives in unsanitary living conditions. D. The client displayed poor health habits due to his/her pattern of severe and persistent m ental illness symptoms. E. As the client has stabilized his/her severe and persistent mental illness symptoms, he/she has displayed better health habits. 9. Financial Limitations (8) A. The client has failed to access or follow through with medical trea tment due to financial limitations. B. The client has obtained financial resources to assist with his/her medical treatment. C. The client's medical problems have improved due to economically available medical treatment. 10. Chemical Dependence Complica tions (9) A. The client has developed medical complications because of his/her chronic chemical dependence history. B. The client has accepted that he/she has deteriorated medically because of his/her chemical dependence pattern and has terminated substa nce abuse. C. The client is in denial about the negative medical effects of his/her substance abuse and continues his/her self-destructive pattern. D. The client's medical condition has improved subsequent to termination of substance abuse. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HEALTH ISSUES 133 INTERVENTIONS IMPLEMENTED 1. Refer to a Physician (1) * A. The client was referred to a physician for a complete physical to evaluate his/her medical condition. B. The essential arrangements were made for the client to obtain necessary medical testing. C. The client followed through with a referral to a physician for a medical evaluation and was reinforced for obtaining proper health care. D. The client was supported for following through with the recommended medical testing, and the results were processed. E. The client has failed to follow through on the recommendation to obtain a medical evaluation and was redirected to do so. 2. Consult with a Physician ( 2) A. The client's physician has been contacted in order to review his/her orders with the client. B. The client was encouraged to follow the treatment orders as described by his/her physician during a consultation contact. C. The client signed a release of information allowing the clinician to obtain medical information from the physician for the purposes of treatment coordination and follow-through monitoring. 3. Provide Medical Information for Making Treatment Decisions (3) A. The client was provided with appropriate literature and references to material that would increase his/her understanding of his/he r medical condition. B. The client was encouraged to contact medical resources to obtain more information regarding his/her medical condition. C. The client was assisted in making decisions about his/her current medical treatment needs. D. Arrangements were made for the client to obtain the necessary medical services. E. The client was supported for obtaining appropriate medical treatment. F. The client has declined to seek further information regarding his/her medical condition, its treatment, and the prognosis and was redirected to do so. 4. Acknowledge Denial/Avoidance while Reinforcing Acceptance (4) A. The client's denial of the seriousness of his/her medical condition was acknowledged as a common emotional response. B. The client's denial of th e seriousness of his/her medical condition was confronted, and he/she was reinforced for showing any acceptance of the medical condition. C. The client accepted the confrontation regarding the seriousness of his/her medical condition and verbalized increa sed acceptance of the need for medical intervention. D. The client was reinforced for showing acceptance of the reality of his/her medical problems. E. The client was supported for his/her realistic statements regarding his/her medical condition. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
134 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER F. The client continues to be in denial regarding the seriousness of his/her medical condition and was given additional feedback in this area. G. The client continues to struggle with the reality of his/her medical problems and was provided with additional feed back in this area. 5. Inform/Encourage Support from Family and Friends (5) A. A proper authorization to release information was obtained in order to provide family and friends with information regarding the client's medical needs. B. In a conjoint sessi on, family members, friends, or other important individuals in the client's life were provided with specific information regarding his/her medical needs. C. Family, friends, and other important individuals in the client's life have been more supportive of him/her subsequent to learning about his/her medical needs, and this was processed. D. The client's family, friends, and support network received encouragement regarding their emotional support and positive reinforcement for his/her adherence to medical treatment. E. The client's experience of emotional support from his/her family and friends was processed. F. Despite additional information regarding the client's medical needs, family, friends, and others have not been supportive of his/her medical need s, and he/she was given emotional support in this area. 6. Educate about Nutrition ( 6) A. The client was educated about healthy food choices. B. The client was educated about the effect of a healthy diet on long-term medical well-being. C. The client w as supported for his/her increased understanding of his/her nutritional choices. D. The client was reinforced for healthy nutritional choices that have assisted in stabilizing his/her medical well-being. E. The client continues to make poor nutritional c hoices, and he/she was redirected in this area. 7. Facilitate Access to a Grocery Store ( 7) A. The client was assisted in attaining regular access to a full-service grocery store to help meet his/her nutritional needs. B. The client was accompanied to t he grocery store to help increase his/her comfort level. C. The client reported feeling more comfortable in accessing the services of a grocery store, and the benefits of this were reviewed. D. The client continues to struggle with obtaining appropriate supplies for his/her nutritional well-being due to limited access and comfort with the grocery store and was assisted in problem-solving this situation. 8. Educate about Healthy Foods (8) A. The client was educated about his/her food shopping choices. B. The client was taught how to compare healthy foods with unhealthy foods. C. The client was provided with positive reinforcement for making healthier food choices. D. The client continues to make unhealthy choices regarding his/her foods and was given remedial information in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HEALTH ISSUES 135 9. Refer to a Dietician ( 9) A. The client was referred to a dietician who will explain proper nutrition that will enhance his/her medical recovery. B. The client was reinforced for accepting the dietician referral and a ttending an appointment. C. The client has verbalized an increased knowledge about how proper nutrition can have a positive impact on his/her medical condition, and he/she was provided with encouragement in this area. D. The client has refused to follow through on the referral to a dietician and was encouraged to do so. 10. Assess for and Refer for Substance Abuse (1 0) A. The client was assessed for substance abuse that may exacerbate his/her medical problems. B. The client was referred for a substanc e abuse evaluation. C. The client was identified as having a concomitant substance abuse problem and was referred for treatment. D. The client was referred to a 12-step recovery program (e. g., Alcoholics Anonymous or Narcotics Anonymous). E. The client has been admitted to a substance abuse treatment program and was supported for this follow-through. F. Upon review, the client does not display evidence of a substance abuse problem, which was reflected to him/her. G. The client has refused the referral to a substance abuse treatment program, and this refusal was processed. 11. Educate about Substance Abuse Effects (1 1) A. The client was educated about the short-term effects of substance abuse. B. The client was educated about the long-term effects of substance abuse. C. The client was provided with positive feedback about his/her understanding about the long- and short-term effects of substance abuse. 12. Assess Personal Hygiene Needs (1 2) A. The client was asked to prepare an inventory of positive and negative functioning regarding his/her personal hygiene needs. B. The client prepared his/her inventory of positive and negative functioning regarding his/her personal hygiene needs, and this was reviewed within the session. C. The client was given p ositive feedback regarding his/her accurate inventory of positive and negative functioning regarding his/her personal hygiene needs. D. The client prepared his/her inventory of positive and negative functioning regarding his/her personal hygiene needs but needed additional feedback to develop an accurate assessment. E. The client has not prepared an inventory of positive and negative functioning regarding his/her personal hygiene needs and was redirected to do so. 13. Refer to a Psychoeducational Group ( 13) A. The client was referred to a psychoeducational group focused on teaching personal hygiene skills. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
136 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client learned, through the psychoeducational group, to give and receive feedback about personal hygiene skill implementation. C. The client has attended a psychoeducational group and received feedback about personal hygiene skill implementation, which was processed within the session. D. The client was verbally reinforced for using the group feedback about personal hygiene skill implementatio n. E. The client has not attended the psychoeducational group for personal hygiene skill implementation and was redirected to do so. 14. Institute a Checklist Regarding Personal Hygiene Needs (1 4) A. The client was assisted in developing a self-monitori ng program for performing his/her personal hygiene needs. B. The client was provided with positive feedback and encouragement regarding his/her use of a self-monitoring program for performing his/her personal hygiene needs. C. The client has not implemen ted or used a self-monitoring program for performing personal hygiene needs and was encouraged to do so. 15. Teach about Exercise ( 15) A. The client was taught about the benefits of the regular use of exercise. B. The client was provided with informatio n about the health benefits that are related to exercise. C. The client was provided with positive feedback as he/she displayed an understanding of his/her need for exercise. D. The client denies any need for exercise, and this was processed within the s ession. 16. Refer to an Activity Therapist ( 16) A. The client was referred to an activity therapist for recommendations regarding physical fitness activities that are available in the community. B. The client was referred to community physical fitness r esources (e. g., health clubs and other recreational programs). C. The client has been actively participating in community physical fitness programs and was reinforced for this. D. The client has declined involvement in community physical fitness programs and was redirected to do so. 17. Refer to an Exercise Group ( 17) A. The client was referred to a community-sponsored exercise group (e. g., aerobics or a walking club). B. An agency-sponsored exercise group has been developed and offered to the client. C. The client has participated in the exercise group, and his/her increased health functioning was noted. D. The client's membership at a local health club or YMCA/YWCA was facilitated. E. The client has joined a local health club or YMCA/YWCA fitness program and was reinforced for doing so. F. The client has declined involvement in the exercise opportunities and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HEALTH ISSUES 137 18. Coordinate Ongoing Medical Care ( 18) A. The client was referred to a general physician for routine and ongoin g medical evaluation and care. B. The client's access to a general physician for routine and ongoing medical evaluation and care was coordinated. C. The client's regular access to routine medical care was reviewed. D. The client continues to struggle wi th access to basic health care services and was provided with additional assistance in this area. 19. Plan a Psychiatric Hospitalization ( 19) A. A psychiatric hospitalization has been planned on an intermittent basis to complete all needed medical servic es in a structured, safe, familiar setting. B. The client's medical services were coordinated to coincide with his/her planned psychiatric hospitalization. C. The client has received the necessary medical services during his/her psychiatric hospitalizati on. D. The client has declined the planned, intermittent psychiatric hospitalization to complete his/her medical needs. 20. Facilitate Attendance at Health Care Appointments (20) A. The client's attendance at his/her medical, dental, and other health ca re appointments was monitored. B. The client was provided with transportation to medical, dental, and other health care appointments. C. The client was accompanied to his/her doctor's appointments. D. The scheduling receptionist at the client's health c are facility was requested to contact the clinician regarding appointment changes scheduling so that the clinician can guarantee the client's attendance. E. The clinician was actively involved in maintaining the client's attendance at his/her health care appointments. F. The client has maintained regular attendance at his/her health care appointments and was provided with positive reinforcement for this. G. The client continues to be sporadic in his/her attendance at health care appointments and was redirected to be more consistent. 21. Educate Providers Regarding Mental Illness Symptoms (21) A. An authorization to release information was obtained in order to share information with the client's other health care providers. B. The client's other health care providers were educated regarding his/her needs relative to his/her mental illness symptoms. C. The client's health care providers have displayed an increased understanding about his/her needs relative to his/her mental illness symptoms and were than ked for their increased cooperation. D. The client declined to allow the sharing of information with other health care providers and was urged to reconsider this. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
138 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 22. Coordinate Regular Dental Care (2 2) A. The client was referred to a dentist to determi ne his/her dental treatment needs. B. Specific dental treatment needs were identified, and ongoing care was coordinated. C. No specific dental treatment needs were identified, but a routine follow-up appointment was made. D. The client has not followed through on the referral for dental services and was redirected to do so. 23. Increase Dental Care ( 23) A. The client was trained in the proper use of brushing teeth and flossing. B. The client was encouraged to use regular brushing and flossing practic es. C. The client was reinforced for his/her regular use of brushing and flossing. D. The client has not regularly used brushing and flossing and was provided with redirection to do so. 24. Coordinate Hearing/Vision Evaluations ( 24) A. A hearing evalua tion was coordinated for the client. B. A vision evaluation was coordinated for the client. C. The client has attended his/her appropriate evaluations, and the results of these appointments were reviewed. D. The client has been assisted in following up on recommendations from the hearing and vision evaluations. E. The client has not participated in hearing and vision evaluations and was redirected to do so. 25. Assist the Client in Filing for Benefits ( 25) A. The client was assisted in making his/her application for the appropriate public health insurance program and other entitlements. B. The client has successfully obtained health insurance or other benefits, and the positive effects of this were reviewed with him/her. C. The client has failed to c omplete the necessary documentation for applicable benefits and was provided with additional assistance in this area. 26. Refer to Low-Cost Health Care Providers ( 26) A. The client was provided with a list of health care providers who accept public insur ance or provide services at a reduced cost or at no cost. B. The client has used the agency list of available health care providers to obtain appropriate medical care, and the results of these services were discussed. C. The client has not used the list of health care providers available to him/her and was redirected to do so. 27. Maintain a Stable Residence ( 27) A. The client was assisted in developing a more stable residence. B. The client was provided with assistance to help maintain his/her current residence. C. As the client has been able to remain in a stable residence, his/her severe and persistent mental illness symptoms have lessened. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HEALTH ISSUES 139 D. The client continues to have an unstable residence and was provided with additional suggestions to improve this situation. 28. Refer to a Personal Safety Class ( 28) A. The client was referred to a personal safety class, focusing on self-defense and precautions for safety. B. The client has participated in personal safety classes, and key points from this cl ass were reviewed. C. The client has not used personal safety classes and was redirected to do so. 29. Access Client in Own Environment ( 29) A. Health care services were delivered to the client in his/her own environment. B. The client was provided wit h services through his/her homeless shelter. C. The client was provided with health care services through a mobile health care van. D. The client continues to avoid using health care services, despite these services being provided where he/she is accessi ble, and this was reflected to him/her. 30. Refer to a Physician or Psychiatrist for Physical Evaluation (3 0) A. The client was referred to a physician who is knowledgeable about the client's medical condition for an evaluation for a prescription of psyc hotropic medications. B. The client's psychiatric evaluator was urged to also provide a complete physical evaluation for the client. C. The client was provided with a physical examination in conjunction with his/her psychiatric evaluation. D. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. E. The client has been prescribed psychotropic medications. F. The client's physical examinatio n was used to compliment his/her psychiatric evaluation. G. The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 31. Educate about Psychotropic Medications ( 31) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. The client was monitored for compliance with, effectiveness of, and the side effects of his/her psychotropic medication regimen. C. The client wa s provided with positive feedback about his/her regular use of psychotropic medications. D. The possible side effects of the client's medications were reviewed with him/her. E. Medical staff were specifically consulted regarding the confounding effects o f poly pharmacy. F. Possible side effects of the client's medication were reviewed, but he/she denied experiencing any side effects. 32. Educate about Sexually Transmitted Diseases (STDs) (32) A. The client was provided with education regarding precauti ons to take to avoid HIV infection and other STDs. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
140 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was provided with information specific to his/her gender, sexual orientation, and mental illness pattern to help shape his/her perspective of his/her own HIV risk. C. The client was reinfor ced for displaying an understanding of the risk of HIV and other STDs. D. The client has not displayed an understanding of his/her HIV/STD risk and was provided with additional information in this area. 33. Obtain Condoms or Clean Needles ( 33) A. The cl ient was referred to programs that will supply free condoms and/or needles to help reduce the risk of HIV infection and other STDs. B. The client has reduced his/her risk for HIV and other health concerns through the use of condoms and clean needles, and this was reviewed with him/her. C. The client continues to be at high risk for HIV and other health concerns due to his/her health behaviors and was strongly redirected to take precautions. 34. Use Peer Education ( 34) A. The client was assisted through a peer education model in learning more about HIV and other STD concerns. B. The client was reinforced for an increased understanding of STDs through the use of the peer education model. C. The client has begun to educate others using the peer education model regarding HIV and other STDs and was supported for this. D. The client refused involvement in the peer education model and was urged to seek out involvement in this area. 35. Include Partner in STD Education (35) A. The client's partner was includ ed in education about HIV and other STDs. B. With proper authorization to release confidential information, the client and his/her partner were assisted in discussing HIV and other STD issues. C. The client's partner has declined any involvement in discu ssion about HIV or other STDs and was reminded of this option. 36. Observe and Support Caregivers ( 36) A. The client's caregivers were observed for signs of frustration that may reduce their ability to interact effectively with him/her. B. The client's caregivers were provided with opportunities to express their feelings of frustration relative to providing care for him/her. C. As the client's caregivers have been assisted in venting their frustrations with providing care for the severely and persistent ly mentally ill client, his/her care has improved. D. The client's caregivers were confronted if they became demeaning toward him/her while venting. E. The client's caregivers denied any pattern of frustration or difficulty in providing care for him/her and were invited to access the clinical support should they feel more stressed by his/her pattern of symptoms. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HEALTH ISSUES 141 37. Refer Caregivers to a Support Group ( 37) A. The client's caregivers were referred to a support group for those who are affected by another' s mental illness. B. The client's caregivers were supported for attending the support group for caregivers of the mentally ill and reporting positive experiences. C. The client's caregivers have attended the support group but do not believe that it has b een helpful for them, and this negative perception was processed. D. The client's caregivers have not attended the support group and were redirected to do so. 38. Teach Stress Reduction to Caregivers ( 38) A. The client's caregivers were taught stress re duction techniques (e. g., muscle relaxation, abdominal breathing, and safe-place imagery). B. The client's caregivers have used stress reduction techniques, and the benefits of this were discussed. C. The client's caregivers have not used stress reductio n techniques and were redirected to do so. 39. Refer to a Respite Program ( 39) A. The client was referred to a respite program to provide his/her caregivers with a brief rest from the demands of caring for a mentally ill patient. B. As the client has us ed the respite program, caregivers report decreased stress subsequent to the brief reprieve, and this was noted. C. The respite program has not been used, even though caregivers report an ongoing pattern of significant stress; therefore, they were provide d with additional encouragement. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
142 HOMELESSNESS CLIENT PRESENTATION 1. Living on the Streets (1) * A. The client described a history of living on the street on a short-term, sporadic basis. B. The client has adopted a lifestyle of living on the streets on a long-term basis. C. The client has moved into a residence. 2. No Permanent Address (2) A. The client described chronic periods in which he/she has not maintained a permanent address. B. The client has moved around to a variety of residences within his/her support network. C. The cl ient has not been able to access services or entitlements due to his/her failure to maintain a permanent address. D. The client has maintained a permanent address. 3. Extensive Use of Homeless Programs (3) A. The client has often used shelters for the h omeless. B. The client has used transitional housing or other supportive living placements. C. As the client has stabilized his/her severe and persistent mental illness symptoms, he/she has established a more permanent residence. 4. Failure to Make Paym ents (4) A. The client described a pattern of a failure to make rent, mortgage, or utility payments, leading to a loss of residence. B. The client presented his/her bill invoices, which indicated that he/she has failed to make payments necessary to maint ain a residence and is at risk of losing his/her residence. C. The client has been more regular in making his/her bill payments, leading to a more stable pattern of residence. 5. Behavioral Problems Due to Mental Illness (5) A. The client is at risk of eviction from his/her residence due to behavioral problems related to his/her severe mental illness symptoms. B. The client described a pattern of eviction from his/her residence due to his/her psychotic or other severe mental illness symptoms. C. As the client's psychotic or other severe mental illness symptoms have been better controlled, his/her risk of eviction has ended. 6. Lack of Basic Skills (6) A. The client described a lack of knowledge regarding the basic skills that are needed to maintain a residence (e. g., cleaning, small repairs, budgeting). * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HOMELESSNESS 143 B. The client has been taught about basic skills needed to maintain a residence but does not apply these on a regular basis. C. The client has used his/her knowledge regarding the basic skills to main tain a residence, and this has helped create a more stable living situation. INTERVENTIONS IMPLEM ENTED 1. Refer to a Homeless Shelter (1) * A. The client was referred to a local shelter for the homeless. B. The client was provided with information about how to access a local homeless shelter. C. The client has used a local homeless shelter and was provided with reinforcement for doing so. D. The client has declined to use a local homeless shelter and was redirected to use this service. 2. Coordinate Cr isis Residential Funds (2) A. The client was placed in a crisis residential program. B. Funds for the crisis residential program were coordinated (e. g., motel voucher or transitional program placement). C. The client was provided with positive reinforce ment for his/her use of the crisis residential placement. D. The client has declined the use of a crisis residential placement and was redirected in this area. 3. Facilitate Placement within Support Network (3) A. The placement of the client at the home of a family member, friend, or peer was facilitated. B. Family members, friends, or peers have volunteered to take the client into their home, and he/she was encouraged to use this resource. C. The client reported greater satisfaction due to living with a family member, friend, or peer, and this was processed. D. The client has declined offers of placement in the home of a family member, friend, or peer and was redirected in this area. 4. Inquire about History of Homelessness (4) A. The client was req uested to describe his/her history of successful and problematic residential situations. B. The client was directed to prepare a time line of living in a residence, periods of homelessness, and use of transitional housing. C. Factors contributing to the client's lifestyle of sporadic homelessness were processed. D. Empathy and active listening were used as the client reviewed his/her history of successful and problematic residential situations. E. The client was supported as he/she gave a complete accou nt of his/her history of homelessness. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same titl e in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
144 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 5. Express Emotions (5) A. The client was encouraged to share his/her feelings regarding his/her pattern of homelessness (e. g., fear, sadness, loss). B. The client has shared his/her feelings and has been assisted in identifying causes for the emotions. C. Emotions such as frustration, discouragement, and embarrassment were acknowledged as natural emotions related to the client's experience of homelessness. D. The distorted cognitive messages that contribute to th e client's emotional response were identified and processed. E. The client was provided with support and understanding regarding his/her emotional concerns relative to his/her homeless situation. F. The client was supported as he/she presented with a sad affect and tearfulness when describing his/her feelings. G. The client described increased acceptance of his/her emotions regarding homelessness, and this was processed within the session. 6. Explore Fears Regarding Seeking a Permanent Residence (6) A. Possible fears associated with seeking a permanent residence were explored, including the fear of rejection, embarrassment, or failure. B. The client was provided with support and empathy as he/she described his/her fears related to seeking a permanent r esidence. C. The client tended to avoid and deny any expression of negative emotions related to seeking a permanent residence and was encouraged to share these when he/she is able to do so. 7. Provide Feedback Regarding Paranoia (7) A. The client was pr ovided with realistic feedback regarding his/her paranoia or other irrational delusions. B. The client accepted the more realistic feedback provided regarding his/her paranoia or other irrational delusions and was reinforced for becoming more reality focu sed. C. The client denied the realistic feedback provided regarding his/her paranoia or other irrational delusions and was encouraged to seek a reality check for his/her perceptions. 8. Encourage Maintaining Relationships When Becoming Independent ( 8) A. The client was encouraged to maintain important relationships at the homeless shelter when he/she moves to a more independent status. B. The client has moved into a more independent status and was encouraged to continue his/her important relationships a t the homeless shelter regardless of his/her more independent status. C. The client was reinforced for maintaining important relationships that have helped to ease the emotional stress of a more independent living situation. D. The client has not maintai ned important relationships at the homeless shelter, and this was reviewed. 9. Describe Barriers to Maintaining Housing ( 9) A. The client was asked to describe specific barriers to maintaining his/her housing. B. The client was provided with feedback re garding his/her specific barriers to maintaining his/her housing. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HOMELESSNESS 145 C. The client was assisted in resolving specific barriers to housing. D. The client struggled to identify his/her barriers to maintaining his/her long-term housing and was provided with te ntative ideas in this area. 10. Educate about Residential Supports and Services ( 10) A. The client was educated about the available options regarding the continuum of supports and services that are available to assist with his/her residential status. B. The client was assisted in developing a list of pros and cons for each of the housing options available to him/her. C. The supports and services that are available to assist the client with his/her residential status seem to be well understood, and he/sh e was provided with positive feedback about this knowledge. D. The client was provided with a structure for making his/her own decision regarding housing. E. The client was provided with support for his/her decisions regarding his/her housing. F. The cl ient continued to display a poor understanding about the continuum of supports and services that are available to help with his/her residential status, and he/she was given additional, remedial information in this area. 11. Apply for Housing Programs (1 1) A. The client was assisted in beginning the application process for desired housing programs. B. The client was provided with directions and given feedback regarding completing the application process for a desired housing program. C. The client was ac companied to begin the application process for a desired housing program. D. The client has refused to complete the application process for housing, and his/her resistance was processed. 12. Refer to a Physician (12) A. The client was referred to a phys ician for an evaluation for a prescription of psychotropic medications. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The cli ent has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 13. Educate about and Monitor Psychotropic Medications ( 13) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The client displayed a lack of understanding of the indications for and expected benefits of psychotropic medications and was provided with additional information and feedback regarding his/her medications. D. The client was monitored for compliance with his/her psychotropic medication regimen. E. The client was provided with positive feedback about his/her regular use of psychotropic medications. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
146 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER F. The client was monitored for the effectiveness and side effects of his/her prescribe d medications. G. Concerns about the client's medication effectiveness and side effects were communicated to the physician. 14. Review Side Effects of Medications (1 4) A. The possible side effects of the client's medications were reviewed with him/her. B. The client identified significant medication side effects, and these were reported to the medical staff. C. Possible side effects of the client's medication were reviewed, but he/she denied experiencing any side effects. 15. Store Medications (1 5) A. The homeless client's medications were stored in a safe, easily accessible facility. B. The client was assisted in making certain that his/her storage site for his/her medications was safe and easily accessible. C. The client was reinforced for more reg ular use of his/her medications that have been stored safely. D. The client has not used the safe, easily accessible storage facility for his/her medications and was redirected to do so. 16. Provide Smaller, Immediate Supplies of Medication (1 6) A. The client was provided with smaller supplies of medications, as he/she has no site available to store them. B. The client was reinforced for using smaller, immediate supplies of medications, which has contributed to his/her consistent use of them. C. The cl ient does not regularly come to obtain his/her smaller, immediate supplies of medications and was redirected to do so. 17. Rent a Secure Storage Space (1 7) A. A secure storage space was rented for the client (e. g., locker or mailbox) in which he/she may store necessary medications. B. The client was reinforced for regularly using a secure storage space to store his/her necessary medications. C. The client does not use the secure storage space and was redirected to do so. 18. Assess for Safety ( 18) A. The client was assessed for his/her level of safety to himself/herself and to others regarding his/her readiness for independent living. B. The client was provided with feedback regarding his/her level of safety relative to his/her readiness for independe nt living. C. The client was provided with remedial assistance to assist in making him/her safer regarding his/her independent housing options. D. The client refused to accept that his/her safety was in jeopardy and was confronted with additional concern s. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HOMELESSNESS 147 19. Refer for an Intellectual Assessment ( 19) A. The client was referred for an assessment of cognitive abilities and deficits. B. The client received objective psychological testing to assess his/her cognitive strengths and weaknesses. C. The clien t cooperated with the psychological testing, and feedback about the results was given to him/her. D. The psychological testing confirmed the presence of specific cognitive abilities and deficits. E. The client was not compliant with taking the psychologi cal evaluation and was encouraged to participate completely. 20. Coordinate a Physical Evaluation (2 0) A. The client was referred for a complete physical evaluation by a medical professional that is knowledgeable in both physical health and mental illnes s concerns. B. The client has completed his/her physical evaluation, and the results of this evaluation were processed. C. The client has not submitted to a physical evaluation and was redirected to do so. 21. Obtain Financial Entitlements and Subsidies (21) A. The client was assisted in obtaining, completing, and filing forms for Social Security Disability benefits or other public aid. B. The client has completed all necessary documentation for filing for Social Security Disability benefits or other p ublic aid, and this material was reviewed. C. The client's application for Social Security Disability benefits and other public aid was incomplete, and he/she received assistance in completing these applications. D. The client was assisted in applying fo r subsidies for housing that are available for mentally ill individuals. E. The client has appropriately applied for specific subsidies for mentally ill individuals in need of housing and was reinforced for this follow-through. F. The client has been abl e to obtain subsidies to assist with his/her payment for housing, and the implications of this progress were processed. G. The client has not pursued available subsidies for housing for mentally ill individuals and was redirected to do so. 22. Encourage or Assist with Regular Employment (2 2) A. The client was encouraged to obtain regular employment to increase income and defray housing costs. B. The client was assisted in seeking and obtaining regular employment. C. The client has found regular employm ent, and the economic benefits for his/her employment were reviewed. D. The client has not obtained regular employment; he/she continues to struggle with his/her income level and was redirected in this area. 23. Develop a Budget (23) A. The client was r equested to develop a basic budget, including income, necessary expenses, additional spending, and savings plans. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
148 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client has developed a basic budget, and this material was reviewed. C. The client was given positive feedback for his/her comprehens ive, realistic budget. D. The client has not developed a basic budget and was redirected to do so. 24. Assist in Obtaining a Bank Account (2 4) A. The client was assisted in obtaining a low-interest, no-fee bank account with a participating bank. B. The waiving of basic fees was coordinated with the participating bank to assist the client in stabilizing his/her financial concerns. C. The client has refused to use a bank account and was redirected in this area. 25. Obtain Emergency Funds ( 25) A. Emerge ncy funds were obtained for payment of the client's rent, mortgage, or utilities in order to prevent eviction. B. The client was directed as to how to seek out emergency funds for payment of rent, mortgage, or utilities to prevent eviction. C. The client has assertively accessed emergency funds for payment of rent, mortgage, or utilities, which has helped him/her to prevent eviction, and this was reviewed with him/her. D. The client has failed to follow through on obtaining emergency funds that support h ousing expenses, and he/she was again encouraged to do so. 26. Plan Discharge Housing Early in Inpatient Hospitalization ( 26) A. The discharge-planning coordinator of the client's current inpatient psychiatric setting was contacted to coordinate discharg e planning regarding housing. B. Although the client has recently been psychiatrically hospitalized and is not ready to be discharged, his/her housing upon discharge has been strongly emphasized and is being coordinated. C. Although the client remains in an inpatient psychiatric setting, arrangements for his/her housing have been made, and the housing is waiting for him/her upon discharge. D. Efforts to coordinate housing for the client upon discharge from the inpatient psychiatric setting have not resul ted in a specific discharge plan, and these plans continue to be developed. 27. Develop Housing Plans for After Incarceration ( 27) A. While the client has been incarcerated, regular meetings have occurred to develop housing plans for him/her subsequent t o his/her release from incarceration. B. A specific plan was developed for the client to have stable housing subsequent to his/her release from incarceration. C. The client has not developed a housing plan for his/her release from incarceration and was redirected to focus on this area and ask for assistance as needed. 28. Coordinate Visits to a Less Restrictive Setting ( 28) A. As the client is planning a move to a new, less restrictive setting, he/she was provided with ample visits to the new setting. B. The client's questions regarding his/her new, less restrictive setting were answered, and he/she was provided with ongoing reassurance. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HOMELESSNESS 149 C. The client was supported as he/she has become more comfortable with the use of the new, less restrictive setting. D. The client continues to feel uncertain about the new, less restrictive setting, despite ample visitation, and was provided with additional support. 29. Refer for Substance Abuse Treatment ( 29) A. The client was referred to a 12-step recovery program (e. g., Alcoholics Anonymous or Narcotics Anonymous). B. The client was referred to a substance abuse treatment program. C. The client has been admitted to a substance abuse treatment program and was supported for this follow-through. D. The client has refused the referral to a substance abuse treatment program, and this refusal was processed. 30. Refer to a Drug-Free Housing Program (3 0) A. The client was referred to a drug-free housing program. B. The client reports that he/she has been more able to remain substance-free through the use of a residence in a drug-free housing program, and he/she was provided with positive feedback for this progress. C. As the client has continued to use mind-altering substances, his/her residence has not been as stable, and this was processed. 31. Coordinate Mental Health and Substance Abuse Treatment (3 1) A. The client's mental health and substance abuse services were coordinated within his/her residential setting. B. The client was reinforced for participating mor e fully in both the mental health and substance abuse services provided within his/her residential setting. C. The client has terminated the substance abuse that has interfered in maintaining his/her residence and was provided with positive feedback for t his progress. D. The client has continued to use substances, despite the use of coordinated mental health and substance abuse services. 32. Encourage the Family and Friends to Support, Teach, and Monitor (32) A. The client's family members and friends w ere encouraged to support, teach, and monitor him/her regarding his/her progress with basic living needs, medication administration, and financial management. B. Family members were provided with positive feedback for their support, teaching, and monitori ng of the client. C. Despite extensive support from the client's support network, he/she continues to experience significant concerns related to his/her basic living needs, medication administration, and financial management and was given further feedback in these areas. 33. Refer to a Support Group (3 3) A. The client was referred to a support group for individuals with severe and persistent mental illness. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
150 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client has attended the support group for individuals with severe and persistent mental illness, and the benefits of this support group were reviewed. C. The client reported that he/she has not experienced any positive benefit from the use of a support group but was encouraged to continue to attend. D. The client has not used the support grou p for individuals with severe and persistent mental illness and was redirected to do so. 34. Match with a Mentor (3 4) A. The client agreed to be matched with a mentor who has already successfully moved from homelessness to a stable living environment. B. A specific mentor was coordinated for the client to provide him/her with feedback about how to successfully move from homelessness to a stable living environment. C. The client's contact with his/her mentor was processed, and he/she described that this contact was helpful in providing insight into moving from homelessness to a stable living environment. D. The client has not regularly met with his/her housing mentor and was redirected to do so. 35. Teach Housekeeping Skills ( 35) A. The client was taug ht about basic housekeeping skills. B. Sources such as Mary Ellen's Complete Home Reference Book by Pinkham and Burg or The Cleaning Encyclopedia: Your A-Z Illustrated Guide to Cleaning Like the Pros by Aslett were used to teach the client specific housek eeping skills. C. The client was provided with positive feedback about his/her increased understanding of basic housekeeping skills. D. The client's use of basic housekeeping skills has noticeably improved, and he/she was provided with support for this. E. The client has not improved his/her basic housekeeping skills and was provided with additional feedback in this area. 36. Refer for Training ( 36) A. The client was referred to a structured program to obtain hands-on training in basic skills for trans itioning to more independent care. B. The client was taught many of the basic skills needed for transitioning to more independent care. C. The client has failed to learn the basic skills needed for transitioning to more independent care and was provided with additional remedial training in this area. 37. Obtain Homemaker Assistance ( 37) A. The client was offered the use of homemaker assistance because he/she is not capable of doing basic housekeeping activities. B. The client was assisted in applying f or homemaker assistance because he/she is not capable of performing basic housekeeping activities. C. The client has been provided with homemaker assistance. D. The client's overall ability to maintain an independent home or apartment has improved throug h the use of a visiting homemaker. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
HOMELESSNESS 151 38. Meet with the Housing Manager ( 38) A. A meeting was held with the client's housing manager to provide education about mental illness issues and the client's rights, to mitigate his/her problematic behaviors, and to assist in rent reviews and dwelling inspections. B. Regular meetings continue to be held with the client's housing manager to train about mental illness issues and the client's rights, to mitigate his/her problematic behaviors, and to assist in rent revie ws and dwelling inspections. C. The client's increased level of communication with his/her housing manager has helped to avert crises that could have threatened his/her residential status, and he/she was directed to continue this pattern of communication. D. The client's housing manager was provided with 24-hour access to the clinician or agency staff should emergencies arise. E. The client's housing manager was urged to contact the clinician or agency staff with questions or crisis concerns. F. The cli ent's potential decompensation has been arrested through the use of immediate contact with his/her housing manager, and this was reflected to the manager and the client. 39. Provide Emergency Health Information Card ( 39) A. The client was provided with a n emergency health information card, which includes individualized information about whom to call in a crisis situation, including the case manager and physicians. B. The client was reinforced for using the emergency health information card to help avert crisis situations. C. The client has failed to use the emergency health information card when experiencing a crisis and was reminded about this resource. 40. Coordinate Funds to Maintain Residence during Decompensation (40) A. Funds were coordinated to maintain the client's residence during times when he/she would be unable to obtain resources for paying his/her bills (e. g., hospitalization or when he/she briefly loses eligibility for benefits). B. The client has been able to maintain stability, as he/s he has been able to keep his/her regular residence even during periods of brief decompensation, and this was reviewed with him/her. 41. Provide Training Regarding Rights (41) A. The client was provided with training about his/her rights as related to the Americans with Disabilities Act, including reasonable accommodations that must be made for him/her. B. The client was reinforced for displaying an understanding of his/her rights and the reasonable accommodations that must be made for him/her. C. The cl ient displayed a poor understanding of his/her rights and reasonable accommodations and was provided with additional education and guidance in this area. 42. Educate about Tenant's Rights (4 2) A. The client was educated about tenant's rights. B. The cli ent was referred to information about tenant's rights described in Renter's Rights by Portman and Stewart. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
152 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client displayed increased understanding about tenant's rights and was urged to assert these with his/her landlord. D. The client was provid ed with positive feedback regarding his/her assertion of tenant's rights to maintain a more regular and stable living environment. E. The client has failed to assert his/her rights as a tenant and was provided with additional encouragement to do so. 43. Coordinate Legal Assistance ( 43) A. Contact with legal assistance programs was coordinated due to the client's rights continuing to be violated. B. Legal assistance has been provided to the client to assist in enforcing his/her basic rights and needed ac commodations. C. Legal assistance programs have declined to assist the client, and further advocacy was provided. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
153 INDEPENDENT ACTIVITI ES OF DAILY LIVING ( IADL) CLIENT PRESENTATION 1. Lack of Access to IADLs (1) * A. The client has had limited access to IADLs (e. g., transportation, banking, shopping, or use of community services). B. The client has often been barred from using IADLs due to his/her mental illness. C. The client has begun to access IADLs. D. The client displays an increased pattern of independence through engaging in IADLs. 2. Lack of Experience with IADLs (1) A. The client described a pattern of in experience with IADLs (e. g., transportation, banking, shopping, or use of community services). B. The client has often relied on others for IADLs. C. The client reports increased experience with IADLs. D. The client displays more independence as he/she gains experience with IADLs. 3. Poor Functioning on IADLs (1) A. The client described poor functioning on IADLs, despite his/her regular access to and experience with areas such as transportation, banking, shopping, or use of community services. B. As t he client's severe and persistent mental illness symptoms have stabilized, he/she has improved his/her functioning relative to IADLs. C. The client regularly takes care of his/her own IADLs in a functional manner. 4. Anxiety Regarding Increasing IADLs (2 ) A. The client described feelings of anxiety regarding becoming more independent. B. The client reported feelings of uncertainty and fear regarding specific areas of IADLs. C. The client is avoidant of areas in which he/she could increase his/her IADLs. D. The client has become more confident regarding performing his/her IADLs. 5. Lack of Community Resource Knowledge (3) A. The client has limited information regarding available community resources. B. The client often fails to use community resource s due to his/her ignorance in this area. C. As the client has gained increased knowledge of community resources, he/she has increased his/her independence. 6. Poor Emergency Response (4) A. The client has failed to respond appropriately in emergency sit uations. * The numbers in parenthe ses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
154 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client displayed a lack of knowledge about emergency services, their function, or how to access them. C. The client's severe and persistent mental illness symptoms have affected his/her ability to respond appropriately to emergency situat ions. D. As the client has stabilized his/her severe and persistent mental illness symptoms, he/she has learned more about appropriate emergency responses. E. The client has appropriately used emergency resources. 7. Symptoms Affect Independent Use of C ommunity Resources (5) A. Experiences of severe and persistent mental illness symptoms have affected the client's ability to use community resources independently. B. As the client has stabilized his/her severe and persistent mental illness symptoms, his /her ability to use community resources has increased. C. The client reports that he/she is regularly using community resources on an independent basis. 8. Unfamiliarity with Services (6) A. The client described that he/she has not had experience with r esources such as banking, stores, and other services. B. The client has increased his/her familiarity with resources such as banking, stores, and other services. C. The client displays independent functioning regarding the use of banking, stores, and oth er services. 9. Poor Organization (7) A. The client reported a pattern of poor attention to and organization of personal responsibilities. B. The client has displayed poor attention to and organization of personal responsibilities, as evidenced by unpai d bills and unkept appointments. C. As the client has become more organized, he/she has regularly met his/her personal responsibilities (e. g., paying bills and keeping appointments). 10. Limited Access of Community Resources (8) A. The client has failed to access community resources such as worship centers, libraries, recreational areas, or businesses. B. The client's failure to access community resources has resulted in his/her decreased involvement within the community. C. As the client's severe and persistent mental illness symptoms have stabilized, he/she has increased his/her access to community resources. D. The client regularly uses community resources such as worship centers, libraries, recreational areas, or businesses. 11. Restricted from Co mmunity Resources (9) A. The client's access to community resources has been restricted due to his/her bizarre behaviors. B. The client has been banned from using specific community resources due to his/her history of bizarre behavior related to his/her severe and persistent mental illness symptoms. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INDEPENDENT ACTIVITI ES OF DAILY LIVING ( IADL) 155 C. As the client's severe and persistent mental illness symptoms have improved, his/her behavior has been more stable. D. The client has gained access to previously restricted community resources due to his/ her regular pattern of stability. 12. Others Take Responsibility for IADLs (10) A. The client described a history of allowing others to take responsibility for performing IADLs for him/her. B. The client's family members were noted to have been taking r esponsibility for performing his/her IADLs. C. As the client has stabilized his/her severe and persistent mental illness symptoms, he/she has been able to take increased responsibility for performing IADLs. D. The client's family members have ceased taki ng inappropriate responsibility for performing his/her IADLs. INTERVENTIONS IMPLEM ENTED 1. Assign an Inventory of IADLs (1) * A. The client was asked to prepare an inventory of positive and negative functioning regarding his/her IADLs. B. The client prep ared his/her inventory of positive and negative functioning regarding IADLs, and this inventory was reviewed. C. The client was given positive feedback regarding his/her accurate inventory of positive and negative functioning regarding IADLs. D. The clie nt has prepared his/her inventory of positive and negative functioning regarding IADLs but needed assistance to develop a more accurate assessment. E. The client has not prepared an inventory of positive and negative functioning regarding IADLs and was re directed to do so. 2. Examine Problematic IADL Areas ( 2) A. The client's problematic IADL areas were examined with him/her. B. Specific patterns of behavior and thought that contribute to the client's failure at independent functioning were identified. C. The client described increased understanding of his/her problematic behaviors and cognitions subsequent to reviewing his/her problematic IADL areas. D. The client has no insight as to failures regarding IADLs or the causes for those failures; addition al realistic feedback was provided. 3. Obtain Feedback from a Support Network (3) A. A proper authorization to release confidential information was obtained in order to review IADLs with the client's support network. * The numbers in paren theses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
156 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. Specific feedback was obtained fr om the client's family members, friends, and caregivers about his/her performance of IADLs. C. The client's support network's feedback about his/her performance of IADLs was reviewed with the client. D. The client displayed increased understanding of IAD L issues subsequent to reviewing feedback from the support network. E. The client rejected the IADL feedback provided by his/her support network and was urged to consider this important information. 4. Identify Needed IADLs ( 4) A. The client was assiste d in identifying those IADLs that are desired but are not present in his/her current repertoire. B. The client received feedback regarding his/her description of IADLs that he/she wishes to increase. C. The client was unable to identify specific IADLs th at he/she wishes to increase and was assisted in reviewing this area. 5. Refer for Psychological Testing ( 5) A. The client was referred for an assessment of cognitive abilities and deficits. B. The client underwent objective psychological testing to ass ess his/her cognitive strengths and weaknesses. C. The client cooperated with the psychological testing, and feedback about the results was given to him/her. D. The psychological testing confirmed the presence of specific cognitive abilities and deficits. E. The client has not complied with taking the psychological evaluation and was encouraged to participate completely. 6. Recommend Remediating Programs ( 6) A. The client was referred to remedial programs that are focused on removing deficits for perfo rming IADLs, including skill-building groups, token economies, and behavior-shaping programs. B. The client was assisted in remediating his/her deficits for performing IADLs through the use of skill-building groups, token economies, and behavior-shaping p rograms. C. As specific programs have assisted the client in removing deficits for performing IADLs, his/her activities of daily living (ADLs) have gradually increased. D. The client has not complied with the referral to skill-building groups and was aga in encouraged to do so. 7. Explore Social Anxiety ( 7) A. The client's experience of social anxiety related to increased independence and social contacts was explored. B. The client was provided with support and empathy as he/she described his/her experi ence of anxiety. C. The client denied any anxiety related to increased independence, and this was noted. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INDEPENDENT ACTIVITI ES OF DAILY LIVING ( IADL) 157 8. Teach and Reinforce Social Skills ( 8) A. The client was taught some skills that are necessary for appropriate social behavior. B. The client was provided with feedback regarding his/her use of social skills. C. As the client has developed more appropriate social skills, his/her social interaction has been more appropriate, and he/she was provided with positive feedback about this progress. D. The client was confronted about not learning appropriate social skills, and not increasing the frequency and appropriateness of his/her social interactions. 9. Develop IADL Completion Schedule ( 9) A. The client was assisted in developing a specific schedul e for completing IADLs (e. g., arranging finances on Monday mornings or going to the grocery store on Tuesday). B. The client has developed his/her own schedule for completing IADLs, and this schedule was reviewed. C. The client's use of scheduling IADLs has helped him/her complete these on a regular basis, and he/she was provided with positive feedback for this follow-through. D. The client was taught about situations in which he/she should break from his/her established routine. E. The client acknowled ged specific situations in which he/she should break from his/her established routine (e. g., do the banking on a different day due to a holiday or do the weekly cleaning one day earlier to attend a desired social function) and was provided with support for this flexible approach. F. The client has not used his/her schedule for completing IADLs and was redirected to do so. 10. Educate about Mental Illness (1 0) A. The client was educated about the expected or common symptoms of his/her mental illness, whic h may negatively impact IADL functioning. B. As the client's symptoms of mental illness were discussed, he/she displayed an understanding of how these symptoms may affect his/her IADL functioning. C. The client struggled to identify how symptoms of his/h er mental illness may negatively impact IADL functioning and was given additional feedback in this area. 11. Interpret Psychiatric Decompensation (11) A. The client's poor performance on IADLs was interpreted as an indicator of psychiatric decompensation. B. The client's pattern of poor IADLs and psychiatric decompensation was shared with him/her, along with caregivers and medical staff. C. The client acknowledged his/her poor performance on IADLs as prodromals of his/her psychiatric decompensation, and this was supported. D. The client, caregivers, and medical staff concurred regarding his/her general psychiatric decompensation. E. The client denied psychiatric decompensation, despite being told that his/her poor performance on IADLs is an indication of psychiatric decompensation. 12. Refer to a Physician (12) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medications. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
158 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client declined evaluation by a physician for a prescription of psychotropic medications and was re directed to cooperate with this referral. 13. Educate about Psychotropic Medications (1 3) A. The client was taught about the indications for and the expected benefits of psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for and expected benefits of the medications. C. The client displayed a lack of understanding of the indications for and expected benefits of psychotropic medications and was provided with addition al information and feedback regarding his/her medications. 14. Monitor Medications (14) A. The client was monitored for compliance with his/her psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medications. C. The client was monitored for the effectiveness and side effects of his/her prescribed medications. D. Concerns about the client's medication effectiveness and side effects were communicated to the physician. E. Although t he client was monitored for medication side effects, he/she reported no concerns in this area. 15. Review/Model Procurement of Medications ( 15) A. Protocol for procuring the client's medications was reviewed with him/her. B. The procurement of the clien t's medication was modeled to him/her. C. The client was shadowed for support as he/she procured his/her own medications. D. The client does not appropriately and regularly procure his/her own medications and was provided with additional training in this area. 16. Develop Agreement Regarding Monitoring of Medications ( 16) A. An agreement was developed with the client regarding the level of responsibility and independence that he/she must display to trigger a decrease in the clinician's monitoring of medications. B. The closeness with which the clinician monitors the client's medications has been decreased as he/she has displayed increased responsibility and independence. C. The client's medications continue to be closely monitored as he/she has failed to display the needed level of responsibility and independence. 17. Coordinate an Agreement with the Pharmacist ( 17) A. An agreement was coordinated between the client, the pharmacist, and the clinician regarding circumstances that would trigger a transf er of medication monitoring back to the clinician. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INDEPENDENT ACTIVITI ES OF DAILY LIVING ( IADL) 159 B. The client was supported for his/her understanding of circumstances in which the pharmacist would contact the clinician (e. g., failure to pick up the monthly prescription or trying to refill the prescr iption too soon). C. The client was provided with positive feedback regarding his/her appropriate use of the pharmacy to obtain medications. D. As the client has failed to appropriately use the pharmacy to obtain his/her medications, his/her medication u sage has been more closely monitored. 18. Brainstorm Transportation Resources ( 18) A. The client was assisted in brainstorming possible transportation resources available for his/her use. B. Specific transportation resources (e. g., public transportation, personal vehicle, agency resources, friends and family, walking, or bicycling) were identified. C. The client was encouraged to independently use available transportation resources. D. The client was verbally reinforced for his/her independent use of t ransportation resources. E. The client continues to be uncertain about what type of transportation resources to use and was provided with additional feedback in this area. 19. Teach about Public Transportation Options ( 19) A. The client was taught about available public transportation options by discussing these options and reviewing written schedules. B. The client was accompanied on the use of community transportation services, which has helped to teach him/her the safe, socially appropriate use of pu blic transportation. C. The typical expectations for using public transportation were reviewed, including paying for the transportation, time schedules, and social norms for behavior. D. The client was praised for his/her understanding of typical expecta tions for using public transportation. E. The client has displayed appropriate adherence to social and other expectations while using public transportation and received positive feedback for this. F. The client has failed to understand the typical expect ations for using public transportation and was given further education in this area. G. The client declined to be accompanied on his/her use of public transportation services, and this choice was accepted. 20. Predict Severe and Persistent Mental Illness Influences and Brainstorm Remedial Techniques (2 0) A. The client's pattern of severe and persistent mental illness symptoms was reviewed. B. Possible influences of the client's severe and persistent mental illness symptoms on his/her ability to use comm unity services were predicted. C. The client was supported as he/she realistically identified the effects of his/her severe and persistent mental illness symptoms on his/her ability to use community services. D. The client was assisted in brainstorming t echniques to decrease the effects of his/her severe and persistent mental illness symptoms (e. g., relaxation techniques, escape/avoidance plans, and graduated steps to independence). | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
160 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client was realistic in his/her identification of techniques to d ecrease the effects of his/her severe and persistent mental illness symptoms on his/her ability to use community services and was provided with encouragement in this area. F. The client was in a state of denial regarding his/her severe and persistent ment al illness symptoms and their effect on his/her ability to use community services and was redirected in this area. 21. Ride Along on Public Transportation (2 1) A. The client was accompanied on public transportation to a variety of destinations. B. The c lient has identified that he/she is more comfortable with using public transportation without accompaniment and was provided with positive feedback about this. 22. Develop and Budget Income Sources ( 22) A. The client was assisted in obtaining, completing, and filing forms for Social Security Disability benefits or other public aid. B. The client was assisted in identifying ways to increase income through obtaining employment. C. The client has obtained regular income and is now able to afford the use of resources within the community, and he/she was provided with positive feedback for this progress. D. The client has not developed any regular sources of income and was redirected to do so. E. The client was requested to develop a basic budget, including income, necessary expenses, additional spending, and savings plans. F. The client was given positive feedback for his/her comprehensive, realistic budget. G. The client has not developed a basic budget and was redirected to do so. 23. Review Banking Pr os and Cons ( 23) A. The advantage of using the banking system to assist with IADLs was reviewed with the client, including increased security, financial organization, and convenience for paying bills. B. The client was cautioned about the hazards related to banking (e. g., credit debt, overdrawn checking account charges). C. The procedures used within the banking system were reviewed. D. The client was reinforced for his/her verbalization of an increased understanding of the issues related to using a ban king system for IADLs. E. The client displayed a poor understanding of the use of the banking system to assist with IADLs and was provided with further information in this area. 24. Coordinate a Helping Relationship with Bank Staff ( 24) A. A helping rel ationship was coordinated between the client and specific members of the banking staff. B. Permission to release information to the bank staff was obtained. C. The staff of the bank was informed about the client's needs and disabilities. D. The client r eported feeling more comfortable through the use of a helpful relationship with specific bank staff, and this experience was processed. 25. Encourage the Use of a Specific Employee at Bank ( 25) A. The client was encouraged to select and use a specific st aff member at a specific bank branch in order to develop a more personal and understanding relationship. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INDEPENDENT ACTIVITI ES OF DAILY LIVING ( IADL) 161 B. The client has regularly sought out a specific employee at the bank, and this was noted to be helping the client feel more comfortable and to know what to expect in the interaction. C. The client continues to approach his/her use of the banking system in a rather haphazard manner, and he/she was provided with redirection in this approach. 26. Coordinate a Notification Agreement ( 26) A. An agreemen t was coordinated between the client, a specified bank staff member, and the clinician regarding the circumstances under which the clinician should be notified of an irregularity. B. Specific situations were identified within an agreement with the banking staff about when to notify the clinician, such as a manic attempt by the client to withdraw his/her entire savings account. C. The client has agreed to allow the bank staff to contact the clinician under certain circumstances. D. The client has declined the use of an agreement between himself/herself, a specified bank staff member, and the clinician regarding when the clinician should be notified, and this was accepted. 27. Familiarize with Commercial Resources ( 27) A. The client was familiarized with commercial resources that are available in his/her area through a review of newspaper advertisements and a tour of the business districts within the community. B. The client was provided with positive feedback regarding his/her understanding about the commercial resources available in his/her area. C. The client continues to have a poor understanding of the commercial resources available in his/her area and was provided with additional information about this topic. 28. Role-Play Shopping Situations ( 28) A. Role-playing was used to teach the client how to handle commonly occurring shopping situations. B. The client was assisted in role-playing specific shopping situations (e. g., asking for assistance, declining a pushy salesperson, or returning a defecti ve item). C. The client was provided with feedback about his/her functioning in commonly occurring shopping situations. D. The client has not been able to increase his/her understanding of the needed response in typical shopping situations and was provid ed with additional information in this area. 29. Accompany to Local Businesses (29) A. The client was accompanied on visits to local businesses where he/she has felt anxious or unsure. B. The client has identified that he/she is now more comfortable wit h using area businesses without accompaniment and was reinforced for this progress. 30. Support Assertiveness and Advocate Regarding Discrimination (3 0) A. The client was provided with support and feedback as he/she identified instances in which he/she w as discriminated against due to his/her mental illness symptoms. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
162 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER B. The client was taught assertive steps to respond to discrimination due to his/her mental illness symptoms. C. The client was supported as he/she implemented assertive responses to instan ces of discrimination due to his/her mental illness symptoms. D. Further education and encouragement were provided to the client, as he/she has not used assertive responses to the situations in which he/she has been discriminated against due to his/her me ntal illness symptoms. E. The client was provided with support as he/she identified area businesses or service providers who have restricted access to him/her due to concerns over his/her mental illness symptoms. F. Advocacy was provided on the client's behalf with area businesses or service providers who have restricted his/her access due to his/her mental illness symptoms. 31. Link to Advocacy and Support Groups ( 31) A. The client was referred to an advocacy group that will directly assist him/her in developing open access to community businesses and services. B. The client was reinforced for attending a support group focused on assisting him/her in developing more open access to community businesses and services. C. The client's greater access to co mmunity businesses and services was processed. D. The client has not taken advantage of support and advocacy groups to develop greater access to community businesses and services and was provided with encouragement to do so. 32. Explore Contacts with Eme rgency Response Professionals ( 32) A. The client's history of prior contacts with emergency response professionals was explored. B. The client was assisted in identifying situations in which emergency response staff was required to coerce the client (e. g., a prior involuntary hospitalization). C. The client was assisted in identifying situations in which he/she may have manipulated emergency response staff (e. g., threatened to harm himself/herself for some secondary gain such as obtaining food or a place to sleep). D. The client was provided with positive feedback as he/she accurately reviewed his/her history of contact with emergency response professionals. E. The client tended to deny his/her pattern of past involvement with emergency response profess ionals and was redirected to review these areas. 33. List Preferred Emergency Response Professionals ( 33) A. The client was assisted in developing a list of specific emergency response professionals who respond effectively to mentally ill individuals (e. g., a police unit mental health liaison or a specific nurse/orderly at the emergency room). B. The client was directed to seek out specific professionals when he/she contacts certain agencies or facilities. C. Regular contact has been maintained with the identified professionals to facilitate greater understanding of the client's needs. D. The client has not used the identified professionals and continues to misuse the emergency response system; he/she was redirected in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INDEPENDENT ACTIVITI ES OF DAILY LIVING ( IADL) 163 34. Provide 24-Hour Cr isis Consultation ( 34) A. The area emergency response professionals were provided with 24-hour crisis consultation to assist in responding to the client's use of emergency systems. B. Provision of the 24-hour crisis consultation has helped to decrease in appropriate use of the emergency response system and inappropriate response to the client by the emergency system. 35. Teach Appropriate Use of Emergency Services ( 35) A. The client was taught about the appropriate use of specific emergency service profe ssionals, including their responsibilities and limitations. B. The client was provided with positive feedback for his/her accurate understanding of responsible use of emergency service professionals, their responsibilities, and limitations. C. The client was assisted in brainstorming alternative resources that are available to him/her for use instead of nuisance calls to emergency response staff. D. The client was assisted in developing specific alternatives to use instead of nuisance calls to emergency response staff (e. g., contact a crisis line rather than the police for psychotic symptom development; contact a support group member when feeling lonely instead of going to the emergency room; contact family first if feeling ill). E. The client has decre ased his/her pattern of nuisance calls to emergency response staff and was provided with positive feedback for this progress. F. The client has not used alternative resources instead of nuisance calls to emergency response staff and was urged to modify th is practice. 36. Discuss Making Amends ( 36) A. The client was taught regarding the need for making amends to businesses or service providers who have been affected by his/her past inappropriate behavior. B. The form of restitution to businesses, service providers, or others who have been affected by the client's past inappropriate behavior was brainstormed. C. Specific areas of the restitution plan were reviewed (e. g., how to approach the business owner, what service could be offered in restitution, whe re the client would get the money to pay the business owner for debt). D. The client has made amends to businesses or service providers who have been affected by his/her past inappropriate behavior, and he/she was provided with positive feedback in this area. E. The client denied the need to make amends with businesses or service providers who have been affected by his/her past inappropriate behavior and was accepted for this position. F. The client resisted endorsing a specific plan for how to implement restitution to those affected by his/her past inappropriate behavior and was provided with additional feedback in this area. 37. Develop a List of Resources for IADLs ( 37) A. The client was asked to identify a list of personal resources that he/she can use for assistance in carrying out IADLs. B. The client was assisted in identifying specific resources that he/she can use for carrying out IADLs (e. g., family and friends, support group members, neighbors). C. The client has failed to identify a list of personal resources to assist him/her in carrying out IADLs and was urged to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
164 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 38. Role-Play Asking for Assistance ( 38) A. Role-playing was used to help the client practice how to approach strangers for basic assistance (e. g., asking for directions). B. Feedback was provided to the client about his/her approach, personal hygiene, and dress, plus how appearance and manner affect a stranger's comfort level. C. The client displayed an understanding of the issues related to asking others for assistance and was praised for this insight. D. The client displayed poor understanding of how his/her appearance and manner affect others' comfort level and was provided with additional feedback in this area. 39. Develop a Written Plan for Decompensation (39) A. The client was assisted in developing a written plan for use when he/she is at risk of decompensation. B. The client's written plan regarding decompensation includes telephone numbers of resources and how to obtain clinical assistance, and this was noted to be a rather comprehensive plan. C. The client was praised for the development of his/her written plan for resources and assistance when he/she is at risk for decompensation. D. The client was reinforced for his/her use of his/her plan when he/she fee ls to be at risk of decompensation. E. The client has not used his/her written plan for early responding to decompensation and was reminded of how and when to use this resource. 40. Refer to an Activity Therapist ( 40) A. The client was referred to an ac tivity therapist for recommendations regarding physical fitness activities that are available in the community. B. The client was referred to community physical fitness resources (e. g., health clubs and other recreational programs). C. The client has bee n actively participating in community physical fitness programs and was reinforced for this. D. The client has declined involvement in community physical fitness programs and was redirected to do so. 41. Assist in Identifying and Learning about Recreatio nal Activities ( 41) A. The client was assisted in identifying a variety of recreational activities in which he/she might be interested in participating. B. The client was provided with educational material regarding his/her chosen activities. C. The cli ent displayed an increased understanding regarding how to access chosen activities as a result of reviewing the information provided to him/her. D. The client has been reluctant to identify or learn about recreational activities and was redirected to do s o. 42. Shadow at Recreational Activities ( 42) A. As the client attended his/her chosen recreational activities, he/she was shadowed in order to provide support and direction. B. To decrease stigma and increase independent functioning, the client was all owed to determine how closely the clinician was involved as he/she was shadowed at his/her selected activity. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INDEPENDENT ACTIVITI ES OF DAILY LIVING ( IADL) 165 C. The client has been able to increase his/her involvement and comfort level at his/her chosen activities because of the support and encourageme nt provided by the shadowing clinician. D. The client declined to have the clinician shadow him/her at the chosen activities, and he/she was accepted for this position. 43. Coordinate a Mentor ( 43) A. Contact between the client and another mentally ill individual who is further along in his/her recovery was coordinated in order to help the client process how others have achieved increased independence. B. The client has followed up on his/her contact with another mentally ill individual who is further a long in his/her recovery, and this contact was processed. C. The client has not followed up on contact with another mentally ill individual in recovery and was redirected to do so. 44. Explore Spiritual Interests ( 44) A. The client's interest in involve ment with spiritual activities was explored. B. The client was accepted for his/her identified interest in spiritual activities. C. The potential for the client to experience confusion regarding spiritual messages and imagery due to his/her severe and pe rsistent mental illness symptoms was acknowledged. D. The client was assisted in differentiating between spiritual concerns and symptoms of mental illness. E. The client was provided with positive feedback regarding his/her ability to differentiate betwe en legitimate spiritual concerns and his/her spiritually oriented hallucinations and delusions. F. The client was provided with specific direction and feedback as he/she displayed difficulty understanding and accepting the difference between spiritual con cerns and severe and persistent mental illness symptoms. G. The client indicated no interest in spiritual activities and was accepted for this decision. 45. Coordinate Worship Attendance ( 45) A. The client's attendance at his/her preferred place of wors hip was coordinated. B. The client was accompanied to his/her preferred place of worship to assist in increasing his/her comfort level. C. The client's attendance at his/her preferred place of worship was reviewed and processed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
166 INTIMATE RELATIONSHI P CONFLICTS CLIENT PRESENTATION 1. Indifferent to Emotional Needs (1) * A. The client displayed a pattern of indifference toward the emotional needs of his/her partner. B. The client's partner has complained about the client's pattern of indifference toward the partner's emotional needs. C. When the client's partner expresses emotional needs, the client becomes critical, frustrated, and overly reactive. D. The client reported an increased focus on his/her partner's needs. E. The cli ent consistently takes notice of and considers the emotional needs of his/her partner. 2. Distrust Due to Paranoia (2) A. The client described a pattern of consistent distrust of his/her partner. B. The client offered no sufficient basis for his/her pat tern of distrust of his/her partner. C. The client's level of distrust toward his/her partner has diminished. D. The client verbalized trust in his/her partner despite the previously held extreme distrust. 3. Relationship Stress (3) A. The effects of t he client's erratic behavior (e. g., legal problems, impulsive spending, inability to work) have led to increased levels of stress within the relationship. B. The client's intimate relationship is at risk for dissolution due to the increased levels of stre ss relating to the effects of his/her erratic behavior. C. Stress levels have decreased significantly for the client and his/her partner as the effects of the client's erratic behavior have decreased. D. As the client's erratic behavior has decreased, hi s/her relationship with his/her partner has become significantly more stable. 4. Pattern of Discontinuation of Relationships (4) A. The client described a pattern of repeated discontinuation of relationships due to personal deficiencies in problem solvin g, social skills, or assertion. B. The client's current relationship is at risk of dissolution due to his/her personal deficiencies in problem solving, social skills, or assertion. C. As the client has gained conflict resolution and social skills to help relationship problems, his/her relationship has become more stable. 5. Impulsive Sexual Involvement (5) A. The client described a pattern of impulsive sexual involvement outside of the committed relationship. * The numbers in parentheses correlate to the number of the Behavioral Definition stat ement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INTIMATE RELATIONSHI P CONFLICTS 167 B. The client described a pattern of impuls ive sexual involvement outside of the committed relationship and subsequent regret. C. The client acknowledged that he/she has developed an unhealthy pattern of impulsive sexual involvement outside of the committed relationship. D. The client has termina ted his/her pattern of impulsive sexual involvement outside of the committed relationship. 6. Increased Spousal Discontent (6) A. The client reported that his/her partner has identified increased discontent with the changes that have occurred in the rela tionship due to his/her severe and persistent mental illness symptoms. B. The client's partner reported discontent with the changes in the relationship due to the client's severe and persistent mental illness symptoms. C. As the client has stabilized his /her pattern of severe and persistent mental illness symptoms, he/she describes a more contented relationship with his/her partner. 7. Violence or Abuse between Partners (7) A. The client reported incidents of verbal abuse that occur within the relations hip. B. The client described incidents of physical abuse that occur within the relationship. C. The client has taken steps to remove himself/herself from the abusive relationship. D. The client reported that the pattern of abusive behavior has been term inated. INTERVENTIONS IMPLEM ENTED 1. Explore Relationship History (1) * A. The client's history of intimate relationships was explored. B. The client was assisted in identifying the positive and negative outcomes of his/her history of intimate relationsh ips. C. The client was provided with positive feedback as he/she displayed insight into his/her pattern of intimate relationships. D. The client failed to identify positive and negative outcomes related to his/her pattern of intimate relationships and wa s provided with additional feedback in this area. 2. Develop a Time line (2) A. A graphic time line display was used to help the client chart his/her pattern of intimate relationship conflicts. B. The client was assisted in identifying his/her precursor s, triggers, intimate relationship conflicts, and outcomes on a time line to review how he/she experiences and is affected by the relationship conflicts. C. The client displayed a greater understanding of his/her pattern of intimate relationship conflicts and was given support and positive feedback for this insight. * The numbers in parentheses correlate to the number of the Therapeutic Interventio n statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
168 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER D. The client failed to understand his/her pattern of intimate relationship conflicts and was redirected in this area. 3. Obtain Family Feedback (3) A. The client's partner was consulted abo ut the history of their relationship conflicts. B. The client's extended family was solicited for feedback about his/her history of relationship successes and problems. C. The client's family members supplied feedback regarding their relationship conflic ts; this was presented to the client. D. Each partner has demonstrated a tendency to project blame onto the other for his/her conflicts, and this was reflected to him/her. E. Although the client's partner was asked to provide perceptions regarding the re lationship, no information was forthcoming. F. The client was praised for his/her increased understanding of his/her pattern of relationship successes and problems. G. The client was provided with additional feedback as he/she indicated poor understandin g of his/her pattern of relationship successes and problems. 4. Identify Current Relationship Successes and Challenges ( 4) A. The client was requested to identify the successes and challenges in his/her current relationship. B. The client's pattern of s uccesses and challenges in his/her current relationship was reviewed and processed. C. The client failed to identify current successes and challenges in his/her relationship and was redirected to review this area more closely. 5. Assess Marital Satisfact ion (5) A. The administration of marital satisfaction surveys was coordinated for the client and his/her partner. B. The Marital Satisfaction Inventory (Snyder) or The Marital Status Inventory (Weiss and Correto) was administered to the client and his/he r partner. C. The results of the marital satisfaction survey were shared with the client and his/her partner. D. The marital satisfaction survey results indicated a significant degree of dissatisfaction on the part of the partners. 6. Educate about Ment al Illness, Emphasizing Accurate Causes ( 6) A. The client and his/her partner were taught about the expected or common symptoms of his/her mental illness that may negatively impact his/her intimate relationships. B. The client and his/her partner were re ferred to specific books for further information about mental illness (e. g., Schizophrenia: The Facts by Tsuang and Faraone or Bipolar Disorder: A Guide for Patients and Families by Mondimore). C. As the client's mental illness symptoms were discussed, he /she and his/her partner displayed an understanding of how these symptoms may affect their relationship. D. Emphasis was placed on the fact that neither the family nor the partner are the cause of the client's mental illness. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INTIMATE RELATIONSHI P CONFLICTS 169 E. The client, his/her partn er, and his/her family were supported as they displayed an accurate understanding about the causes for his/her mental illness. F. The client failed to identify how symptoms of his/her mental illness may negatively impact his/her intimate relationships and was given additional feedback in this area. G. The client, his/her partner, and his/her family members continue to inappropriately place blame for the client's mental illness and were provided with additional feedback and information in this area. 7. Request Examples of Symptoms' Effects on Relationship ( 7) A. The client and his/her partner were requested to identify at least two ways in which their relationship has been affected by the severe and persistent mental illness symptoms. B. The client and h is/her partner identified ways in which their relationship has been affected by the severe and persistent mental illness symptoms, and these effects were reviewed. C. The client and his/her partner failed to identify ways in which their relationship has b een affected by the severe and persistent mental illness symptoms and were encouraged to review this area more thoroughly. 8. Refer to a Physician ( 8) A. The client was referred to a physician for an evaluation for a prescription of psychotropic medicati ons. B. The client was reinforced for following through on a referral to a physician for an assessment for a prescription of psychotropic medications, but none were prescribed. C. The client has been prescribed psychotropic medications. D. The client de clined evaluation by a physician for a prescription of psychotropic medications and was redirected to cooperate with this referral. 9. Educate about Psychotropic Medications ( 9) A. The client and his/her partner were taught about the indications for, the expected benefits of, and the possible side effects from psychotropic medications. B. As the client's psychotropic medications were reviewed, he/she displayed an understanding about the indications for, expected benefits of, and possible side effects fro m the medications. C. The client displayed a lack of understanding of the indications for, expected benefits of, and possible side effects from the psychotropic medications and was provided with additional information and feedback regarding his/her medica tions. D. The client's partner was noted to display a clear understanding of the medication concerns. E. The client's partner was noted to display a poor understanding of the medication concerns. 10. Monitor Medications (1 0) A. The client was monitored for compliance with, effectiveness of, and side effects from his/her psychotropic medication regimen. B. The client was provided with positive feedback about his/her regular use of psychotropic medications. C. Concerns about the client's medication effe ctiveness and side effects were communicated to the physician. D. Although the client was monitored for medication side effects, he/she reported no concerns in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
170 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. The client's partner provided feedback regarding the client's medication complia nce and medication efficacy, which was used to help monitor his/her use of medications. F. The client's partner refused to monitor the client's medication compliance and efficacy; this resistance was processed. 11. Coordinate Medication Agreement (1 1) A. An agreement was coordinated between the client and his/her partner about the responsibility for administration and monitoring of the client's medications, including the circumstances under which control of medications will be returned to the client. B. The client and his/her partner were reinforced for developing a helpful, supportive agreement to make certain that his/her medication is administered and monitored appropriately. C. As a result of the client's agreement regarding the responsibility for a dministration and monitoring of his/her medications, he/she has been more regular in his/her use of medications and has stabilized psychiatrically; reinforcement was given for this progress. D. Specific criteria (e. g., extended period of time in remission ) were developed to identify when the client should be able to regain control of administration of his/her medications. E. The client was reinforced for agreeing to specific plans for regaining control of his/her medications. F. The client has declined t o develop an agreement with his/her partner regarding the administration and monitoring of his/her medications, and additional redirection was given in this area. 12. Assign Reading Material for the Partner (1 2) A. The client's partner was assigned to re ad books on coping with a loved one who has a severe and persistent mental illness. B. The client's partner was referred to specific texts regarding coping with mental illness (e. g., When Someone You Love Has a Mental Illness by Woolis; Surviving Schizoph renia: A Manual for Families, Consumers, and Providers by Torrey; or Bipolar Puzzle Solution: A Mental Health Client's Perspective by Cort and Nelson). C. The client's partner has read books on coping with a loved one who has severe and persistent mental illness symptoms, and this information was reviewed and processed. D. The client's partner has not read books on coping with a loved one who has a mental illness and was redirected to review this information. 13. Teach the Partner Techniques for Managing the Client (13) A. The client's partner was taught specific techniques to help manage the client when he/she is agitated, psychotic, or manic (e. g., maintaining a calm demeanor, providing basic directives, giving redirection). B. The client's partner wa s supported for displaying an understanding of the specific techniques that were taught to help manage the client during agitation, psychosis, or mania. C. The client's partner was provided with reinforcement for regular use of management techniques when the client is agitated, psychotic, or manic. D. The client's partner has not used specific techniques to help manage the client when he/she is agitated, psychotic, or manic and was redirected to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INTIMATE RELATIONSHI P CONFLICTS 171 14. Process Emotional Reaction ( 14) A. Emotional re actions from the client's partner due to the client's onset or recurrence of severe and persistent mental illness symptoms were processed. B. The client's partner was assisted in expressing emotional reactions due to the onset or recurrence of the client' s severe and persistent mental illness symptoms. C. The client's partner refused to express feelings related to the client's illness and was urged to do so when comfortable with such disclosure. 15. Reassure Accessibility ( 15) A. The client's partner wa s reassured about how accessible the clinician will be for consultation, questions, or support. B. The client's partner has accessed the clinician for consultation, questions, or support. C. The client's partner has not contacted the clinician for suppor t or consultation and was again encouraged to do so. D. The client's partner was provided with telephone numbers to access 24-hour crisis lines for professional assistance when the clinician is not available. E. The client's partner was supported for usi ng 24-hour crisis lines for professional assistance when the clinician is not available. F. The client's partner has refused to use the 24-hour crisis lines and was again encouraged to do so. 16. Emphasize Outside Interests ( 16) A. The client's partner and family members were urged to maintain interests outside of the mental illness concerns that the client may present. B. The client's partner and family members have maintained interests outside of the mental illness concerns that the client may presen t and were provided with positive support for this activity. C. The client's partner and family members have failed to maintain interests outside of the mental illness concerns that the client may present and were redirected to do so. 17. Refer Partner t o a Support Group ( 17) A. The client's partner was referred to a stress management or support group specifically designed for the family and friends of individuals with severe and persistent mental illness. B. The client's partner has used the stress man agement and support groups and was reinforced for this. C. The client's partner has not used the stress management or support groups and was redirected to do so. 18. Clarify Emotions ( 18) A. The client was encouraged to share his/her emotions regarding the severe and persistent mental illness symptoms and how these affect the relationship. B. The client has continued to share his/her feelings and has been assisted in identifying causes for them. C. Distorted cognitive messages that contribute to the cl ient's emotional response were identified. D. The client demonstrated a sad affect and tearfulness as his/her emotions were reviewed. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
172 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER E. As the client has been assisted in developing better coping mechanisms, he/she reports a decrease in his/her negative feelings related to his/her pattern of severe and persistent mental illness symptoms and their effect on the relationships. F. The client's emotions continue to confuse him/her, and additional support and clarification were given. 19. Facilitate Conjoin t Sessions ( 19) A. Both partners were asked to commit themselves to a series of conjoint sessions to address issues of communication and problem solving. B. Both partners were supported for agreeing to the conjoint sessions to work toward strengthening t heir relationship. C. Both partners were assisted in clarifying their communication and expression of feelings within conjoint sessions. D. Both partners have reported that they have increased the quality and frequency of communication with each other du e to the conjoint sessions. E. Both partners have not committed to regularly attending conjoint sessions and were redirected to commit themselves in this area. 20. Teach Healthy Communication Skills (2 0) A. The client and his/her partner were taught hea lthy communication skills (e. g., expressing specific positive and negative emotions, making requests, communicating information clearly, giving “I” messages, and implementing active listening). B. The client and his/her partner were reinforced for display ing increased understanding of the communication skills that were being taught. C. The use of healthy communication skills by each partner was reviewed. D. The client and his/her partner have failed to regularly use appropriate healthy communication skills, and they were redirected to use these types of skills. 21. Identify Mistrust Due to Mental Illness (2 1) A. The client and his/her partner were focused on identifying trust issues that are attributable to mental illness symptoms. B. The client and hi s/her partner were assisted in identifying how specific mental illness symptoms (e. g., paranoia or mania) have caused mistrust within the relationship. C. The nonvolitional aspects of the client's mental illness symptoms were emphasized during the discuss ion of trust issues and mental illness symptoms. D. The client and his/her partner have not been able to consistently identify trust issues as being attributable to mental illness symptoms and were provided with additional feedback in this area. 22. Expl ore Closeness Vulnerability (2 2) A. Each partner's fears regarding getting too close and feeling vulnerable to hurt, rejection, and abandonment were explored. B. The partners have clarified their own fears of getting too close to each other out of fear o f being hurt and were accepted for this insight. C. The partners were assisted in identifying experiences in their past that have contributed to their fear of closeness. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INTIMATE RELATIONSHI P CONFLICTS 173 D. The partners denied fear of emotional vulnerability and were encouraged to recons ider their denial. 23. Generalize Increased Trust ( 23) A. The client and his/her partner were requested to identify specific areas in which they have experienced increased trust. B. The client and his/her partner were focused on ways in which they can g eneralize their experience of trust into other areas of their relationship. C. The client and his/her partner were provided with positive feedback regarding their increased pattern of trust. D. The client and his/her partner have struggled to generalize trust into other areas and were urged to continue to focus in this area. 24. Identify Relationship Changes Due to Mental Illness ( 24) A. The client and his/her partner were requested to identify changes that have occurred in their relationship due to the client's pattern of mental illness symptoms. B. The client and his/her partner were assisted in identifying the changes that have occurred in the relationship due to the client's mental illness symptoms. C. The client and his/her partner were provided w ith positive feedback regarding their insight into the changes that have occurred in their relationship due to the client's mental illness symptoms. D. The client and his/her partner could not identify changes that have occurred in the relationship due to the client's mental illness symptoms and were requested to review this area more closely. 25. Challenge the Couple to Share Power and Control ( 25) A. The client and his/her partner were focused on the need to share power and control, despite the client' s mental illness symptoms. B. The client and his/her partner were challenged to identify specific ways in which power and control within the relationship can be shared, despite the client's mental illness symptoms. C. The client and his/her partner were given suggestions about specific ways in which power and control can be shared, despite the client's mental illness symptoms (e. g., develop advanced directives regarding treatment expectations, returning responsibility to the mentally ill partner during pe riods of stabilization). D. The client and his/her partner could not identify ways to share power and control within the relationship and were given additional feedback in this area. 26. Legitimize Mourning ( 26) A. The client and his/her partner were pr ovided with support regarding the legitimate need to mourn the loss of functioning within the relationship due to the client's severe and persistent mental illness symptoms. B. The client and his/her partner used the support provided to express their grie f regarding the loss of functioning in the relationship. C. The client and his/her partner denied any grief regarding the loss of functioning in the relationship due to the client's severe and persistent mental illness symptoms, and they were given additi onal feedback regarding grieving. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
174 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER 27. Explore Substance Abuse ( 27) A. The role of substance abuse was explored regarding its contribution to conflict within the relationship, as well as contributing to the client's severe and persistent mental illness symptoms. B. Substance abuse by one of the partners was acknowledged as a strong contributing factor to escalating conflict between them. C. Although substance abuse appears to be a critical component of relationship conflict, neither partner was willing t o acknowledge the fact of substance abuse being a factor. D. The client was confronted with his/her need for substance abuse treatment in addition to continued treatment for his/her severe and persistent mental illness. 28. Integrate Substance Abuse and Mental Health Treatment ( 28) A. The client's mental health and substance abuse treatment were coordinated so they can be provided in an integrated manner. B. Clinicians focusing primarily on the client's severe and persistent mental health treatment were urged to integrate his/her substance abuse treatment as well. C. Treatment staff, focusing on the client's substance abuse treatment, were alerted to the need to also treat his/her severe and persistent mental illness. 29. Discuss Closeness versus Distan ce (29) A. A discussion was facilitated between the client and his/her partner regarding the factors that contribute to a desire for closeness versus those that promote distance/safety. B. The client and his/her partner were provided with assistance in i dentifying factors that contribute to a closeness or for distance/safety. C. The need for a waiting period for the client's partner to regain trust was acknowledged as a normal expectation. D. The client and his/her partner were provided with feedback re garding the partner's caution about resuming normal levels of trust, interaction, sexual activity, and so forth, subsequent to the client's symptoms abating. E. The client was praised for his/her acceptance of his/her partner's need for caution prior to resuming normal closeness. F. The client and his/her partner have argued over the level of closeness expected after the client's symptoms have abated and were provided with additional feedback in this area. 30. Emphasize the Sexual Relationship as a Mirro r (30) A. Emphasis was placed on the concept of the sexual relationship being a mirror of the rest of the relationship. B. The need for positive emotional interaction prior to sexual involvement was emphasized. C. The client was provided with positive r einforcement for his/her focus on positive emotional interaction with his/her intimate partner. D. The client's partner reported that the client does not focus on positive emotional interaction, and the client was provided with additional education in thi s area. 31. Physician Evaluation Referral (3 1) A. The couple was referred to a physician who specializes in sexual dysfunction to obtain an evaluation of any organic causes for their sexual problems. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INTIMATE RELATIONSHI P CONFLICTS 175 B. The physician evaluation did not identify any orga nic basis for the couple's sexual dysfunction, and the implication of this finding was processed. C. The medical problems identified by the physician as causes for the sexual dysfunction are being treated. D. The client was urged to follow up on recommen dations from his/her physician regarding treatment for sexual dysfunction (e. g., medications, specialty assessments, or lab work). E. The client was provided with assistance for following up on the recommendations from the physician regarding sexual dysfu nction treatment. F. The client's treating psychiatrist has been informed about the client's sexual dysfunction concerns, physical exam, and follow-up needs. G. The client has failed to comply with directives regarding physician assessment, treatment, an d follow-up for sexual dysfunction and was redirected to do so. 32. Focus on Sexual Arousal Issues ( 32) A. The client was focused on how his/her physical appearance and personal hygiene needs may affect his/her partner's sexual arousal. B. The client wa s reinforced for displaying an understanding of the need for better personal hygiene and physical appearance as a way to increase sexual arousal for his/her partner. C. The client was provided with positive reinforcement for his/her attempts to improve hi s/her physical appearance and personal hygiene needs. D. The client has failed to improve his/her personal appearance and personal hygiene needs and was provided with additional direction in this area. 33. Assign Reading on Human Sexual Functioning ( 33) A. The client and his/her intimate partner were assigned to read books on human sexual functioning. B. The client and his/her imitate partner were referred to specific books (e. g., The New Joy of Sex by Comfort or The Reader's Digest Guide to Love and Se x by Roberts and Padgett-Yawn). C. The client was referred to watch sexual education videos. D. The client was referred to specific video programs (e. g., Better Sex Videos from the Sinclair Institute). E. The client and his/her intimate partner have not sought out educational material regarding human sexual functioning and were redirected to do so. 34. Identify and Process a Pattern of Impulsive Sexual Activity ( 34) A. The client was assisted in identifying his/her history of impulsive sexual acting ou t and how it has affected his/her intimate relationship. B. The client was provided with positive feedback as he/she was realistic and truthful about his/her sexual acting out and the effect it has had on the relationship. C. The client was in denial reg arding his/her pattern of impulsive sexual acting out and was urged to provide a more complete review of this behavior pattern. D. The client's partner was assisted in identifying feelings related to the client's history of infidelity. E. The faithful pa rtner was supported in expressing the hurt, disappointment, and anxiety that has resulted from the unfaithful partner's affairs. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
176 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER F. The client was reinforced for displaying understanding regarding his/her partner's pain related to his/her history of infid elity. G. The client tended to be quite rejecting of the partner's feelings generated by his/her history of infidelity and was redirected in this area. 35. Manage Impulsivity ( 35) A. The client's impulsive behavior was repeatedly reviewed so as to help him/her identify this pattern and the negative consequences that result from it. B. The negative consequences of the client's self-defeating and impulsive behavior was reviewed. C. The client was given specific directives about how to manage his/her mani c or impulsive behaviors. D. The client has difficulty identifying his/her impulsive behaviors and was given additional feedback in this area 36. Develop Boundaries ( 36) A. The client and his/her intimate partner were assisted in developing a clear set of boundaries for sexual, emotional, and social contact with others. B. The client and his/her intimate partner were provided with feedback regarding the boundaries they have established for sexual, emotional, and social contact with others. C. The clien t and his/her intimate partner have not developed a clear set of boundaries for sexual, emotional, and social contact with others and were redirected to do so. 37. Teach Anger Control Techniques ( 37) A. The client was taught some specific anger control t echniques. B. The client and his/her partner were assisted in developing a clear verbal or behavioral signal to be used by either partner to terminate interaction immediately if either of them fears impending abuse. C. Role-playing and modeling were used to teach how the conflict termination signal could be used in future disagreements between the client and his/her partner. D. The client was provided with positive feedback as he/she displayed understanding regarding the anger techniques he/she has been taught. E. The client and his/her partner were provided with positive reinforcement for their use of conflict termination signals. F. The client has not used the anger control techniques and was redirected to do so. 38. Develop a Safety Plan ( 38) A. The client's partner was assisted in developing a safety plan to help manage the client and maintain his/her own safety during periods when the client is emotionally and behaviorally unstable. B. The client's partner was assisted in developing an understand ing of when to contact public safety officials. C. The client was informed about the safety plan to be implemented when he/she is not in control of his/her behavior. D. The safety plan has been used, and its effectiveness was reviewed. E. The safety pla n has not been helpful toward containing the client's anger outbursts, and additional plans were developed in this area. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
INTIMATE RELATIONSHI P CONFLICTS 177 39. Identify Symptom Effects on Children ( 39) A. The client and his/her partner were assisted in identifying how mental illness sympt oms affect the children in the relationship. B. The client and his/her partner identified specific effects of mental illness on the children in the relationship (e. g., confusion, embarrassment, or caretaking), and these were processed with the client. C. The client and his/her partner failed to identify how mental illness symptoms affect the children in the relationship and were provided with general examples in this area. 40. Teach Effective Child Rearing Practices ( 40) A. The client and his/her partne r were taught effective child rearing practices. B. The client and his/her partner were referred to specific resources to learn effective child rearing practices. C. The client was reinforced for a decrease in family problems due to more consistent child rearing practices. D. The client has not used consistent child rearing practices, continues to have problematic family relationships, and was provided with additional encouragement for change. 41. Develop a Parenting Agreement ( 41) A. An agreement was facilitated between the client and his/her partner regarding acceptable parenting practices (e. g., discipline and rewards, or when the partner should become involved). B. The client and his/her partner were reinforced for using the parenting agreement to become more consistent in their parenting choices. C. The client and his/her partner have not adhered to their parenting agreement and were provided with feedback in this area. 42. Assist in Obtaining Income ( 42) A. The client was assisted in obtaining employment. B. The client was assisted in obtaining alternative sources of income (e. g., disability payments). C. The client has obtained regular income and reported that this has helped to decrease some of the relationship conflicts he/she had experienc ed. 43. Refer to Credit Counseling ( 43) A. The client and his/her intimate partner were referred to a credit counseling/budget assistance program. B. The client and his/her partner were reinforced for following through with the use of budgeting assistan ce. C. The client and his/her partner have not used the referral for budgeting counseling and were redirected to do so. 44. Encourage Expressing Emotions about Relationship Loss ( 44) A. The client was encouraged to express his/her feelings regarding the loss of his/her relationship. B. The client was provided with support, feedback, and empathy as he/she expressed his/her emotions regarding the loss of his/her relationship. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
178 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. The client has not expressed his/her emotions regarding the loss of his/her relationship and was provided with additional support and encouragement in this area. D. The client was assigned to read material regarding how to deal with grief that is associated with the loss of a relationship. E. The client was assigned to read How to Survive the Loss of a Love by Colgrove, Bloomfield, and Mc Williams. F. The client has followed through on reading the assigned grief material associated with the breakup of a relationship, and this material was processed. G. The client has not read th e grief material regarding the loss of a relationship and was encouraged to do so. 45. Refer to a Divorce Support Group (4 5) A. The client was referred to a support group for divorced or divorcing people to assist in resolving the loss and adjusting to a new life. B. The client verbalized the feelings associated with grieving the loss of a relationship, and those feelings were processed. C. The client was supported for participating in a divorce group where he/she has clarified and expressed his/her fee lings associated with the loss of the relationship. D. The client has not followed through on attending a support group for divorced people and was encouraged to do so. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
179 LEGAL CONCERNS CLIENT PRESENTATION 1. Illegal Behavior (1) * A. The client has a long history of illegal behavior, including theft, assault, disorderly conduct, or threats to others. B. The client described a pattern of engaging in illegal behavior witho ut empathy for the effects of his/her behavior on others. C. The client showed little remorse for his/her illegal activities. D. As treatment has progressed, the client has decreased his/her pattern of illegal behavior. 2. Criminal Justice Involvement ( 2) A. The client described a history of multiple arrests due to his/her illegal behavior. B. The client has had numerous convictions for his/her illegal activity. C. The client has spent extensive time incarcerated in jail or prison due to his/her illeg al behaviors. D. The client has recently been released from incarceration. 3. Current Legal Involvement (3) A. The client has been arrested and has legal charges pending. B. The client's legal charges have been processed, and a sentence has been handed down. C. The client is currently incarcerated. D. The client is currently receiving oversight through a probation/parole program. E. The client has completed all legal involvement, and is not under jurisdiction of any court program. 4. Poor Functionin g in the Corrections Setting (4) A. The client displayed a pattern of poor adjustment to the corrections setting due to his/her persistent paranoia, mania, or other severe mental illness symptoms. B. The client reports numerous problems with corrections staff and other inmates due to his/her severe mental illness symptoms. C. As the client has stabilized, his/her ability to function within the corrections setting has increased. 5. Vulnerable While Incarcerated (5) A. Due to his/her mental illness, the client has been vulnerable to attack or manipulation by others while incarcerated. B. The client described a variety of specific situations in which he/she has been attacked or manipulated by others while incarcerated. * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
180 THE SEVERE AND PERSI STENT MENTAL ILLNESS PROGRESS NOTES PLAN NER C. Advocacy with the corrections st aff and stabilization in mental illness symptoms has decreased the client's pattern of vulnerability while incarcerated. 6. Addiction Problems (6) A. The client has engaged in illegal behaviors related to substance use or abuse (e. g., drunk driving, drug possession). B. The client engages in illegal behaviors to support his/her addiction problems. C. As treatment has progressed, the client's addiction problems have decreased with a commensurate decrease in his/her illegal behaviors. 7. Guardianship (7) A. The client is being evaluated for having a guardian placed over him/her. B. The client has had a guardian dictated by the courts. C. As the client has stabilized, he/she is pursuing his/her own guardianship. D. The client has become his/her own gua rdian. 8. Others Pursuing Guardianship (8) A. Significant others involved in the client's life have petitioned the court to name a legal guardian over him/her. B. A temporary guardian has been named over the client. C. Legal proceedings to name a perma nent guardian over the client have been initiated. D. A permanent guardian has been approved by the court. E. Although others have sought guardianship over the client, he/she has proved himself/herself capable of being his/her own guardian within the cou rt setting. 9. Court-Ordered Hospitalization (9) A. As the client was an imminent threat to harm himself/herself or others due to his/her mental illness symptoms, an involuntary hospitalization was ordered by the court. B. The client has been maintained in a psychiatric hospital on an involuntary basis due to a court order. C. The client has been released from the court mandate for hospitalization. 10. Legal Representation Needs (10) A. The client has a need for legal representation due to arrests. B. The client has a need for legal representation due to guardianship procedures. C. The client has a need for legal representation due to involuntary hospitalization. D. The client has been appointed an attorney through the court system to represent him/ her. 11. Loss of Personal Rights (11) A. The client has experienced the loss of basic personal rights due to a lack of advocacy. B. The client has been limited or restricted due to poor understanding of his/her mental illness symptoms. C. Advocacy has helped to restore the client's basic personal rights. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |
LEGAL CONCERNS 181 INTERVENTIONS IMPLEM ENTED 1. Identify Legal Concerns (1) * A. The client was requested to identify his/her history of illegal behaviors. B. The client was requested to identify the legal system respon se to his/her illegal behaviors. C. The client was provided with positive feedback as he/she gave a complete description of his/her pattern of illegal behaviors. D. The client appeared to minimize or deny his/her pattern of illegal behaviors, and this te ndency was pointed out to him/her. 2. Review Guardianship ( 2) A. A copy of the client's guardianship stipulations was reviewed with him/her. B. As guardianship stipulations were discussed, specific reasons for the stipulations were identified. C. The c lient was provided with positive feedback as he/she displayed a good understanding of his/her guardianship and the reasons for the guardianship. 3. Obtain and Compare Criminal History ( 3) A. Specific information regarding the client's current legal charg es was obtained, including police reports, court documents, or attorney reports. B. The client's official criminal history was compared with his/her disclosed history. C. Inconsistencies between the client's disclosed criminal history and his/her officia l list of arrests and convictions were identified and questioned. D. More specific information regarding the client's current legal charges has helped to more clearly define his/her current concerns. E. The client's description of his/her past criminal h istory and his/her official list of arrests and convictions were quite similar, and the client was praised for his/her honesty. F. Specific information was provided to the client regarding his/her current legal charges that has helped him/her gain a more complete understanding of his/her situation. G. Little specific information regarding the client's legal charges was available, despite efforts to get more complete information. 4. Assess for Antisocial Behavior (4) A. The client's pattern of behavior w as assessed for any antisocial traits. B. The client's antisocial behavior pattern was interpreted as being linked to past emotional conflicts and abusive experiences. C. The client has accepted the interpretation of his/her antisocial behavior and is be ginning to disclose feelings related to past abuse. D. The client's behavior did not display any pattern of antisocial trends, and this was reflected to him/her. E. The client rejected any interpretation of his/her behavior as antisocial and was encourag ed to reconsider this assessment. * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Severe and Persistent Mental Illness Treatment Planner, 2nd ed. (Berghuis and Jongsma) by John Wiley & Sons, 2008. | Arthur E. Jr. Jongsma David J. Berghuis - The Severe and Persistent Mental Illness Progress Notes Planner Practice Planners 2008.pdf |