The Addiction Progress Notes Planner. Группа авторов
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39 Read About Spirituality in AA's Big Book (39)The client was assigned to read about spirituality and the role of a higher power in portions of Adult Children of Alcoholics's Red Book and AA's Big Book.The client reported reading Adult Children of Alcoholics's Red Book and AA's Big Book on the topic of spirituality and the role of a higher power, and this topic was discussed.The client was helped to process the material related to spirituality from Adult Children of Alcoholics's Red Book and AA's Big Book and identified ways in which this related to their situation.The client did not read the portions of Adult Children of Alcoholics's Red Book and AA's Big Book on the topic of spirituality, and this was reassigned.
40 Identify Issues for a Higher Power (40)The client was asked to identify circumstances in their life that could benefit from being turned over to a higher power.The client was assigned “Understanding Spirituality” or “Finding a Higher Power That Makes Sense” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was assisted in identifying specific issues that need to be turned over to a higher power.The client was reinforced in identifying specific steps that they are taking to turn specific issues over to a higher power.The client denied any need for turning any issues over to a higher power and was urged to remain open to this concept.
41 Teach Assertiveness Skills (41)The client was taught assertiveness skills through the use of modeling, behavior rehearsal, and role-playing.The client was assigned the “Becoming Assertive” exercise from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client displayed an understanding of assertiveness skills that they have been taught.The client's journal of assertiveness experiences was reviewed.The client listed several different situations in which they have been able to be assertive; this success was celebrated.The client reported finding it very difficult to implement assertiveness skills, and remedial assistance was provided.
42 Teach Assertiveness Formula (42)The client was taught the “I feel … when you…. I would prefer it if…” assertiveness formula.The client and the therapist role-played several applications of the assertiveness formula in the client's life.The client was reinforced while displaying an understanding and mastery of assertiveness techniques.The client was assigned to use the assertiveness formula three times per day.The client struggled to understand the techniques and usefulness of the assertiveness formula and was provided with remedial assistance in this area.
43 Teach the Share Check Method (43)The client was taught the share check method of building trust in relationships.The therapist and client role-played several applications of the share check method in the client's life.The client was noted to have indicated a desire to increase their level of trust in others and has implemented the share check method to do so.The client continues to be distrustful of others and has not implemented the share check method to increase trust in others; the client was redirected to do so.
44 Reinforce Honest Sharing (44)The client was encouraged and reinforced to share honestly and openly with a trusted person.As the client identified situations in which they have shared honestly and openly with a trusted person, strong reinforcement was given.It was reflected that the client continues to struggle with sharing openly and honestly with a trusted person.
45 Refer for Psychopharmacological Intervention (45)A referral to a physician was made to evaluate the client for a prescription for psychotropic medication.The client has followed through on the referral to a physician and has been assessed for a prescription of psychotropic medication, but none were prescribed.The client has been prescribed psychotropic medications.The client has refused a prescription of psychotropic medication provided by the physician.
46 Administer Medications (46)The medical staff administered medications as prescribed.The medical staff assisted the client in administering their own medications.The client refused to accept medication as prescribed.
47 Monitor Medication Effectiveness and Side Effects (47)As the client has taken psychotropic medication prescribed by a physician, the effectiveness and side effects of the medication were monitored.It was noted that the client has reported that the psychotropic medication has been beneficial.The client reported that the psychotropic medication has not been beneficial; this was relayed to the prescribing clinician.The client identified side effects of the medications; this was relayed to the prescribing clinician.The client has not consistently taken the prescribed medication and has been redirected to do so.
48 Develop 5-Year Plan (48)The client was asked to set goals for recovery from ACA traits at 6 months, 12 months, and 5 years.The identification of specific steps toward recovery was emphasized.The client was assigned the “Personal Recovery Plan” exercise in The Alcoholism and Drug Abuse Client Workbook (Perkinson).The client was unable to set goals for recovery, and roadblocks were assessed and managed.
49 Assess Satisfaction (49)A treatment satisfaction survey was administered to the client.The client's survey responses indicated a high level of satisfaction with treatment services; these results were processed.The client's survey responses indicated a medium level of satisfaction with treatment services; these results were processed.The client's survey responses indicated a low level of satisfaction with treatment services; these results were processed.Although the client was encouraged to complete a treatment satisfaction survey, it was refused.
NOTES
1 * The numbers in parentheses correlate to the number of the Behavioral Definition statement in the companion chapter with the same title in The Addiction Treatment Planner, Sixth Edition, by Perkinson, Jongsma, & Bruce (Wiley, 2022).
2 * The numbers in parentheses correlate to the number of the Therapeutic Intervention statement in the companion chapter with the same title in The Addiction Treatment Planner, Sixth Edition, by Perkinson, Jongsma, & Bruce (Wiley, 2022).
ANGER
CLIENT PRESENTATION
1 Explosive, Destructive Outbursts (1)*The client described a history of loss of temper in which they have destroyed property in fits of rage, often when intoxicated.The client described a history of loss of temper involving substance use that dates back to adolescence, including verbal outbursts and property destruction.The client has reported increased control over their temper and a significant reduction in the incidence of poor anger management.The client has reported no recent incidents of explosive outbursts that have resulted in destruction of any property or intimidating verbal assaults.
2 Substance Abuse to Cope With Anger (2)The client acknowledged using substances in an attempt to cope with angry feelings.The client described situations in which they have used substances to cope with angry feelings but had difficulty identifying the relationship between the substance abuse and anger.The client identified that substance abuse had a direct connection to anger problems.The client has maintained total abstinence, which is confirmed by the family.
3 Cognitive Biases Toward Anger (3)The client shows a pattern of cognitive