The Family Therapy Progress Notes Planner

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PracticePlanners Arthur E. Jongsma, Jr., Series EditorThe Family TherapyProgress Notes PlannerDavid J. BerghuisArthur E. Jongsma, Jr.John Wiley & Sons, Inc.

The Family TherapyProgress Notes Planner

PRACTICEPLANNERS SERIESTreatment PlannersThe Complete Adult Psychotherapy Treatment Planner, Third EditionThe Child Psychotherapy Treatment Planner, Third EditionThe Adolescent Psychotherapy Treatment Planner, Third EditionThe Addiction Treatment Planner, Second EditionThe Continuum of Care Treatment PlannerThe Couples Psychotherapy Treatment PlannerThe Employee Assistance Treatment PlannerThe Pastoral Counseling Treatment PlannerThe Older Adult Psychotherapy Treatment PlannerThe Behavioral Medicine Treatment PlannerThe Group Therapy Treatment PlannerThe Gay and Lesbian Psychotherapy Treatment PlannerThe Family Therapy Treatment PlannerThe Severe and Persistent Mental Illness Treatment PlannerThe Mental Retardation and Developmental Disability Treatment PlannerThe Social Work and Human Services Treatment PlannerThe Crisis Counseling and Traumatic Events Treatment PlannerThe Personality Disorders Treatment PlannerThe Rehabilitation Psychology Treatment PlannerThe Special Education Treatment PlannerThe Juvenile Justice and Residential Care Treatment PlannerThe School Counseling and School Social Work Treatment PlannerThe Sexual Abuse Victim and Sexual Offender Treatment PlannerThe Probation and Parole Treatment PlannerThe Psychopharmacology Treatment PlannerThe Speech and Language Pathology Treatment PlannerThe Suicide and Homicide Risk Assessment & Prevention Treatment PlannerThe College Student Counseling Treatment PlannerProgress Note PlannersTheTheTheTheTheTheTheChild Psychotherapy Progress Notes Planner, Second EditionAdolescent Psychotherapy progress Notes Planner, Second EditionAdult Psychotherapy Progress Notes Planner, Second EditionAddiction Progress Notes PlannerSevere and Persistent Mental Illness Progress Notes PlannerCouples Psychotherapy Progress Notes PlannerFamily Therapy Progress Notes PlannerHomework PlannersBrief Therapy Homework PlannerBrief Couples Therapy Homework PlannerBrief Adolescent Therapy Homework PlannerBrief Child Therapy Homework PlannerBrief Employee Assistance Homework PlannerBrief Family Therapy Homework PlannerGrief Counseling Homework PlannerGroup Therapy Homework PlannerDivorce Counseling Homework PlannerSchool Counseling and School Social Work Homework PlannerChild Therapy Activity and Homework PlannerAddiction Treatment Homework Planner, Second EditionAdolescent Psychotherapy Homework Planner IIAdult Psychotherapy Homework PlannerClient Education Handout PlannersAdult Client Education Handout PlannerChild and Adolescent Client Education Handout PlannerCouples and Family Client Education Handout PlannerDocumentation SourcebooksTheTheTheTheTheTheTheClinical Documentation Sourcebook, Second EditionForensic Documentation SourcebookPsychotherapy Documentation PrimerChemical Dependence Treatment Documentation SourcebookClinical Child Documentation SourcebookCouple and Family Clinical Documentation SourcebookContinuum of Care Clinical Documentation SourcebookComplete PlannersThe Complete Depression Treatment and Homework PlannerThe Complete Anxiety Treatment and Homework Planner

PracticePlanners Arthur E. Jongsma, Jr., Series EditorThe Family TherapyProgress Notes PlannerDavid J. BerghuisArthur E. Jongsma, Jr.John Wiley & Sons, Inc.

This book is printed on acid-free paper.Copyright 2004 by David J. Berghuis and Arthur E. Jongsma, Jr. All rights reserved.Published by John Wiley & Sons, Inc., Hoboken, New Jersey.Published simultaneously in Canada.No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means,electronic, mechanical, photocopying, recording, scanning, or otherwise, except as permitted under Section 107 or 108 of the1976 United States Copyright Act, without either the prior written permission of the Publisher, or authorization through paymentof the appropriate per-copy fee to the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, (978) 7508400, fax (978) 646-8600, or on the web at Requests to the Publisher for permission should be addressed tothe Permissions Department, John Wiley & Sons, Inc., 111 River Street, Hoboken, NJ 07030, (201) 748-6011, fax (201) 7486008.Limit of Liability/Disclaimer of Warranty: While the publisher and author have used their best efforts in preparing this book, theymake no representations or warranties with respect to the accuracy or completeness of the contents of this book and specificallydisclaim any implied warranties of merchantability or fitness for a particular purpose. No warranty may be created or extended bysales representatives or written sales materials. The advice and strategies contained herein may not be suitable for your situation.You should consult with a professional where appropriate. Neither the publisher nor author shall be liable for any loss of profit orany other commercial damages, including but not limited to special, incidental, consequential, or other damages.This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is soldwith the understanding that the publisher is not engaged in rendering professional services. If legal, accounting, medical,psychological or any other expert assistance is required, the services of a competent professional person should be sought.Designations used by companies to distinguish their products are often claimed as trademarks. In all instances where John Wiley& Sons, Inc. is aware of a claim, the product names appear in initial capital or all capital letters. Readers, however, should contactthe appropriate companies for more complete information regarding trademarks and registration.All references to diagnostic codes are reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders,Fourth Edition, Text Revision. Copyright 2000. American Psychiatric Association.For general information on our other products and services please contact our Customer Care Department within the UnitedStates at (800) 762-2974, outside the United States at (317) 572-3993 or fax (317) 572-4002.Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available inelectronic books. For more information about Wiley products, visit our web site at of Congress Cataloging-in-Publication Data:Berghuis, David J.The family therapy progress notes planner / David J. Berghuis, Arthur E.Jongsma, Jr.p. cm.Includes bibliographical references and index.ISBN 0-471-48443-11. Family psychotherapy—Handbooks, manuals, etc. 2. Familypsychotherapy—Planning—Handbooks, manuals, etc. I. Jongsma, Arthur E.,1943– II. Title.RC488.5.B47832004616.89' 156—dc222004000226Printed in the United States of America.10987654321

To Lucy Berghuis and Tom Ranney, who have helped to complete our family.—David J. BerghuisTo Justin, Carter, Tyler, and Kaleigh—grandchildren who enrich our family circle with theirenergy and love.—Arthur E. Jongsma, Jr

CONTENTSPracticePlanners Series Family ImbalanceAdolescent/Parent ConflictsAdoption IssuesAlcohol AbuseAnger ManagementAnxietyBlameBlended Family ProblemsChild/Parent ConflictsCommunicationCompulsive BehaviorsDeath of a ChildDeath of a ParentDependency IssuesDepression in Family MembersDisengagement/Loss of Family CohesionEating DisorderExtrafamilial Sexual AbuseFamily Activity DisputesFamily Business ConflictsFamily Member SeparationFamily-of-Origin InterferenceFinancial ChangesGeographic RelocationIncest SurvivorInfidelityInheritance Disputes between SiblingsInterracial Family tyLife-Threatening/Chronic 174181187194200206213224228234240250260xi

xiiCONTENTSMultiple Birth DilemmasPhysical/Verbal/Psychological AbuseReligious/Spiritual ConflictsSeparation/DivorceSexual Orientation ConflictsTraumatic Life EventsUnwanted/Unplanned Pregnancy269274287294308319328

PRACTICEPLANNERS SERIES PREFACEThe Family Therapy Progress Notes Planner is the next step in the evolution of thePracticePlanners series from John Wiley & Sons. This book is written as a companion to TheFamily Therapy Treatment Planner as it provides a menu of sentences that can be selected forconstructing a progress note based on the Behavioral Definitions and Therapeutic Interventionsfrom the Treatment Planner. The content in this book is available in electronic form that can beimported into the treatment planning and record keeping software, TheraScribe 4.0. Using thesimple point-and-click action, progress notes statements can be selected from the database to fityour client’s session description.This progress note format has evolved through several stages before it arrived at its finalform for publication. Our hope and desire is that both students and seasoned clinicians will findthis resource helpful in writing progress notes that are thoroughly unified with the client’streatment plan. We have tried to provide a range of content covered by the progress notesentences that can document how a client presented and what interventions were used in thesession.The PracticePlanners series has continued to expand, especially in the area of TreatmentPlanners. There are now 28 Treatment Planners published with several others in the developmentstage. The original flagship books of this series, The Complete Psychotherapy TreatmentPlanner, The Child and Adolescent Psychotherapy Treatment Planner, and The ChemicalDependence Treatment Planner have all been completely revised into new edition books entitledThe Complete Adult Psychotherapy Treatment Planner, 3rd Edition, The AdolescentPsychotherapy Treatment Planner, 3rd Edition, The Child Psychotherapy Treatment Planner, 3rdEdition, and The Addiction Treatment Planner, 2nd Edition. Books for specialized clientpopulations continue to evolve such as The Probation and Parole Treatment Planner and TheSexual Abuse Victim and Sexual Offender Treatment Planner. All of these Treatment Planners areavailable in an optional electronic version that can be easily imported into the software,TheraScribe 4.0: The Treatment Planning and Clinical Record Management System for MentalHealth Professionals. The PracticePlanners series also includes several psychotherapyHomework Planners that are coordinated with the treatment planners or can be usedindependently. Several Documentation Sourcebooks containing useful examples of clinicalrecord-keeping forms, lecture outlines and handouts round out the PracticePlanners series.ARTHUR E. JONGSMA, JR.Grand Rapids, Michiganxiii

ACKNOWLEDGMENTSWe want to thank many people who helped make this book a reality. The professionalcommunity who found these books to be so helpful made it necessary for the series to beexpanded. This is the latest installment in making the PracticePlanners a complete treatmentpackage. We thank the clinicians who find our books helpful. This book is a companion book toThe Family Therapy Treatment Planner by Frank Dattilio and Arthur E. Jongsma, Jr.; we thankthem for their work. A special nod goes to the colleagues we have served with over several yearsof practice. We are also indebted to the clients who have taught us so much about how to workwith a family’s problems, and we thank them as well.As with each of the books in this series, the final product is a collaborative effort. BarbBerghuis did a great deal to complete the manuscript. She worked tirelessly to transcribe theclinical content of the book, suggested revisions, and provided emotional support. Jen Byrnehelped to compile hundreds of pages of text into an actual manuscript that could be submitted forpublication. David Bernstein and Cris Wojdylo of John Wiley & Sons have coached us throughthe publishing process as well. As always, Judy Jongsma understood how to grease the wheelwhen the process became tedious.D.J.B.A.E.J.xv

INTRODUCTIONINTENT AND FOCUSThe Family Therapy Progress Notes Planner is another step in the evolution of the PracticePlanner series. This book is written as a close companion to The Family Therapy TreatmentPlanner (Dattilio and Jongsma, John Wiley & Sons, 2000) providing a menu of sentences thatcan be selected for constructing a progress note based on the Behavioral Definitions and Therapeutic Interventions from The Family Therapy Treatment Planner.Our hope and desire is that both students and seasoned clinicians find this resource helpful inwriting progress notes that are thoroughly unified with the family treatment plan. In our progressnote sentences, we have tried to provide a range of content that can document how a familypresented and what interventions were used in the session.INTERFACE WITH TREATMENT PLANNERProgress notes are the primary source for documenting the therapeutic process. In addition, theyare one of the main factors in determining the client’s eligibility for reimbursable treatment.Although the books can be used independently, The Family Therapy Progress Notes Plannerprovides prewritten sentences that are directly coordinated with the symptom descriptions in theBehavioral Definitions section and with the clinical activity description in the Therapeutic Interventions section of The Family Therapy Treatment Planner. Used together, you’ll find thesebooks both a time saver, and a guidepost to complete, integrated clinical record keeping.Organization of Progress Notes PlannerEach chapter title is a reflection of the family’s potential presenting problem and reflects exactlythe chapter titles from The Family Therapy Treatment Planner. The first section of the chapter,Client Presentation, provides a detailed menu of statements that may describe how

The Behavioral Medicine Treatment Planner The Group Therapy Treatment Planner The Gay and Lesbian Psychotherapy Treatment Planner . Psychotherapy Treatment Planner, 3rd Edition, The Child Psychotherapy Treatment Planner, 3rd Edition, and. The Addiction Treatment Planner, 2nd Edition.

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