have persisted, in spite of attempts to get them to be more realistic.The client's sense of self-esteem and beliefs in their capabilities have become more reality based.The client has presented no recent evidence of inflated self-esteem or exaggerated, euphoric beliefs.4 Increased, Pressured Speech (4)The client gave evidence of increased, excessive, and pressured speech within the session.The client reported that their speech rate increases as they feel stressed.The client's pressured speech has shown evidence of a decrease in intensity.The client showed no evidence of pressured speech in today's session.
5 Racing Thoughts (5)The client demonstrated a pattern of racing thoughts, moving from one subject to another without maintaining focus.The client reported experiencing racing thoughts, including difficulty concentrating on one thought because other thoughts interfere.The client reported that at times of quiet reflection, they are disturbed by thoughts racing through their mind.The client's thoughts are not racing as they had been, and the client is able to stay focused.
6 Poor Attention Span/Distraction (6)The client gave evidence of a short attention span and a high level of distractibility.The client reported being unable to focus thoughts on one topic.The client's attention shifted from one stimulus to the next.The client has shown increased ability to focus attention and has reduced distractibility.
7 Increased Energy (7)The client displays an increased level of energy.The client's behavior appears to be rigidly goal directed but not efficient.As the client has stabilized their mood disorder, their energy level appears to be more appropriate.
8 Potentially Self-Damaging Activities (8)The client reported a behavior pattern that reflected a lack of normal inhibition and an increase in potentially self-damaging activities (e.g., buying sprees, sexual acting out, foolish business investments).The client's impulsivity has been reflected in sexual acting out, poor financial decisions, and social offenses.The client has gained more control over impulses and has returned to a normal level of inhibition and social propriety.
9 Increased Addictive Behavior (9)The client described an increase in impulsively engaging in addictive behaviors without regard for the consequences.The client reported attempting to decrease impulsive, addictive behaviors, with little success.The client has gained more control over addictive behavior and is more focused on the consequences of such behavior.
10 Episodes of Depression (10)The client reported having had periods when they felt deeply sad and tearful on an almost daily basis.The client's depressive affect was clearly evident within the session as tears were shed on more than one occasion.The client reports a history of an irritable mood.The client reported beginning to feel less sad and experiencing periods of joy.The client appeared to be happier within the session and there is no evidence of tearfulness.
11 Variable Appetite (11)The client described a pattern of eating far less than normal amounts of food.The client has gone through periods of time when they have had very little to eat for an entire day.The client reported periods of greatly increased appetite and food consumption.As the client's mania has begun to diminish, they have begun to return to a more normal eating pattern.The client is eating at least two meals per day.
12 Lack of Activity Enjoyment (12)The client reported a diminished interest in or enjoyment of activities that were previously found pleasurable.The client has begun to engage in activities that they previously found pleasurable.The client has returned to an active interest in and enjoyment of activities.
13 Psychomotor Abnormalities (13)The client demonstrated psychomotor agitation within the session.The client reported that with the onset of the mood symptoms, they have felt unable to relax or sit quietly.The client demonstrated evidence of psychomotor retardation within the session.The client moved and responded very slowly, showing a lack of energy and motivation.The client reported a significant decrease in psychomotor agitation and the ability to sit more quietly.It was evident within the session that the client has become more relaxed and less agitated.As the depression has lifted, the client has responded more quickly and psychomotor retardation has diminished.
14 Decreased Sleep (14)The client described a pattern of attaining far less sleep than would ordinarily be needed.The client has gone through periods when they did not sleep for 24 consecutive hours or more because their energy level was so high.As the client's mania has begun to diminish, they have begun to return to a more normal sleeping pattern.The client is getting 6 to 8 hours of sleep per night, 5 of 7 nights per week.
15 Lack of Energy (15)The client reported feeling a very low level of energy compared to normal times in their life.It was evident within the session that the client has low levels of energy, as demonstrated by slowness of walking, minimal movement, lack of animation, and slow responses.The client's energy level has increased as the depression has lifted.It was evident within the session that the client is demonstrating normal levels of energy.
16 Lack of Concentration (16)The client reported being unable to maintain concentration and is easily distracted.The client reported being unable to read material with good comprehension because of being easily distracted.The client reported increased ability to concentrate as depression has lifted.
17 Social Withdrawal (17)The client has withdrawn from social relationships that were important to them.As the client's depression has deepened, they have increasingly self-isolated.The client has begun to reach out to social contacts as the depression has begun to lift.The client has resumed normal social interactions.
18 Suicidal Ideation (18)The client expressed experiencing suicidal thoughts but has not taken any action on these thoughts.The client reported suicidal thoughts that have resulted in suicidal gestures.Suicidal urges have been reported as diminished as the depression has lifted.The client denied any suicidal thoughts or gestures and is more hopeful about the future.
19 Feelings of Hopelessness/Worthlessness (19)The client has experienced feelings of hopelessness and worthlessness that began as the depression deepened.The client's feelings of hopelessness and worthlessness have diminished as the depression is beginning to lift.The client expressed feelings of hope for the future and affirmation of self-worth.
20 Inappropriate Guilt (19)The client described feelings of pervasive, irrational guilt.Although the client verbalized an understanding that guilt was irrational, it continues to plague the client.The depth of irrational guilt has lifted as the depression has subsided.The client no longer expresses feelings of irrational guilt.
21 Preoccupation With Death (20)The client reported recurrent thoughts of their own death.The client identified that they wished for their own death to occur.The intensity and frequency of the recurrent thoughts of death have diminished.The client reported no longer having thoughts of their own death.
INTERVENTIONS IMPLEMENTED
1 Build Trust and Establish Rapport (1)*Caring was conveyed to the client through support, warmth, and empathy.The client was provided with nonjudgmental support and a level of trust was developed.The client was urged to feel safe in expressing bipolar symptoms.The client began to express feelings more freely as rapport and trust level have increased.The client has continued to experience difficulty being open and direct about the expression of painful feelings; the client was encouraged to use the safe haven of therapy to express these difficult issues.
2 Focus on Strengthening Therapeutic Relationship (2)The relationship with the client was strengthened using empirically supported factors.The relationship with client was strengthened through the implementation of a collaborative approach, agreement on goals, demonstration of empathy, verbalization of positive regard, and collection of client feedback.The client reacted positively to the relationship-strengthening measures taken.The client verbalized feeling supported and understood
