The Addiction Progress Notes Planner

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.

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 during therapy sessions.Despite attempts to strengthen the therapeutic relationship the client reports feeling distant and misunderstood.The client has indicated that sessions are not helpful and will be terminating therapy.

3 Assess Mood Episodes (3)An assessment was conducted of the client's current and past mood episodes, including the features, frequency, intensity, and duration of the mood episodes.The Young Mania Rating Scale, Montgomery-Asberg Depression Rating Scale, or Inventory to Diagnose Depression was used to assess the client's current and past mood episodes.The results of the mood episode assessment reflected severe mood concerns and this was presented to the client.The results of the mood episode assessment reflected moderate mood concerns and this was presented to the client.The results of the mood episode assessment reflected mild mood concerns and this was presented to the client.

4 Assign Step 1 Exercise for Addiction and Mania/Hypomania (4)A 12-step recovery program's Step 1 was used to help the client see the powerlessness and unmanageability that have resulted from using addictive behavior to cope with the manic/hypomanic symptoms.The client displayed an understanding of the concept presented regarding powerlessness, unmanageability, addiction, and manic/hypomanic symptoms.The client was able to endorse the concept of powerlessness and unmanageability that have resulted from using addiction to deal with manic/hypomanic symptoms; this progress was reinforced.The client rejected the concept of powerlessness and unmanageability over their symptoms; the client was asked to monitor these issues.

5 Teach About the Symptoms of Mania/Hypomania and Addiction (5)The client was taught about the signs and symptoms of mania/hypomania and how these symptoms can foster addictive behavior.The client was assigned “Early Warning Signs of Mania/Hypomania” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).The client was noted to have an increased understanding about symptoms of mania/hypomania.The client was able to connect addictive behavior to their symptoms of mania/hypomania; this insight was highlighted.The client struggled to understand symptoms of mania/hypomania and how they can lead to addictive behaviors; the client was provided with additional feedback.

6 Explore Addiction/Mania/Hypomania Connection (6)The client's addictive behavior history was explored, along with their pattern of manic/hypomanic states.The client was assigned “Mania, Addiction and Recovery” from the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).Active listening was provided as the client identified that they have often engaged in addictive behavior when experiencing manic/hypomanic states.The client denied any pattern of behavior relating to manic/hypomanic states and addictive behaviors; the client was urged to monitor this dynamic.

7 Refer for Physician Assessment Regarding Etiology (7)The client was referred to a physician to rule out nonpsychiatric medical etiologies for bipolar disorder.The client was referred to a physician to rule out substance-induced etiologies for bipolar disorder.The client has complied with the referral to a physician and the results of this evaluation were reviewed.The client has not complied with the referral for a medical evaluation and was redirected to do so.

8 Arrange Substance Abuse Evaluation (8)The client's use of alcohol and other mood-altering substances was assessed.The client was assessed to have a pattern of mild substance use.The client was assessed to have a pattern of moderate substance use.The client was assessed to have a pattern of severe substance use.The client was referred for a substance use treatment.The client was found to not have any substance use concerns.

9 Administer Assessment for Mania/Hypomania Symptoms (9)The client was administered psychological instruments designed to objectively assess the strength of mania/hypomania symptoms.The Beck Depression Inventory-II or the Beck Hopelessness Scale was administered to the client.The Perceived Criticism Scale was administered to the client.The client has completed the assessment of mania/hypomania symptoms, but minimal traits were identified; these results were reported to the client.The client has completed the assessment of mania/hypomania symptoms, and significant traits were identified; these results were reported to the client.The client refused to participate in the psychological assessment of mania/hypomania symptoms, and the focus was turned toward this defensiveness.

10 Assess Level of Insight (10)The client's level of insight toward the presenting problems was assessed.The client was assessed in regard to the syntonic versus dystonic nature of their insight about the presenting problems.The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.The client was noted to be in agreement with others’ concerns and is motivated to work on change.The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.

11 Assess for Correlated Disorders (11)The client was assessed for evidence of research-based correlated disorders.The client was assessed in regard to the level of vulnerability to suicide.The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.The client has been assessed for any correlated disorders, but none were found.

12 Assess for Culturally Based Confounding Issues (12)The client was assessed for age-related issues that could help to better understand their clinical presentation.The client was assessed for gender-related issues that could help to better understand their clinical presentation.The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand their clinical presentation.Alternative factors have been identified as contributing to the client's currently defined “problem behavior” and these were taken into account in regard to treatment.Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.