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 Behaviors, Emotional Dysregulation, and Cognitions (3)The client's experience of distress and disability was assessed to identify targets of therapy.The client's pattern of behaviors (e.g., self-harm, anger outbursts, apparent competence, active passivity) was assessed to help identify targets for therapy.The client's emotional dysregulation, including mood swings, sensitivity, and painful emptiness, was assessed in regard to targets for therapy.The client's cognitions were assessed, including biases such as dichotomous thinking, overgeneralization, and catastrophizing, to assist in identifying targets for therapy.Specific targets for therapy were identified.
4 Explore Childhood Abuse/Abandonment (4)Experiences of childhood physical or emotional abuse, neglect, or abandonment were explored.As the client identified instances of abuse and neglect, the feelings surrounding these experiences were processed.The client's experiences with perceived abandonment were highlighted and related to current fears of this experience occurring in the present.As the client's experience of abuse and abandonment in childhood was processed, the client denied any emotional impact of these experiences.The client denied any experience of abuse and abandonment in childhood and was urged to talk about these types of concerns as they deem it necessary in the future.
5 Assess Substance Use History (5)The client's use of alcohol and other mood-altering substances was assessed.The client's use of alcohol and other mood-altering substances can be treated as a self-harm behavior.The client's use of alcohol and other mood-altering substances can be treated as an impulsive behavior.The client was referred for a more in-depth substance use assessment.
6 Arrange Substance Abuse Evaluation (6)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.
7 Assess Level of Insight (7)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.
8 Assess for Correlated Disorders (8)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.
9 Assess for Culturally Based Confounding Issues (9)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.
10 Assess Severity of Impairment (10)The severity of the client's impairment was assessed to determine the appropriate level of care.The client was assessed in regard to their impairment in social, relational, vocational, and occupational endeavors.It was reflected to the client that their impairment appears to create mild to moderate effects on the client's functioning.It was reflected to the client that their impairment appears to create severe to very severe effects on the client's functioning.The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.
11 Refer for Medication Evaluation (11)The client was assessed in regard to the need for psychotropic medication.The client was referred to a prescribing clinician to be evaluated for psychotropic medications to stabilize mood.The client has cooperated with a referral to a prescribing clinician and has attended the evaluation for psychotropic medications.The client has refused to attend a medication evaluation for psychotropic medications and was redirected to do so.
12 Monitor Medication Adherence (12)The client's adherence with prescribed medications was monitored, and effectiveness of the medication on their level of functioning was noted.The client reported that the medication has been beneficial in stabilizing mood and was encouraged to continue its use.The client reported that the medication has not been beneficial in stabilizing mood; this was reflected to the prescribing clinician.The client reported side effects of the medication that they found intolerable; these side effects were relayed to the prescribing clinician.
13 Monitor Misuse (13)The client was informed of the risks of misusing medications.The client reported appropriate use of medication and was encouraged to continue its use.The client reported misusing medication and was redirected; this was reflected to the prescribing clinician.
14 Orient to Dialectical Behavioral Therapy (DBT) (14)The client was oriented to DBT.The multiple facets of DBT were highlighted, including support, collaboration, mindfulness, distress tolerance, coping, and interpersonal skill building.The use of exchange and negotiation, balancing of the rational and emotional mind, and acceptance and change strategies were emphasized.
15 Teach Biosocial View (15)The biosocial view related to borderline personality disorder was emphasized with the client.Biological and environmental vulnerabilities were explored with the client.
16 Assign Reading on Borderline Personality Disorder (16)The client was asked to read selected materials that reinforce therapeutic interventions.Portions of DBT Skills Training Handouts and Worksheets (Linehan) or The Dialectical Behavioral Therapy Skills Workbook (McKay, Wood, & Brantley) were assigned to the client.The client has read assigned materials and key concepts were reinforced.The client has not read assigned materials that reinforce therapeutic interventions and was redirected to do so.
17 Solicit Agreement for DBT (17)Using commitment strategies and motivational interviewing, an agreement was solicited from the client to work collaboratively within the parameters of the DBT approach.The client was assigned “Addressing Readiness and Motivation” in the Addiction Treatment Homework Planner (Lenz, Finley, & Jongsma).A written agreement was developed with the client to work collaboratively within the parameters of the DBT approach.The client has agreed to work within the DBT approach, including staying in therapy for the specified time period, attending scheduled therapy sessions, reducing self-harm and suicidal behaviors, staying sober, and participating in skills training to address the behavioral, emotional, and cognitive vulnerabilities targeted in treatment.The client was reinforced for commitment to working within the DBT program.The client has not agreed to work within the DBT program and was referred back to “treatment as usual.”
18 Explore Self-Harm Behavior (18)The client's history and nature of self-harm and suicidal behaviors were explored thoroughly.The client