suicidal behaviors that has dated back several years.The client's self-harm and suicidal behaviors were identified as being associated with feelings of depression, fear, and anger, as well as a lack of self-identity.
19 Assess Suicidal Behavior (19)The client's history and current status regarding suicidal gestures were assessed.The onset, frequency, triggers, seriousness/risks, means, access to means, intent and immediate consequences that may reward or maintain the self-harm behaviors were identified.Alternative responses to these thoughts and actions were proposed.
20 Arrange Hospitalization (20)As the client was judged to be harmful of self, arrangements were made for voluntary psychiatric hospitalization.As the client refused a necessary psychiatric hospitalization, the proper steps to involuntarily hospitalize the client were initiated.The client has been psychiatrically hospitalized.Ongoing contact with the psychiatric hospital has been maintained in order to coordinate the most helpful treatment while in the hospital.
21 Assign Self-Monitoring Forms (21)The client was informed of the usefulness of self-monitoring forms, such as DBT Diary Cards.The client was assigned self-monitoring forms to assess self-harm risk.The client completed assigned self-monitoring forms and these were reviewed at the start of each session.The client did not complete assigned self-monitoring forms and was redirected to do so.
22 Refer to Emergency Helpline (22)The client was provided with an emergency helpline telephone number that is available 24 hours a day.Positive feedback was provided as the client promised to use the emergency helpline telephone number rather than engaging in any self-harm behaviors.The client has not used the emergency helpline telephone system in place of engaging in self-harm behaviors and was reminded about this useful resource.
23 Provide Therapist Contact Information (23)The client was provided with the therapist's telephone number for phone coaching of skills learned in therapy.The client was provided with clear instructions for proper use of phone contact, including establishing limits.The client used the provided telephone number and was appropriate in its use.The client used the provided telephone number but was inappropriate in its use and was redirected in this area.The client has not used the provided telephone number and was reminded of its usefulness.
24 Elicit Contact Contract (24)An agreement was elicited from the client that they will initiate contact with the therapist or an emergency helpline if the suicidal urge becomes strong and before any self-injurious behavior is enacted.The client completed “No Self-Harm Contract” in the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was reinforced in promising to terminate self-mutilation behavior and to contact emergency personnel if urges for such behavior arise.The client has followed through on the non-self-harm contract by contacting emergency service personnel rather than enacting any suicidal gestures or self-mutilating behavior; the client was reinforced for this healthy use of support.The client's potential for suicide was consistently assessed despite the suicide prevention contract.
25 Teach Distress Tolerance Skills (25)The client was taught about how to apply DBT distress tolerance skills and chain analysis.The client was reinforced for using distress tolerance skills and chain analysis to identify and intervene to reduce self-harm and suicidal behaviors.The client struggled to understand distress tolerance skills and chain analysis and was provided with remedial information.
26 Assign Self-Monitoring Homework (26)The client was assigned self-monitoring homework (e.g., DBT Diary Card) to help guide in-session chain analysis and problem-solving.The client completed self-monitoring homework, and this was reviewed.The client did not complete self-monitoring homework and was redirected to do so.
27 Resolve Therapy-Interfering Behaviors (27)The client's pattern of therapy-interfering behavior (e.g., missing appointments, noncompliance, abruptly leaving therapy) was consistently monitored.The client was confronted for therapy-interfering behaviors.The clinician took appropriate responsibility for the clinician's own therapy-interfering behaviors.Therapy-interfering behaviors were resolved.
28 Use Strategies to Manage Maladaptive Behaviors, Thoughts, and Feelings (28)Validation, dialectical strategies, and cognitive-behavioral strategies were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.Therapeutic techniques as described in Dialectical Behavior Therapy in Clinical Practice (Dimeff & Koerner) were used to help the client manage symptoms.The client was assigned “Plan Before Acting” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).Validation was consistently used to help the client manage, reduce, and stabilize maladaptive behaviors, thoughts, and feelings.Dialectical strategies, such as metaphor or devil's advocacy, were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.Cognitive-behavioral strategies, such as cost-benefit analysis, chain analysis, and problem-solving were used to help the client manage, reduce, or stabilize maladaptive behaviors, thoughts, and feelings.It was noted that the client has decreased maladaptive behaviors, thought patterns, and feelings.
29 Conduct Skills Training (29)Group skills training was used to teach responses to identified problem behaviors.Individual skills training was used to teach the client responses to personal vulnerabilities and skill deficits.The client was taught to analyze own behavior, mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance skills.The client has participated in skills training for specific behavioral problems, and the benefit of this treatment was reviewed.The client has not participated in group skills training and was redirected to do so.
30 Teach Skills for Regular Use (30)Behavioral strategies were taught to the client via instruction, modeling, and advising.Role-playing and exposure exercises were used to strengthen the client's use of behavioral strategies.The client was provided with regular homework assignments to help incorporate the behavioral strategies into everyday life.The client was reinforced for regular use and understanding of behavioral strategies.The client has struggled to understand the behavioral strategies and was provided with remedial information in this area.
31 Conduct Trauma Work (31)As the client's adaptive behavior patterns have been evident, work on posttraumatic sequelae was initiated.The client was assisted in using new adaptive behavior patterns and emotional regulation skills to reduce denial and increase insight into the effects of previous trauma.The client was helped to reduce maladaptive emotional and/or behavioral responses to trauma-related stimuli through the regular use of adaptive behavioral patterns and emotional skills.The client was assisted in reducing self-blame and increasing acceptance and tolerance.The client has been noted to be successful in using adaptive behavioral patterns and emotional regulation skills in managing the effects of previous trauma.The client has become more emotionally dysregulated because of the trauma work and was redirected to use behavioral and emotional regulation skills.
32 Explore Schema and Self-Talk (32)The client was assisted in exploring how their schema, underlying assumptions, and self-talk mediate trauma-related and other fears.The client's distorted schema, assumptions, and self-talk were reviewed.The client was reinforced for insight into self-talk, assumptions, and schema that support trauma-related and other fears.The client struggled to develop insight into self-talk, assumptions, and schema and was provided with tentative examples of these concepts.
33 Assign Exercises on Self-Talk (33)The client was assigned homework exercises in which they identify fearful self-talk and create reality-based alternatives.The client was assigned the homework exercise “Journal and Replace Self-Defeating Thoughts” from the Adult Psychotherapy Homework Planner (Jongsma & Bruce).The client was directed to complete the “Daily Record of Dysfunctional Thoughts” from Cognitive Therapy of Depression (Beck, Rush, Shaw, & Emery).The client's replacement of fearful self-talk with reality-based alternatives was critiqued.The client was reinforced for successes at replacing fearful self-talk with reality-based alternatives.The client has not completed assignments for identifying and replacing dysfunctional self-talk and was redirected to do so.
34 Reinforce Positive Self-Talk (34)The client was reinforced for implementing positive, realistic self-talk that enhances self-confidence and increases adaptive action.The client noted several instances from daily life that reflected the implementation of positive self-talk, and these successful experiences were reinforced.
35 Develop Hierarchy of Triggers (35)The client was directed to develop a hierarchy of feared