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The Addiction Progress Notes Planner. Группа авторов
Читать онлайн.Название The Addiction Progress Notes Planner
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isbn 9781119793076
Автор произведения Группа авторов
Жанр Медицина
Издательство John Wiley & Sons Limited
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 biases commonly associated with anger.The client makes demanding expectations of others.The client tends to generalize labeling the targets of their anger.The client tends to have anger in reaction to perceived slights.As treatment has progressed, the client displays decreased patterns of cognitive biases associated with anger.
4 Evidence of Physiological Arousal (4)The client displayed direct evidence of physiological arousal in relation to feelings of anger.The client displays indirect evidence of physiological arousal related to feelings of anger.As treatment has progressed, the client's level of physiological arousal has decreased as anger has become more managed.
5 Explosive, Destructive Outbursts (5)The client described a history of loss of temper in which they have 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 their 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.
6 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 their anger.The client has been arrested for assaultive attacks on others when they have lost control of their temper.The client has used assaultive acts as well as threats and intimidation to control others.The client has made a commitment to control their 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.
7 Overreactive Irritability (6)The client described a history of reacting too angrily to rather insignificant irritants in daily life.The client indicated that they recognize that they become 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 over-reactivity to minor irritants.
8 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 onto others for aggressive encounters.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 aggressive patterns and seems to be trying to interact with more assertiveness rather than aggression.
9 Verbal