The Adult Psychotherapy Progress Notes Planner

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Copyright © 2014 by Arthur E. Jongsma, Jr., and David J. Berghuis. All rights reserved.

Published by John Wiley & Sons, Inc., Hoboken, New Jersey.

Published simultaneously in Canada.

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Library of Congress Cataloging-in-Publication Data:

Jongsma, Arthur E., Jr., 1943- author.

The adult psychotherapy progress notes planner / Arthur E. Jongsma, Jr., David J. Berghuis. -- Fifth edition.

1 online resource. -- (Practice planners series)

ISBN 978-1-118-41872-7 (ebk.) -- ISBN 978-1-118-41586-3 (ebk.) -- ISBN 978-1-118-06675-1 (pbk.)

1. Psychotherapy--Handbooks, manuals, etc. 2. Medical records--Handbooks, manuals, etc. 3. Adulthood--Psychological aspects--Handbooks, manuals, etc. 4. Mental illness--Treatment--Handbooks, manuals, etc. I. Berghuis, David J., author. II. Title.

RC480.5

616.89'14--dc23

To my manuscript manager, Sue Rhoda, who has brought to the task wonderful organizational skills and a genuine warmth and pleasantness.

Arthur E. Jongsma, Jr.

To my wife, Barbara, with all my love.

David J. Berghuis

PracticePlanners® Series Preface

Accountability is an important dimension of the practice of psychotherapy. Treatment programs, public agencies, clinics, and practitioners must justify and document their treatment plans to outside review entities in order to be reimbursed for services. The books and software in the PracticePlanners® series are designed to help practitioners fulfill these documentation requirements efficiently and professionally.

The PracticePlanners® series includes a wide array of treatment planning books including not only the original Complete Adult Psychotherapy Treatment Planner, Child Psychotherapy Treatment Planner, and Adolescent Psychotherapy Treatment Planner, all now in their fifth editions, but also Treatment Planners targeted to specialty areas of practice, including:

Addictions

Co-occurring disorders

Behavioral medicine

College students

Couples therapy

Crisis counseling

Early childhood education

Employee assistance

Family therapy

Gays and lesbians

Group therapy

Juvenile justice and residential care

Mental retardation and developmental disability

Neuropsychology

Older adults

Parenting skills

Pastoral counseling

Personality disorders

Probation and parole

Psychopharmacology

Rehabilitation psychology

School counseling and school social work

Severe and persistent mental illness

Sexual abuse victims and offenders

Social work and human services

Special education

Speech-language pathology

Suicide and homicide risk assessment

Veterans and active military duty

Women's issues

In addition, there are three branches of companion books that can be used in conjunction with the Treatment Planners, or on their own:

Progress Notes Planners provide a menu of progress statements that elaborate on the client's symptom presentation and the provider's therapeutic intervention. Each Progress Notes Planner statement is directly integrated with the behavioral definitions and therapeutic interventions from its companion Treatment Planner.

Homework Planners include homework assignments designed around each presenting problem (such as anxiety, depression, chemical dependence, anger management, eating disorders, or panic disorder) that is the focus of a chapter in its corresponding Treatment Planner.

Client Education Handout Planners provide brochures and handouts to help educate and inform clients on presenting problems and mental health issues, as well as life skills techniques. The handouts are included on CD-ROMs for easy printing from your computer and are ideal for use in waiting rooms, at presentations, as newsletters, or as information for clients struggling with mental illness issues. The topics covered by these handouts correspond to the presenting problems in the Treatment Planners.

Adjunctive books, such as The Psychotherapy Documentation Primer and The Clinical Documentation Sourcebook, contain forms and resources to aid the clinician in mental health practice management.

The goal of our series is to provide practitioners with the resources they need in order to provide high quality care in the era of accountability. To put it simply: We seek to help you spend more time on patients, and less time on paperwork.

ARTHUR E. JONGSMA, JR.

Grand Rapids, Michigan

Acknowledgments

Again, I am deeply indebted to David Berghuis, who managed the project of updating this fifth edition of The Adult Psychotherapy Progress Notes Planner. He is responsible for modifying the evidence-based chapters to make them coordinate exactly with the new fifth edition of The Complete Adult Psychotherapy Treatment Planner. Thank you, Dave, for your fine work.

A.E.J.

PROGRESS NOTES INTRODUCTION

ABOUT PRACTICEPLANNERS® PROGRESS NOTES

Progress notes are not only the primary source for documenting the therapeutic process, but also one of the main factors in determining the client's eligibility for reimbursable treatment. The purpose of the Progress Notes Planner series is to assist the practitioner in easily and quickly constructing progress notes that are thoroughly unified with the client's treatment plan.

Each Progress Notes Planner:

Saves you hours of time-consuming paperwork.

Offers the freedom to develop customized progress notes.

Features over 1,000 prewritten progress notes summarizing patient presentation and treatment delivered.

Provides an array of treatment approaches that correspond with the behavioral problems and DSM-IV and DSM-5 diagnostic categories in the corresponding companion Treatment Planner.

Offers sample progress notes that conform to the requirements of most third-party payors and accrediting agencies, including JCAHO, COA, CARF, and NCQA.

HOW TO USE THIS PROGRESS NOTES PLANNER

This Progress Notes Planner provides a menu of sentences that can be selected for constructing progress notes based on the behavioral definitions (or client's symptom presentation) and therapeutic interventions from its companion Treatment Planner. All progress notes must be tied to the patient's treatment plan—session notes should elaborate on the problems, symptoms, and interventions contained in the plan.

Each chapter title is a reflection of the client's potential presenting problem. The first section of the chapter, Client Presentation, provides a detailed menu of statements that may describe how that presenting problem manifested itself in behavioral signs and symptoms. The numbers in parentheses within the Client Presentation section correspond to the numbers of the Behavioral Definitions from the Treatment Planner.

The second section of each chapter, Interventions Implemented, provides a menu of statements related to the action that was taken within the session to assist the client in making progress. The numbering of the items in the Interventions Implemented section follows exactly the numbering of Therapeutic Intervention items in the corresponding Treatment Planner.

All item lists begin with a few keywords. These words are meant to convey the theme or content of the sentences that are contained in that listing. The clinician may peruse the list of keywords to find content that matches the client's presentation and the clinician's intervention.

It is expected that the clinician may modify the prewritten statements contained in this book to fit the exact circumstances of the client's presentation and treatment. To maintain complete client records, in addition to progress note statements that may be selected and individualized from this book, the date, time, and length of a session; those present within the session; the provider; the provider's credentials; and a signature must be entered in the client's record.

A FINAL NOTE ABOUT PROGRESS NOTES AND HIPAA

Federal regulations under the Health Insurance Portability and Accountability Act (HIPAA) govern the privacy of a client's psychotherapy notes, as well as other protected health information (PHI). PHI and psychotherapy notes must be kept secure and the client must sign a specific authorization to release this confidential information to anyone beyond the client's therapist or treatment team. Further, psychotherapy notes receive other special treatment under HIPAA; for example, they may not be altered after they are initially drafted. Instead, the clinician must create and file formal amendments to the notes if he or she wishes to expand, delete, or otherwise change them.

Does the information contained in this book, when entered into a client's record as a progress note, qualify as a psychotherapy note and therefore merit confidential protection under HIPAA regulations? If the progress note that is created by selecting sentences from the database contained in this book is kept in a location separate from the client's PHI data, then the note could qualify as psychotherapy note data that is more protected than general PHI. However, because the sentences contained in this book convey generic information regarding the client's progress, the clinician may decide to keep the notes mixed in with the client's PHI and not consider it psychotherapy note data. In short, how you treat the information (separated from or integrated with PHI) can determine if this progress note planner data is psychotherapy note information. If you modify or edit these generic sentences to reflect more personal information about the client or you add sentences that contain confidential information, the argument for keeping these notes separate from PHI and treating them as psychotherapy notes becomes stronger. For some therapists, our sentences alone reflect enough personal information to qualify as psychotherapy notes and they will keep these notes separate from the client's PHI and require specific authorization from the client to share them with a clearly identified recipient for a clearly identified purpose.

ANGER CONTROL PROBLEMS

CLIENT PRESENTATION

Episodic Excessive Anger (1)*

The client described a history of loss of temper in response to specific situations.

The client described a history of loss of temper that dates back many years, including verbal outbursts and property destruction, typically related to specific emotional themes.

As treatment has progressed, the client has reported increased control of his/her situational episodic excessive anger.

The client has had no recent incidents of episodic excessive anger.

General Excessive Anger (2)

The client shows a pattern of general, excessive anger across many situations.

The client does not appear to be experiencing anger in response to specific issues, but as a general pattern.

As treatment has progressed, the client has verbalized insight into his/her pattern of excessive anger.

The client has made progress in controlling his/her pattern of excessive anger.

Cognitive Biases Toward Anger (3)

The client shows a pattern of cognitive biases commonly associated with anger.

The client makes demanding expectations of others.

The client tends to generalize labeling the targets of his/her anger.

The client tends to have anger in reaction to perceived slights.

As treatment has progressed, the subject displays decreased patterns of cognitive biases associated with anger.

Evidence of Physiological Arousal (4)

The client displayed direct evidence of physiological arousal in relation to his/her feelings of anger.

The client displays indirect evidence of physiological arousal related to his/her feelings of anger.

As treatment has progressed, the subject's level of physiological arousal has decreased as anger has become more managed.

Explosive, Destructive Outbursts (5)

The client described a history of loss of temper in which he/she has destroyed property during fits of rage.

The client described a history of loss of temper that dates back to childhood, involving verbal outbursts as well as property destruction.

As therapy has progressed, the client has reported increased control over his/her temper and a significant reduction in incidents of poor anger management.

The client has had no recent incidents of explosive outbursts that have resulted in destruction of property or intimidating verbal assaults.

Explosive, Assaultive Outbursts (5)

The client described a history of loss of anger control to the point of physical assault on others who were the target of his/her anger.

The client has been arrested for assaultive attacks on others when he/she has lost control of his/her temper.

The client has used assaultive acts as well as threats and intimidation to control others.

The client has made a commitment to control his/her temper and terminate all assaultive behavior.

There have been no recent incidents of assaultive attacks on anyone, in spite of the client having experienced periods of anger.

Overreactive Irritability (6)

The client described a history of reacting too angrily to rather insignificant irritants in his/her daily life.

The client indicated that he/she recognizes that he/she becomes too angry in the face of rather minor frustrations and irritants.

Minor irritants have resulted in explosive, angry outbursts that have led to destruction of property and/or striking out physically at others.

The client has made significant progress at increasing frustration tolerance and reducing explosive overreactivity to minor irritants.

Physical/Emotional Abuse (7)

The client reported physical encounters that have injured others or have threatened serious injury to others.

The client showed little or no remorse for causing pain to others.

The client projected blame for his/her aggressive encounters onto others.

The client has a violent history and continues to interact with others in a very intimidating, aggressive style.

The client has shown progress in controlling his/her aggressive patterns and seems to be trying to interact with more assertiveness rather than aggression.

Harsh Judgment Statements (8)

The client exhibited frequent incidents of being harshly critical of others.

The client's family members reported that he/she reacts very quickly with angry, critical, and demeaning language toward them.

The client reported that he/she has been more successful at controlling critical and intimidating statements made to or about others.

The client reported that there have been no recent incidents of harsh, critical, and intimidating statements made to or about others.

Angry/Tense Body Language (9)

The client presented with verbalizations of anger as well as tense, rigid muscles and glaring facial expressions.

The client expressed his/her anger with bodily signs of muscle tension, clenched fists, and refusal to make eye contact.

The client appeared more relaxed, less angry, and did not exhibit physical signs of aggression.

The client's family reported that he/she has been more relaxed within the home setting and has not shown glaring looks or pounded his/her fist on the table.

Passive-Aggressive Behavior (10)

The client described a history of passive-aggressive behavior in which he/she would not comply with directions, would complain about authority figures behind their backs, and would not meet expected behavioral norms.

The client's family confirmed a pattern of the client's passive-aggressive behavior in which he/she would make promises of doing something, but not follow through.

The client acknowledged that he/she tends to express anger indirectly through social withdrawal or uncooperative behavior, rather than using assertiveness to express feelings directly.

The client has reported an increase in assertively expressing thoughts and feelings and terminating passive-aggressive behavior patterns.

Time Bomb (11)

The client tends to passively withhold feelings, and then explodes in a rage.

The client seems to be adding up slights and irritations, waiting until enough have been banked and then explodes into a rage.

The client appears to have rageful feelings under the surface, but presents in a passive manner.

As treatment has progressed, the client has improved in regard to being able to express his/her feelings appropriately, and has decreased the reactive rage episodes.

Overreaction to Perceived Negative Circumstances (12)

The client seems to overreact to perceived disapproval, rejection, or criticism.

The client can become angry even when no disapproval, rejection, or criticism exists.

The client tends to have a bias toward his/her experience of disapproval, rejection, or criticism.

As treatment has progressed, the client has decreased his/her pattern of overreaction to disapproval, rejection, or criticism.

The client has decreased his/her angry overreaction to perceived disapproval, rejection, or criticism.

Verbal Abuse (13)

The client acknowledged that he/she frequently engages in verbal abuse of others as a means of expressing anger or frustration with them.

Significant others in the client's family have indicated that they have been hurt by his/her frequent verbal abuse toward them.

The client has shown little empathy toward others for the pain that he/she has caused because of his/her verbal abuse of them.

The client has become more aware of his/her pattern of verbal abuse of others and is becoming more sensitive to the negative impact of this behavior on them.

There have been no recent incidents of verbal abuse of others by the client.

Rationalization and Blaming (14)

The client has a history of projecting blame for his/her angry outbursts or aggressive behaviors onto other people or outside circumstances.

The client did not accept responsibility for his/her recent angry outbursts or aggressive behaviors.

The client has begun to accept greater responsibility for his/her anger control problems and blame others less often for his/her angry outbursts or aggressive behaviors.

The client verbalized an acceptance of responsibility for the poor control of his/her anger or aggressive impulses.

The client expressed guilt about his/her anger control problems and apologized to significant others for his/her loss of control of anger.

Aggression to Achieve Power and Control (15)

The client appears to use aggression as a means to achieve power and control over others.

The client uses veiled threats of aggression as a way to intimidate others.

As treatment has progressed, the client has decreased aggression as mean of achieving power and control over others.

INTERVENTIONS IMPLEMENTED

Build Trust (1)*

Consistent eye contact, active listening, unconditional positive regard, and warm acceptance were used to help build trust with the client.

The client was urged to feel safe in expressing his/her anger symptoms.

The client began to express feelings more freely as rapport and trust level have increased.

The client has continued to experience difficulty being open and direct about his/her expression of painful feelings; he/she was encouraged to use the safe haven of therapy to express these difficult issues.

Assess Anger Dynamics (2)

The client was assessed for various stimuli that have triggered his/her anger.

The client was assisted in identifying situations, people, and thoughts that have triggered his/her anger.

The client was assisted in identifying the thoughts, feelings, and actions that have characterized his/her anger responses.

Administer Psychological Testing (3)

The client was administered psychometric instruments designed to objectively assess anger expression.

The client was assessed with the Anger, Irritability, and Assault Questionnaire (AIAQ).

The client was assessed with the Buss-Durkee Hostility Inventory (BDHI).

The client was assessed with the State-Trait Anger Expression Inventory (STAXI).

The client was given feedback about the results of the assessment.

Refer for Physical Examination (4)

The client was referred to a physician for a complete physical examination to rule out organic contributors (e.g., brain damage, tumor, elevated testosterone levels) to his/her anger.

The client has complied with the physical examination and the results were shared with him/her.

The physical examination has identified organic contributors to poor anger control and treatment was suggested.

The physical examiner has not identified any organic contributors to poor anger control and this was reflected to the client.