PracticePlanners : Complete Adult Psychotherapy Treatment Planner (5th Edition)

The Complete Adult

Psychotherapy Treatment

Planner,

Fifth Edition

PracticePlanners

Series

Treatment Planners

The Complete Adult Psychotherapy Treatment Planner, Fifth Edition

The Child Psychotherapy Treatment Planner, Fifth Edition

The Adolescent Psychotherapy Treatment Planner, Fifth Edition

The Addiction Treatment Planner, Fifth Edition

The Continuum of Care Treatment Planner

The Couples Psychotherapy Treatment Planner, Second Edition

The Employee Assistance Treatment Planner

The Pastoral Counseling Treatment Planner

The Older Adult Psychotherapy Treatment Planner, Second Edition

The Behavioral Medicine Treatment Planner

The Group Therapy Treatment Planner

The Gay and Lesbian Psychotherapy Treatment Planner

The Family Therapy Treatment Planner, Second Edition

The Severe and Persistent Mental Illness Treatment Planner, Second Edition

The Mental Retardation and Developmental Disability Treatment Planner

The Social Work and Human Services Treatment Planner

The Crisis Counseling and Traumatic Events Treatment Planner, Second Edition

The Personality Disorders Treatment Planner

The Rehabilitation Psychology Treatment Planner

The Special Education Treatment Planner

The Juvenile Justice and Residential Care Treatment Planner

The School Counseling and School Social Work Treatment Planner, Second Edition

The Sexual Abuse Victim and Sexual Offender Treatment Planner

The Probation and Parole Treatment Planner

The Psychopharmacology Treatment Planner

The Speech-Language Pathology Treatment Planner

The Suicide and Homicide Treatment Planner

The College Student Counseling Treatment Planner

The Parenting Skills Treatment Planner

The Early Childhood Intervention Treatment Planner

The Co-Occurring Disorders Treatment Planner

The Complete Women’s Psychotherapy Treatment Planner

The Veterans and Active Duty Military Psychotherapy Treatment Planner

Progress Notes Planners

The Child Psychotherapy Progress Notes Planner, Fifth Edition

The Adolescent Psychotherapy Progress Notes Planner, Fifth Edition

The Adult Psychotherapy Progress Notes Planner, Fifth Edition

The Addiction Progress Notes Planner, Fifth Edition

The Severe and Persistent Mental Illness Progress Notes Planner, Second Edition

The Couples Psychotherapy Progress Notes Planner, Second Edition

The Family Therapy Progress Notes Planner, Second Edition

The Veterans and Active Duty Military Psychotherapy Progress Notes Planner

Homework Planners

Couples Therapy Homework Planner, Second Edition

Family Therapy Homework Planner, Second Edition

Grief Counseling Homework Planner

Group Therapy Homework Planner

Divorce Counseling Homework Planner

School Counseling and School Social Work Homework Planner, Second Edition

Child Therapy Activity and Homework Planner

Addiction Treatment Homework Planner, Fifth Edition

Adolescent Psychotherapy Homework Planner, Fifth Edition

Adult Psychotherapy Homework Planner, Fifth Edition

Child Psychotherapy Homework Planner, Fifth Edition

Parenting Skills Homework Planner

Veterans and Active Duty Military Psychotherapy Homework Planner

Client Education Handout Planners

Adult Client Education Handout Planner

Child and Adolescent Client Education Handout Planner

Couples and Family Client Education Handout Planner

Complete Planners

The Complete Depression Treatment and Homework Planner

The Complete Anxiety Treatment and Homework Planner

Arthur E. Jongsma, Jr., Series Editor

The Complete Adult

Psychotherapy

Treatment Planner,

Fifth Edition

Arthur E. Jongsma, Jr.

L. Mark Peterson

Timothy J. Bruce

PracticePlanners

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Library of Congress Cataloging-in-Publication Data:

Jongsma, Arthur E., Jr., 1943–

The complete adult psychotherapy treatment planner / Arthur E. Jongsma, Jr., L. Mark Peterson,

Timothy J. Bruce.—Fifth edition.

pages cm.—(PracticePlanners series)

Includes bibliographical references.

ISBN 978-1-118-06786-4 (pbk.)

ISBN 978-1-118-41883-3 (ebk.)

ISBN 978-1-118-41602-0 (ebk.)

1. Psychotherapy—Planning—Handbooks, manuals, etc. 2. Psychiatric records—Handbooks, manuals,

etc. I. Peterson, L. Mark. II. Bruce, Timothy J. III. Title.

RC480.5.J664 2014

616.89'14—dc23 2013030810

Printed in the United States of America

10 9 8 7 6 5 4 3 2 1

We dedicate this book to our most influential teachers and mentors early in

our professional journey:

Dr. Solomon E. Feldman

Dr. Richard A. Westmaas

Dr. Richard Brown

Dr. Jack Carr

Dr. David H. Barlow

Dr. James Mancuso

CONTENTS

PracticePlanners

Series Preface xi

Acknowledgments xiii

Introduction 1

Sample Treatment Plan 10

Anger Control Problems 14

Antisocial Behavior 27

Anxiety 38

Attention Deficit Disorder (ADD)—Adult 50

Bipolar Disorder—Depression 62

Bipolar Disorder—Mania 75

Borderline Personality Disorder 87

Childhood Trauma 97

Chronic Pain 105

Cognitive Deficits 116

Dependency 129

Dissociation 138

Eating Disorders and Obesity 147

Educational Deficits 161

Family Conflict 169

Female Sexual Dysfunction 180

Financial Stress 192

Grief/Loss Unresolved 200

Impulse Control Disorder 209

Intimate Relationship Conflicts 220

Legal Conflicts 231

Low Self-Esteem 238

Male Sexual Dysfunction 246

Medical Issues 257

Obsessive-Compulsive Disorder (OCD) 268

Panic/Agoraphobia 278

Paranoid Ideation 289

Parenting 296

Phase of Life Problems 309

CONTENTS

Phobia 318

Posttraumatic Stress Disorder (PTSD) 328

Psychoticism 342

Sexual Abuse Victim 354

Sexual Identity Confusion 364

Sleep Disturbance 372

Social Anxiety 382

Somatization 393

Spiritual Confusion 406

Substance Use 413

Suicidal Ideation 427

Type A Behavior 437

Unipolar Depression 447

Vocational Stress 460

Appendix A Bibliotherapy Suggestions 472

Appendix B References to Empirical Support and Clinical

Resources for Evidence-Based Chapters 504

Appendix C Recovery Model Objectives and Interventions 570

Appendix D Alphabetical Index of Sources for Assessment

Instruments and Clinical Interview Forms Cited in Interventions 577

PRACTICEPLANNERS

SERIES PREFACE

Accountability is an important dimension of the practice of psychotherapy.

Treatment programs, public agencies, clinics, and practitioners must justify

and document their treatment plans to outside review entities in order to be

reimbursed for services. The books and software in the PracticePlanners

series are designed to help practitioners fulfill these documentation

requirements efficiently and professionally.

The PracticePlanners

series includes a wide array of treatment planning

books including not only the original Complete Adult Psychotherapy

Treatment Planner, Child Psychotherapy Treatment Planner, and Adolescent

Psychotherapy Treatment Planner, all now in their fifth editions, but also

Treatment Planners targeted to specialty areas of practice, including:

• Addictions

• Co-occurring disorders

• Behavioral medicine

• College students

• Couples therapy

• Crisis counseling

• Early childhood education

• Employee assistance

• Family therapy

• Gays and lesbians

• Group therapy

• Juvenile justice and residential care

• Mental retardation and developmental disability

• Neuropsychology

• Older adults

• Parenting skills

• Pastoral counseling

• Personality disorders

• Probation and parole

• Psychopharmacology

• Rehabilitation psychology

• School counseling and school social work

• Severe and persistent mental illness

• Sexual abuse victims and offenders

• Social work and human services

PRACTICEPLANNERS

SERIES PREFACE xii

• Special education

• Speech-Language pathology

• Suicide and homicide risk assessment

• Veterans and active military duty

• Women’s issues

In addition, there are three branches of companion books that can be used in

conjunction with the Treatment Planners, or on their own:

• Progress Notes Planners provide a menu of progress statements that

elaborate on the client’s symptom presentation and the provider’s

therapeutic intervention. Each Progress Notes Planner statement is

directly integrated with the behavioral definitions and therapeutic

interventions from its companion Treatment Planner.

• Homework Planners include homework assignments designed around

each presenting problem (such as anxiety, depression, substance use,

anger control problems, eating disorders, or panic disorder) that is the

focus of a chapter in its corresponding Treatment Planner.

• Client Education Handout Planners provide brochures and handouts to

help educate and inform clients on presenting problems and mental

health issues, as well as life skills techniques. The handouts are included

on CD-ROMs for easy printing from your computer and are ideal for

use in waiting rooms, at presentations, as newsletters, or as information

for clients struggling with mental illness issues. The topics covered by

these handouts correspond to the presenting problems in the Treatment

Planners.

The series also includes adjunctive books, such as The Psychotherapy Docu-

mentation Primer and The Clinical Documentation Sourcebook, contain forms

and resources to aid the clinician in mental health practice management.

The goal of our series is to provide practitioners with the resources they

need in order to provide high-quality care in the era of accountability. To

put it simply: We seek to help you spend more time on patients, and less time

on paperwork.

ARTHUR E. JONGSMA, JR.

Grand Rapids, Michigan

xiii

ACKNOWLEDGMENTS

Since 2005 we have turned to research evidence to inform the treatment

Objectives and Interventions in our latest editions of the Psychotherapy

Treatment Planner books. While much of the content of our Planners was

“best practice” and also from the mainstream of sound psychological

procedure, we have benefited significantly from a thorough review that

looked through the lens of evidence-based practice. The later editions of the

Planners now stand as content not just based on “best practice” but based on

reliable research results. Although several of my coauthors have contributed

to this recertification of our content, Timothy J. Bruce has been the main

guiding force behind this effort. I am very proud of the highly professional

content provided by so many coauthors who are leaders in their respective

subspecialties in the field of psychology such as addiction, family therapy,

couples therapy, personality disorder treatment, group treatment, women’s

issues, military personnel treatment, older adult treatment, and many others.

Added to this expertise over the past 7 years has been the contribution of Dr.

Tim Bruce who has used his depth of knowledge regarding evidence-

supported treatment to shape and inform the content of the last two editions

of Adult, Adolescent, Child, and Addiction Psychotherapy Treatment Planners.

I welcome Tim aboard as an author for these books and consider it an honor

to have him as a friend, colleague, and coauthor.

I must also add my acknowledgment of the supportive professionalism

of the Wiley staff, especially that of my editor, Marquita Flemming. Wiley

has been a trusted partner in this series for almost 20 years now and I am

blessed to be published by such a highly respected company. Thank you to

all my friends at Wiley!

And then there is our manuscript manager, Sue Rhoda, who knows just

what to do to make a document presentable right up to the standards

required by a publisher. Thank you, Sue.

ACKNOWLEDGMENTS

xiv

Finally, I tip my hat to my coauthor, Mark Peterson, who launched this

Adult Psychotherapy Treatment Planner with his original content contributions

many years ago and has supported all the efforts to keep it fresh and evidence-

based.

AEJ

I am fortunate to have been invited some seven years ago by Dr. Art

Jongsma to work with him on his well-known and highly regarded

Psychotherapy Treatment Planner series and now to be welcomed as one of

his coauthors on this Planner along with Mark Peterson. As readers know,

Art’s treatment planners are highly regarded as works of enormous value to

practicing clinicians as well as terrific educational tools for “students” of our

profession. That Art’s brainchild would have this type of value to our field is

no surprise when you work with him. He is the consummate psychologist,

with enormous breadth and depth of experience, a profound intellect, and a

Rogerian capacity for empathy and understanding—all of which he would

modestly deny. When you work with Art you not only get to know him, you

get to know his family, colleagues, and friends. In doing so, you get to know

his values. If you are like me, you have relationships that you prize because

they are with people whom you know to be, simply stated, good. Well, to use

an expression I grew up with, Art is good people. And it is my honor to have

him as a friend, colleague, and coauthor. Thank you, Art!

I also would like thank Marquita Flemming and the staff at Wiley &

Sons for their immeasurable support, guidance, and professionalism. It is

just my opinion, but I think Marquita should publish her own book on

author relations.

I would also like to extend a big thank-you to our manuscript manager,

Sue Rhoda, for her exacting work and (needed) patience. In fact, I am sure

Sue will take it in stride when we ask to do one more edit of this

acknowledgment section after it has been “finalized.”

Lastly, I would like thank my wife, Lori, and our children, Logan and

Madeline, for all they do. They’re good people, too.

TJB

The Complete Adult

Psychotherapy Treatment

Planner,

Fifth Edition

INTRODUCTION

ABOUT PRACTICE PLANNERS

TREATMENT

PLANNERS

Pressure from third-party payors, accrediting agencies, and other outside

parties has increased the need for clinicians to quickly produce effective,

high-quality treatment plans. Treatment Planners provide all the elements

necessary to quickly and easily develop formal treatment plans that satisfy

the needs of most third-party payors and state and federal review agencies.

Each Treatment Planner:

• Saves you hours of time-consuming paperwork.

• Offers the freedom to develop customized treatment plans.

• Includes over 1,000 clear statements describing the behavioral manifes-

tations of each relational problem, and includes long-term goals, short-

term objectives, and clinically tested treatment options.

• Has an easy-to-use reference format that helps locate treatment plan

components by behavioral problem.

As with the rest of the books in the PracticePlanners

series, our aim is

to clarify, simplify, and accelerate the treatment planning process so you

spend less time on paperwork and more time with your clients.

ABOUT THIS FIFTH EDITION COMPLETE ADULT

PSYCHOTHERAPY TREATMENT PLANNER

This fifth edition of the Complete Adult Psychotherapy Treatment Planner

has been improved in many ways:

• Updated with new and revised evidence-based Objectives and

Interventions

• Revised, expanded, and updated Appendix B: Professional References

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

• Many more suggested homework assignments integrated into the

Interventions

• Extensively expanded and updated self-help book list in Appendix A:

Bibliotherapy Suggestions

• Appendix C: New Recovery Model listing Goals, Objectives, and

Interventions allowing the integration of a recovery model orientation

into treatment plans

• Addition of a chapter on Bipolar Disorder—Depression (former chapter

on Depression has been renamed Unipolar Depression and Mania/

Hypomania has been renamed Bipolar Disorder—Mania)

• Complete revision of the Cognitive Deficits chapter

• Integrated DSM-5 diagnostic labels and ICD-10-CM codes into the

Diagnostic Suggestions section of each chapter

• Added Appendix D which provides an alphabetical index of the sources

for assessment instruments and clinical interview forms cited in

interventions

Evidence-based practice (EBP) is steadily becoming the standard of care in

mental healthcare as it has in medical healthcare. Professional organizations

such as the American Psychological Association, National Association of

Social Workers, and the American Psychiatric Association, as well as

consumer organizations such the National Alliance for the Mentally Ill

(NAMI) have endorsed the use of EBP. In some practice settings, EBP is

becoming mandated. It is clear that the call for evidence and accountability

is being increasingly sounded. So, what is EBP and how is its use facilitated

by this Planner?

Borrowing from the Institute of Medicine’s definition (Institute of

Medicine, 2001), the American Psychological Association (APA) has defined

EBP as, “the integration of the best available research with clinical expertise

in the context of patient characteristics, culture, and preferences” (APA

Presidential Task Force on Evidence-Based Practice, 2006). Consistent with

this definition, we have identified those psychological treatments with the

best available supporting evidence, added Objectives and Interventions

consistent with them in the pertinent chapters, and identified these with this

symbol:

. As most practitioners know, research has shown that although

these treatment methods have demonstrated efficacy (e.g., Nathan &

Gorman, 2007), the individual psychologist (e.g., Wampold, 2001), the

treatment relationship (e.g., Norcross, 2002), and the patient (e.g., Bohart &

Tallman, 1999) are also vital contributors to the success of psychotherapy.

As noted by the APA, “Comprehensive evidence-based practice will consider

all of these determinants and their optimal combinations” (APA, 2006,

p. 275). For more information and instruction on constructing evidence-

based psychotherapy treatment plans, see our DVD-based training series

entitled Evidence-based Psychotherapy Treatment Planning (Jongsma &

Bruce, 2010–2012).

INTRODUCTION

The sources listed in Appendix B: Professional References and used to

identify the evidence-based treatments integrated into this Planner are many.

They include supportive studies from the psychotherapy outcome literature,

current expert individual, group, and organizational reviews, as well as

evidence-based practice guideline recommendations. Examples of specific

sources used include the Cochrane Collaboration reviews, the work of the

Society of Clinical Psychology (Division 12 of the American Psychological

Association) identifying research-supported psychological treatments,

evidence-based treatment reviews such as those in Nathan and Gorman’s A

Guide to Treatments That Work and the Substance Abuse and Mental Health

Services Administration’s (SAMHSA) National Registry of Evidence-Based

Programs and Practices [NREPP], as well as evidence-based practice

guidelines from professional organizations such as the American Psychiatric

Association, the National Institute for Health and Clinical Excellence in

Great Britain, the National Institute on Drug Abuse (NIDA), and the

Agency for Healthcare Research and Quality (AHRQ) to name a few.

Although each of these sources uses its own criteria for judging levels of

empirical support for any given treatment, we favored those that use more

rigorous criteria typically requiring demonstration of efficacy through

randomized controlled trials or clinical replication series, good experimental

design, and independent replication. Our approach was to evaluate these

various sources and include those treatments supported by the highest level

of evidence and for which there was consensus in conclusions and

recommendations. For any chapter in which EBP is identified, references to

the sources used are listed in Appendix B: Professional References and can

be consulted by those interested for further information regarding criteria

and conclusions. In addition to these references, this appendix also includes

references to Clinical Resources. Clinical Resources are books, manuals, and

other resources for clinicians that describe the details of the application or

“how to” of the treatment approaches described in a chapter.

There is debate regarding evidence-based practice among mental health

professionals who are not always in agreement regarding the best treatment or

how to weigh the factors that contribute to good outcomes. Some practitioners

are skeptical about changing their practice on the basis of research evidence,

and their reluctance is fueled by the methodological challenges and problems

inherent in psychotherapy research. Our intent in this book is to accommodate

these differences by providing a range of treatment plan options, some

supported by the evidence-based value of “best available research” (APA,

2006), others reflecting common clinical practices of experienced clinicians, and

still others representing emerging approaches so the user can construct what

they believe to be the best plan for their particular client.

Each of the chapters in this edition has also been reviewed with the goal

of integrating homework exercise options into the Interventions. Many

(but not all) of the client homework exercise suggestions were taken from

and can be found in the Adult Psychotherapy Homework Planner (Jongsma,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

2014). You will find many more homework assignments suggested in this

fifth edition of the Complete Adult Psychotherapy Treatment Planner than in

previous editions.

The Bibliotherapy Suggestions Appendix A of this Planner has been

significantly expanded and updated from previous editions. It includes many

recently published offerings as well as more recent editions of books cited in

our earlier editions. All of the self-help books and client workbooks cited in

the chapter Interventions are listed in this appendix. There are also many

additional books listed that are supportive of the treatment approaches

described in the respective chapters. Each chapter has a list of self-help

books consistent with its topic and listed in this appendix.

In its final report entitled Achieving the Promise: Transforming Mental

Health Care in America, The President’s New Freedom Commission on

Mental Health called for recovery to be the “common, recognized outcome of

mental health services” (New Freedom Commission on Mental Health, 2003).

To define recovery, the Substance Abuse and Mental Health Services

Administration (SAMHSA) within the U.S. Department of Health and

Human Services and the Interagency Committee on Disability Research in

partnership with six other Federal agencies convened the National Consensus

Conference on Mental Health Recovery and Mental Health Systems

Transformation (SAMHSA, 2004). Over 110 expert panelists participated

including mental health consumers, family members, providers, advocates,

researchers, academicians, managed care representatives, accreditation bodies,

State and local public officials, and others. From these deliberations, the

following consensus statement was derived:

Mental health recovery is a journey of healing and transformation for a

person with a mental health problem to be able to live a meaningful life in a

community of his or her choice while striving to achieve maximum human

potential. Recovery is a multi-faceted concept based on the following 10

fundamental elements and guiding principles:

• Self-direction

• Individualized and person-centered

• Empowerment

• Holistic

• Nonlinear

• Strengths-based

• Peer support

• Respect

• Responsibility

• Hope

These principles are defined in Appendix C. We have also created a set of

Goal, Objective, and Intervention statements that reflect these 10 principles.

INTRODUCTION

The clinician who desires to insert into the client treatment plan specific

statements reflecting a Recovery Model orientation may choose from this list.

In addition to this list, we believe that many of the Goal, Objective, and

Intervention statements found in the chapters reflect a recovery orientation.

For example, our assessment interventions are meant to identify how the

problem affects this unique client and the strengths that the client brings to

the treatment. Additionally, an intervention statement such as, “Review with

the client the success he/she has had and the sources of love and concern that

exist in his/her life,” from the Suicidal Ideation chapter, is evidence that

recovery model content permeates items listed throughout our chapters.

However, if the clinician desires a more focused set of statements directly

related to each principle guiding the recovery model, they can be found in

Appendix C.

We have done a bit of reorganizing of chapter content for this edition.

We have renamed the Depression chapter as Unipolar Depression. This

makes it distinct from the new chapter written for Bipolar Disorder—

Depression. We also renamed the Mania/Hypomania chapter as Bipolar

Disorder—Mania to be a companion to the Bipolar Disorder—Depression

chapter. You will note that some of the content from the Bipolar Disorder—

Depression chapter is repeated in the Bipolar Disorder—Mania chapter, but

that the EBT symbol may or may not be present for the same content. This is

done to indicate that the particular EBP has support for its efficacy on that

particular chapter’s problem (e.g., symptoms of mania), but not necessarily

on other aspects of the disorder (e.g., symptoms of bipolar depression). If

more information is desired regarding the specific effects of any evidence-

based treatment, one can find them by consulting the references to empirical

support for that chapter in the Professional References Appendix. Finally,

we have deleted the Chemical Dependence—Relapse chapter from this

edition because the relapse issue is now adequately dealt with in the

Substance Use chapter and most of the other components of the Relapse

chapter were redundant with those in the Substance Use chapter.

The Cognitive Deficits chapter was thoroughly revised by an invited

expert in the Rehabilitation Psychology field, Dr. Michele Rusin. Dr. Rusin

has extensive experience in providing treatment for clients who present with

cognitive deficits resulting from brain trauma or medical conditions. She is

the primary author of the Rehabilitation Psychology Treatment Planner, one

of the books in the PracticePlanner series. She has supplied guidance for the

general practitioner in assessing and providing first-level treatment for mild

cognitive deficits. Obviously, if more severe symptoms present themselves

the client must be referred to a psychology and medical specialist for more

in-depth therapy.

With the publication of the DSM-5 (American Psychiatric Association

[APA], 2013), we have updated the Diagnostic Suggestions listed at the end

of each chapter. The DSM-IV-TR (APA, 2000) was used in previous editions

of this Planner. Although many of the diagnostic labels and codes remain the

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

same, several have changed with the publication of the DSM-5 and are

reflected in this Planner.

Some clinicians have asked that the Objective statements in this Planner

be written such that the client’s attainment of the Objective can be measured.

We have written our Objectives in behavioral terms and many are

measurable as written. For example, this Objective from the Anxiety chapter

is one that is measurable as written because it either can be done or it cannot:

“Verbalize an understanding of the role that cognitive biases play in

excessive irrational worry and persistent anxiety symptoms.” But at times the

statements are too broad to be considered measurable. Consider, for

example, this Objective from the Anxiety chapter: “Identify, challenge, and

replace biased, fearful self-talk with positive, realistic, and empowering self-

talk.” To make it quantifiable a clinician might modify it to read, “Give two

examples of identifying, challenging, and replacing biased, fearful self-talk

with positive, realistic, and empowering self-talk.” Clearly, the use of two

examples is arbitrary, but it does allow for a quantifiable measurement of the

attainment of the Objective. Or consider this example from the Anxiety

chapter: “Identify and engage in pleasant activities on a daily basis.” To

make it more measurable the clinician might simply add a desired target

number of pleasant activities, thus: “Identify and report engagement in two

pleasant activities on a daily basis.” The exact target number that the client

is to attain is subjective and should be selected by the individual clinician in

consultation with the client. Once the exact target number is determined,

then our content can be very easily modified to fit the specific treatment

situation. For more information on psychotherapy treatment plan writing,

see Jongsma (2005).

Finally, we have added Appendix D which provides an alphabetical

index of the sources for assessment instruments and clinical interview forms

cited in interventions. We hope that this appendix allows the reader to find

these resources easily if he/she wants to add them to a treatment plan.

We hope you find these improvements to this fifth edition of the Planner

useful to your treatment planning needs.

HOW TO USE THIS TREATMENT PLANNER

Use this Treatment Planner to write treatment plans according to the

following progression of six steps:

1. Problem Selection. Although the client may discuss a variety of issues

during the assessment, the clinician must determine the most significant

problems on which to focus the treatment process. Usually a primary

problem will surface, and secondary problems may also be evident.

Some other problems may have to be set aside as not urgent enough to

require treatment at this time. An effective treatment plan can only deal

INTRODUCTION

with a few selected problems or treatment will lose its direction. Choose

the problem within this Planner that most accurately represents your

client’s presenting issues.

2. Problem Definition. Each client presents with unique nuances as to how

a problem behaviorally reveals itself in his or her life. Therefore, each

problem that is selected for treatment focus requires a specific definition

about how it is evidenced in the particular client. The symptom pattern

should be associated with diagnostic criteria and codes such as those

found in the DSM-5 or the International Classification of Diseases. This

Planner offers such behaviorally specific definition statements to choose

from or to serve as a model for your own personally crafted statements.

3. Goal Development. The next step in developing your treatment plan is to

set broad goals for the resolution of the target problem. These

statements need not be crafted in measurable terms but can be global,

long-term goals that indicate a desired positive outcome to the treatment

procedures. This Planner provides several possible goal statements for

each problem, but one statement is all that is required in a treatment

plan.

4. Objective Construction. In contrast to long-term goals, objectives must

be stated in behaviorally measurable language so that it is clear to review

agencies, health maintenance organizations, and managed care

organizations when the client has achieved the established objectives.

The objectives presented in this Planner are designed to meet this

demand for accountability. Numerous alternatives are presented to

allow construction of a variety of treatment plan possibilities for the

same presenting problem.

5. Intervention Creation. Interventions are the actions of the clinician

designed to help the client complete the objectives. There should be at

least one intervention for every objective. If the client does not

accomplish the objective after the initial intervention, new interventions

should be added to the plan. Interventions should be selected on the

basis of the client’s needs and strengths and the treatment provider’s full

therapeutic repertoire. This Planner contains interventions from a broad

range of therapeutic approaches, and we encourage the provider to write

other interventions reflecting his or her own training and experience.

Some suggested interventions listed in the Planner refer to specific

books that can be assigned to the client for adjunctive bibliotherapy.

Appendix B contains a full bibliographic reference list of these materials,

including these two popular choices: Read Two Books and Let’s Talk Next

Week: Using Bibliotherapy in Clinical Practice by Maidman, Joshua, and

DiMenna and Rent Two Films and Let’s Talk in the Morning: Using

Popular Movies in Psychotherapy, Second Edition by Hesley and Hesley

(both books are published by Wiley). For further information about self-

help books, mental health professionals may wish to consult the

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

Authoritative Guide to Self-Help Resources in Mental Health, Revised

Edition (Norcross et al., 2003).

6. Diagnosis Determination. The determination of an appropriate diagnosis

is based on an evaluation of the client’s complete clinical presentation.

The clinician must compare the behavioral, cognitive, emotional, and

interpersonal symptoms that the client presents with the criteria for

diagnosis of a mental illness condition as described in DSM-5. Despite

arguments against diagnosing clients in this manner, diagnosis is a

reality that exists in the world of mental health care, and it is a necessity

for third-party reimbursement. It is the clinician’s thorough knowledge

of DSM-5 criteria and a complete understanding of the client assessment

data that contribute to the most reliable, valid diagnosis.

Congratulations! After completing these six steps, you should have a

comprehensive and individualized treatment plan ready for immediate

implementation and presentation to the client. A sample treatment plan for

Anxiety is provided at the end of this introduction.

A FINAL NOTE ON TAILORING THE TREATMENT PLAN

TO THE CLIENT

One important aspect of effective treatment planning is that each plan should

be tailored to the individual client’s problems and needs. Treatment plans

should not be mass-produced, even if clients have similar problems. The

individual’s strengths and weaknesses, unique stressors, social network, family

circumstances, and symptom patterns must be considered in developing a

treatment strategy. Drawing upon our own years of clinical experience and the

best available research, we have put together a variety of treatment choices.

These statements can be combined in thousands of permutations to develop

detailed treatment plans. Relying on their own good judgment, clinicians can

easily select the statements that are appropriate for the individuals whom they

are treating. In addition, we encourage readers to add their own definitions,

goals, objectives, and interventions to the existing samples. As with all of the

books in the Treatment Planner series, it is our hope that this book will help

promote effective, creative treatment planning—a process that will ultimately

benefit the client, clinician, and mental health community.

REFERENCES

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental

disorders (4th ed., text rev.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Washington, DC: Author.

INTRODUCTION

American Psychological Association Presidential Task Force on Evidence-Based

Practice. (2006). Evidence-based practice in psychology. American Psychologist,

61(4), 271–285.

Bohart, A., & Tallman, K. (1999). How clients make therapy work: The process of

active self-healing. Washington, DC: American Psychological Association.

Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the

21st century. Washington DC: National Academy Press. Available from

http://www.iom.edu/Reports.aspx?sort=alpha&page=15

Jongsma, A. (2005). Psychotherapy treatment plan writing. In G. P. Koocher, J. C.

Norcross, & S. S. Hill (Eds.), Psychologists’ desk reference (2nd ed., pp. 232–236).

New York, NY: Oxford University Press.

Jongsma, A. E. (2013). Adult psychotherapy homework planner (5th ed.). Hoboken,

NJ: Wiley.

Jongsma, A. E., & Bruce, T. J. (2010–2012). Evidence-based psychotherapy treatment

planning [DVD-based series]. Hoboken, NJ: Wiley [Online]. Available from

www.Wiley.com/go/ebtdvds

Nathan, P. E., & Gorman, J. M. (Eds.). (2007). A guide to treatments that work

(3rd ed.). New York: Oxford University Press.

New Freedom Commission on Mental Health. (2003). Achieving the promise:

Transforming mental health care in America (Final report. DHHS Publication

No. SMA-03-3832). Rockville, MD: Author. Available from http://www.mental

healthcommission.gov

Norcross, J. C., Santrock, J. W., Campbell, L. F., Smith, T. P., Sommer, R., &

Zuckerman, E. L. (2003). Authoritative guide to self-help resources in mental

health, revised edition. New York: Guilford Press.

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work: Therapist

contributions and responsiveness to patient needs. New York, NY: Oxford

University Press.

Substance Abuse and Mental Health Services Administration’s (SAMHSA)

National Mental Health Information Center: Center for Mental Health

Services. (2004). National consensus statement on mental health recovery.

Washington, DC: Author. Available from http://mentalhealth.samhsa.gov/

publications/allpubs/sma05-4129/

Wampold, B. E. (2001). The great psychotherapy debate: Models, methods, and

findings. Mahwah, NJ: Erlbaum.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

SAMPLE TREATMENT PLAN

ANXIETY

Definitions:

Excessive and/or unrealistic worry that is difficult to control

occurring more days than not for at least 6 months about

a number of events or activities.

Motor tension (e.g., restlessness, tiredness, shakiness, muscle

tension).

Autonomic hyperactivity (e.g., palpitations, shortness of

breath, dry mouth, trouble swallowing, nausea, diarrhea).

Hypervigilance (e.g., feeling constantly on edge, experiencing

concentration difficulties, having trouble falling or staying

asleep, exhibiting a general state of irritability).

Goals:

Reduce overall frequency, intensity, and duration of the

anxiety so that daily functioning is not impaired.

Learn and implement coping skills that result in a reduction

of anxiety and worry, and improved daily functioning.

OBJECTIVES

INTERVENTIONS

1. Describe situations, thoughts,

feelings, and actions associated

with anxieties and worries, their

impact on functioning, and

attempts to resolve them.

1. Focus on developing a level of

trust with the client; provide

support and empathy to

encourage the client to feel safe

in expressing his/her GAD

symptoms.

2. Ask the client to describe his/her

past experiences of anxiety and

their impact on functioning;

assess the focus, excessiveness,

and uncontrollability of the

worry and the type, frequency,

intensity, and duration of his/her

anxiety symptoms (consider using

a structured interview such as

The Anxiety Disorders Interview

Schedule–Adult Version).

2. Verbalize an understanding of

the cognitive, physiological, and

behavioral components of

anxiety and its treatment.

1. Discuss how generalized anxiety

typically involves excessive

worry about unrealistic threats,

various bodily expressions of

INTRODUCTION

tension, overarousal, and

hypervigilance, and avoidance of

what is threatening that interact

to maintain the problem (see

Mastery of Your Anxiety and

Worry—Therapist Guide by

Zinbarg, Craske, and Barlow;

Treating GAD by Rygh and

Sanderson).

2. Discuss how treatment targets

worry, anxiety symptoms, and

avoidance to help the client

manage worry effectively, reduce

overarousal, and eliminate

unnecessary avoidance.

3. Assign the client to read

psychoeducational sections of

books or treatment manuals on

worry and generalized anxiety

(e.g., Mastery of Your Anxiety

and Worry—Workbook by

Craske and Barlow; Overcoming

Generalized Anxiety Disorder by

White).

3. Learn and implement calming

skills to reduce overall anxiety

and manage anxiety symptoms.

1. Teach the client calming/

relaxation skills (e.g., applied

relaxation, progressive muscle

relaxation, cue controlled

relaxation; mindful breathing;

biofeedback) and how to

discriminate better between

relaxation and tension; teach the

client how to apply these skills to

his/her daily life (e.g., New

Directions in Progressive Muscle

Relaxation by Bernstein,

Borkovec, and Hazlett-Stevens;

Treating GAD by Rygh and

Sanderson).

2. Assign the client homework each

session in which he/she practices

relaxation exercises daily,

gradually applying them

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

progressively from non-anxiety-

provoking to anxiety-provoking

situations; review and reinforce

success while providing

corrective feedback toward

improvement.

4. Learn and implement a strategy

to limit the association between

various environmental settings

and worry, delaying the worry

until a designated “worry time.”

1. Explain the rationale for using a

worry time as well as how it is to

be used; agree upon a worry time

with the client and implement.

2. Teach the client how to

recognize, stop, and postpone

worry to the agreed-upon worry

time using skills such as thought

stopping, relaxation, and

redirecting attention (or assign

“Making Use of the Thought-

Stopping Technique” and/or

“Worry Time” in the Adult

Psychotherapy Homework

Planner by Jongsma to assist

skill development); encourage

use in daily life; review and

reinforce success while providing

corrective feedback toward

improvement.

5. Verbalize an understanding of

the role that cognitive biases play

in excessive irrational worry and

persistent anxiety symptoms.

1. Assist the client in analyzing

his/her worries by examining

potential biases such as the

probability of the negative

expectation occurring, the real

consequences of it occurring,

his/her ability to control the

outcome, the worst possible

outcome, and his/her ability to

accept it (see “Analyze the

Probability of a Feared Event”

in the Adult Psychotherapy

Homework Planner by Jongsma;

Cognitive Therapy of Anxiety

Disorders by Clark and Beck).

INTRODUCTION

6. Identify, challenge, and replace

biased, fearful self-talk with

positive, realistic, and

empowering self-talk.

1. Explore the client’s schema and

self-talk that mediate his/her fear

response; assist him/her in

challenging the biases; replacing

the distorted messages with

reality-based alternatives and

positive, realistic self-talk that

will increase his/her self-

confidence in coping with

irrational fears (see Cognitive

Therapy of Anxiety Disorders by

Clark and Beck).

2. Assign the client a homework

exercise in which he/she identifies

fearful self-talk, identifies biases

in the self-talk, generates

alternatives, and tests through

behavioral experiments (or

assign “Negative Thoughts

Trigger Negative Feelings” in the

Adult Psychotherapy Homework

Planner by Jongsma); review and

reinforce success, providing

corrective feedback toward

improvement.

DIAGNOSIS

300.02 (F41.1)* Generalized Anxiety Disorder

*ICD-9-CM Code (ICD-10-CM Code)

ANGER CONTROL PROBLEMS

BEHAVIORAL DEFINITIONS

1. Shows a pattern of episodic excessive anger in response to specific

situations or situational themes.

2. Shows a pattern of general excessive anger across many situations.

3. Shows cognitive biases associated with anger (e.g., demanding

expectations of others, overly generalized labeling of the targets of

anger, anger in response to perceived “slights”).

4. Shows direct or indirect evidence of physiological arousal related to

anger.

5. Reports a history of explosive, aggressive outbursts out of proportion

with any precipitating stressors, leading to verbal attacks, assaultive

acts, or destruction of property.

6. Displays overreactive verbal hostility to insignificant irritants.

7. Engages in physical and/or emotional abuse against significant other.

8. Makes swift and harsh judgmental statements to or about others.

9. Displays body language suggesting anger, including tense muscles (e.g.,

clenched fist or jaw), glaring looks, or refusal to make eye contact.

10. Shows passive-aggressive patterns (e.g., social withdrawal, lack of

complete or timely compliance in following directions or rules, com-

plaining about authority figures behind their backs, uncooperative in

meeting expected behavioral norms) due to anger.

11. Passively withholds feelings and then explodes in a rage.

12. Demonstrates an angry overreaction to perceived disapproval, rejection,

or criticism.

13. Uses abusive language meant to intimidate others.

14. Rationalizes and blames others for aggressive and abusive behavior.

15. Uses aggression as a means of achieving power and control.

__. _____________________________________________________________

_____________________________________________________________

ANGER CONTROL PROBLEMS

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Learn and implement anger management skills to reduce the level of

anger and irritability that accompanies it.

2. Increase respectful communication through the use of assertiveness and

conflict resolution skills.

3. Develop an awareness of angry thoughts, feelings, and actions,

clarifying origins of, and learning alternatives to aggressive anger.

4. Decrease the frequency, intensity, and duration of angry thoughts,

feelings, and actions and increase the ability to recognize and

respectfully express frustration and resolve conflict.

5. Implement cognitive behavioral skills necessary to solve problems in a

more constructive manner.

6. Come to an awareness and acceptance of angry feelings while developing

better control and more serenity.

7. Become capable of handling angry feelings in constructive ways that

enhance daily functioning.

8. Demonstrate respect for others and their feelings.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Work cooperatively with the

therapist to identify situations,

thoughts, and feelings associated

with anger, angry verbal and/or

behavioral actions, and the

targets of those actions. (1, 2)

1. Develop a level of trust with the

client; provide support and

empathy to encourage the client

to feel safe in expressing his/her

angry emotions as well as the

impact anger expression has had

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

on his/her life as the interview

focuses on the impact of anger

on the client’s life.

2. As the client describes his/her

history and nature of anger

issues in his/her own words,

thoroughly assess the various

stimuli (e.g., situations, people,

thoughts) that have triggered the

client’s anger and the thoughts,

feelings, and actions that have

characterized his/her anger

responses.

2. Complete psychological testing

or objective questionnaires for

assessing anger expression. (3)

3. Administer to the client

psychometric instruments

designed to objectively assess

anger expression (e.g., Anger,

Irritability, and Assault

Questionnaire; Buss-Durkee

Hostility Inventory; State-Trait

Anger Expression Inventory); give

the client feedback regarding the

results of the assessment; re-

administer as indicated to assess

treatment response.

3. Cooperate with a medical

evaluation to assess possible

medical conditions contributing

to anger control problems. (4)

4. Refer the client to a physician

for a complete medical

evaluation to rule out medical

conditions or substances possibly

causing or contributing to the

anger control problems (e.g.,

brain damage, tumor, elevated

testosterone levels, stimulant

use).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of in-

sight (syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

ANGER CONTROL PROBLEMS

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Cooperate with a medication

evaluation for possible treatment

9. Assess the client for the need and

willingness to take psychotropic

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

with psychotropic medications to

assist in anger control; take

medications consistently, if

prescribed. (9, 10)

medication to assist in control of

anger; refer him/her to a

physician for an evaluation and

prescription of medication, if

needed.

10. Monitor the client for

prescription compliance,

effectiveness, and side effects;

provide feedback to the

prescribing physician.

6. Keep a daily journal of persons,

situations, and other triggers of

anger; record thoughts, feelings,

and actions taken. (11, 12)

11. Ask the client to self-monitor,

keeping a daily journal in which

he/she documents persons,

situations, thoughts, feelings,

and actions associated with

moments of anger, irritation,

or disappointment (or assign

“Anger Journal” in the Adult

Psychotherapy Homework

Planner by Jongsma); routinely

process the journal toward

helping the client understand

his/her contributions to

generating his/her anger.

12. Assist the client in generating a

list of anger triggers; process the

list toward helping the client

understand the causes and

expressions of his/her anger.

7. Verbalize increased awareness of

anger expression patterns, their

causes, and their consequences.

(13, 14, 15, 16)

13. Assist the client in re-

conceptualizing anger as

involving different dimensions

(cognitive, physiological,

affective, and behavioral) that

interact predictably (e.g.,

demanding expectations not

being met leading to increased

arousal and anger leading to

acting out) and that can be

understood, challenged, and

changed.

14. Process the client’s list of anger

triggers and other relevant

ANGER CONTROL PROBLEMS

journal information toward

helping the client understand

how cognitive, physiological,

and affective factors interplay

to produce anger.

15. Ask the client to list and discuss

ways anger has negatively

impacted his/her daily life (e.g.,

hurting others or self, legal

conflicts, loss of respect from

self and others, destruction of

property); process this list.

16. Assist the client in identifying

the positive consequences

of managing anger (e.g.,

respect from others and self,

cooperation from others,

improved physical health, etc.)

(or assign “Alternatives to

Destructive Anger” in the Adult

Psychotherapy Homework

Planner by Jongsma).

8. Explore motivation and

willingness to participate in

therapy, and agree to participate

to learn new ways to think about

and manage anger. (17)

17. Use motivational interviewing

techniques to help the client

clarify his/her motivational stage,

moving the client to the action

stage in which he/she agrees to

learn new ways to conceptualize

and manage anger.

9. Verbalize an understanding of

how the treatment is designed to

decrease anger and improve the

quality of life. (18)

18. Discuss the rationale for

treatment, emphasizing how

functioning can be improved

through change in the various

dimensions of anger; revisit

relevant themes throughout

therapy to help the client

consolidate his/her

understanding.

10. Read a book or treatment

manual that supplements the

therapy by improving

understanding of anger and

anger control problems. (19)

19. Assign the client reading material

that educates him/her about

anger and its management (e.g.,

Overcoming Situational and

General Anger: Client Manual by

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

Deffenbacher and McKay; Of

Course You’re Angry by Rosselini

and Worden; The Anger Control

Workbook by McKay and

Rogers; Anger Management for

Everyone by Kassinove and

Tafrate); process and revisit

relevant themes throughout

therapy to help the client

consolidate his/her understanding

of the treatment.

11. Learn and implement calming

and coping strategies as part of

an overall approach to managing

anger. (20)

20. Teach the client calming

techniques (e.g., progressive

muscle relaxation, breathing

induced relaxation, calming

imagery, cue-controlled

relaxation, applied relaxation,

mindful breathing) as part of a

tailored strategy for reducing

chronic and acute physiological

tension that accompanies the

escalation of his/her angry

feelings.

12. Identify, challenge, and replace

anger-inducing self-talk with

self-talk that facilitates a less

angry reaction. (21, 22, 23)

21. Explore the client’s self-talk that

mediates his/her angry feelings

and actions (e.g., demanding

expectations reflected in should,

must, or have-to statements);

identify and challenge biases,

assisting him/her in generating

appraisals and self-talk that

corrects for the biases and

facilitates a more flexible and

temperate response to

frustration. Combine new self-

talk with calming skills as part of

a set of coping skills to manage

anger.

22. Assign the client a homework

exercise in which he/she

identifies angry self-talk and

generates alternatives that help

moderate angry reactions;

review; reinforce success,

ANGER CONTROL PROBLEMS

providing corrective feedback

toward improvement.

23. Role-play the use of relaxation

and cognitive coping to

visualized anger-provoking

scenes, moving from low- to

high-anger scenes. Assign the

implementation of calming

techniques in his/her daily life

and when facing anger-triggering

situations; process the results,

reinforcing success and problem-

solving obstacles.

13. Learn and implement thought-

stopping to manage intrusive

unwanted thoughts that trigger

anger. (24)

24. Assign the client to implement a

“thought-stopping” technique in

which he/she shouts STOP to

himself/herself in his/her mind

and then replaces the thought

with an alternative that is

calming (or assign “Making Use

of the Thought-Stopping

Technique” in the Adult

Psychotherapy Homework

Planner by Jongsma); review

implantation, reinforcing success

and providing corrective

feedback for failure.

14. Verbalize an understanding of

assertive communication and

how it can be used to express

thoughts and feelings of anger in

a controlled, respectful way. (25)

25. Use instruction, modeling, and/or

role-playing to teach the client

the distinctive elements as well as

the pros and cons of assertive,

unassertive (passive), and

aggressive communication.

15. Learn and implement problem-

solving and/or conflict resolution

skills to manage interpersonal

problems. (26, 27, 28)

26. Teach the client problem-solving

skills (e.g., defining the problem

clearly, brainstorming multiple

solutions, listing the pros and

cons of each solution, seeking

input from others, selecting and

implementing a plan of action,

evaluating the outcome, and

readjusting the plan as

necessary).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

27. Teach the client conflict

resolution skills (e.g., empathy,

active listening, “I messages,”

respectful communication,

assertiveness without aggression,

compromise); use modeling, role-

playing, and behavior rehearsal

to work through several current

conflicts.

28. Conduct conjoint sessions

to help the client implement

assertion, problem-solving,

and/or conflict resolution skills

in the presence of his/her

significant other.

16. Practice using new anger

management skills in session

with the therapist and during

homework exercises. (29, 30, 31)

29. Assist the client in constructing a

client-tailored strategy for

managing anger that combines

any of the somatic, cognitive,

communication, problem-

solving, and/or conflict

resolution skills relevant to

his/her needs.

30. Select situations in which the

client will be increasingly

challenged to apply his/her new

strategies for managing anger.

31. Use any of several techniques,

including relaxation, imagery,

behavioral rehearsal, modeling,

role-playing, or in vivo

exposure/behavioral experiments

to help the client consolidate the

use of his/her new anger

management skills.

17. Decrease the number, intensity,

and duration of angry outbursts,

while increasing the use of new

skills for managing anger. (32)

32. Monitor the client’s reports of

angry outbursts toward the goal

of decreasing their frequency,

intensity, and duration through

the client’s use of new anger

management skills (or assign

“Alternatives to Destructive

Anger” in the Adult

ANGER CONTROL PROBLEMS

Psychotherapy Homework

Planner by Jongsma); review

progress, reinforcing success and

providing corrective feedback

toward improvement.

18. Verbalize an understanding of

relapse prevention and the

difference between a lapse and

relapse. (33, 34)

33. Provide a rationale for relapse

prevention that discusses the risk

and introduces strategies for

preventing it.

34. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

an initial and reversible angry

outburst and relapse with the

choice to return routinely to the

old pattern of anger.

19. Identify potential situations that

could trigger a lapse and

implement strategies to manage

these situations. (35, 36, 37, 38)

35. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses back to anger could

occur.

36. Instruct the client to routinely

use the new anger management

strategies learned in therapy

(e.g., calming, adaptive self-talk,

assertion, and/or conflict

resolution) to respond to

frustrations.

37. Develop a “coping card” or

other reminder on which new

anger management skills and

other important information

(e.g., calm yourself, be flexible in

your expectations of others,

voice your opinion calmly,

respect others’ point of view) are

recorded for the client’s later

use.

38. Schedule periodic “maintenance”

sessions to help the client

maintain therapeutic gains.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

20. Identify the advantages and

disadvantages of holding on to

anger and of forgiveness; discuss

with therapist. (39, 40)

39. Discuss with the client

forgiveness of the perpetrators of

pain as a process of letting go of

his/her anger.

40. Assign the client to read Forgive

and Forget by Smedes; process

the content as to how it applies

to the client’s own life.

21. Write a letter of forgiveness to

the perpetrator of past or present

pain and process this letter with

the therapist. (41)

41. Ask the client to write a

forgiving letter to the target of

anger as a step toward letting go

of anger; process this letter in

session.

22. Participate in Acceptance and

Commitment Therapy (ACT)

for learning a new approach to

anger and anger management.

(42, 43, 44, 45)

42. Use an ACT approach to help

the client experience and accept

the presence of worrisome

thoughts and images without

being overly impacted by them,

and committing his/her time and

efforts to activities that are

consistent with identified,

personally meaningful values

(see Acceptance and Commitment

Therapy by Hayes, Strosahl, and

Wilson).

43. Teach mindfulness meditation

to help the client recognize the

negative thought processes

associated with PTSD and

change his/her relationship with

these thoughts by accepting

thoughts, images, and impulses

that are reality-based while

noticing but not reacting to non-

reality-based mental phenomena

(see Guided Mindfulness

Meditation [Audio CD] by

Zabat-Zinn).

44. Assign the client homework in

which he/she practices lessons

from mindfulness meditation

and ACT in order to consolidate

the approach into everyday life.

ANGER CONTROL PROBLEMS

45. Assign the client reading

consistent with the mindfulness

and ACT approach to

supplement work done in session

(see Get Out of Your Mind and

Into Your Life: The New

Acceptance and Commitment

Therapy by Hayes).

23. Gain insight into the origins of

anger control problems by

discussing past relationships

with significant others. (46)

46. Assist the client in identifying

past relationship conflicts (e.g.,

with father, mother, others) that

may have influenced the

development of current anger

control problems; discuss how

these experiences have positively

or negatively influenced the way

he/she handles anger.

24. Identify social supports that will

help facilitate the

implementation of anger

management skills. (47)

47. Encourage the client to discuss

his/her anger management goals

with trusted persons who are

likely to support his/her change.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

312.34 Intermittent Explosive Disorder

296.xx Bipolar I Disorder

296.89 Bipolar II Disorder

312.8 Conduct Disorder

310.1 Personality Change Due to Axis III Disorder

309.81 Posttraumatic Stress Disorder

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

V61.12 Physical Abuse of Adult (by Partner)

V61.83 Physical Abuse of Adult (by non-Partner)

_____

_____________________________________

_____

_____________________________________

Axis II:

301.83 Borderline Personality Disorder

301.7 Antisocial Personality Disorder

301.0 Paranoid Personality Disorder

301.81 Narcissistic Personality Disorder

301.9 Personality Disorder NOS

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

312.34 F63.81 Intermittent Explosive Disorder

296.xx F31.xx Bipolar I Disorder

296.89 F31.81 Bipolar II Disorder

312.8 F91.x Conduct Disorder

310.1 F07.0 Personality Change Due to Another

Medical Condition

309.81 F43.10 Posttraumatic Stress Disorder

V61.12 Z69.12 Encounter for Mental Health Services for

Perpetrator of Spouse or Partner Violence,

Physical

V62.83 Z69.82 Encounter for Mental Health Services for

Perpetrator of Nonspousal Adult Abuse

301.83 F60.3 Borderline Personality Disorder

301.7 F60.2 Antisocial Personality Disorder

301.0 F60.0 Paranoid Personality Disorder

301.81 F60.81 Narcissistic Personality Disorder

301.9 F60.9 Unspecified Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

ANTISOCIAL BEHAVIOR

BEHAVIORAL DEFINITIONS

1. An adolescent history of consistent rule-breaking, lying, stealing, physical

aggression, disrespect for others and their property, and/or substance

abuse resulting in frequent confrontation with authority.

2. Failure to conform with social norms with respect to the law, as shown by

repeatedly performed antisocial acts (e.g., destroying property, stealing,

pursuing an illegal job) for which he/she may or may not have been

arrested.

3. Pattern of interacting in an angry, confrontational, aggressive, and/or

argumentative way with authority figures.

4. Consistently uses alcohol or other mood-altering drugs until high,

intoxicated, or passed out.

5. Little or no remorse for causing pain to others.

6. Consistent pattern of blaming others for what happens to him/her.

7. Little regard for truth, as reflected in a pattern of consistently lying to

and/or conning others.

8. Frequent angry initiation of verbal or physical fighting.

9. History of reckless behaviors that reflect a lack of regard for self or

others and show a high need for excitement, fun, and living on the edge.

10. Pattern of sexual promiscuity; has never been totally monogamous in

any relationship for a year and does not take responsibility for children

resulting from relationships.

11. Pattern of impulsive behaviors, such as moving often, traveling with no

goal, or quitting a job without having secured another one.

12. Inability to sustain behavior that would maintain consistent employment.

13. Failure to function as a consistently concerned and responsible parent.

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Accept responsibility for own behavior and keep behavior within the

acceptable limits of the rules of society.

2. Develop and demonstrate a healthy sense of respect for social norms, the

rights of others, and the need for honesty.

3. Improve method of relating to the world, especially authority figures; be

more realistic, less defiant, and more socially sensitive.

4. Come to an understanding and acceptance of the need for conforming to

prevailing social limits and boundaries on behavior.

5. Maintain consistent employment and demonstrate financial and

emotional responsibility for children.

6. Embrace the recovery model’s emphasis on accepting responsibility for

treatment decisions as well as the expectation of being able to live, work,

and participate fully in the community.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Admit to illegal and/or unethical

behavior that has trampled on

the law and/or the rights and

feelings of others. (1, 2)

1. Explore the history of the

client’s pattern of illegal and/or

unethical behavior and confront

his/her attempts at minimization,

denial, or projection of blame

while showing how the client’s

own thinking pattern leads to

illegal behavior (or assign

“Crooked Thinking Leads to

Crooked Behavior” or “Accept

ANTISOCIAL BEHAVIOR

Responsibility for Illegal

Behavior” from the Adult

Psychotherapy Homework

Planner by Jongsma).

2. Review the consequences for the

client and others of his/her

antisocial behavior.

2. Provide honest and complete

information for a Substance Use

history. (3)

3. Assess the client for the presence

of chemical dependence and refer

for focused substance abuse

treatment if warranted (see the

Substance Use chapter in this

Planner).

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (4, 5, 6, 7)

4. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

5. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

6. Assess for any issues of age,

gender, or culture that could

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

7. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

4. Explore and resolve ambivalence

associated with commitment to

change behaviors related to

antisocial behavior pattern,

including substance abuse if

present. (8, 9, 10)

8. Using a directive, client-centered,

empathic style derived from

motivational enhancement

therapy (see Motivational

Interviewing by Miller and

Rollnick; and Addiction and

Change by DiClemente),

establish rapport with the client

and listen reflectively, asking

permission before providing

information or advice.

9. Ask open-ended questions

to explore the client’s own

motivations for change,

affirming his or her change-

related statements and efforts

(see Substance Abuse Treatment

and the Stages of Change by

Connors, Donovan, and

DiClemente).

10. Elicit recognition of the

discrepancy gap between current

behavior and desired life goals,

ANTISOCIAL BEHAVIOR

reflecting resistance without

direct confrontation or

argumentation.

5. Verbalize an understanding of

the benefits for self and others of

living within the laws and rules

of society. (11, 12)

11. Teach the client that the basis for

all relationships is trust that the

other person will treat one with

respect and kindness.

12. Teach the client the need for

lawfulness as the basis for trust

that forestalls anarchy in society

as a whole.

6. Make a commitment to live

within the rules and laws of

society. (13, 14)

13. Solicit a commitment from the

client to conform to a prosocial,

law-abiding lifestyle.

14. Emphasize the reality of negative

consequences for the client if

he/she continues to practice

lawlessness.

7. List relationships that have been

broken because of disrespect,

disloyalty, aggression, or

dishonesty. (15)

15. Review relationships that have

been lost due to the client’s

antisocial attitudes and practices

(e.g., disloyalty, dishonesty,

aggression).

8. Acknowledge a pattern of self-

centeredness in virtually all

relationships. (16, 17)

16. Confront the client’s lack of

sensitivity to the needs and

feelings of others.

17. Point out the self-focused, me-

first, look-out-for-number-one

attitude that is reflected in the

client’s antisocial behavior.

9. Make a commitment to be

honest and reliable. (18, 19, 20)

18. Teach the client the value for self

of honesty and reliability in all

relationships, since he/she

benefits from social approval as

well as increased trust and

respect.

19. Teach the client the positive

effect that honesty and reliability

have for others, since they are

not disappointed or hurt by lies

and broken promises.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

20. Ask the client to make a

commitment to be honest and

reliable.

10. Verbalize an understanding of

the benefits to self and others of

being empathetic and sensitive to

the needs of others. (11, 21, 22)

11. Teach the client that the basis for

all relationships is trust that the

other person will treat one with

respect and kindness.

21. Attempt to sensitize the client

to his/her lack of empathy

for others by revisiting the

consequences of his/her behavior

on others; use role reversal

techniques.

22. Confront the client when he/she

is rude or not being respectful of

others and their boundaries.

11. List three actions that will be

performed that will be acts of

kindness and thoughtfulness

toward others. (23)

23. Assist the client in listing three

actions that he/she will perform

as acts of service or kindness for

others.

12. Indicate the steps that will be

taken to make amends or

restitution for hurt caused to

others. (24, 25, 26)

24. Assist the client in identifying

those who have been hurt by

his/her antisocial behavior

(or assign “How I Have Hurt

Others” from the Adult

Psychotherapy Homework

Planner by Jongsma).

25. Teach the client the value of

apologizing for hurt caused as a

means of accepting responsibility

for behavior and of developing

sensitivity to the feelings of

others.

26. Encourage the client’s

commitment to specific steps

that will be taken to apologize

and make restitution to those

who have suffered from his/her

hurtful behaviors (or assign

“Letter of Apology” from the

Adult Psychotherapy Homework

Planner by Jongsma).

ANTISOCIAL BEHAVIOR

13. Verbally demonstrate an

understanding of the rules and

duties related to employment.

(27)

27. Review the rules and

expectations that must govern

the client’s behavior in the work

environment.

14. Attend work reliably and treat

supervisors and coworkers with

respect. (28, 29)

28. Monitor the client’s attendance

at work and reinforce reliability

as well as respect for authority.

29. Ask the client to make a list of

behaviors and attitudes that

must be modified in order to

decrease his/her conflict with

authorities; process the list.

15. Verbalize the obligations of

parenthood that have been

ignored. (30, 31)

30. Confront the client’s avoidance

of responsibilities toward his/her

children.

31. Assist the client in listing the

behaviors that are required to be

a responsible, nurturing, and

consistently reliable parent.

16. State a plan to meet responsi-

bilities of parenthood. (32)

32. Develop a plan with the client

that will begin to implement the

behaviors of a responsible parent.

17. Increase statements of accepting

responsibility for own behavior.

(33, 34, 35)

33. Confront the client when he/she

makes blaming statements or

fails to take responsibility for

own actions, thoughts, or

feelings (or assign “Accept

Responsibility for Illegal

Behavior” from the Adult

Psychotherapy Homework

Planner by Jongsma).

34. Explore the client’s reasons for

blaming others for his/her own

actions (e.g., history of physically

abusive punishment, parental

modeling, fear of rejection,

shame, low self-esteem, avoidance

of facing consequences).

35. Give verbal positive feedback to

the client when he/she takes

responsibility for his/her own

behavior.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

18. Verbalize an understanding of

how childhood experiences of

pain have led to an imitative

pattern of self-focused protection

and aggression toward others.

(36, 37)

36. Explore the client’s history of

abuse, neglect, or abandonment

in childhood (or assign “Describe

the Trauma” from the Adult

Psychotherapy Homework

Planner by Jongsma); explain

how the cycle of abuse or neglect

is repeating itself in the client’s

behavior.

37. Point out that the client’s pattern

of emotional detachment in

relationships and self-focused

behavior is related to a

dysfunctional attempt to protect

self from pain.

19. Identify situations, thoughts, and

feelings that trigger anger, angry

verbal and/or aggressive

behavioral actions. (38)

38. As the client describes his/her

history and nature of anger

issues in his/her own words,

thoroughly assess the various

stimuli (e.g., situations, people,

thoughts) that have triggered the

client’s anger and the thoughts,

feelings, and aggressive actions

that have characterized his/her

anger responses (consider

assigning the exercise “Anger

Journal” from the Adult

Psychotherapy Homework

Planner by Jongsma).

20. Complete psychological testing

or objective questionnaires for

assessing anger expression. (39)

39. Administer to the client

psychological instruments

designed to objectively assess

anger expression (e.g., Anger,

Irritability, and Assault

Questionnaire; Buss-Durkee

Hostility Inventory; State-Trait

Anger Expression Inventory);

give the client feedback

regarding the results of the

assessment; readminister as

indicated to assess treatment

response.

ANTISOCIAL BEHAVIOR

21. Learn and implement calming

and coping strategies as part of

an overall approach to managing

anger. (40, 41)

40. Teach the client calming

techniques (e.g., progressive

muscle relaxation, breathing-

induced relaxation, calming

imagery, cue-controlled

relaxation, applied relaxation)

as part of a tailored strategy for

reducing chronic and acute

physiological tension that

accompanies his/her angry

feelings.

41. Role-play the use of relaxation

and cognitive coping to visualized

anger-provoking scenes, moving

from low- to high-anger scenes.

Assign the implementation of

calming techniques in his/her

daily life when facing anger

trigger situations; process the

results, reinforcing success and

problem-solving obstacles.

22. Identify, challenge, and replace

anger-inducing self-talk with

self-talk that facilitates a less

angry reaction. (42, 43)

42. Explore the client’s self-talk that

mediates his/her angry feelings

and actions (e.g., demanding

expectations reflected in should,

must, or have-to statements);

identify and challenge biases,

assisting him/her in generating

appraisals and self-talk that

corrects for the biases and

facilitates a more flexible and

temperate response to

frustration. Combine new self-

talk with calming skills as part of

developing coping skills for

managing anger.

43. Assign the client a homework

exercise in which he/she identifies

angry self-talk and generates

alternatives that help moderate

angry reactions; review while

reinforcing success, providing

corrective feedback toward

improvement.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

23. Verbalize a list of constructive

alternatives to aggressive anger

in response to trigger situations.

(44)

44. Review with the client

alternatives (e.g., assertiveness,

relaxation, diversion, calming

self-talk, etc.) to destructive

anger in response to trigger

situations; role-play the

application of some of these

alternatives to real life situations

(or assign “Alternatives to

Destructive Anger” from the

Adult Psychotherapy Homework

Planner by Jongsma).

24. Verbalize a desire to forgive

perpetrators of childhood abuse.

(45)

45. Teach the client the value of

forgiving the perpetrators of hurt

versus holding on to hurt and

rage and using the hurt as an

excuse to continue antisocial

practices.

25. Practice trusting a significant

other with disclosure of personal

feelings. (46, 47, 48)

46. Explore the client’s fears

associated with placing trust in

others.

47. Identify some personal thoughts

and feelings that the client could

share with a significant other

as a means of beginning to

demonstrate trust in someone.

48. Process the experience of the

client making himself/herself

vulnerable by self-disclosing to

someone.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

ANTISOCIAL BEHAVIOR

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

303.90 Alcohol Dependence

304.20 Cocaine Dependence

304.80 Polysubstance Dependence

312.8 Conduct Disorder

312.34 Intermittent Explosive Disorder

_____

__________________

_____

_____________________________________

Axis II:

301.7 Antisocial Personality Disorder

301.81 Narcissistic Personality Disorder

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

________________________________

____

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

304.20 F14.20 Cocaine Use Disorder, Moderate or Severe

309.3 F43.24 Adjustment Disorder, With Disturbance of

Conduct

312.8 F91.x Conduct Disorder

312.34 F63.81 Intermittent Explosive Disorder

301.7 F60.2 Antisocial Personality Disorder

301.81 F60.81 Narcissistic Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

ANXIETY

BEHAVIORAL DEFINITIONS

1. Excessive and/or unrealistic worry that is difficult to control occurring

more days than not for at least 6 months about a number of events or

activities.

2. Motor tension (e.g., restlessness, tiredness, shakiness, muscle tension).

3. Autonomic hyperactivity (e.g., palpitations, shortness of breath, dry

mouth, trouble swallowing, nausea, diarrhea).

4. Hypervigilance (e.g., feeling constantly on edge, experiencing concentra-

tion difficulties, having trouble falling or staying asleep, exhibiting a

general state of irritability).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Reduce overall frequency, intensity, and duration of the anxiety so that

daily functioning is not impaired.

2. Stabilize anxiety level while increasing ability to function on a daily basis.

3. Resolve the core conflict that is the source of anxiety.

4. Enhance ability to effectively cope with the full variety of life’s worries

and anxieties.

5. Learn and implement coping skills that result in a reduction of anxiety

and worry, and improved daily functioning.

ANXIETY

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe situations, thoughts,

feelings, and actions associated

with anxieties and worries, their

impact on functioning, and

attempts to resolve them. (1, 2)

1. Focus on developing a level of

trust with the client; provide

support and empathy to

encourage the client to feel safe

in expressing his/her GAD

symptoms.

2. Ask the client to describe his/her

past experiences of anxiety and

their impact on functioning;

assess the focus, excessiveness,

and uncontrollability of the

worry and the type, frequency,

intensity, and duration of his/her

anxiety symptoms (consider

using a structured interview

such as The Anxiety Disorders

Interview Schedule-Adult

Version).

2. Complete psychological tests

designed to assess worry and

anxiety symptoms. (3)

3. Administer psychological tests or

objective measures to help assess

the nature and degree of the

client’s worry and anxiety and

their impact on functioning

(e.g., The Penn State Worry

Questionnaire; OQ-45.2; the

Symptom Checklist-90-R.

3. Complete a medical evaluation

to assess for possible con-

tribution of medical or

substance-related conditions

to the anxiety. (4)

4. Refer the client to a physician

for a medical evaluation to

rule out general medical or

substance-related causes of

the GAD.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

ANXIETY

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Cooperate with a medication

evaluation by a physician. (9, 10)

9. Refer the client to a physician

for a psychotropic medication

consultation.

10. Monitor the client’s

psychotropic medication

compliance, side effects, and

effectiveness; confer regularly

with the physician.

6. Verbalize an understanding

of the cognitive, physiological,

and behavioral components of

anxiety and its treatment.

(11, 12, 13)

11. Discuss how generalized anxiety

typically involves excessive

worry about unrealistic threats,

various bodily expressions

of tension, overarousal, and

hypervigilance, and avoidance

of what is threatening that

interact to maintain the problem

(see Mastery of Your Anxiety an

Worry: Therapist Guide by

Zinbarg, Craske, and Barlow;

Treating Generalized Anxiety

Disorder by Rygh and

Sanderson).

12. Discuss how treatment targets

worry, anxiety symptoms, and

avoidance to help the client

manage worry effectively, reduce

overarousal, and eliminate

unnecessary avoidance.

13. Assign the client to read

psychoeducational sections of

books or treatment manuals on

worry and generalized anxiety

(e.g., Mastery of Your Anxiety

and Worry: Workbook by Craske

and Barlow; Overcoming

Generalized Anxiety Disorder

by White).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

7. Learn and implement calming

skills to reduce overall anxiety

and manage anxiety symptoms.

(14, 15, 16)

14. Teach the client calming/

relaxation skills (e.g., applied re-

laxation, progressive muscle

relaxation, cue controlled

relaxation; mindful breathing;

biofeedback) and how to

discriminate better between

relaxation and tension; teach

the client how to apply these

skills to his/her daily life (e.g.,

New Directions in Progressive

Muscle Relaxation by Bernstein,

Borkovec, and Hazlett-Stevens;

Treating Generalized Anxiety

Disorder by Rygh and

Sanderson).

15. Assign the client homework

each session in which he/she

practices relaxation exercises

daily, gradually applying them

progressively from non-anxiety-

provoking to anxiety-provoking

situations; review and reinforce

success while providing

corrective feedback toward

improvement.

16. Assign the client to read about

progressive muscle relaxation

and other calming strategies in

relevant books or treatment

manuals (e.g., Progressive

Relaxation Training by Bernstein

and Borkovec; Mastery of Your

Anxiety and Worry: Workbook

by Craske and Barlow).

8. Learn and implement a strategy

to limit the association between

various environmental settings

and worry, delaying the worry

until a designated “worry time.”

(17, 18)

17. Explain the rationale for using

a worry time as well as how it

is to be used; agree upon and

implement a worry time with

the client.

18. Teach the client how to

recognize, stop, and postpone

worry to the agreed upon worry

time using skills such as thought

ANXIETY

stopping, relaxation, and

redirecting attention (or assign

“Making Use of the Thought-

Stopping Technique” and/or

“Worry Time” in the Adult

Psychotherapy Homework

Planner by Jongsma to assist

skill development); encourage

use in daily life; review and

reinforce success while providing

corrective feedback toward

improvement.

9. Verbalize an understanding of

the role that cognitive biases play

in excessive irrational worry and

persistent anxiety symptoms.

(19, 20, 21)

19. Discuss examples demonstrating

that unrealistic worry typically

overestimates the probability

of threats and underestimates

or overlooks the client’s ability

to manage realistic demands

(or assign “Past Successful

Anxiety Coping” in the Adult

Psychotherapy Homework

Planner by Jongsma).

20. Assist the client in analyzing

his/her worries by examining

potential biases such as the

probability of the negative

expectation occurring, the real

consequences of it occurring,

his/her ability to control the

outcome, the worst possible

outcome, and his/her ability to

accept it (see “Analyze the

Probability of a Feared Event”

in the Adult Psychotherapy

Homework Planner by Jongsma;

Cognitive Therapy of Anxiety

Disorders by Clark and Beck).

21. Help the client gain insight into

the notion that worry may

function as a form of avoidance

of a feared problem and that it

creates acute and chronic

tension.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

10. Identify, challenge, and replace

biased, fearful self-talk with

positive, realistic, and

empowering self-talk. (22, 23)

22. Explore the client’s schema and

self-talk that mediate his/her

fear response; assist him/her in

challenging the biases; replace

the distorted messages with

reality-based alternatives and

positive, realistic self-talk that

will increase his/her self-

confidence in coping with

irrational fears (see Cognitive

Therapy of Anxiety Disorders

by Clark and Beck).

23. Assign the client a homework

exercise in which he/she identifies

fearful self-talk, identifies biases

in the self-talk, generates

alternatives, and tests through

behavioral experiments (or

assign “Negative Thoughts

Trigger Negative Feelings” in the

Adult Psychotherapy Homework

Planner by Jongsma); review and

reinforce success, providing

corrective feedback toward

improvement.

11. Undergo gradual repeated

imaginal exposure to the feared

negative consequences predicted

by worries and develop

alternative reality-based

predictions. (24, 25, 26, 27)

24. Direct and assist the client in

constructing a hierarchy of two

to three spheres of worry for use

in exposure (e.g., worry about

harm to others, financial

difficulties, relationship

problems).

25. Select initial exposures that have

a high likelihood of being a

success experience for the client;

develop a plan for managing the

negative effect engendered by

exposure; mentally rehearse the

procedure.

26. Ask the client to vividly imagine

worst-case consequences of

worries, holding them in mind

until anxiety associated with them

weakens (up to 30 minutes);

ANXIETY

generate reality-based alternatives

to that worst case and process

them (see Mastery of Your

Anxiety and Worry: Therapist

Guide by Zinbarg, Craske, and

Barlow).

27. Assign the client a homework

exercise in which he/she does

worry exposures and records

responses (see Mastery of Your

Anxiety and Worry: Workbook

by Craske and Barlow or

Generalized Anxiety Disorder by

Brown, O’Leary, and Barlow);

review, reinforce success, and

provide corrective feedback

toward improvement.

12. Learn and implement problem-

solving strategies for realistically

addressing worries. (28, 29)

28. Teach the client problem-solving

strategies involving specifically

defining a problem, generating

options for addressing it,

evaluating the pros and cons

of each option, selecting and

implementing an optional action,

and reevaluating and refining

the action (or assign “Applying

Problem-Solving to Interpersonal

Conflict” in the Adult Psycho-

therapy Homework Planner by

Jongsma).

29. Assign the client a homework

exercise in which he/she

problem-solves a current

problem (see Mastery of Your

Anxiety and Worry: Workbook

by Craske and Barlow or

Generalized Anxiety Disorder by

Brown, O’Leary, and Barlow);

review, reinforce success, and

provide corrective feedback

toward improvement.

13. Identify and engage in pleasant

activities on a daily basis. (30)

30. Engage the client in behavioral

activation, increasing the client’s

contact with sources of reward,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

identifying processes that inhibit

activation, and teaching skills

to solve life problems (or assign

“Identify and Schedule Pleasant

Activities” in the Adult

Psychotherapy Homework

Planner by Jongsma); use

behavioral techniques such as

instruction, rehearsal, role-

playing, role reversal as needed

to assist adoption into the

client’s daily life; reinforce

success.

14. Learn and implement personal

and interpersonal skills to

reduce anxiety and improve

interpersonal relationships.

(31, 32)

31. Use instruction, modeling, and

role-playing to build the client’s

general social, communication,

and/or conflict resolution

skills.

32. Assign the client a homework

exercise in which he/she

implements communication

skills training into his/her daily

life (or assign “Restoring

Socialization Comfort” in the

Adult Psychotherapy Homework

Planner by Jongsma); review,

reinforce success, and provide

corrective feedback toward

improvement.

15. Learn and implement relapse

prevention strategies for

managing possible future anxiety

symptoms. (33, 34, 35, 36, 37)

33. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

an initial and reversible return

of worry, anxiety symptoms, or

urges to avoid, and relapse with

the decision to continue the

fearful and avoidant patterns.

34. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur.

35. Instruct the client to routinely

use new therapeutic skills (e.g.,

ANXIETY

relaxation, cognitive

restructuring, exposure, and

problem-solving) in daily life to

address emergent worries, anxiety,

and avoidant tendencies.

36. Develop a “coping card” on

which coping strategies and

other important information

(e.g., “Breathe deeply and relax,”

“Challenge unrealistic worries,”

“Use problem-solving”) are

written for the client’s later

use.

37. Schedule periodic “maintenance”

sessions to help the client

maintain therapeutic gains.

16. Learn to accept limitations in life

and commit to tolerating, rather

than avoiding, unpleasant

emotions while accomplishing

meaningful goals. (38)

38. Use techniques from Acceptance

and Commitment Therapy to

help client accept uncomfortable

realities such as lack of complete

control, imperfections, and

uncertainty and tolerate

unpleasant emotions and

thoughts in order to accomplish

value-consistent goals.

17. Utilize a paradoxical

intervention technique to reduce

the anxiety response. (39)

39. Develop a paradoxical

intervention (see Ordeal Therapy

by Haley) in which the client is

encouraged to have the problem

(e.g., anxiety) and then schedule

that anxiety to occur at specific

intervals each day (at a time of

day/night when the client would

be clearly wanting to do

something else) in a specific way

and for a defined length of time.

18. Complete a Cost Benefit

Analysis of maintaining the

anxiety. (40)

40. Ask the client to evaluate the

costs and benefits of worries

(e.g., complete the Cost Benefit

Analysis exercise in Ten Days to

Self-Esteem! by Burns) in which

he/she lists the advantages and

disadvantages of the negative

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

thought, fear, or anxiety; process

the completed assignment.

19. Identify the major life conflicts

from the past and present that

form the basis for present

anxiety. (41, 42, 43)

41. Assist the client in becoming

aware of key unresolved life

conflicts and in starting to work

toward their resolution.

42. Reinforce the client’s insights

into the role of his/her past

emotional pain and present

anxiety.

43. Ask the client to develop and

process a list of key past and

present life conflicts that

continue to cause worry.

20. Maintain involvement in work,

family, and social activities. (44)

44. Support the client in following

through with work, family, and

social activities rather than

escaping or avoiding them to

focus on anxiety.

21. Reestablish a consistent sleep-

wake cycle. (45)

45. Teach and implement sleep

hygiene practices to help the

client reestablish a consistent

sleep-wake cycle; review,

reinforce success, and provide

corrective feedback toward

improvement.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

ANXIETY

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.02 Generalized Anxiety Disorder

300.00 Anxiety Disorder NOS

309.24 Adjustment Disorder With Anxiety

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.02 F41.1 Generalized Anxiety Disorder

300.09 F41.8 Other Specified Anxiety Disorder

300.00 F41.9 Unspecified Anxiety Disorder

309.24 F43.22 Adjustment Disorder, With Anxiety

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

ATTENTION DEFICIT DISORDER

(ADD)—ADULT

BEHAVIORAL DEFINITIONS

1. Childhood history of Attention Deficit Disorder (ADD) that was either

diagnosed or later concluded due to the symptoms of behavioral problems

at school, impulsivity, temper outbursts, and lack of concentration.

2. Unable to concentrate or pay attention to things of low interest, even

when those things are important to his/her life.

3. Easily distracted and drawn from task at hand.

4. Restless and fidgety; unable to be sedentary for more than a short time.

5. Impulsive; has an easily observable pattern of acting first and thinking

later.

6. Rapid mood swings and mood lability within short spans of time.

7. Disorganized in most areas of his/her life.

8. Starts many projects but rarely finishes any.

9. Has a “low boiling point” and a “short fuse.”

10. Exhibits low stress tolerance; is easily frustrated, hassled, or upset.

11. Chronic low self-esteem.

12. Tendency toward addictive behaviors.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

ATTENTION DEFICIT DISORDER (ADD)—ADULT

LONG-TERM GOALS

1. Reduce impulsive actions while increasing concentration and focus on

low-interest activities.

2. Minimize ADD behavioral interference in daily life.

3. Accept ADD as a chronic issue and need for continuing medication

treatment.

4. Sustain attention and concentration for consistently longer periods of

time.

5. Achieve a satisfactory level of balance, structure, and intimacy in

personal life.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe past and present

experiences with ADD including

its effects on functioning. (1, 2)

1. Establish rapport with the client

toward building a therapeutic

alliance.

2. Conduct a thorough

psychosocial assessment

including past and present

symptoms of ADD and their

effects on educational,

occupational, and social

functioning.

2. Cooperate with and complete

psychological testing. (3)

3. Conduct or arrange for psy-

chological testing to further

assess ADD, other possible

psychopathology (e.g., anxiety,

depression), and relevant rule-

outs (e.g., ADHD, conduct/

antisocial features); provide

feedback of testing results.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

3. Cooperate with and complete a

psychiatric evaluation. (4)

4. Arrange for a psychiatric

evaluation of the client to rule

out medical and substance-

related etiologies and assess

his/her need for psychotropic

medication.

4. Comply with all recom-

mendations based on the

psychiatric and/or psychological

evaluations. (5, 6)

5. Process the results of the

psychiatric evaluation and/or

psychological testing with the

client and answer any questions

that may arise.

6. Conduct a conjoint session with

significant others and the client

to present the results of the

psychological and psychiatric

evaluations; answer any

questions they may have

and solicit their support in

dealing with the client’s

condition.

5. Disclose any history of substance

use that may contribute to and

complicate the treatment of

ADD. (7)

7. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

6. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature

of the therapy relationship.

(8, 9, 10, 11)

8. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

ATTENTION DEFICIT DISORDER (ADD)—ADULT

9. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

10. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

11. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

7. Take psychotropic medication as

prescribed, on a regular,

consistent basis. (12, 13)

12. Monitor and evaluate the

client’s psychotropic medication

prescription compliance, side

effects, and the effectiveness of

the medications on his/her level

of functioning.

13. Confer with the client’s

psychiatrist on a regular basis

regarding the effectiveness and

side effects of the medication

regimen.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

8. Identify specific benefits of

taking prescribed psychotropic

medications on a long-term

basis. (14, 15)

14. Ask the client to make a “pros

and cons” spreadsheet regarding

staying on psychotropic

medications; process the results.

15. Encourage and support the client

in remaining on psychotropic

medication and warmly but

firmly confront thoughts of

discontinuing when they surface

(or assign “Why I Dislike Taking

My Medication” in the Adult

Psychotherapy Homework

Planner by Jongsma).

9. Identify the current specific

ADD behaviors that cause the

most difficulty. (16, 17, 18)

16. Assist the client in identifying the

current specific behaviors that

cause him/her the most difficulty

functioning as part of identifying

treatment targets (i.e., a func-

tional analysis).

17. Review the results of

psychological testing and/or

psychiatric evaluation again with

the client assisting in identifying

or in affirming his/her choice of

the most problematic behavior(s)

to address.

18. Ask the client to have extended

family members and close

collaterals complete a ranking

of the behaviors they see as

interfering the most with his/her

daily functioning (e.g., mood

swings, temper outbursts, easily

stressed, short attention span,

never completes projects).

10. List the negative consequences o

the ADD problematic behavior.

(19)

19. Assign the client to make a list of

negative consequences that

he/she has experienced or that

could result from a continuation

of the problematic behavior;

process the list (or assign

“Impulsive Behavior Journal” in

the Adult Psychotherapy

Homework Planner by Jongsma).

ATTENTION DEFICIT DISORDER (ADD)—ADULT

11. Invite a significant other to join

in the therapy to provide support

throughout therapy. (20, 21)

20. Direct the client to invite a

significant other to participate in

the therapy; train the significant

other throughout therapy to help

support the change and reduce

friction in the relationship

introduced by the ADHD.

21. Instruct the client’s significant

other in the HOPE technique

(i.e., Help, Obligations, Plans,

and Encouragement) to help

support the client’s positive

changes (see Driven to Distraction

by Hallowell and Ratey).

12. Increase knowledge of ADHD

and its treatment. (22, 23, 24)

22. Educate the client about the signs

and symptoms of ADHD and

how they disrupt functioning

through the influence of

distractibility, poor planning

and organization, maladaptive

thinking, frustration, impulsivity,

and possible procrastination.

23. Discuss a rationale for treatment

where the focus will be improve-

ment in organizational and

planning skills, management

of distractibility, cognitive

restructuring, and overcoming

procrastination (see Mastering

Your Adult ADHD: Therapist

Manual by Safren et al.).

24. Assign the client readings

consistent with the treatment

model to increase their

knowledge of ADHD and its

treatment (e.g., Mastering Your

Adult ADHD: Client Workbook

by Safren et al; The Attention

Deficit Disorder in Adults

Workbook by Weis).

13. Read self-help books about

ADHD to improve

25. Assign the client self-help

readings that help facilitate the

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

understanding of the condition

and its features. (25)

client’s understanding of ADHD

(e.g., Driven to Distraction by

Hallowell and Ratey; ADHD:

Attention-Deficit Hyperactivity

Disorder in Children,

Adolescents, and Adults by

Wender; Putting on the Brakes

by Quinn and Stern; You Mean

I’m Not Lazy, Stupid or Crazy?

by Kelly and Ramundo); process

the material read.

14. Learn and implement

organization and planning skills.

(26, 27, 28, 29)

26. Teach the client organization

and planning skills including the

routine use of a calendar and

daily task list.

27. Develop with the client a

procedure for classifying and

managing mail and other

papers.

28. Teach the client problem-solving

skills (i.e., identify problem,

brainstorm all possible options,

evaluate the pros and cons of

each option, select best option,

implement a course of action,

and evaluate results) as an

approach to planning; for

each plan, break it down into

manageable time-limited steps

to reduce the influence of

distractibility.

29. Assign homework (e.g.,

“Problem-Solving: An

Alternative to Impulsive Action”

in the Adult Psychotherapy

Homework Planner by Jongsma)

asking the client to apply

problem-solving skills to an

everyday problem (i.e., impulse

control, anger outbursts, mood

swings, staying on task,

attentiveness); review and

provide corrective feedback

toward improving the skill.

ATTENTION DEFICIT DISORDER (ADD)—ADULT

15. Learn and implement skills to

reduce the disruptive influence o

distractibility. (30, 31, 32, 33)

30. Assess the client’s typical

attention span by having them

do a few “boring” tasks (e.g.,

sorting bills, reading something

uninteresting) to the point that

they report distraction; use this

as an approximate measure of

their typical attention span.

31. Teach the client stimulus control

techniques that use external

structure (e.g., lists, reminders,

files, daily rituals) to improve

on-task behavior; remove

distracting stimuli in the

environment; encourage the

client to reward himself/herself

for successful focus and follow-

through.

32. Teach the client to break down

tasks into meaningful smaller

units that can be completed

without being distracted based

on their demonstrated attention

span.

33. Teach the client to use timers or

other cues to remind him/her to

stop tasks before he/she gets

distracted in an effort to reduce

the time they may be distracted

and off-task (see Mastering Your

Adult ADHD: Therapist Guide

by Safren et al.).

16. Identify, challenge, and change

self-talk that contributes to

maladaptive feelings and actions.

(34, 35)

34. Use cognitive therapy techniques

to help client identify maladap-

tive self-talk (e.g., “I must do this

perfectly,” “I can do this later,”

“I can’t organize all these

things”); challenge biases,

and generate alternatives.

35. Assign homework asking client

to implement cognitive

restructuring skills while doing

tasks in which maladaptive

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

thinking has occurred

previously; review and provide

corrective feedback toward

improving the skills.

17. Acknowledge procrastination

and the need to reduce it. (36)

36. Assist the client in identifying

positives and negatives of

procrastinating toward the goal

of engaging him/her in staying

focused.

18. Learn and implement skills to

reduce procrastination.

(37, 38, 39)

37. Teach the client to apply new

problem-solving skills to

planning as a first step in

overcoming procrastination;

for each plan, break it down

into manageable time-limited

steps to reduce the influence of

distractibility.

38. Teach the client to apply new

cognitive restructuring skills

to challenge thoughts that

encourage the use of procras-

tination (e.g., “I can do this

later” or “I’ll finish this after

I watch my TV show”) and

embrace thoughts encouraging

action.

39. Assign homework asking the

client to accomplish identified

tasks without procrastination

using the techniques learned in

therapy; review and provide

corrective feedback toward

improving the skill and

decreasing procrastination.

19. Combine skills learned in

therapy into a new daily

approach to managing ADHD.

(40, 41, 42)

40. Teach the client meditational

and self-control strategies (e.g.,

“stop, look, listen, and think”)

to delay the need for instant

gratification and inhibit impulses

to achieve more meaningful,

longer-term goals.

41. Select situations in which the

client will be increasingly

ATTENTION DEFICIT DISORDER (ADD)—ADULT

challenged to apply his/her new

strategies for managing ADHD,

starting with situations highly

likely to be successful.

42. Use any of several techniques,

including imagery, behavioral

rehearsal, modeling, role-

playing, or in vivo exposure/

behavioral experiments to help

the client consolidate the use of

his/her new ADHD management

skills.

20. Implement relaxation procedures

to reduce tension and physical

restlessness. (43)

43. Instruct the client in various

relaxation techniques (e.g., deep

breathing, meditation, guided

imagery) and encourage him/her

to use them daily or when stress

increases (recommend The

Relaxation and Stress Reduction

Workbook by Davis, Robbins-

Eshelman, and McKay).

21. Cooperate with brainwave

biofeedback (neurotherapy) to

improve impulse control and

reduce distractibility. (44, 45)

44. Conduct, refer for, or administer

EEG biofeedback (neurotherapy)

to improve attention span,

impulse control, and mood

regulation.

45. Encourage the client to transfer

the biofeedback training skills of

relaxation and cognitive focusing

to everyday situations (e.g.,

home, work, social).

22. List coping skills that will be

used to manage ADD

symptoms. (46)

46. Review with the client the

symptoms that have been

problematic and the newly

learned coping skills he/she will

use to manage the symptoms

(or assign “Symptoms and

Fixes for ADD” in the Adult

Psychotherapy Homework

Planner by Jongsma).

23. Attend an ADD support group

with or without significant other.

(47)

47. Refer the client to a specific

group therapy for adults with

ADD to increase the client’s

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

understanding of ADD, to boost

his/her self-esteem, and to obtain

feedback from others; encourage

inclusion of significant other.

24. Report improved listening skills

without defensiveness. (48)

48. Use role-playing and modeling

to teach the client how to listen

and accept feedback from others

regarding his/her behavior.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

314.00 Attention-Deficit/Hyperactivity Disorder,

Predominantly Inattentive Type

314.01 Attention-Deficit/Hyperactivity Disorder,

Predominantly Hyperactive-Impulsive Type

314.9 Attention-Deficit/Hyperactivity Disorder

NOS

296.xx Bipolar I Disorder

301.13 Cyclothymic Disorder

296.90 Mood Disorder NOS

312.30 Impulse-Control Disorder NOS

303.90 Alcohol Dependence

305.00 Alcohol Abuse

304.30 Cannabis Dependence

305.20 Cannabis Abuse

_____

_____________________________________

_____

_____________________________________

ATTENTION DEFICIT DISORDER (ADD)—ADULT

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

314.00 F90.0 Attention-Deficit/Hyperactivity Disorder,

Predominately Inattentive Presentation

314.01 F90.1 Attention-Deficit/Hyperactivity Disorder,

Predominately Hyperactive/Impulsive

Presentation

314.01 F90.9 Unspecified Attention-

Deficit/Hyperactivity Disorder

314.01 F90.8 Other Specified Attention-

Deficit/Hyperactivity Disorder

296.xx F31.xx Bipolar I Disorder

301.13 F34.0 Cyclothymic Disorder

312.9 F91.9 Unspecified Disruptive, Impulse Control,

and Conduct Disorder

312.89 F91.8 Other Specified Disruptive, Impulse

Control, and Conduct Disorder

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

305.00 F10.10 Alcohol Use Disorder, Mild

304.30 F12.20 Cannabis Use Disorder, Moderate or

Severe

305.20 F12.10 Cannabis Use Disorder, Mild

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

BIPOLAR DISORDER—DEPRESSION

BEHAVIORAL DEFINITIONS

1. Depressed or irritable mood.

2. Decrease or loss of appetite.

3. Diminished interest in or enjoyment of activities.

4. Psychomotor agitation or retardation.

5. Sleeplessness or hypersomnia.

6. Lack of energy.

7. Poor concentration and indecisiveness.

8. Social withdrawal.

9. Suicidal thoughts and/or gestures.

10. Feelings of hopelessness, worthlessness, or inappropriate guilt.

11. Low self-esteem.

12. Unresolved grief issues.

13. Mood-related hallucinations or delusions.

14. History of chronic or recurrent depression for which the client has taken

antidepressant medication, been hospitalized, had outpatient treatment,

or had a course of electroconvulsive therapy.

15. History of at least one hypomanic, manic, or mixed mood episode.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Alleviate depressive symptoms and return to previous level of effective

functioning.

BIPOLAR DISORDER—DEPRESSION

2. Develop healthy thinking patterns and beliefs about self, others, and the

world that lead to the alleviation and help prevent the relapse of

depression.

3. Develop healthy interpersonal relationships that lead to the alleviation

and help prevent the relapse of depression.

4. Appropriately grieve the loss in order to normalize mood and to return

to previously adaptive level of functioning.

5. Normalize energy level and return to usual activities, good judgment,

stable mood, more realistic expectations, and goal-directed behavior.

6. Achieve controlled behavior, moderated mood, more deliberative speech

and thought process, and a stable daily activity pattern.

7. Develop healthy cognitive patterns and beliefs about self and the world

that lead to alleviation and help prevent the relapse of mood episodes.

8. Talk about underlying feelings of low self-esteem or guilt and fears of

rejection, dependency, and abandonment.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe mood state, energy

level, amount of control over

thoughts, and sleeping pattern.

(1, 2)

1. Encourage the client to share

his/her thoughts and feelings;

express empathy and build

rapport while assessing primary

cognitive, behavioral, interper-

sonal, or other symptoms of the

mood disorder.

2. Assess presence, severity, and

impact of past and present mood

episodes on social, occupational,

and interpersonal functioning;

supplement with semi-structured

inventory, if desired (e.g.,

Montgomery-Asberg Depression

Rating Scale, Inventory to

Diagnose Depression).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

2. Complete psychological testing

to assess the nature and impact

of mood problems. (3)

3. Arrange for the administration

of an objective instrument(s)

for evaluating relevant features

of the bipolar disorder such as

symptoms, communication

patterns with family/significant

others, expressed emotion (e.g.,

Beck Depression Inventory–II

and/or Beck Hopelessness Scale;

Perceived Criticism Measure);

evaluate results and process

feedback with the client or client

and family; readminister as

indicated to assess treatment

response.

3. Disclose any history of substance

use that may contribute to and

complicate the treatment of

bipolar depression. (4)

4. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in

this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

BIPOLAR DISORDER—DEPRESSION

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Verbalize any history of past and

present suicidal thoughts and

actions. (9)

9. Assess the client’s history of

suicidality and current state of

suicide risk (see the Suicidal

Ideation chapter in this Planner

if suicide risk is present).

6. State no longer having thoughts

of self-harm. (10, 11)

10. Continuously assess and monitor

the client’s suicide risk.

11. Arrange for or continue

hospitalization if the client is

judged to be potentially harmful

to self or others, unable to care

for his/her own basic needs, or

symptom severity warrants it.

7. Cooperate with a medical/

psychiatric evaluation for

12. Arrange for an evaluation with

a psychiatrist to determine

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

medication needs to stabilize

symptoms. (12)

appropriate pharmacotherapy

(e.g., lithium carbonate,

Depakote, Lamictal).

8. Take prescribed medications as

directed. (13, 14)

13. Monitor the client for

psychotropic medication

prescription compliance, side

effects, and effectiveness.

14. Monitor the client’s symptom

improvement toward stabilization

sufficient to allow participation in

psychotherapy.

9. Achieve a level of symptom

stability that allows for

meaningful participation in

psychotherapy. (15)

15. Provide psychoeducation to

the client and family using all

modalities necessary, including

reviewing the signs, symptoms,

and phasic relapsing nature

of the client’s mood episodes;

destigmatize and normalize.

10. Verbalize an understanding of

the causes for, symptoms of,

and treatment of mixed and/or

depressive bipolar episodes.

(16, 17)

16. Teach the client a stress diathesis

model of bipolar disorder that

emphasizes the strong role of

a biological predisposition to

mood episodes that is vulnerable

to stresses that are manageable

and the need for medication

compliance.

17. Provide the client with a

rationale for treatment involving

ongoing medication and

psychosocial treatment to

recognize, manage, and reduce

biological and psychological

vulnerabilities that could

precipitate relapse.

11. Verbalize acceptance of the need

to take psychotropic medication

and commit to prescription

compliance with blood level

monitoring. (18, 19)

18. Educate the client about the

importance of medication

compliance; teach him/her the

risk for relapse when medication

is discontinued and work toward

a commitment to prescription

adherence.

BIPOLAR DISORDER—DEPRESSION

19. Assess factors (e.g., thoughts,

feelings, stressors) that have

precipitated the client’s

prescription noncompliance;

develop a plan for recognizing

and addressing them (see “Why I

Dislike Taking My Medication”

in the Adult Psychotherapy

Homework Planner by

Jongsma).

12. Attend group psychoeducational

sessions designed to inform

members of the nature, causes,

and treatment of bipolar

disorder. (20, 21)

20. Conduct or refer the client to a

group psychoeducation program

that teaches clients the psycho-

logical, biological, and social

influences in development of

bipolar disorder, its biological

and psychological treatment (see

the Psychoeducation Manual for

Bipolar Disorder by Colom and

Vieta).

21. Teach the group members illness

management skills (e.g., early

warning signs, common triggers,

coping strategies), problem-

solving focused on life goals,

and a personal care plan that

emphasizes a regular sleep

routine, the need to comply

with medication, and ways to

minimize relapse through stress

regulation.

13. Client and family members

verbalize an understanding of

bipolar disorder, factors that

influence it, the role of

medication and therapy. (22)

22. Conduct Family-Focused

Treatment with the client and

significant others beginning with

psychoeducation emphasizing

the biological nature of bipolar

disorder, the need for medication

and medication adherence, risk

factors for relapse such as

personal and interpersonal

triggers, and the importance of

effective communication,

problem-solving, and early

episode intervention (see Bipolar

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

Disorder by Miklowitz and

Goldstein).

14. Family members implement

skills that help manage the

client’s bipolar disorder and

improve the quality of life of the

family and its members.

(23, 24, 25, 26, 27)

23. Assess and educate the client and

family about the role of aversive

communication (e.g., high

expressed emotion) in family

distress and risk for the client’s

relapse.

24. Use cognitive-behavioral

techniques (education, modeling,

role-playing, corrective feedback,

and positive reinforcement) to

teach family members communi-

cation skills, including: offering

positive feedback, active listening,

making positive requests of

others for behavior change, and

giving constructive feedback in

an honest and respectful manner

while reducing negative expressed

emotion.

25. Assist the client and family in

identifying conflicts that can be

addressed with problem-solving

techniques.

26. Use cognitive-behavioral

techniques (education, modeling,

role-playing, corrective feedback,

and positive reinforcement)

to teach the client and family

problem-solving skills, including:

defining the problem con-

structively and specifically;

brainstorming solution options;

evaluating options; choosing an

option and implementing a plan;

evaluating the results; and

adjusting the plan.

27. Assign the client and family

homework exercises to use and

record use of newly learned

communication and problem-

solving skills; process results in

BIPOLAR DISORDER—DEPRESSION

session toward effective use;

problem-solve obstacles; (see

“Plan Before Acting” or

“Problem-Solving: An

Alternative to Impulsive Action”

in the Adult Psychotherapy

Homework Planner by Jongsma);

process results in session.

15. Develop a “relapse drill” in

which roles, responsibilities, and

a course of action is agreed upon

in the event that signs of relapse

emerge. (28)

28. Help the client and family draw

up a “relapse drill” detailing

roles and responsibilities (e.g.,

who will call a meeting of the

family to problem-solve

potential relapse; who will call

the client’s physician, schedule a

serum level to be taken, or

contact emergency services, if

needed); problem-solve obstacles

and work toward a commitment

to adherence with the plan.

16. Identify and replace thoughts

and behaviors that trigger manic

or depressive symptoms.

(29, 30, 31)

29. Use cognitive therapy techniques

to explore and educate the client

about cognitive biases that

trigger his/her elevated or

depressive mood (see Cognitive

Therapy for Bipolar Disorder

by Lam et al.).

30. Assign the client a homework

exercise in which he/she identifies

self-talk reflective of mania,

biases in the self-talk,

alternatives (see “Journal

and Replace Self-Defeating

Thoughts” in the Adult

Psychotherapy Homework

Planner by Jongsma); review

and reinforce success, providing

corrective feedback toward

improvement.

31. Teach the client cognitive-

behavioral coping and relapse

prevention skills including

delaying impulsive actions,

structured scheduling of daily

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

activities, keeping a regular sleep

routine, avoiding unrealistic goal

striving, using relaxation

procedures, identifying and

avoiding episode triggers such

as stimulant drug use, alcohol

consumption, breaking sleep

routine, or exposing self to high

stress (see Cognitive Therapy

for Bipolar Disorder by Lam

et al.).

17. Maintain a pattern of regular

rhythm to daily activities.

(32, 33, 34, 35)

32. Conduct Interpersonal and

Social Rhythm Therapy

beginning with the assessment

of the client’s daily activities

using an interview and the Social

Rhythm Metric (see Treating

Bipolar Disorder by Frank).

33. Assist the client in establishing a

more routine pattern of daily

activities such as sleeping, eating,

solitary and social activities, and

exercise; use and review a form

to schedule, assess, and modify

these activities so that they occur

in a predictable rhythm every

day.

34. Teach the client about the

importance of good sleep

hygiene (see “Sleep Pattern

Record” in the Adult Psycho-

therapy Homework Planner by

Jongsma); assess and intervene

accordingly (see the Sleep

Disturbance chapter in this

Planner).

35. Engage the client in a balanced

schedule of “behavioral

activation” by scheduling

rewarding activities while not

over-stimulating; (see “Identify

and Schedule Pleasant

Activities” in the Adult

Psychotherapy Homework

BIPOLAR DISORDER—DEPRESSION

Planner by Jongsma); use

activity and mood monitoring

to facilitate an optimal balance

of activity; reinforce success.

18. Discuss and resolve troubling

personal and interpersonal

issues. (36, 37, 38)

36. Conduct the interpersonal

component of Interpersonal

and Social Rhythm Therapy

beginning with the assessment

the client’s current and past

significant relationships; assess

for themes related to grief,

interpersonal role disputes,

interpersonal role transitions,

and interpersonal skills deficits

(see Treating Bipolar Disorder

by Frank).

37. Use interpersonal therapy

techniques to explore and resolve

issues surrounding grief, role

disputes, role transitions, and

social skills deficits; provide

support and strategies for

resolving identified interpersonal

issues.

38. Establish a “rescue protocol”

with the client and significant

others to identify and manage

clinical deterioration; include

medication use, sleep pattern

restoration, maintaining a daily

routine and conflict-free social

support.

19. Participate in periodic

“maintenance” sessions. (39)

39. Hold periodic “maintenance”

sessions within the first few

months after therapy to facilitate

the client’s positive changes;

problem-solve obstacles to

improvement.

20. Increase understanding of

bipolar illness by reading a book

on the disorder. (40)

40. Ask the client to read a book

on bipolar disorder to reinforce

psychoeducation done in session

(e.g., The Bipolar Disorder

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

Survival Guide by Miklowitz;

Bipolar 101: A Practical Guide to

Identifying Triggers, Managing

Medications, Coping with

Symptoms, and More by White

and Preston); review and process

concepts learned through the

reading.

21. Differentiate between real and

imagined losses, rejections, and

abandonments. (41, 42, 43)

41. Pledge to be there consistently to

help, listen to, and support the

client.

42. Explore the client’s fears of

abandonment by sources of love

and nurturance.

43. Help the client differentiate

between real and imagined,

actual and exaggerated losses.

22. Verbalize grief, fear, and anger

regarding real or imagined losses

in life. (44, 45, 46)

44. Probe real or perceived losses in

the client’s life.

45. Review ways for the client to

replace the losses and put them

in perspective.

46. Probe the causes for the

client’s low self-esteem and

abandonment fears in the family-

of-origin history.

23. Use mindfulness and acceptance

strategies to reduce experiential

and cognitive avoidance and

increase value-based behavior.

(47)

47. Conduct Acceptance and

Commitment Therapy (see ACT

for Depression by Zettle)

including mindfulness strategies

to help the client decrease

experiential avoidance,

disconnect thoughts from

actions, accept one’s experience

rather than change or control

symptoms, and behave according

to his/her broader life values;

assist the client in clarifying

his/her goals and values and

commit to behaving

accordingly).

BIPOLAR DISORDER—DEPRESSION

24. Increasingly verbalize hopeful

and positive statements

regarding self, others, and the

future (48, 49)

48. Assign the client to write at least

one positive affirmation

statement daily regarding

himself/herself and the future

(see “Positive Self-Talk” in the

Adult Psychotherapy Homework

Planner by Jongsma).

49. Teach the client more about

depression and how to recognize

and accept some sadness as a

normal variation in feeling.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

296.xx Bipolar I Disorder

296.89 Bipolar II Disorder

301.13 Cyclothymic Disorder

295.70 Schizoaffective Disorder

296.80 Bipolar Disorder NOS

310.1 Personality Change Due to Axis III Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

296.xx F31.1x Bipolar I Disorder, Manic

296.89 F31.81 Bipolar II Disorder

301.13 F34.0 Cyclothymic Disorder

295.70 F25.1 Schizoaffective Disorder, Depressive Type

296.80 F31.9 Unspecified Bipolar and Related Disorder

310.1 F07.0 Personality Change Due to Another

Medical Condition

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

BIPOLAR DISORDER—MANIA

BEHAVIORAL DEFINITIONS

1. Exhibits an abnormally and persistently elevated, expansive, or irritable

mood with at least three symptoms of mania (i.e., inflated self-esteem or

grandiosity, decreased need for sleep, pressured speech, flight of ideas,

distractibility, excessive goal-directed activity or psychomotor agitation,

excessive involvement in pleasurable, high-risk behavior).

2. The elevated mood or irritability (mania) causes marked impairment in

occupational functioning, social activities, or relationships with others.

3. Demonstrates loquaciousness or pressured speech.

4. Reports flight of ideas or thoughts racing.

5. Verbalizes grandiose ideas and/or persecutory beliefs.

6. Shows evidence of a decreased need for sleep.

7. Reports little or no appetite.

8. Exhibits increased motor activity or agitation.

9. Displays a poor attention span and is easily distracted.

10. Loss of normal inhibition leads to impulsive and excessive pleasure-

oriented behavior without regard for painful consequences.

11. Engages in bizarre dress and grooming patterns.

12. Exhibits an expansive mood that can easily turn to impatience and

irritable anger if goal-oriented behavior is blocked or confronted.

13. Lacks follow-through in projects, even though energy is very high, since

behavior lacks discipline and goal-directedness.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

LONG-TERM GOALS

1. Alleviate manic/hypomanic mood and return to previous level of effective

functioning.

2. Normalize energy level and return to usual activities, good judgment,

stable mood, more realistic expectations, and goal-directed behavior.

3. Reduce agitation, impulsivity, and pressured speech while achieving

sensitivity to the consequences of behavior and having more realistic

expectations.

4. Achieve controlled behavior, moderated mood, more deliberative speech

and thought process, and a stable daily activity pattern.

5. Develop healthy cognitive patterns and beliefs about self and the world

that lead to alleviation and help prevent the relapse of manic/hypomanic

episodes.

6. Talk about underlying feelings of low self-esteem or guilt and fears of

rejection, dependency, and abandonment.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe mood state, energy

level, amount of control over

thoughts, and sleeping pattern.

(1, 2)

1. Encourage the client to share

his/her thoughts and feelings;

express empathy, and build

rapport while assessing primary

cognitive, behavioral, interper-

sonal, or other symptoms of the

mood disorder.

2. Assess presence, severity, and

impact of past and present mood

episodes including mania (i.e.,

pressured speech, impulsive

behavior, euphoric mood, flight

of ideas, reduced need for sleep,

inflated self-esteem, and high

energy) on social, occupational,

and interpersonal functioning;

BIPOLAR DISORDER—MANIA

supplement with semi-structured

inventory, if desired (e.g., Young

Mania Rating Scale; the Clinical

Monitoring Form); readminister

as indicated to assess treatment

response.

2. Complete psychological testing

to assess the nature and impact

of mood problems. (3)

3. Arrange for the administration

of an objective instrument(s) for

evaluating relevant features of

the bipolar disorder such as

communication patterns with

family/significant others,

particularly expressed emotion

(e.g., Perceived Criticism

Measure); evaluate the results

and process feedback with the

client or client and family.

3. Disclose any history of substance

use that may contribute to and

complicate the treatment of

bipolar mania. (4)

4. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Cooperate with a medical/

psychiatric evaluation for

medication needs and possible

hospitalization to stabilize

symptoms. (9, 10)

9. Arrange for or continue

hospitalization if the client is

judged to be potentially harmful

to self or others, unable to care

for his/her own basic needs, or

symptom severity warrants it.

10. Arrange for a medication

evaluation with a psychiatrist to

determine appropriate pharma-

cotherapy (e.g., lithium carbonate,

Depakote, Lamictal).

6. Take prescribed medications as

directed. (11, 12)

11. Monitor the client for use and

effectiveness of psychotropic

BIPOLAR DISORDER—MANIA

medication (e.g., compliance,

side effects, and effectiveness).

12. Continually evaluate the client’s

compliance with the psycho-

tropic medication prescription.

7. Achieve a level of symptom

stability that allows for

meaningful participation in

psychotherapy. (13)

13. Monitor the client’s symptom

improvement toward

stabilization sufficient to allow

participation in individual or

group psychotherapy.

8. Verbalize an understanding of

the causes for, symptoms of, and

treatment of manic, hypomanic,

and/or mixed episodes.

(14, 15, 16)

14. Provide psychoeducation to the

client and family, using all

modalities necessary, including

reviewing the signs, symptoms,

and phasic relapsing nature of

the client’s manic mood

episodes; destigmatize and

normalize (see Psychoeducation

Manual for Bipolar Disorder by

Colom and Vieta).

15. Teach the client a stress diathesis

model of bipolar disorder that

emphasizes the strong role of

a biological predisposition to

mood episodes that is vulnerable

to stresses that are manageable

and the need for medication

compliance.

16. Provide the client with a

rationale for treatment

involving ongoing medication

and psychosocial treatment to

recognize, manage, and reduce

biological and psychological

vulnerabilities that could

precipitate relapse.

9. Verbalize acceptance of the need

to take psychotropic medication

and commit to prescription

compliance with blood level

monitoring. (17, 18)

17. Educate the client about the

importance of medication

compliance; teach him/her the

risk for relapse when medication

is discontinued, and work

toward a commitment to

prescription adherence.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

18. Assess factors (e.g., thoughts,

feelings, stressors) that have

precipitated the client’s

prescription noncompliance;

develop a plan for recognizing

and addressing them (or assign

“Why I Dislike Taking My

Medication” in the Adult

Psychotherapy Homework

Planner by Jongsma).

10. Attend group psychoeducational

sessions designed to inform

members of the nature, causes,

and treatment of bipolar

disorder. (19, 20)

19. Conduct or refer client to

a group psychoeducation

program that teaches clients the

psychological, biological, and

social influences in development

of BPD, its biological and

psychological treatment (see

Structured Group Psychotherapy

for Bipolar Disorder by Bauer

and McBride; Psychoeducation

Manual for Bipolar Disorder by

Colom and Vieta).

20. Teach the group members illness

management skills (e.g., early

warning signs, common triggers,

coping strategies), problem-

solving focused on life goals,

and a personal care plan that

emphasizes a regular sleep

routine, the need to comply

with medication, and ways to

minimize relapse through stress

regulation.

11. Identify and replace thoughts

and behaviors that trigger manic

or depressive symptoms.

(21, 22, 23)

21. Use cognitive therapy techniques

to explore and educate the

client’s about cognitive biases

that trigger his/her elevated or

depressive mood (see Cognitive

Therapy for Bipolar Disorder by

Lam et al.).

22. Assign the client a homework

exercise in which he/she identifies

self-talk reflective of mania, biases

BIPOLAR DISORDER—MANIA

in the self-talk, alternatives (or

assign “Journal and Replace Self-

Defeating Thoughts” in the Adult

Psychotherapy Homework Planner

by Jongsma); review and reinforce

success, providing corrective

feedback toward improvement.

23. Teach the client cognitive

behavioral coping and relapse

prevention skills including

delaying impulsive actions,

structured scheduling of daily

activities, keeping a regular sleep

routine, avoiding unrealistic goal

striving, using relaxation

procedures, identifying and

avoiding episode triggers such as

stimulant drug use, alcohol

consumption, breaking sleep

routine, or exposing self to high

stress (see Cognitive Therapy for

Bipolar Disorder by Lam et al.).

12. Client and family members

verbalize an understanding of

bipolar disorder, factors that

influence it, and the role of

medication and therapy. (24, 25)

24. Conduct Family-Focused

Treatment with the client and

significant others beginning with

psychoeducation emphasizing

the biological nature of bipolar

disorder, the need for medication

and medication adherence, risk

factors for relapse such as

personal and interpersonal

triggers, and the importance

of effective communication,

problem-solving, and early

episode intervention (see Bipolar

Disorder by Miklowitz and

Goldstein).

25. Assess and educate the client and

family about the role of aversive

communication (e.g., high

expressed emotion) in family

distress and risk for the client’s

relapse.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

13. Family members implement

skills that help manage the

client’s bipolar disorder and

improve the quality of life of

the family and its members.

(26, 27, 28, 29)

26. Use cognitive-behavioral

techniques (education, modeling,

role-playing, corrective feedback,

and positive reinforcement) to

teach family members communi-

cation skills, including offering

positive feedback, active listening,

making positive requests of

others for behavior change, and

giving constructive feedback in an

honest and respectful manner.

27. Assist the client and family in

identifying conflicts that can be

addressed with problem-solving

techniques.

28. Use cognitive-behavioral

techniques (education, modeling,

role-playing, corrective feedback,

and positive reinforcement)

to teach the client and family

problem-solving skills, including

defining the problem con-

structively and specifically,

brainstorming solution options,

evaluating the pros and cons of

each option, choosing an option

and implementing a plan,

evaluating the results, and

adjusting the plan.

29. Assign the client and family

homework exercises to use and

record use of newly learned

communication and problem-

solving skills (or assign “Plan

Before Acting” or “Problem-

Solving: An Alternative to

Impulsive Action” in the Adult

Psychotherapy Homework

Planner by Jongsma); process

results in session toward effective

use; problem-solve obstacles.

14. Develop a “relapse drill” in

which roles, responsibilities, and

a course of action is agreed upon

30. Help the client and family draw

up a “relapse drill” detailing

roles and responsibilities

BIPOLAR DISORDER—MANIA

in the event that signs of relapse

emerge. (30)

(e.g., who will call a meeting of

the family to problem-solve

potential relapse; who will call

the client’s physician, schedule

a serum level to be taken, or

contact emergency services, if

needed); problem-solve obstacles

and work toward a commitment

to adherence with the plan.

15. Maintain a pattern of regular

rhythm to daily activities.

(31, 32, 33, 34)

31. Conduct Interpersonal and

Social Rhythm Therapy

beginning with the assessment of

the client’s daily activities using

an interview and the Social

Rhythm Metric (see Treating

Bipolar Disorder by Frank).

32. Assist the client in establishing

a more routine pattern of daily

activities such as sleeping, eating,

solitary and social activities, and

exercise; use and review a form

to schedule, assess, and modify

these activities so that they occur

in a predictable rhythm every

day.

33. Teach the client about the

importance of good sleep

hygiene (or assign “Sleep Pattern

Record” in the Adult Psycho-

therapy Homework Planner by

Jongsma); assess and intervene

accordingly (see the Sleep

Disturbance chapter in this

Planner).

34. Engage the client in a balanced

schedule of “behavioral

activation” by scheduling

rewarding activities while not

over-stimulating (see “Identify

and Schedule Pleasant

Activities” in the Adult

Psychotherapy Homework

Planner by Jongsma); use

activity and mood monitoring

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

to facilitate an optimal balance

of activity; reinforce success.

16. Discuss and resolve troubling

personal and interpersonal

issues. (35, 36, 37)

35. Conduct the interpersonal

component of Interpersonal

and Social Rhythm Therapy

beginning with the assessment

of the client’s current and past

significant relationships; assess

for themes related to grief,

interpersonal role disputes,

interpersonal role transitions,

and interpersonal skills deficits.

36. Use interpersonal therapy

techniques to explore and resolve

issues surrounding grief, role

disputes, role transitions, and

social skills deficits; provide

support and strategies for

resolving identified interpersonal

issues.

37. Establish a “rescue protocol”

with the client and significant

others to identify and manage

clinical deterioration; include

medication use, sleep pattern

restoration, maintaining a daily

routine, and conflict-free social

support.

17. Participate in periodic

“maintenance” sessions. (38)

38. Hold periodic “maintenance”

sessions within the first few

months after therapy to facilitate

the client’s positive changes;

problem-solve obstacles to

improvement.

18. Increase understanding of

bipolar illness by reading a book

on the disorder. (39)

39. Ask the client to read a book

on bipolar disorder to reinforce

psychoeducation done in session

(e.g., The Bipolar Disorder

Survival Guide by Miklowitz;

Bipolar 101: A Practical Guide to

Identifying Triggers, Managing

Medications, Coping with

Symptoms, and More by White

BIPOLAR DISORDER—MANIA

and Preston); review and process

concepts learned through the

reading.

19. Differentiate between real and

imagined losses, rejections, and

abandonments. (40, 41, 42)

40. Pledge to be there consistently to

help, listen to, and support the

client.

41. Explore the client’s fears of

abandonment by sources of love

and nurturance.

42. Help the client differentiate

between real and imagined,

actual and exaggerated losses.

20. Verbalize grief, fear, and anger

regarding real or imagined losses

in life. (43, 44)

43. Probe real or perceived losses in

the client’s life.

44. Review ways for the client to

replace the losses and put them

in perspective.

21. Acknowledge the low self-esteem

and fear of rejection that

underlie the braggadocio.

(45, 46)

45. Probe the causes for the

client’s low self-esteem and

abandonment fears in the family-

of-origin history.

46. Confront the client’s grandiosity

and demandingness gradually

but firmly; emphasize his/her

good qualities (or assign “What

Are My Good Qualities?” or

“Acknowledging My Strengths”

in the Adult Psychotherapy

Homework Planner by Jongsma).

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

296.xx Bipolar I Disorder

296.89 Bipolar II Disorder

301.13 Cyclothymic Disorder

295.70 Schizoaffective Disorder

296.80 Bipolar Disorder NOS

310.1 Personality Change Due to Axis III Disorder

_____

_____________________________________

_____

___________________________

_________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

296.xx F31.1x Bipolar I Disorder, Manic

296.89 F31.81 Bipolar II Disorder

301.13 F34.0 Cyclothymic Disorder

295.70 F25.0 Schizoaffective Disorder, Bipolar Type

296.80 F31.9 Unspecified Bipolar and Related Disorder

310.1 F07.0 Personality Change Due to Another

Medical Condition

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

BORDERLINE PERSONALITY DISORDER

BEHAVIORAL DEFINITIONS

1. A minor stress leads to extreme emotional reactivity (anger, anxiety, or

depression) that usually lasts from a few hours to a few days.

2. A pattern of intense, chaotic interpersonal relationships.

3. Marked identity disturbance.

4. Impulsive behaviors that are potentially self-damaging.

5. Recurrent suicidal gestures, threats, or self-mutilating behavior.

6. Chronic feelings of emptiness and boredom.

7. Frequent eruptions of intense, inappropriate anger.

8. Easily feels unfairly treated and believes that others can’t be trusted.

9. Analyzes most issues in simple, dichotomous terms (e.g., right/wrong,

black/white, trustworthy/deceitful) without regard for extenuating cir-

cumstances or complex situations.

10. Becomes very anxious with any hint of perceived abandonment in a

relationship.

11. Transient stress-related paranoid ideation or dissociation symptoms.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Develop and demonstrate coping skills to deal with mood swings.

2. Develop the ability to control impulsive behavior.

3. Replace dichotomous thinking with the ability to tolerate ambiguity and

complexity in people and issues.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

4. Develop and demonstrate anger management skills.

5. Learn and practice interpersonal relationship skills.

6. Terminate self-damaging behaviors (such as substance abuse, reckless

driving, sexual acting out, binge eating, or suicidal behaviors).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Discuss openly the history

of cognitive, emotional, and

behavioral difficulties that have

led to seeking treatment. (1, 2, 3)

1. Assess the client’s experiences

of distress and disability,

identifying behaviors (e.g.,

parasuicidal acts, angry

outbursts, overattachment),

affect (e.g., mood swings,

emotional overreactions, painful

emptiness), and cognitions (e.g.,

biases such as dichotomous

thinking, overgeneralization,

catastrophizing) that will become

the targets of therapy.

2. Explore the client’s history of

abuse and/or abandonment,

particularly in childhood years.

3. Validate the client’s distress and

difficulties as understandable

given his/her particular cir-

cumstances, thoughts, and

feelings.

2. Disclose any history of substance

use that may contribute to and

complicate the treatment of

borderline personality. (4)

4. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

BORDERLINE PERSONALITY DISORDER

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

4. Verbalize an accurate and

reasonable understanding of the

process of therapy and what the

therapeutic goals are. (9, 10)

9. Orient the client to Dialectical

Behavior Therapy (DBT),

highlighting its multiple facets

(e.g., support, collaboration, and

coping/personal/interpersonal

skills-building); its emphasis on

exchange and negotiation,

balancing the rational and

emotional, and acceptance and

change; as well as the dialectical/

biosocial view of borderline

personality, including

constitutional and social

influences (see Cognitive-

Behavioral Treatment of

Borderline Personality Disorder

by Linehan).

10. Throughout therapy, ask the

client to read selected sections of

books or manuals that reinforce

therapeutic interventions (e.g.,

Skills Training Manual for

Treating Borderline Personality

Disorder by Linehan).

5. Verbalize a decision to work

collaboratively with the therapist

toward the therapeutic goals.

(11)

11. Solicit from the client an agree-

ment to work collaboratively

within the parameters of the

DBT approach including staying

in therapy for the specified time

period, attending scheduled

therapy sessions, working

toward reducing suicidal

behaviors, and participating

in skills training to address

the behaviors, emotions, and

cognitions that have been

identified as causing problems

in his/her life.

BORDERLINE PERSONALITY DISORDER

6. Verbalize any history of self-

mutilation and suicidal urges

and behavior. (12, 13, 14, 15)

12. Probe the nature and history

of the client’s self-mutilating

behavior.

13. Assess the client’s suicidal

gestures as to triggers, frequency,

seriousness, secondary gain, and

onset.

14. Arrange for hospitalization,

as necessary, when the client is

judged to be harmful to self.

15. Provide the client with an

emergency helpline telephone

number that is available 24 hours

a day.

7. Promise to initiate contact

with the therapist or helpline

if experiencing a strong urge to

engage in self-harmful behavior.

(16, 17)

16. Interpret the client’s self-

mutilation as an expression of

the rage and helplessness that

could not be expressed as

a child victim of emotional

abandonment or abuse; express

the expectation that the client

will control his/her response to

the urge to self-mutilate.

17. Elicit a promise (as part of

a self-mutilation and suicide

prevention contract) from the

client that he/she will initiate

contact with the therapist or

a helpline if a suicidal urge

becomes strong and before any

self-injurious behavior occurs;

throughout the therapy process,

consistently assess the strength

of the client’s suicide potential.

8. Reduce actions that interfere

with participating in therapy.

(18)

18. Continuously monitor, confront,

and problem-solve client actions

that threaten to interfere with

the continuation of therapy

such as missing appointments,

noncompliance, and/or abruptly

leaving therapy.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

9. Cooperate with an evaluation

by a physician for psychotropic

medication and take medication,

if prescribed. (19, 20)

19. Assess the client’s need for

medication (e.g., selective

serotonin reuptake inhibitors)

and arrange for prescription,

if appropriate.

20. Monitor and evaluate the

client’s psychotropic medication

prescription compliance and the

effectiveness of the medication

on his/her level of functioning.

10. Reduce the frequency of

maladaptive behaviors,

thoughts, and feelings that

interfere with attaining a

reasonable quality of life. (21)

21. Use validation, dialectical

strategies (e.g., metaphor, devil’s

advocate), and cognitive-

behavioral strategies (e.g., cost-

benefit analysis, cognitive

restructuring, personal and

interpersonal skills training)

to help the client manage,

reduce, or regulate maladaptive

behaviors (e.g., angry outbursts,

binge drinking, abusive

relationships, high-risk sex,

uncontrolled spending), thoughts

(e.g., all-or-nothing thinking,

catastrophizing, personalizing),

and feelings (e.g., rage,

hopelessness, abandonment); see

Cognitive-Behavioral Treatment

of Borderline Personality

Disorder by Linehan).

11. Participate in a group

(preferably) or individual

personal/interpersonal skills

development course. (22, 23)

22. Conduct group or individual

skills training tailored to the

client’s identified problematic

behavioral patterns with an

emphasis on emotional

regulation, distress tolerance,

interpersonal effectiveness,

and mindfulness.

23. Use behavioral strategies to

teach identified skills (e.g.,

instruction, modeling, advising),

strengthen them (e.g., role-

playing, exposure exercises),

BORDERLINE PERSONALITY DISORDER

and facilitate incorporation into

the client’s everyday life (e.g.,

homework assignments).

12. Discuss previous or current

posttraumatic stress. (24)

24. After adaptive behavioral

patterns and emotional

regulation skills are evident,

work with the client on

remembering the facts of

previous trauma, reducing

avoidance or denial, increasing

insight into its effects, reducing

maladaptive emotional and/or

behavioral responses to trauma-

related stimuli, reducing self-

blame, and increasing

acceptance.

13. Identify, challenge, and replace

biased, fearful self-talk with

reality-based, positive self-talk.

(25, 26, 27)

25. Explore the client’s schema and

self-talk that mediates his/her

trauma-related and other fears;

identify and challenge biases;

assist him/her in generating

thoughts that correct for

the negative biases, accept

uncertainty, and build self-

confidence.

26. Assign the client a homework

exercise in which he/she identifies

fearful self-talk and creates

reality-based alternatives; review

and reinforce success, providing

corrective feedback for failure

(see “Journal and Replace Self-

Defeating Thoughts” in the

Adult Psychotherapy Homework

Planner by Jongsma or “Daily

Record of Dysfunctional

Thoughts” in Cognitive Therapy

of Depression by Beck, Rush,

Shaw, and Emery).

27. Reinforce the client’s positive,

reality-based cognitive messages

that reduce personal distress,

enhance self-confidence, and

increase adaptive action.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

14. Participate in imaginal and/or in

vivo exposure to trauma-related

memories until talking or

thinking about the trauma does

not cause marked distress.

(28, 29, 30, 31)

28. Direct and assist the client in

constructing a hierarchy of

feared and avoided trauma-

related stimuli.

29. Direct imaginal exposure to the

trauma in session by having

the client describe a chosen

traumatic experience at an

increasing, but client-chosen

level of detail; integrate cognitive

restructuring and repeat until

associated anxiety reduces and

stabilizes; record the session and

have the client listen to it

between sessions (see “Share the

Painful Memory” in the Adult

Psychotherapy Homework

Planner by Jongsma and

Dialectical Behavior Therapy

in Clinical Practice by Linehan,

Dimeff, and Koerner); review

and reinforce progress, problem-

solve obstacles.

30. Assign the client a homework

exercise in which he/she does an

exposure exercise and records

responses or listens to a

recording of an in-session

exposure (see Dialectical

Behavior Therapy in Clinical

Practice by Linehan, Dimeff,

and Koerner); review and

reinforce progress; problem-

solve obstacles.

31. For client with comorbid PTSD,

conduct prolonged exposure

therapy, cognitive processing

therapy, or eye movement

desensitization and reprocessing

(see the PTSD chapter in this

Planner).

15. Verbalize a sense of self-respect

that is not dependent on others’

opinions. (32)

32. Help the client to clarify, value,

believe, and trust in his/her

evaluations of himself/herself,

BORDERLINE PERSONALITY DISORDER

others, and situations and to

examine them nondefensively

and independent of others’

opinions in a manner that builds

self-reliance but does not isolate

the client from others.

16. Engage in practices that help

enhance a sustained sense of joy.

(33)

33. Facilitate the client’s personal

and interpersonal growth and

“capacity for sustained joy” by

helping him/her choose

experiences that strengthen self-

awareness, personal values, and

appreciation of life (e.g., engaging

in value-consistent activities,

spiritual practices, other relevant

life experiences).

17. Learn and apply problem-

solving skills to conflicts in daily

life. (34)

34. Teach the client problem-solving

skills (e.g., defining the problem

clearly, brainstorming multiple

solutions, listing the pros and

cons of each solution, seeking

input from others, selecting and

implementing a plan of action,

evaluating the outcome, and

readjusting the plan as

necessary); use role-playing and

modeling to apply this skill to

daily life situations (or assign

“Plan Before Acting” in the

Adult Psychotherapy Homework

Planner by Jongsma).

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.4 Dysthymic Disorder

296.3x Major Depressive Disorder, Recurrent

_____

_____________________________________

_____

_____________________________________

Axis II:

301.83 Borderline Personality Disorder

301.9 Personality Disorder NOS

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.4 F34.1 Persistent Depressive Disorder

296.3x F33.x Major Depressive Disorder, Recurrent

Episode

301.83 F60.3 Borderline Personality Disorder

301.9 F60.9 Unspecified Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

CHILDHOOD TRAUMA

BEHAVIORAL DEFINITIONS

1. Reports of childhood physical, sexual, and/or emotional abuse.

2. Description of parents as physically or emotionally neglectful as they were

chemically dependent, too busy, absent, etc.

3. Description of childhood as chaotic as parent(s) was substance abuser

(or mentally ill, antisocial, etc.), leading to frequent moves, multiple

abusive spousal partners, frequent substitute caretakers, financial

pressures, and/or many stepsiblings.

4. Reports of emotionally repressive parents who were rigid, perfectionist,

threatening, demeaning, hypercritical, and/or overly religious.

5. Irrational fears, suppressed rage, low self-esteem, identity conflicts,

depression, or anxious insecurity related to painful early life experiences.

6. Dissociation phenomenon (multiple personality, psychogenic fugue or

amnesia, trance state, and/or depersonalization) as a maladaptive coping

mechanism resulting from childhood emotional pain.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Develop an awareness of how childhood issues have affected and

continue to affect one’s family life.

2. Resolve past childhood/family issues, leading to less anger and depression,

greater self-esteem, security, and confidence.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

3. Release the emotions associated with past childhood/family issues,

resulting in less resentment and more serenity.

4. Let go of blame and begin to forgive others for pain caused in

childhood.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe what it was like to grow

up in the home environment.

(1, 2)

1. Actively build the level of trust

with the client in individual

sessions through consistent

eye contact, active listening,

unconditional positive regard,

and warm acceptance to help

increase his/her ability to identify

and express feelings.

2. Develop the client’s family

genogram and/or symptom line

and help identify patterns of

dysfunction within the family.

2. Acknowledge any dissociative

phenomena that have resulted

from childhood trauma. (3, 4)

3. Assist the client in understanding

the role of dissociation in

protecting himself/herself from

the pain of childhood abusive

betrayals (see the Dissociation

chapter in this Planner).

4. Assess the severity of the client’s

dissociation phenomena and

hospitalize as necessary for

his/her protection.

3. State the role substance abuse

has in dealing with emotional

pain of childhood. (5)

5. Assess the client’s substance

abuse behavior that has

developed, in part, as a means of

coping with feelings of childhood

CHILDHOOD TRAUMA

trauma. If alcohol or drug abuse

is found to be a problem,

encourage treatment focused on

this issue (see the Substance Use

chapter in this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (6, 7, 8, 9)

6. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgement

of the “problem described,”

is not concerned, and has no

motivation to change).

7. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

8. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

9. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

100

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Describe each family member

and identify the role each played

within the family. (10)

10. Assist the client in clarifying

his/her role within the family and

his/her feelings connected to that

role.

6. Identify patterns of abuse,

neglect, or abandonment within

the family of origin, both current

and historical, nuclear and

extended. (11, 12)

11. Assign the client to ask parents

about their family backgrounds

and develop insight regarding

patterns of behavior and causes

for parents’ dysfunction.

12. Explore the client’s painful

childhood experiences (or assign

“Share the Painful Memory”

in the Adult Psychotherapy

Homework Planner by Jongsma).

7. Identify feelings associated with

major traumatic incidents in

childhood and with parental

child-rearing patterns.

(13, 14, 15)

13. Support and encourage the client

when he/she begins to express

feelings of rage, sadness, fear,

and rejection relating to family

abuse or neglect.

14. Assign the client to record

feelings in a journal that

describes memories, behavior,

and emotions tied to his/her

traumatic childhood experiences

(or assign “How the Trauma

Affects Me” in the Adult

Psychotherapy Homework

Planner by Jongsma).

15. Ask the client to read books on

the emotional effects of neglect

and abuse in childhood (e.g., It

CHILDHOOD TRAUMA

Will Never Happen to Me by

Black; Outgrowing the Pain by

Gil; Healing the Child Within

by Whitfield); process insights

attained.

8. Identify how own parenting has

been influenced by childhood

experiences. (16)

16. Ask the client to compare his/her

parenting behavior to that

of parent figures of his/her

childhood; encourage the client

to be aware of how easily we

repeat patterns that we grew

up with.

9. Enroll in dialectical behavior

therapy. (17)

17. For the client whose current

distress and/or disability results

from borderline personality

disorder, provide or refer to

dialetical behavior therapist

(see the Borderline Personality

Disorder chapter in this Planner).

10. Enroll in treatment for

posttraumatic stress. (18)

18. For the client who is manifesting

posttraumatic stress disorder,

provide or refer to prolonged

exposure therapy, cognitive

processing therapy, or eye

movement desensitization and

reprocessing therapy (see the

PTSD chapter in this Planner).

11. Decrease feelings of shame by

being able to verbally affirm self

as not responsible for abuse.

(19, 20, 21, 22)

19. Assign writing a letter to mother,

father, or other abuser in which

the client expresses his/her

feelings regarding the abuse.

20. Hold conjoint sessions where the

client confronts the perpetrator

of the abuse.

21. Guide the client in an empty

chair exercise with a key figure

connected to the abuse (i.e.,

perpetrator, sibling, or parent);

reinforce the client for placing

responsibility for the abuse or

neglect on the caretaker.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

102

22. Consistently reiterate that

responsibility for the abuse falls

on the abusive adults, not the

surviving child (for deserving the

abuse), and reinforce statements

that accurately reflect placing

blame on perpetrators and on

nonprotective, nonnurturant

adults.

12. Identify the positive aspects for

self of being able to forgive all

those involved with the abuse.

(23, 24, 25)

23. Assign the client to write

a forgiveness letter to the

perpetrator of abuse (or assign

“Feelings and Forgiveness

Letter” in the Adult Psycho-

therapy Homework Planner by

Jongsma); process the letter.

24. Teach the client the benefits (i.e.,

release of hurt and anger, putting

issue in the past, opens door for

trust of others, etc.) of beginning

a process of forgiveness of

(not necessarily forgetting

or fraternizing with) abusive

adults.

25. Recommend the client read

books on the topic of forgiveness

(e.g., Forgive and Forget by

Smedes; When Bad Things

Happen to Good People by

Kushner).

13. Decrease statements of being

a victim while increasing

statements that reflect personal

empowerment. (26, 27)

26. Ask the client to complete

an exercise that identifies the

positives and negatives of being

a victim and the positives and

negatives of being a survivor;

compare and process the lists.

27. Encourage and reinforce the

client’s statements that reflect

movement away from viewing

self as a victim and toward

personal empowerment as a

survivor (or assign “Changing

from Victim to Survivor” in the

CHILDHOOD TRAUMA

Adult Psychotherapy Homework

Planner by Jongsma).

14. Increase level of trust of others

as shown by more socialization

and greater intimacy tolerance.

(28, 29)

28. Teach the client the share-check

method of building trust in

relationships (sharing a little

information and checking as to

the recipient’s sensitivity in

reacting to that information).

29. Teach the client the advantages

of treating people as trustworthy

given a reasonable amount of

time to assess their character.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.4 Dysthymic Disorder

296.xx Major Depressive Disorder

300.3 Obsessive-Compulsive Disorder

300.02 Generalized Anxiety Disorder

309.81 Posttraumatic Stress Disorder

300.14 Dissociative Identity Disorder

995.53 Sexual Abuse of Child, Victim

995.54 Physical Abuse of Child, Victim

995.52 Neglect of Child, Victim

_____

_____________________________________

_____

_____________________________________

Axis II:

301.83 Borderline Personality Disorder

301.7 Antisocial Personality Disorder

301.6 Dependent Personality Disorder

301.4 Obsessive-Compulsive Personality Disorder

_____

_____________________________________

_____

_____________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

104

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.4 F34.1 Persistent Depressive Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

300.3 F42 Obsessive-Compulsive Disorder

300.02 F41.1 Generalized Anxiety Disorder

309.81 F43.10 Posttraumatic Stress Disorder

300.14 F44.81 Dissociative Identity Disorder

995.53 T74.22XA Child Sexual Abuse, Confirmed, Initial

Encounter

995.53 T74.22XD Child Sexual Abuse, Confirmed,

Subsequent Encounter

995.54 T74.12XA Child Physical Abuse, Confirmed, Initial

Encounter

995.54 T74.12XD Child Physical Abuse, Confirmed,

Subsequent Encounter

995.52 T74.02XA Child Neglect, Confirmed, Initial

Encounter

995.52 T74.02XD Child Neglect, Confirmed, Subsequent

Encounter

301.7 F60.2 Antisocial Personality Disorder

301.6 F60.7 Dependent Personality Disorder

301.4 F60.5 Obsessive-Compulsive Personality

Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

CHRONIC PAIN

BEHAVIORAL DEFINITIONS

1. Experiences pain beyond the normal healing process (six months or

more) that significantly limits physical activities.

2. Complains of generalized pain in many joints, muscles, and bones that

debilitates normal functioning.

3. Uses increased amounts of medications with little, if any, pain relief.

4. Experiences tension, migraine, cluster, or chronic daily headaches of

unknown origin.

5. Experiences back or neck pain, interstitial cystitis, or diabetic neuropathy.

6. Experiences intermittent pain such as that related to rheumatoid

arthritis or irritable bowel syndrome.

7. Has decreased or stopped activities such as work, household chores,

socializing, exercise, sex, or other pleasurable activities because of pain.

8. Experiences an increase in general physical discomfort (e.g., fatigue,

night sweats, insomnia, muscle tension, body aches).

9. Exhibits signs and symptoms of depression.

10. Makes many complaintive, depressive statements like “I can’t do what I

used to”; “No one understands me”; “Why me?”; “When will this go

away?”; “I can’t take this pain anymore”; and “I can’t go on.”

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

106

LONG-TERM GOALS

1. Acquire and utilize the necessary pain management skills.

2. Regulate pain in order to maximize daily functioning and return to

productive employment.

3. Find relief from pain and build renewed contentment and joy in

performing activities of everyday life.

4. Find an escape route from the pain.

5. Accept the chronic pain and move on with life as much as possible.

6. Lessen daily suffering from pain.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the nature of, history

of, impact of, and understood

causes of chronic pain. (1, 2)

1. Assess the manifestation of

chronic pain, its history, current

status, triggers, and methods of

coping (see The Handbook of

Pain Assessment by Turk and

Melzack).

2. Assess the impact of the pain

on the patient’s functioning in

everyday life, including changes

in the client’s mood, attitude,

social, vocational, and

familial/marital roles.

2. Complete a thorough medical

evaluation to rule out any

alternative causes for the pain

and reveal any new treatment

possibilities. (3)

3. Refer the client to a physician

or clinic to undergo a thorough

medical evaluation to rule out

any undiagnosed condition and

to receive recommendations on

any further treatment options.

3. Disclose any history of substance

use that may contribute to and

4. Arrange for a substance abuse

evaluation and refer the client

CHRONIC PAIN

complicate the treatment of

chronic pain. (4)

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of in-

sight (syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

108

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Follow through on a referral

to a pain management or

rehabilitation program.

(9, 10, 11)

9. Give the client information on

the options of pain management

specialists or rehabilitation

programs that are available and

help him/her make a decision on

which would be the best for

him/her.

10. Make a referral to a pain

management specialist or clinic

of the client’s choice and have

him/her sign appropriate releases

for the therapist to have updates

on progress from the program

and to coordinate services.

11. Elicit from the client a verbal

commitment to cooperate with

pain management specialists or

rehabilitation program.

6. Complete a thorough medication

review by a physician who is a

specialist in dealing with chronic

pain or headache conditions.

(12)

12. Ask the client to complete

a medication review with a

specialist in chronic pain;

confer with the physician

afterward about his/her

recommendations and process

them with the client.

7. Participate in a cognitive-

behavioral group therapy for

pain management. (13)

13. Form a small, closed enrollment

cognitive-behavioral treatment

group (4–8 clients) pain

management (see Group

Therapy for Patients with

Chronic Pain by Keefe et al.);

supplement with Managing

CHRONIC PAIN

Chronic Pain: A Cognitive-

Behavioral Therapy Approach

Workbook by Otis.

8. Verbalize an understanding

of pain. (14)

14. Teach the client key concepts of

rehabilitation versus biological

healing, conservative versus

aggressive medical interventions,

acute versus chronic pain, benign

versus nonbenign pain, cure

versus management, appropriate

use of medication, role of self-

regulation techniques and other

management techniques.

9. Verbalize an understanding of

the rationale for treatment.

(15, 16)

15. Teach the client a rationale for

treatment that helps him/her

understand that thoughts,

feelings, and behavior can affect

pain; that there are coping

techniques and skills that can be

used to help them to adapt and

respond to pain and the resultant

problems; emphasize the role

that the client can play in

managing his/her own pain.

16. Assign the client to read sections

from books or treatment

manuals that describe pain

conditions and their cognitive-

behavioral treatment (e.g., The

Chronic Pain Control Workbook

by Catalano and Hardin).

10. Identify and monitor specific

pain triggers. (17)

17. Teach the client self-monitoring

of his/her symptoms; ask the

client to keep a pain journal that

records time of day, where and

what he/she was doing, the

severity of stress at the time, the

severity of, and what was done

to alleviate the pain (or assign

“Pain and Stress Journal” in the

Adult Psychotherapy Homework

Planner by Jongsma); process the

journal with the client to increase

understanding of the nature of

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

110

the pain, cognitive, affective,

and behavioral triggers, and

the positive or negative effects

of the coping strategies he/she is

currently using.

11. Learn and implement calming

skills such as relaxation,

biofeedback, or mindfulness

meditation to ease pain.

(18, 19, 20, 21, 22)

18. Teach the client relaxation

skills (e.g., progressive muscle

relaxation, guided imagery,

slow diaphragmatic breathing)

or mindfulness meditation,

explaining the rationale and how

to apply these skills to his/her

daily life (see New Directions in

Progressive Muscle Relaxation

by Bernstein, Borkovec, and

Hazlett-Stevens).

19. Conduct or refer the client to

biofeedback training (e.g., EMG

for muscle tension-related pain);

assign practice of the skill at

home.

20. Identify areas in the client’s life

where he/she can implement

skills learned through relaxation

or biofeedback.

21. Assign a homework exercise in

which the client implements

somatic pain management skills

and records the result; review

and process during the treatment

session.

22. Assign the client to read about

progressive muscle relaxation

and other calming strategies in

relevant books or treatment

manuals (e.g., The Relaxation

and Stress Reduction Workbook

by Davis, Robbins-Eshelman,

and McKay; Living Beyond Your

Pain by Dahl and Lundgren).

12. Incorporate physical therapy

into daily routine. (23)

23. Refer the client for phys-

ical therapy if pain is

heterogeneous.

CHRONIC PAIN

111

13. Learn mental coping skills and

implement with somatic skills for

managing acute pain. (24)

24. Teach the client distraction

techniques (e.g., pleasant

imagery, counting techniques,

alternative focal point) and how

to use them with relaxation skills

for the management of acute

episodes of pain (or assign

“Controlling the Focus on

Physical Problems” in the Adult

Psychotherapy Homework

Planner by Jongsma).

14. Participate in Acceptance and

Commitment Therapy for

chronic pain. (25)

25. Conduct Acceptance and

Commitment Therapy including

mindfulness strategies to help

the client: decrease avoidance,

disconnect thoughts from

actions, accept one’s experience

rather than try to change or

control symptoms, behave

according to his/her broader life

values, clarify his/her goals and

values and commit to behaving

accordingly (see Acceptance and

Commitment Therapy for

Chronic Pain by Dahl, Wilson,

Luciano, and Hayes).

15. Increase the level and range of

activity by identifying and

engaging in values-consistent

pleasurable activities. (26)

26. Ask the client to create a list

of activities that are pleasurable

to him/her and/or consistent

with identified goals and values;

process the list, developing a

plan of increasing the frequency

of engaging in the selected

activities.

16. Incorporate physical exercise

into daily routine. (27, 28)

27. Assist the client in recognizing

the benefits of regular exercise,

encouraging him/her to

implement exercise in daily

life and monitor results (see

Exercising Your Way to Better

Mental Health by Leith); offer

ongoing encouragement to stay

with the regimen.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

112

28. Refer the client to an athletic

club to develop an individually

tailored exercise or physical

therapy program that is

approved by his/her personal

physician.

17. Identify, challenge, and change

maladaptive thoughts and

beliefs about pain and pain

management and replace them

with more adaptive thoughts and

beliefs. (29, 30, 31, 32, 33)

29. Explore the client’s schema and

self-talk that mediate his/her

pain response, challenging the

biases, assisting him/her in

generating thoughts that correct

for the biases, facilitate coping,

and build confidence in

managing pain.

30. Assign the client a homework

exercise in which he/she identifies

negative pain-related self-talk

and positive alternatives (or

assign “Journal and Replace

Self-Defeating Thoughts” in the

Adult Psychotherapy Homework

Planner by Jongsma); review and

reinforce success, providing

corrective feedback toward

improvement.

31. Use cognitive therapy techniques

to help the client change his/her

view of their pain and suffering

from overwhelming to

manageable.

32. Use cognitive therapy techniques

to help the client change his/her

self-concept and role in pain

management from passive,

reactive, and helpless to active,

resourceful, and competent.

33. Assign the client to read about

cognitive-behavioral approaches

to pain management relevant

books or treatment manuals

(e.g., Managing Chronic Pain: A

Cognitive-behavioral Therapy

Approach Workbook by Otis;

CHRONIC PAIN

The Pain Survival Guide by Turk

and Winter; The Chronic Pain

Control Workbook by Catalano

and Hardin).

18. Learn and implement specific

coping skills as well as when and

how to use them to manage pain

and its consequences. (34)

34. Teach the client specific coping

skills based on an assessment

of need (e.g., problem-solving,

social/communication, conflict

resolution, goal-setting).

19. Engage in positive self-talk as an

alternative to the depressing,

negative thoughts about self and

the world. (35)

35. Assist the client in reframing

thoughts about his/her life as

one that has many positive

elements outside of the pain; ask

him/her to list positive aspects

of himself/herself as well as his

life circumstances (or assign

“Positive Self-Talk” and/or

“What’s Good about Me and

My Life?” in the Adult

Psychotherapy Homework

Planner by Jongsma).

20. Integrate and implement all new

mental, somatic, and behavioral

ways of managing pain. (36)

36. Assist the client in integrating

his/her pain management skills

learned in therapy (e.g., calming,

cognitive coping, distraction,

activity scheduling, problem-

solving); transition use from

therapy sessions to daily life as

mastery becomes evident; review,

reinforcing success and problem-

solving obstacles toward the goal

of integration (see Psychological

Approaches to Pain Management

by Turk and Gatchel).

21. Implement relapse prevention

strategies for managing future

challenges. (37, 38, 39)

37. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

an initial and reversible return of

pain or old habits (e.g., a “bad

day”) and relapse with the

persistent return of pain and

previous cognitive and

behavioral habits that exacerbate

pain.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

114

38. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur, using

the strategies learned during

therapy.

39. Follow-up with the client

periodically to problem-solve

difficulties and reinforce

successes.

22. Make changes in diet that will

promote health and fitness. (40)

40. Refer the client to a dietician

for consultation around eating

and nutritional patterns; process

the results of the consultation,

identifying changes he/she can

make and how he/she might

start implementing these

changes.

23. Investigate the use of alternative

therapies to pain management.

(41)

41. Explore the client’s openness to

alternative therapies for pain

management (e.g., acupuncture,

hypnosis, therapeutic massage);

refer for the services, if indicated.

24. Connect with social network

sources who support the

therapeutic changes. (42)

42. Assess the client’s social support

network and encourage him/her

to connect with those who

facilitate or support the client’s

positive change.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

CHRONIC PAIN

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

307.89 Pain Disorder Associated With Both

Psychological Factors and a General Medical

Condition

307.80 Pain Disorder Associated With Psychological

Factors

300.81 Somatization Disorder

300.11 Conversion Disorder

296.3x Major Depressive Disorder, Recurrent

300.3 Obsessive-Compulsive Disorder

302.70 Sexual Dysfunction NOS

304.10 Sedative, Hypnotic, or Anxiolytic

Dependence

304.80 Polysubstance Dependence

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

307.89 F54 Psychological Factors Affecting Other

Medical Conditions

307.80 F45.1 Somatic Symptom Disorder, With

Predominant Pain

300.81 F45.1 Somatic Symptom Disorder

300.11 F44.x Conversion Disorder

296.3x F33.x Major Depressive Disorder, Recurrent

Episode

300.3 F42 Obsessive-Compulsive Disorder

302.70 F52.9 Unspecified Sexual Dysfunction

304.10 F13.20 Sedative, Hypnotic, or Anxiolytic Use

Disorder, Moderate or Severe

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

COGNITIVE DEFICITS

BEHAVIORAL DEFINITIONS

1. Client or client’s family expresses concern about memory, concentration,

“thinking,” judgment, social behavior, or the ability to complete tasks.

2. Client receives negative feedback about school or work performance,

when performance has typically been satisfactory.

3. Client makes frequent errors in everyday activities that were previously

completed accurately.

4. Noticeable deterioration in everyday tasks such as keeping appointments,

paying bills on time, recalling recent conversations, and processing mail.

5. Difficulty in recall of recent events.

6. Inappropriate or embarrassing social behavior, with history of effective

social functioning.

7. Changes in driving safety not explained by visual problems.

8. Marked change in client’s use of leisure time, with client reducing time

spent on tasks requiring concentration (e.g., reading, woodworking,

knitting, writing, puzzles, Internet searching).

9. Client reports higher levels of stress than usual when working on

cognitively difficult tasks (e.g., organizing income tax information,

making financial decisions, completing occupational tasks).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

Content for this chapter was provided by Michele Rusin, coauthor with Arthur Jongsma of

The Rehabilitation Psychology Treatment Planner (2001). Hoboken, NJ: Wiley.

COGNITIVE DEFICITS

117

LONG-TERM GOALS

1. Maintain effective functioning through the use of cognitive aids and

strategies.

2. Adjust activities and responsibilities to level of cognitive capacity,

cooperating with others who provide assistance or oversight.

3. Maintain physical and emotional health to maximize brain health and

optimize cognitive performance.

4. Experience satisfaction in life while managing cognitive symptoms and

resulting lifestyle changes.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the history, nature, and

severity of cognitive problems

experienced. (1, 2, 3)

1. Ask the client and (with authori-

zation) the client’s family/

support system, about the types

and duration of the client’s

cognitive problems, the temporal

course (sudden, gradual,

intermittent), and significant

stressors occurring near the time

of onset.

2. Ask the client and (with authori-

zation) the client’s family/support

system about the client’s use of

prescribed and nonprescribed

medications and substances

(alcohol, street drugs, herbs).

3. Ask the client and (with

authorization) the client’s

family/support system, and/or

physician(s) about the patient’s

medical history, being attentive to

conditions (e.g., hypothyroidism,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

118

diabetes, hypertension, strokes,

etc.) that might impact cognitive

functioning.

2. Participate in a brief

psychometric assessment to

quantify cognitive and emotional

functioning, and to screen for

alcohol abuse. (4, 5, 6)

4. Administer tests to quantify

patterns of cognitive performance

(e.g., Repeatable Battery for the

Assessment of Neuropsychological

Status) or to screen for dementia/

cognitive impairment (e.g., Mini

Mental State Examination;

Dementia Rating Scale-2;

Memory Impairment Screen),

being attentive to the impact

of age, educational level, and

cultural background on the

interpretation of scores.

5. Ask the client to complete

inventories to assess depression

(e.g., Beck Depression Inventory-

II; Geriatric Depression Scale),

anxiety (e.g., Beck Anxiety

Inventory; State-Trait Anxiety

Inventory), posttraumatic stress

disorder (e.g., Detailed

Assessment of Posttraumatic

Stress), or general emotional

status (Symptom Checklist 90-R;

Brief Symptom Inventory-18).

6. Administer tests to screen for

alcohol abuse (e.g., CAGE or

AUDIT).

3. Give the therapist permission to

speak with others about the

types and durations of cognitive

problems, while developing a

treatment plan. (7)

7. With the client’s authorization,

talk with the client and family

about initial impressions, and

consult with the client’s

physician regarding symptoms,

history, assessment results, and

agree on a plan of care for the

cognitive problem.

4. Cooperate with comprehensive

evaluation procedures to assess

8. Initiate or support referral to

health care professionals skilled

COGNITIVE DEFICITS

cognition and factors impacting

cognitive problems. (8)

in providing an in-depth

assessment of cognitive disorders

(e.g., neurologist, rehabilitation

medicine physician,

neuropsychologist, rehabilitation

psychologist).

5. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature

of the therapy relationship.

(9, 10, 11, 12)

9. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

10. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

11. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

12. Assess for the severity of the

level of impairment to the

client’s functioning to determine

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

120

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

6. Client and/or family describe

their understanding of the

assessment results and

recommendations. (13, 14)

13. Discuss evaluation results with

the client and family members;

provide them with education as

the nature of the deficits found

and treatment options.

14. Assess the degree of the client’s

and family’s realistic appraisal

of the client’s functioning by

inquiring into their perception

of the problem areas, the reason

for the problems, and the typical

clinical course; talk with the

client and family about

differences between their beliefs

and what professionals are

saying.

7. Agree to treatment of emotional

disorders and/or substance

dependence/abuse that may

impact cognitive functioning.

(15)

15. Develop and implement a

treatment plan for depression,

anxiety, and/ or substance abuse

that might depress the client’s

cognition (see the Unipolar

Depression, Anxiety, or

Substance Abuse chapters in this

Planner).

8. Consistently use written records

and/or alarms to remind self of

commitments and planned

activities. (16, 17)

16. To address all levels of memory

problems, recommend use of

written, visible external aids

(e.g., day planners, memory

books, calendars, dry erase

boards) and/or alarms to cue the

client to commitments and

COGNITIVE DEFICITS

121

planned activities; teach the

client to use these aids.

17. Inquire about the client’s use of

written external memory aids,

and reinforce consistent use.

9. Use computerized devices

consistently to compensate for

areas of cognitive weakness.

(18, 19)

18. Assist the client with the

selection of computerized

external aids (e.g., GPS

navigation systems, PDAs, smart

phones) that match his/her

preferences, budget, and ability

to learn to use them; teach the

client to use these aids.

19. Inquire into the client’s use

of computerized devices and

reinforce use.

10. Use internal or covert cognitive

strategies to increase effective

task performance.

(20, 21, 22, 23, 24)

20. For clients having mild

impairments, demonstrate the use

of repetition and enriched

imagery (e.g., learning a person’s

name by repeating the name of

the person during a conversation,

and then associating their name

with a physical feature (e.g.,

“Amy” has dark eyebrows that

are “aiming” toward her nose).

21. For clients having mild

impairments, demonstrate the

use of clustering (e.g., organize

grocery list items into groups:

[4 fruits: bananas, blueberries,

lemons, strawberries; 3 dairy

items: butter, milk, yogurt; 2

bakery items: bagels, bread);

remember these 3 groups, and

then items within them, rather

than trying to remember 9

random items) thereby focusing

attention, enriching images,

decreasing the cognitive load,

and facilitating retrieval of

information.

22. For clients having mild

impairments, teach the peg word

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

122

rhyme (1 is a bun, 2 is a shoe, etc.;

see How to Strengthen Memory

by a New Process by Sambrook)

and demonstrate how use of the

peg word system coupled with

exaggerated imagery, enhances

recall of information (e.g., learn

cell phone number by developing

a mental picture based upon the

rhyme. For example, 573-8821

becomes a huge bee hive (5)

reaching to heaven (7), with a tree

(3) forming a slide down from

heaven. Next are two gates

(8, 8) behind which are an ornate

shoe (2) with a sticky bun (1)

inside.

23. Recommend the client cue self

silently (e.g., “Focus” “Stay on

task”) to maintain concentration

and facilitate persistence.

24. Inquire into the client’s use of

covert aids and reinforce use.

11. Use a systematic approach to

problem-solving. (25)

25. Teach patient to use a systematic

problem solving strategy (e.g.,

SOLVE: S = Situation specified;

O = Options listed with pros

and cons; L = Listen to others;

V = Voice a choice, implement

an option; E = evaluate the

outcome) (see Overcoming Grief

and Loss After Brain Injury by

Niemeier and Karol).

12. Link new recurring activities to

existing recurring activities. (26)

26. Suggest the client use a

behavioral chaining strategy to

add a new recurring activity to

existing recurring activity (e.g.,

instruct client to review day

planner at the end of each meal).

13. Accept and implement

environmental changes to

enhance everyday performance.

(27)

27. Discuss ways to modify the

client’s environment (e.g., reduce

clutter, reduce distractions,

maintain consistent placement

COGNITIVE DEFICITS

of regularly used items, label

locations of commonly used

objects, identify one purse/wallet

that the client will consistently

use) to enhance functioning.

14. Participate in cognitive

rehabilitation sessions and

perform homework exercises.

(28)

28. Refer the client for cognitive

rehabilitation services to address

deficits and learn coping skills.

15. Challenge self to accomplish

cognitively difficult tasks that

have been identified as “safe” by

health care professionals. (29)

29. Work with the client to identify

cognitively challenging, but

reasonable activities (e.g.,

reading, puzzles, Mahjong,

keeping up with sports) to build

into the day.

16. Implement actions to enhance

physical health. (30)

30. Talk with the client about the

positive impact of a healthy

lifestyle (e.g., aerobic exercise,

healthy diet, adequate sleep)

on maintaining and perhaps

improving cognition; inquire

into implementation of these

behaviors.

17. Problem-solve with therapist

around problems affecting

adherence to treatment plan. (31)

31. Support and periodically rein-

force the client’s implementation

of recommendations (e.g.,

adherence with medications,

behavioral recommendations,

participation in cognitive

rehabilitation, use of strategies

and aids, environmental

modifications); problem-solve

any obstacles to consistent

treatment plan compliance.

18. Family members make

adjustments to cope with the

client’s cognitive deficits. (32)

32. Educate family members that

the client’s cognitive changes are

a family problem; talk about the

most commonly encountered

problems and ways to deal with

them, work with family to

identify coping resources,

encourage caregivers to take

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

124

breaks, and recommend

participation in recreational,

social, and spiritual activities.

19. Client and family verbalize

questions, anxiety, sadness, and

other emotions triggered by this

change in client’s functioning.

(33)

33. Assist the client and family

members in working through

grief, anger, and other emotions

associated with the change in the

client’s functioning and their

expectations for the future.

20. Express hope for the ability to

experience satisfaction, love, and

pleasure while managing the

cognitive deficit. (34)

34. Work with the client and family

to create reasonable expectations

about the client’s capacities

and to bolster confidence in

everyone’s ability to have a

satisfying life as they manage

this problem.

21. Participate in an evaluation of

driving skills, accepting results

and recommendations.

(35, 36, 37, 38)

35. Talk with the client and family

members about the potential

impact of the cognitive deficit

on the client’s driving safety.

36. Develop a plan with the client

and family to informally assess

the client’s driving skills (e.g.,

have client navigate through

empty parking lot, observing

the client’s ability to maintain

appropriate speed, to keep

vehicle within a lane, to pull car

into a parking space, to observe

posted signs).

37. Refer the client for an evaluation

of driving skills administered by

a professional trained to assess

the impact of cognitive disorders

on driving-related capacities.

38. Talk with the client and/or

family about the state law

governing responsibilities to

report persons having medical

conditions that affect driving

skills; follow state laws and

HIPAA in taking action (e.g.,

making a report directly to a

COGNITIVE DEFICITS

state agency, discussing concerns

about driving with the client’s

physician); suggest the client

voluntarily surrender his/her

license and promise to not drive.

22. Utilize public transportation,

or accept transportation with

family and friends. (39)

39. Assist the client in identifying

alternate transportation

resources (e.g., public

transportation, handicapped-

accessible public transportation,

volunteer drivers, friends,

extended family); if applicable,

recommend supervision while

the client learns to use these

services.

23. Consider the advice of

professionals and others in

selecting “safe” activities in

which to invest one’s time. (40)

40. Work with the health care team

and family to identify which

activities are safe and what

restrictions are necessary;

provide counsel to the client

regarding deciding which

activities one is free to engage in,

which may require supervision or

partial restrictions, and which

must be abandoned.

24. Family and client implement

restrictions in a way that

preserves client’s experience

of choice, while reducing

confrontation. (41)

41. When possible, offer safe options

for daily activities (e.g., provide

small amounts of spending

money for client to carry in a

wallet, provide credit card with

a low spending limit, review

checks written by the client

prior to mailing them); create

impediments to the client

engaging in dangerous behavior

(e.g., keeping the client’s car

keys, disconnecting the car

battery), if necessary.

25. Family members respond with

empathy to the client’s

experience and allow the client to

manage responsibilities and

problems that are within his/her

capacity. (42)

42. Educate family members about

the positive effect of empathic

responding and emotional

support; describe the negative

impact on functioning if

excessive instrumental support

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

126

is provided, or the client is being

“over-helped.”

26. Seek out reputable sources of

information, advice, and support

related to the underlying

disease/injury. (43)

43. Refer the client and family to

resources to enhance coping

effectiveness through education,

skills-building, and emotional

support; suggest written

materials, web-based resources

(see the Bibliotherapy

Suggestions in Appendix A), and

community support groups.

27. In consultation with an attorney,

complete legal documents

regarding proxy decision making

and other legal issues. (44)

44. Talk with the client and family

about the impact of cognitive

impairment on a person’s ability

to make legally binding decisions

(e.g., contracts, advance

directives, power of attorney

designations, will); refer the

client/family to attorneys with

expertise in these areas (e.g.,

elder law).

28. Verbalize an understanding of

the Americans with Disabilities

Act and ways to request

accommodations in academic,

work, or community settings.

(45)

45. Talk with the client and family

about the Americans with

Disabilities Act and inform as to

how this act allows the client to

obtain accommodations at

school, work, or in other settings.

29. Identify and apply for benefits

triggered by disability. (46)

46. Educate the client and family

about potential financial support

benefits (e.g., disability insurance

benefits, Social Security

Disability, activation of long-

term care policy benefits) and

how to apply for them.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

COGNITIVE DEFICITS

127

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

294.9 Cognitive Disorder, NOS

294.10 Dementia of the Alzheimer’s Type, Without

Behavioral Disturbance

294.11 Dementia of the Alzheimer’s Type, With

Behavioral Disturbance

290.40 Vascular Dementia Uncomplicated

290.41 Vascular Dementia With Delirium

290.42 Vascular Dementia With Delusions

290.43 Vascular Dementia With Depressed Mood

294.1x Dementia Due to (Axis III Disorder)

_____

_____________________________________

_____

_______________________________

Axis II:

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

799.59 R41.9 Unspecified Neurocognitive Disorder

294.11 F02.81 Probable Major Neurocognitive Disorder

Due to (specify disorder), With Behavioral

Disturbance

294.10 F02.80 Probable Major Neurocognitive Disorder

Due to (specify disorder), Without

Behavioral Disturbance

331.9 G31.9 Possible Major Neurocognitive Disorder

Due to (specify disorder)

331.83 G31.84 Mild Neurocognitive Disorder Due to

(specify disorder)

290.40 F01.51 Probable Major Vascular Neurocognitive

Disorder With Behavioral Disturbance

290.40 F01.50 Probable Major Vascular Neurocognitive

Disorder Without Behavioral Disturbance

331.9 G31.9 Possible Major Vascular Neurocognitive

Disorder

331.83 G31.84 Mild Vascular Neurocognitive Disorder

310.1 F07.0 Personality Change Due to Another

Medical Condition

294.8 F06.8 Other Specified Mental Disorder Due to

Another Medical Condition

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

128

294.10 F02.80 Major Neurocognitive Disorder Due to

Another Medical Condition, Without

Behavioral Disturbance

294.11 F02.81 Major Neurocognitive Disorder Due to

Another Medical Condition, With

Behavioral Disturbance

291.2 F10.27 Alcohol-Induced Major Neurocognitive

Disorder, Nonamnestic-Confabulatory

Type, With Moderate or Severe Alcohol

Use Disorder

291.1 F10.26 Alcohol-Induced Major Neurocognitive

Disorder, Amnestic-Confabulatory Type,

With Moderate or Severe Alcohol Use

Disorder

291.89 F10.288 Alcohol-Induced Mild Neurocognitive

Disorder, With Moderate or Severe Use

Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

DEPENDENCY

BEHAVIORAL DEFINITIONS

1. Resists becoming self-sufficient, consistently relying on parents to provide

financial support, housing, or caregiving.

2. A history of many intimate relationships with little, if any, space between

the ending of one and the start of the next.

3. Strong feelings of panic, fear, and helplessness when faced with being

alone as a close relationship ends.

4. Feelings easily hurt by criticism and preoccupied with pleasing others.

5. Inability to make decisions or initiate actions without excessive

reassurance from others.

6. Frequent preoccupation with fears of being abandoned.

7. All feelings of self-worth, happiness, and fulfillment derive from

relationships.

8. Involvement in at least two relationships wherein he/she was physically

abused but had difficulty leaving the relationship.

9. Avoids disagreeing with others for fear of being rejected.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Develop confidence in capability of meeting own needs and of tolerating

being alone.

2. Achieve a healthy balance between independence and dependence.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

130

3. Decrease dependence on relationships while beginning to meet own

needs, build confidence, and practice assertiveness.

4. Break away permanently from any abusive relationships.

5. Emancipate self from emotional and economic dependence on parents.

6. Embrace the recovery model’s emphasis on accepting responsibility for

treatment decisions as well as the expectation of being able to live, work,

and participate fully in the community.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the style and pattern

of emotional dependence in

relationships. (1)

1. Explore the client’s history of

emotional dependence extending

from unmet childhood needs to

current relationships.

2. Verbalize an increased awareness

of own dependency. (2, 3)

2. Develop a family genogram to

increase the client’s awareness

of family patterns of dependence

in relationships and assess how

he/she is repeating them in the

present relationship.

3. Assign the client to read Co-

dependent No More by Beattie or

Women Who Love Too Much by

Norwood; process key ideas.

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (4, 5, 6, 7)

4. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

DEPENDENCY

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

5. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

6. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

7. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

4. Verbalize insight into the

automatic practice of striving to

meet other people’s expectations.

(8, 9, 10)

8. Explore the client’s family

of origin for experiences of

emotional abandonment.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

132

9. Assist the client in identifying

the basis for his/her fear of

disappointing others (or assign

“Taking Steps Toward

Independence” from the Adult

Psychotherapy Homework

Planner by Jongsma).

10. Read with the client the fable

entitled “The Bridge” in

Friedman’s Fables by Friedman;

process the meaning of the fable.

5. List positive things about self.

(11, 12)

11. Assist the client in developing a

list of his/her positive attributes

and accomplishments (or assign

“Acknowledging My Strengths”

from the Adult Psychotherapy

Homework Planner by Jongsma).

12. Assign the client to institute a

ritual of beginning each day with

5 to 10 minutes of solitude where

the focus is personal affirmation.

6. Identify and replace distorted

automatic thoughts associated

with assertiveness, being alone,

or acting independently.

(13, 14, 15, 16)

13. Explore and clarify the client’s

fears or other negative feelings

associated with being more

independent.

14. Use the cognitive restructuring

process (i.e., teaching the

connection between thoughts,

feelings, and actions; identifying

relevant automatic thoughts and

their underlying beliefs or

biases; challenging the biases;

developing alternative positive

perspectives; testing biased

and alternative beliefs through

behavioral experiments) to assist

the client in replacing negative

automatic thoughts associated

with assertiveness, being alone,

or not meeting others’ needs.

15. Reinforce the client for

developing and implementing

positive, reality-based messages

DEPENDENCY

to replace the distorted, negative

self-talk associated with inde-

pendent behaviors (or assign

“Replacing Fears With Positive

Messages” from the Adult

Psychotherapy Homework

Planner by Jongsma).

16. Assign the client a homework

exercise (e.g., “Journal and

Replace Self-Defeating

Thoughts” from the Adult

Psychotherapy Homework

Planner by Jongsma) in which

he/she identifies fearful self-talk,

identifies biases in the self-talk,

generates alternatives, and tests

through behavioral experiments;

review and reinforce success,

providing corrective feedback

toward improvement.

7. Verbalize a decreased sensitivity

to criticism. (17, 18, 19)

17. Explore the client’s sensitivity

to criticism and help him/her

develop new ways of receiving,

processing, and responding to it.

18. Assign the client to read books

on assertiveness (e.g., Your

Perfect Right: Assertiveness

and Equality in Your Life and

Relationships by Alberti and

Emmons).

19. Verbally reinforce the client for

any and all signs of assertiveness

and independence.

8. Increase saying no to others’

requests. (20)

20. Assign the client to say no

without excessive explanation for

a period of one week and process

this with him/her.

9. Report incidents of verbally

stating own opinion. (21, 22)

21. Train the client in assertiveness

or refer him/her to a group that

will facilitate and develop his/her

assertiveness skills via lectures

and assignments.

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134

22. Assign the client to speak his/her

mind for one day, and process

the results with him/her.

10. Identify own emotional and

social needs and ways to fulfill

them. (23, 24)

23. Ask the client to compile a list

of his/her emotional and social

needs and ways that these could

possibly be met; process the list

(or assign “Satisfying Unmet

Emotional Needs” from the

Adult Psychotherapy Homework

Planner by Jongsma).

24. Ask the client to list ways that

he/she could start taking care of

himself/herself; then identify

two to three that could be

started now and elicit the client’s

agreement to do so. Monitor for

follow-through and feelings of

change about self.

11. Report examples of receiving

favors from others without

feeling the necessity of

reciprocating. (25)

25. Assign the client to allow others

to do favors for him/her and to

receive without giving. Process

progress and feelings related to

this assignment.

12. Verbalize an increased sense

of self-responsibility while

decreasing sense of responsibility

for others. (26, 27, 28)

26. Assist the client in identifying

and implementing ways of

increasing his/her level of

independence and making own

decisions in day-to-day life

(or assign “Making Your Own

Decisions” from the Adult

Psychotherapy Homework

Planner by Jongsma).

27. Assist the client in not accepting

responsibility for others’ actions

or feelings; recommend the client

read Taking Responsibility: Self-

Reliance and the Accountable

Life by Branden.

28. Facilitate conjoint session with

the client’s significant other

with focus on exploring ways to

DEPENDENCY

increase independence within the

relationship.

13. Verbalize an increased awareness

of boundaries and when they are

violated. (29, 30, 31)

29. Assign the client to keep a daily

journal regarding boundaries for

taking responsibility for self and

others and when he/she is aware

of boundaries being broken by

self or others.

30. Assign the client to read the

book Boundaries: Where You

End and I Begin by Katherine

and process key ideas.

31. Ask the client to read the chapter

on setting boundaries and limits

in the book A Gift to Myself

by Whitfield and complete the

accompanying survey on personal

boundaries; process the key ideas

and results of the survey.

14. Increase the frequency of

verbally clarifying boundaries

with others. (32)

32. Reinforce the client for

implementing boundaries and

limits for self.

15. Increase the frequency of making

decisions within a reasonable

time and with self-assurance.

(33, 34, 35, 36)

33. Confront the client’s tendency

toward decision avoidance and

encourage his/her efforts to

implement proactive decision

making.

34. Teach the client problem-

resolution skills (e.g., defining

the problem clearly,

brainstorming multiple

solutions, listing the pros and

cons of each solution, seeking

input from others, selecting and

implementing a plan of action,

evaluating outcome, and

readjusting plan as necessary).

35. Use modeling and role-playing

with the client to apply the

problem-solving approach to

his/her avoidance of decision-

making (or assign “Applying

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

136

Problem-Solving to

Interpersonal Conflict” from the

Adult Psychotherapy Homework

Planner by Jongsma); encourage

implementation of action plan,

reinforcing success and

redirecting for failure.

36. Give positive verbal

reinforcement for each timely

thought-out decision that the

client makes.

16. Participate in marital and/or

family therapy. (37)

37. Conduct or refer to marital

and/or family therapy toward the

goal of altering entrenched

dysfunctional marital and/or

family system patterns that

support the client’s dependency.

17. Attend an Al-Anon group. (38) 38. Refer the client to Al-Anon or

another appropriate self-help

group to reinforce efforts to

break the dependency cycle with

a chemically dependent partner.

18. Develop a plan to end the

relationship with abusive

partner, and implement the plan

with therapist’s guidance.

(39, 40, 41)

39. Assign the client to read The

Verbally Abusive Relationship by

Evans; process key ideas and

insights.

40. Refer the client to a safe house

that provides counseling services

to abused women.

41. Refer the client to a domestic

violence program and monitor

and encourage his/her continued

involvement in the program.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DEPENDENCY

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.4 Dysthymic Disorder

995.81 Physical Abuse of Adult, Victim

_____

___________________

_________________

_____

_____________________________________

Axis II:

301.82 Avoidant Personality Disorder

301.83 Borderline Personality Disorder

301.6 Dependent Personality Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.4 F34.1 Persistent Depressive Disorder

995.81 Z69.11 Encounter for Mental Health Services for

Victim of Spouse or Partner Violence,

Physical

301.82 F60.6 Avoidant Personality Disorder

301.83 F60.3 Borderline Personality Disorder

301.6 F60.7 Dependent Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

DISSOCIATION

BEHAVIORAL DEFINITIONS

1. The existence of two or more distinct personality states that recurrently

take full control of one’s behavior.

2. An episode of the sudden inability to remember important personal

identification information that is more than just ordinary forgetfulness.

3. Persistent or recurrent experiences of depersonalization; feeling as if

detached from or outside of one’s mental processes or body during

which reality testing remains intact.

4. Persistent or recurrent experiences of depersonalization; feeling as if one

is automated or in a dream.

5. Depersonalization sufficiently severe and persistent as to cause marked

distress in daily life.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Integrate the various personalities.

2. Reduce the frequency and duration of dissociative episodes.

3. Resolve the emotional trauma that underlies the dissociative disturbance.

4. Reduce the level of daily distress caused by dissociative disturbances.

5. Regain full memory.

__. _____________________________________________________________

_____________________________________________________________

DISSOCIATION

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Identify each personality and

have each one tell its story.

(1, 2, 3)

1. Actively build the level of trust

with the client in individual

sessions through consistent

eye contact, active listening,

unconditional positive regard,

and warm acceptance to help

increase his/her ability to identify

and express feelings.

2. Without undue encouragement

or leading, probe and assess

the existence of the various

personalities that take control

of the client.

3. Conduct a functional analysis

of the variables associated with

dissociative states and their

resolution including thoughts,

feelings, actions, interpersonal

variables, consequences, and

secondary gains.

2. Complete psychological testing

designed to further understand

the nature and extent of

dissociative experiences and

personality. (4)

4. Conduct or refer for psychologi-

cal testing of dissociation (e.g.,

The Dissociative Experiences

Scale) and/or abnormal and

normal personality features

and traits (e.g., MMPI-2).

3. Cooperate with a referral to a

neurologist to rule out organic

factors in amnestic episodes. (5)

5. Refer the client to a neurologist

for evaluation of any organic

cause for memory loss

experiences.

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140

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (6, 7, 8, 9)

6. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

7. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

8. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

9. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

DISSOCIATION

141

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Complete a psychotropic

medication evaluation with a

physician. (10)

10. Arrange for an evaluation of

the client for a psychotropic

medication prescription.

6. Take prescribed psychotropic

medications responsibly at times

ordered by the physician. (11)

11. Monitor and evaluate the client’s

psychotropic medication

prescription for compliance,

effectiveness, and side effects.

7. Participate in a therapy

to address personal and

interpersonal vulnerabilities

to dissociation. (12)

12. In clients whose dissociation

appears functionally related to a

clinical syndrome (e.g., PTSD)

or personality disorder (e.g.,

Borderline Personality

Disorder), conduct or refer

to evidence-based treatment

of the disorder (e.g., cognitive

processing therapy or dialectical

behavior therapy, respectively).

8. Identify the key issues that

trigger a dissociative state.

(13, 14, 15)

13. Explore the feelings and

traumatic circumstances that

trigger the client’s dissociative

state (see the Childhood Trauma

and Sexual Abuse Victim

chapters in this Planner).

14. Explore the client’s sources of

emotional pain or trauma, and

feelings of fear, inadequacy,

rejection, or abuse (or assign

“Describe the Trauma” from the

Adult Psychotherapy Homework

Planner by Jongsma).

15. Assist the client in accepting a

connection between his/her

dissociating and avoidance of

facing emotional conflicts/issues

and painful emotions (e.g.,

experiential avoidance).

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142

9. Decrease the number and

duration of personality changes.

(16, 17)

16. Facilitate integration of the

client’s personality by supporting

and encouraging him/her to stay

focused on reality rather than

escaping through dissociation

(or assign “Staying Focused on

the Present Reality” from the

Adult Psychotherapy Homework

Planner by Jongsma).

17. Emphasize to the client the

importance of a here-and-now

focus on reality rather than a

preoccupation with the traumas

of the past and dissociative

phenomena associated with that

fixation. Reinforce instances of

here-and-now behavior.

10. Practice relaxation and deep

breathing as means of reducing

anxiety that serves as a trigger

for dissociation. (18, 19, 20)

18. Teach the client calming

techniques (e.g., progressive

muscle relaxation, breathing-

induced relaxation, calming

imagery, cue-controlled

relaxation, applied relaxation)

as part of a tailored strategy

for reducing chronic and acute

physiological tension that

triggers dissociation.

19. Role-play the use of relaxation

and cognitive coping to

visualized stress-provoking

scenes, moving from low- to

high-stress scenes. Assign the

implementation of calming

techniques in his/her daily life

when facing these trigger

situations; process the results,

reinforcing success and problem-

solving obstacles.

20. Assign the client to read about

progressive muscle relaxation

and other calming strategies in

relevant books or treatment

manuals (e.g., The Relaxation

DISSOCIATION

and Stress Reduction Workbook

by Davis, Robbins-Eshelman,

and McKay; Mastery of Your

Anxiety and Worry: Workbook

by Craske and Barlow).

11. Identify, challenge, and replace

self-talk that produces negative

emotional reactions with self-

talk that facilitates a better

regulation of emotions.

(21, 22, 23)

21. Explore the client’s self-talk

that mediates his/her strong

negative/painful feelings and

actions (e.g., “I can’t face this”);

identify and challenge biases,

assisting him/her in generating

appraisals and self-talk that

corrects for the biases and

facilitates a more realistic and

regulated response. Combine

new self-talk with calming skills

as part of developing coping

skills to manage negative

emotions.

22. Role-play the use of relaxation

and cognitive coping to

visualized emotion-provoking

scenes, moving from low- to

high-challenge scenes. Assign

the implementation of calming

techniques in his/her daily life

when facing trigger situations;

process the results, reinforcing

success and problem-solving

obstacles.

23. Assign the client a homework

exercise in which he/she identifies

biased self-talk and generates

alternatives that help moderate

emotional reactions; review

while reinforcing success,

providing corrective feedback

toward improvement.

12. Verbalize acceptance of brief

episodes of dissociation as not

being the basis for panic, but

only as passing phenomena.

(24, 25, 26, 27, 28)

24. Teach the client to be calm and

matter-of-fact in the face of brief

dissociative phenomena so as to

not accelerate anxiety symptoms,

but to stay focused on reality.

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144

25. Use an ACT approach to help

the client experience and accept

the presence of painful/troubling

thoughts and feelings without

being overly impacted by them,

and committing his/her time and

efforts to activities that are

consistent with identified,

personally meaningful values

(see Acceptance and Commitment

Therapy by Hayes, Strosahl, and

Wilson).

26. Teach mindfulness meditation

to help the client change his/her

relationship with painful

thoughts and/or feelings,

building acceptance of them

without undue reactivity (see

Guided Mindfulness Meditation

[Audio CD] by Zabat-Zinn).

27. Assign the client homework in

which he/she practices lessons

from mindfulness meditation

and ACT in order to consolidate

the approach into everyday life.

28. Assign the client reading

consistent with the mindfulness

and ACT approach to

supplement work done in session

(e.g., Finding Life Beyond

Trauma: Using Acceptance and

Commitment Therapy to Heal

from Post-Traumatic Stress and

Trauma-Related Problems by

Follette and Pistorello).

13. Discuss the period preceding

memory loss and the period after

memory returns. (14, 29)

14. Explore the client’s sources of

emotional pain or trauma, and

feelings of fear, inadequacy,

rejection, or abuse (or assign

“Describe the Trauma” from the

Adult Psychotherapy Homework

Planner by Jongsma).

DISSOCIATION

29. Arrange and facilitate a session

with the client and significant

others to assist him/her in

regaining lost personal

information.

14. Utilize photos and other

memorabilia to stimulate recall

of personal history. (30, 31)

30. Calmly reassure the client to be

patient in seeking to regain lost

memories.

31. Review pictures and other

memorabilia to gently trigger the

client’s memory recall.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

303.90 Alcohol Dependence

300.14 Dissociative Identity Disorder

300.12 Dissociative Amnesia

300.6 Depersonalization Disorder

300.15 Dissociative Disorder NOS

_____

______

______________________________

_____

_____________________________________

Axis II:

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

146

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

300.14 F44.81 Dissociative Identity Disorder

300.6 F48.1 Depersonalization/Derealization Disorder

300.15 F44.9 Unspecified Dissociative Disorder

300.15 F44.89 Other Specified Dissociative Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued

ICD-9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

147

EATING DISORDERS AND OBESITY

BEHAVIORAL DEFINITIONS

1. Refusal to maintain body weight at or above a minimally normal weight

for age and height (i.e., body weight less than 85% of that expected).

2. Intense fear of gaining weight or becoming fat, even though underweight.

3. Persistent preoccupation with body image related to grossly inaccurate

assessment of self as overweight.

4. Undue influence of body weight or shape on self-evaluation.

5. Strong denial of the seriousness of the current low body weight.

6. In postmenarcheal females, amenorrhea (i.e., the absence of at least three

consecutive menstrual cycles).

7. Escalating fluid and electrolyte imbalance resulting from eating disorder.

8. Recurrent inappropriate compensatory behaviors in order to prevent

weight gain, such as self-induced vomiting; misuse of laxatives, diuretics,

enemas, or other medications; fasting; or excessive exercise.

9. Recurrent episodes of binge eating (a large amount of food is consumed

in a relatively short period of time and there is a sense of lack of control

over the eating behavior).

10. Eating much more rapidly than normal.

11. Eating until feeling uncomfortably full.

12. Eating large amounts of food when not feeling physically hungry.

13. Eating alone because of feeling embarrassed by how much one is eating.

14. Feeling disgusted with oneself, depressed, or very guilty after eating too

much.

15. An excess of body weight, relative to height, that is attributed to an

abnormally high proportion of body fat (Body Mass Index of 30 or

more).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

148

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Restore normal eating patterns, healthy weight maintenance, and a

realistic appraisal of body size.

2. Stabilize medical condition with balanced fluid and electrolytes, resuming

patterns of food intake that will sustain life and gain weight to a normal

level.

3. Terminate the pattern of binge eating and purging behavior with a

return to eating normal amounts of nutritious foods.

4. Terminate overeating and implement lifestyle changes that lead to

weight loss and improved health.

5. Develop healthy cognitive patterns and beliefs about self that lead to

positive identity and prevent a relapse of the eating disorder.

6. Develop healthy interpersonal relationships that lead to alleviation and

help prevent the relapse of the eating disorder.

7. Develop coping strategies (e.g., feeling identification, problem-solving,

assertiveness) to address emotional issues that could lead to relapse of

the eating disorder.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Honestly describe the pattern of

eating including types, amounts,

and frequency of food consumed

or hoarded. (1, 2, 3, 4)

1. Establish rapport with the client

toward building a therapeutic

alliance.

2. Assess the historical course

of the disorder including the

amount, type, and pattern of

the client’s food intake (e.g., too

little food, too much food, binge

eating, or hoarding food);

EATING DISORDERS AND OBESITY

perceived personal and

interpersonal triggers and

personal goals.

3. Compare the client’s calorie

consumption with an average

adult rate of 1,900 (for women)

to 2,500 (for men) calories per

day to determine over- or

undereating.

4. Measure the client’s weight and

assess for minimization and

denial of the eating disorder

behavior and related distorted

thinking and self-perception of

body image.

2. Describe any regular use of

unhealthy weight control

behaviors. (5)

5. Assess for the presence of

recurrent inappropriate purging

and nonpurging compensatory

behaviors such as self-induced

vomiting; misuse of laxatives,

diuretics, enemas, or other

medications; fasting; or excessive

exercise; monitor on an ongoing

basis.

3. Complete psychological tests

designed to assess and track

eating patterns and unhealthy

weight-loss practices. (6)

6. Administer psychological

instruments to the client

designed to objectively assess

eating disorders (e.g., the Eating

Inventory; Stirling Eating

Disorder Scales; or Eating

Disorders Inventory-3); give the

client feedback regarding the

results of the assessment;

readminister as indicated to

assess treatment response.

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (7, 8, 9, 10)

7. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

150

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

8. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

9. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

10. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

EATING DISORDERS AND OBESITY

5. Cooperate with a complete

medical evaluation. (11)

11. Refer the client to a physician

for a medical evaluation to

assess negative consequences

of failure to maintain adequate

body weight and overuse of

compensatory behaviors; stay

in close consultation with the

physician as to the client’s

medical condition.

6. Cooperate with a nutritional

evaluation. (12)

12. Refer the client to a nutritionist

experienced in eating disorders

for an assessment of nutritional

rehabilitation; coordinate

recommendations into the care

plan.

7. Cooperate with a dental exam.

(13)

13. Refer the client to a dentist

for a dental exam to assess the

possible damage to teeth from

purging behaviors and/or poor

nutrition.

8. Cooperate with a psychotropic

medication evaluation by a

physician and, if indicated, take

medications as prescribed.

(14, 15)

14. Assess the client’s need for

psychotropic medications

(e.g., SSRIs); arrange for a

physician to evaluate for and

then prescribe psychotropic

medications, if indicated.

15. Monitor the client for

psychotropic medication

prescription compliance,

effectiveness, and side effects.

9. Cooperate with admission to

inpatient treatment, if indicated.

(16)

16. Refer the client for

hospitalization, as necessary,

if his/her weight loss becomes

severe and physical health is

jeopardized, or if he/she is a

danger to self or others due

to a severe psychiatric disorder

(e.g., severely depressed and

suicidal).

10. Verbalize an accurate

understanding of how eating

disorders develop. (17)

17. Teach the client a model of

eating disorders development

that includes concepts such as

sociocultural pressures to be

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152

thin, overvaluation of body shape

and size in determining self-

image, maladaptive eating

habits (e.g., fasting, binging,

overeating), maladaptive

compensatory weight manage-

ment behaviors (e.g., purging,

exercise), and resultant feelings of

low self-esteem (see Overcoming

Binge Eating by Fairburn; The

Eating Disorders Sourcebook:

A Comprehensive Guide to

the Causes, Treatments, and

Prevention of Eating Disorders

by Costin).

11. Verbalize an understanding

of the rationale for and goals

of treatment. (18, 19)

18. Discuss a rationale for treatment

consistent with the model being

used including how cognitive,

behavioral, interpersonal,

lifestyle, and/or nutritional

factors can promote poor self-

image, uncontrolled eating, and

unhealthy compensatory actions,

and how changing them they

can build physical and mental

health-promoting eating

practices.

19. Assign the client to read

psychoeducational chapters of

books or treatment manuals on

the development and treatment

of eating disorders or obesity

that are consistent with the

treatment model (e.g.,

Overcoming Binge Eating by

Fairburn; Overcoming Your

Eating Disorders: A Cognitive-

Behavioral Therapy Approach

for Bulimia Nervosa and Binge-

Eating Disorder-Workbook by

Apple and Agras; The LEARN

Program for Weight Manage-

ment by Brownell for weight

loss).

EATING DISORDERS AND OBESITY

12. Keep a journal of food

consumption. (20)

20. Assign the client to self-monitor

and record food intake (or assign

“A Reality Journal: Food,

Weight, Thoughts, and Feelings”

in the Adult Psychotherapy

Homework Planner by Jongsma);

process the journal material to

reinforce and facilitate

motivation to change.

13. Establish regular eating patterns

by eating at regular intervals and

consuming optimal daily

calories. (21, 22, 23)

21. Establish an appropriate daily

caloric intake for the client

and assist him/her in meal

planning.

22. Establish healthy weight goals

for the client per the Body Mass

Index (BMI), the Metropolitan

Height and Weight Tables,

or some other recognized

standard.

23. Monitor the client’s weight

(e.g., weekly) and give realistic

feedback regarding body

weight.

14. Attain and maintain balanced

fluids and electrolytes, as well as

resumption of reproductive

functions. (24, 25)

24. Monitor the client’s fluid intake

and electrolyte balance; give

realistic feedback regarding

progress toward the goal of

balance.

25. Refer the client back to the

physician at regular intervals if

fluids and electrolytes need

monitoring due to poor eating

patterns.

15. Identify and develop a list of

high-risk situations for

unhealthy eating or weight loss

practices. (26, 27)

26. Assess the nature of any external

cues (e.g., persons, objects, and

situations) and internal cues

(thoughts, images, and impulses)

that precipitate the client’s

uncontrolled eating and/or

compensatory weight

management behaviors.

27. Direct and assist the client in

construction of a hierarchy of

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154

high-risk internal and external

triggers for uncontrolled eating

and/or compensatory weight

management behaviors.

16. Learn and implement skills for

managing urges to engage in

unhealthy eating or weight loss

practices. (28)

28. Teach the client tailored skills

to manage high-risk situations

including distraction, positive

self-talk, problem-solving,

conflict resolution (e.g.,

empathy, active listening,

“I messages,” respectful

communication, assertiveness

without aggression,

compromise), or other social/

communication skills; use

modeling, role-playing, and

behavior rehearsal to work

through several current

situations.

17. Participate in exercises to build

skills in managing urges to use

maladaptive weight control

practices. (29)

29. Assign homework exercises that

allow the client to practice and

strengthen skills learned in

therapy; select initial high-risk

situations that have a high

likelihood of being a successful

coping experience for the client;

prepare and rehearse a plan for

managing the risk situation;

review/process the real life

implementation by the client,

reinforcing success while

providing corrective feedback

toward improvement.

18. Identify, challenge, and replace

self-talk and beliefs that promote

the anorexia or bulimia.

(30, 31, 32)

30. Conduct Phase One of Cognitive

Behavioral Therapy (see

Cognitive Behavior Therapy and

Eating Disorders by Fairburn)

to help the client understand

the adverse effects of binging

and purging; assigning self-

monitoring of weight and eating

patterns and establishing a

regular pattern of eating (use “A

Reality Journal: Food, Weight,

EATING DISORDERS AND OBESITY

Thoughts, and Feelings” in the

Adult Psychotherapy Homework

Planner by Jongsma); process the

journal material.

31. Conduct Phase Two of Cognitive

Behavioral Therapy (CBT) to

shift the focus to eliminating

dieting, reducing weight and

body image concerns, teaching

problem-solving, and doing

cognitive restructuring to

identify, challenge, and replace

negative cognitive messages that

mediate feelings and actions

leading to maladaptive eating

and weight control practices

(or assign “How Fears Control

My Eating” from the Adult

Psychotherapy Homework

Planner by Jongsma).

32. Conduct Phase Three of CBT

to assist the client in developing

a maintenance and relapse

prevention plan including self-

monitoring of eating and binge

triggers, continued use of

problem-solving and cognitive

restructuring, and setting short-

term goals to stay on track.

19. To begin to resolve bulimic

behavior, identify important

people in the past and present,

and describe the quality, good

and poor, of those relationships.

(33)

33. Conduct Interpersonal Therapy

(see “Interpersonal Psycho-

therapy for Bulimia Nervosa”

by Fairburn) beginning with

the assessment of the client’s

“interpersonal inventory” of

important past and present

relationships, highlighting themes

that may be supporting the eating

disorder (e.g., interpersonal

disputes, role transition conflict,

unresolved grief, and/or

interpersonal deficits).

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156

20. Verbalize a resolution of current

interpersonal problems and a

resulting termination of bulimia.

(34, 35, 36, 37)

34. For grief, facilitate mourning

and gradually help client

discover new activities and

relationships to compensate

for the loss.

35. For disputes, help the client

explore the relationship, the

nature of the dispute, whether

it has reached an impasse, and

available options to resolve

it including learning and

implementing conflict-resolution

skills; if the relationship has

reached an impasse, consider

ways to change the impasse or

to end the relationship.

36. For role transitions (e.g.,

beginning or ending a

relationship or career, moving,

promotion, retirement,

graduation), help the client

mourn the loss of the old role

while recognizing positive and

negative aspects of the new role

and taking steps to gain mastery

over the new role.

37. For interpersonal deficits,

help the client develop new

interpersonal skills and

relationships.

21. Parents and adolescent with

anorexia agree to participate in

all three phases of family-based

treatment of anorexia.

(38, 39, 40)

38. Conduct Phase One (sessions 1–

10) of Family-Based Treatment

(see Treatment Manual for

Anorexia Nervosa: A Family-

Based Approach by Lock et al.)

by confirming with the family

their intent to participate and

strictly adhere to the treatment

plan, taking a history of the

eating disorder, clarifying that

the parents will be in charge of

weight restoration of the client,

establishing healthy weight

EATING DISORDERS AND OBESITY

goals, and asking the family

to participate in the family meal

in session; establish with the

parents and a physician a

minimum daily caloric intake

for the client and focus them on

meal planning; consult with a

physician and/or nutritionist if

fluids and electrolytes need

monitoring due to poor

nutritional habits.

39. Conduct Phase Two of Family-

Based Treatment (FBT) (sessions

11–16) by continuing to closely

monitor weight gain and

physician/nutritionist reports

regarding health status;

gradually return control over

eating decisions back to the

adolescent as the acute

starvation is resolved and

portions consumed are nearing

what is normally expected and

weight gain in demonstrated.

40. Conduct Phase Three of FBT

(sessions 17–20) by reviewing

and reinforcing progress and

weight gain; focus on adolescent

development issues; teach and

rehearse problem-solving and

relapse prevention skills.

22. State a basis for positive identity

that is not based on weight and

appearance but on character,

traits, relationships, and intrinsic

value. (41)

41. Assist the client in identifying a

basis for self-worth apart from

body image by reviewing his/her

talents, successes, positive traits,

importance to others, and

intrinsic spiritual value.

23. Follow through on implementing

the five aspects of the LEARN

program to achieve weight loss.

(42, 43)

42. Assign the client to read the

LEARN manual (see The

LEARN Program for Weight

Management by Brownell) and

then review the five aspects of

the program (i.e., Lifestyle,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

158

Exercise, Attitudes, Relation-

ships, and Nutrition), that will

be emphasized over the next

12 weeks.

43. In weekly sessions, system-

atically work through the five

aspects of the LEARN program

manual (Lifestyle, Exercise,

Attitudes, Relationships, and

Nutrition), applying each

component to the client’s life to

establish new behavioral patterns

designed to achieve weight

loss.

24. Verbalize an understanding of

relapse prevention and the

distinction between a lapse and a

relapse. (44, 45)

44. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

an initial and reversible return

of distress, urges, or to avoid,

and relapse with the decision

to return to the cycle of

maladaptive thoughts and

actions (e.g., feeling anxious,

binging, then purging).

45. Identify with the client future

situations or circumstances in

which lapses could occur.

25. Implement relapse prevention

strategies for managing possible

future anxiety symptoms.

(46, 47, 48)

46. Instruct the client to routinely

use strategies learned in therapy

(e.g., continued exposure to

previous external or internal cues

that arise) to prevent relapse.

47. Develop a “maintenance plan”

with the client that describes

how the client plans to identify

challenges, use knowledge

and skills learned in therapy

to manage them, and maintain

positive changes gained in

therapy.

48. Schedule periodic “maintenance”

sessions to help the client

maintain therapeutic gains and

EATING DISORDERS AND OBESITY

adjust to life without the eating

disorder.

26. Attend an eating disorder group.

(49)

49. Refer the client to a support

group for eating disorders.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

307.1 Anorexia Nervosa

307.51 Bulimia Nervosa

307.50 Eating Disorder NOS

xxx.xx Binge Eating Disorder

316 Psychological Symptoms Affecting Axis III

Disorder (e.g., obesity)

_____

_____________________________________

_____

_____________________________________

Axis II:

301.6 Dependent Personality Disorder

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

307.1 F50.02 Anorexia Nervosa, Binge-Eating/Purging

Type

307.1 F50.01 Anorexia Nervosa, Restricting Type

307.51 F50.2 Bulimia Nervosa

278.00 E66.9 Overweight or Obesity

307.50 F50.9 Unspecified Feeding or Eating Disorder

307.59 F50.8 Other Specified Feeding or Eating

Disorder

301.6 F60.7 Dependent Personality Disorder

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

160

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

EDUCATIONAL DEFICITS

BEHAVIORAL DEFINITIONS

1. Failure to complete requirements for high school diploma or GED

certificate.

2. Possession of no marketable employment skills and need for vocational

training.

3. Functional illiteracy.

4. History of difficulties, not involving behavior, in school or other

learning situations.

5. Lack of confidence in ability to learn.

6. Anxiety in situations requiring learning new skills and information.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Recognize the need for high school completion or GED certificate and

enroll in the necessary courses to obtain it.

2. Seek out vocational training to obtain marketable employment skill.

3. Increase literacy skills.

4. Overcome anxiety associated with learning.

5. Establish the existence of a learning disability and begin the development

of skills to overcome it.

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

162

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Identify the factors that

contributed to termination

of education. (1, 2)

1. Explore the client’s attitude

toward education and the family,

peer, and/or school experiences

that led to termination of

education.

2. Gather an educational history

from the client that includes

family achievement history and

difficulties he/she had with

regard to specific subjects

(e.g., reading, math).

2. Verbally verify the need for a

high school diploma or GED.

(3, 4, 5, 6, 7)

3. Advise the client of his/her need

for further education.

4. Use a motivational interviewing

approach to help the client

explore motivational obstacles

and incentives for acting to reach

educational goals.

5. Assist the client in listing the

negative effects that the lack of a

GED certificate or high school

diploma has had on his/her life.

6. Support and direct the client

toward obtaining further

academic training.

7. Reinforce and encourage the

client in pursuing educational

and/or vocational training by

pointing out the social,

monetary, and self-esteem

advantages (or assign “The

Advantages of Education” from

EDUCATIONAL DEFICITS

the Adult Psychotherapy

Homework Planner by Jongsma).

3. Complete an assessment to

identify style of learning and to

establish or rule out a specific

learning disability. (8)

8. Administer testing or refer the

client to an educational specialist

to be tested for learning style,

cognitive strengths, and to

establish or rule out a learning

disability.

4. Complete a medical evaluation

of health status. (9)

9. Refer to a physician for a

medical evaluation to assess for

medical conditions that could

affect educational performance

and/or motivation (e.g., low

energy/motivation due to

hypothyroidism).

5. Cooperate with a psychological

assessment for symptoms of

another mental disorder that

may affect or have affected

educational achievement. (10)

10. Conduct or refer the client for a

psychological assessment of

Attention Deficit Disorder (see

the Attention Deficit Disorder

(ADD)—Adult chapter in this

Planner) or other mental disorder

that could affect educational

performance or motivation (e.g.,

depression, anxiety).

6. Disclose any history of substance

use that may contribute to and

complicate the treatment of

bipolar depression. (11)

11. Arrange for a substance abuse

evaluation and refer the client for

treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

7. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship.

(12, 13, 14, 15)

12. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

164

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

13. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

14. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

15. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

8. Complete an evaluation for

psychotropic medications.

(16, 17, 18)

16. Refer the client for a medication

evaluation to treat his/her ADD

or other identified mental

disorder that could be affecting

educational performance or

motivation (e.g., depression,

anxiety).

EDUCATIONAL DEFICITS

17. Encourage the client to take

the prescribed psychotropic

medications, reporting as to their

effectiveness and side effects.

18. Monitor the client’s

psychotropic medication

prescription compliance,

effectiveness, and side effects.

9. Implement the recommendations

of evaluations. (19)

19. Encourage the client to imple-

ment the recommendations of the

educational, psychological, and

medical evaluations.

10. Identify the facts and feelings

related to negative, critical

education-related experiences

endured from parents, teachers,

or peers. (20, 21)

20. Ask the client to list the negative

messages he/she has experienced

in learning situations from

teachers, parents, and peers, and

to process this list with the

therapist.

21. Facilitate the client’s openness

regarding shame or embarrass-

ment surrounding lack of

reading ability, educational

achievement, or vocational skill.

11. Verbalize decreased anxiety and

negativity associated with

learning situations.

(22, 23, 24, 25)

22. Give encouragement and verbal

affirmation to the client as he/she

works to increase his/her

educational level.

23. Teach the client relaxation

skills (e.g., progressive muscle

relaxation, imagery, diaphrag-

matic breathing, verbal cues

for deep relaxation), how to

discriminate better between

relaxation and tension, as well

as how to apply these skills to

coping with his/her own fears

and anxieties in learning

situations (e.g., see The Relax-

ation and Stress Reduction

Workbook by Davis, Robbins-

Eshelman, and McKay).

24. Assign the client homework each

session in which he or she

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

166

practices relaxation exercises

daily for at least 15 minutes and

applies the technique to learning

situations; review the exercises,

reinforcing success while

providing corrective feedback

toward improvement.

25. Assign the client to read about

progressive muscle relaxation

and other calming strategies in

relevant books or treatment

manuals (e.g., The Relaxation

and Stress Reduction Workbook

by Davis, Robbins-Eshelman,

and McKay; Mastery of Your

Anxiety and Worry: Workbook

by Craske and Barlow).

12. Identify own academic and

vocational strengths. (26)

26. Assist the client in identifying

his/her realistic academic and

vocational strengths (or assign

“My Academic and Vocational

Strengths” from the Adult

Psychotherapy Homework

Planner by Jongsma).

13. Identify and replace negative

thoughts regarding educational

opportunities and ability level.

(27, 28, 29)

27. Use the cognitive restructuring

process (i.e., teaching the

connection between thoughts,

feelings, and actions; identifying

relevant automatic thoughts

and their underlying beliefs or

biases; challenging the biases;

developing alternative positive

perspectives; testing biased and

alternative beliefs through

behavioral experiments) to assist

the client in replacing negative

automatic thoughts associated

with education and his/her

ability to learn.

28. Reinforce the client for

developing and implementing

positive, reality-based messages

to replace the distorted, negative

self-talk associated with

EDUCATIONAL DEFICITS

education and his/her ability

to learn (or assign “Replacing

Fears with Positive Messages”

from the Adult Psychotherapy

Homework Planner by Jongsma).

29. Assign the client a homework

exercise (e.g., “Journal and

Replace Self-Defeating

Thoughts” from the Adult

Psychotherapy Homework

Planner by Jongsma) in which

he/she identifies fearful self-talk,

identifies biases in the self-talk,

generates alternatives, and tests

through behavioral experiments;

review and reinforce success,

providing corrective feedback

toward improvement.

14. Agree to pursue educational

assistance to attain reading

skills. (30, 31)

30. Assess the client’s reading

deficits.

31. Refer the client to resources for

learning to read; monitor, and

encourage the client’s follow-

through.

15. State commitment to obtain

further academic or vocational

training. (32)

32. Elicit a commitment from the

client to pursue further academic

or vocational training.

16. Make the necessary contacts to

investigate enrollment in high

school, GED, or vocational

classes. (33, 34)

33. Provide the client with

information regarding

community resources available

for adult education, GED, high

school completion, and

vocational skill training.

34. Assign the client to make

preliminary contact with

vocational and/or educational

training agencies and report

back regarding the experience.

17. Attend classes consistently to

complete academic degree and/or

vocational training course. (35)

35. Monitor and support the client’s

attendance at educational or

vocational classes.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

168

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

V62.3 Academic Problem

V62.2 Occupational Problem

315.2 Disorder of Written Expression

315.00 Reading Disorder

_____

_____________________________________

_____

_____________________________________

Axis II:

V62.89 Borderline Intellectual Functioning

317 Mild Mental Retardation

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

V62.3 Z55.9 Academic or Educational Problem

V62.2 Z56.9 Other Problem Related to Employment

315.2 F81.2 Specific Learning Disorder With

Impairment in Written Expression

315.00 F81.0 Specific Learning Disorder With

Impairment in Reading

V62.89 R41.83 Borderline Intellectual Functioning

317 F70 Intellectual Disability, Mild

317 F71 Intellectual Disability, Moderate

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

FAMILY CONFLICT

BEHAVIORAL DEFINITIONS

1. Constant or frequent conflict with parents and/or siblings.

2. A family that is not a stable source of positive influence or support, since

family members have little or no contact with each other.

3. Ongoing conflict with parents, which is characterized by parents

fostering dependence leading to feelings that the parents are overly

involved.

4. Maintains a residence with parents and has been unable to live

independently for more than a brief period.

5. Long period of noncommunication with parents, and description of self as

the “black sheep.”

6. Remarriage of two parties, both of whom bring children into the marriage

from previous relationships.

7. Parents in conflict with each other over parenting methods and styles for

their minor children.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Parents increase their cooperation and mutual support in dealing with

their children.

2. Begin the process of emancipating from parents in a healthy way by

making arrangements for independent living.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

170

3. Decrease the level of present conflict with parents while beginning to let

go of or resolving past conflicts with them.

4. Achieve a reasonable level of family connectedness and harmony where

members support, help, and are concerned for each other.

5. Become a reconstituted/blended family unit that is functional and whose

members are bonded to each other.

6. Reach a level of reduced tension, increased satisfaction, and improved

communication with family and/or other authority figures.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the conflicts and the

causes of conflicts between self

and parents. (1, 2)

1. Give verbal permission for

the client to have and express

own feelings, thoughts, and

perspectives in order to foster a

sense of autonomy from family.

2. Explore the nature of the client’s

family conflicts and their

perceived causes.

2. Attend and participate in family

therapy sessions where the

emphasis is on reducing conflict.

(3, 4)

3. Conduct family therapy sessions

with the client and his/her

parents to facilitate healthy

communication (where the focus

is on controlled, reciprocal,

respectful communication of

thoughts and feelings), conflict

resolution, and the normalization

of the emancipation process.

4. Educate family members that

resistance to change in styles of

relating to one another is usually

high and that change takes

concerted effort by all members.

FAMILY CONFLICT

171

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

172

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

4. Identify own as well as others’

role in the family conflicts.

(9, 10)

9. Confront the client when he/she

is not taking responsibility for

his/her role in the family conflict

and reinforce the client for

owning responsibility for his/her

contribution to the conflict.

10. Ask the client to read material

on resolving family conflict (e.g.,

Making Peace with Your Parents

by Bloomfield and Felder);

encourage and monitor the

selection of concepts to begin

using in conflict resolution.

5. Family members demonstrate

increased openness by sharing

thoughts and feelings about

family dynamics, roles, and

expectations. (11, 12)

11. Conduct a family session in

which a process genogram is

formed that is complete with

members, patterns of interaction,

rules, and secrets.

12. Facilitate each family member in

expressing his/her concerns and

expectations regarding becoming

a more functional family unit.

6. Identify the role that chemical

dependence behavior plays in

triggering family conflict. (13)

13. Assess for the presence of

chemical dependence in the client

or family members; emphasize

the need for chemical depen-

dence treatment, if indicated,

and arrange for such a focus

(see the Substance Use chapter

in this Planner).

7. Verbally describe an

understanding of the role played

by family relationship stress in

triggering substance abuse or

relapse. (14, 15)

14. Help the client to see the triggers

for chemical dependence relapse

in the family conflicts.

15. Ask the client to read material

on the family aspects of chemical

FAMILY CONFLICT

dependence (e.g., It Will Never

Happen to Me by Black;

Bradshaw On the Family by

Bradshaw); process key family

issues from the reading that are

triggers for him/her.

8. Increase the number of positive

family interactions by planning

activities. (16, 17, 18)

16. Refer the family for an experi-

ential weekend at a center for

family education to build skills

and confidence in working

together (consider a physical

confidence class with low or high

ropes courses, etc.).

17. Ask the parents to read material

on positive parenting methods

(e.g., Raising Self-Reliant

Children by Glenn and Nelsen;

Between Parent and Child by

Ginott; Between Parent and

Teenager by Ginott); process key

concepts gathered from their

reading.

18. Assist the client in developing a

list of positive family activities

that promote harmony (e.g.,

bowling, fishing, playing table

games, doing work projects).

Schedule such activities into the

family calendar.

9. Parents report how both are

involved in the home and

parenting process. (19, 20)

19. Elicit from the parents the role

each takes in the parental team

and his/her perspective on

parenting.

20. Read and process in a family

therapy session the fable

“Raising Cain” or “Cinderella”

(see Friedman’s Fables by

Friedman).

10. Identify ways in which the

parental team can be

strengthened. (21)

21. Assist the parents in identifying

areas that need strengthening in

their “parental team,” then work

with them to strengthen these

areas (or assign “Learning to

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

174

Parent as a Team” in the Adult

Psychotherapy Homework

Planner by Jongsma).

11. Parents learn and implement

effective parenting methods to

reduce conflict between

themselves and the children over

parenting. (22, 23, 24, 25, 26)

22. Ask the parents to read material

consistent with a parent training

approach to managing disruptive

children’s behavior (e.g., The

Kazdin Method for Parenting the

Defiant Child by Kazdin; Parents

and Adolescents Living Together:

The Basics by Forgatch and

Patterson; Parents and

Adolescents Living Together:

Family Problem Solving by

Patterson and Forgatch).

23. Describe the Parent Manage-

ment Training approach to teach

the parents how behavioral

interactions with the child can

encourage or discourage positive

or negative behavior by the child

and that changing key elements

of those interactions (e.g.,

prompting and reinforcing

positive behaviors) can be used

to promote positive change (see

Parent Management Training-

Oregon Model by Forgatch and

Patterson).

24. Teach the parents how to

specifically define and identify

problem behaviors, identify their

own reactions to the behavior,

determine whether the reaction

encourages or discourages the

behavior, and generate

alternatives to the problem

behavior (or assign “Using

Reinforcement Principles in

Parenting” in the Adult

Psychotherapy Homework

Planner by Jongsma).

25. Assign the parents to implement

key parenting practices

FAMILY CONFLICT

consistently, including

establishing realistic age-

appropriate rules for acceptable

and unacceptable behavior,

prompting of positive behavior in

the environment, use of positive

reinforcement to encourage

behavior (e.g., praise and clearly

established rewards), use of calm,

clear direct instruction, time out,

and other loss-of-privilege

practices for sustained problem

behavior (assign “A Structured

Parenting Plan” in the Adult

Psychotherapy Homework

Planner by Jongsma).

26. Assign the parents home

exercises in which they

implement and record results

of implementation exercises

(or assign “Clear Rules, Positive

Reinforcement, Appropriate

Consequences” in the Adolescent

Psychotherapy Homework

Planner by Jongsma, Peterson,

and McInnis); review in session,

providing corrective feedback

toward improved, appropriate,

and consistent use of skills.

12. Older children and teens learn

skills for managing anger and

solving problems without

conflict. (27, 28)

27. Use modeling, role-playing, and

behavioral rehearsal to teach the

client anger control techniques

that include stop, think, and act

as well as cognitive problem-

solving skills; role-play the

application of the skills to

multiple situations in the client’s

life.

28. Assign the client to implement

the anger control and problem-

solving techniques in his/her

daily living (or assign “Applying

Problem-Solving to Inter-

personal Conflict” in the Adult

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

176

Psychotherapy Homework

Planner by Jongsma); review

these incidents; reinforce and

provide corrective feedback

toward the goal of sustained

effective use.

13. Report an increase in resolving

conflicts with parents by talking

calmly and assertively rather

than aggressively and

defensively. (29, 30)

29. Use role-playing, role reversal,

modeling, and behavioral

rehearsal to help the client

develop assertive ways to

resolve conflict with parents

(recommend Your Perfect Right:

Assertiveness and Equality in

Your Life and Relationships by

Alberti and Emmons).

30. Assign the parents to read

material on reducing sibling

conflict (e.g., The Kazdin Method

for Parenting the Defiant Child

by Kazdin); process key concepts

and encourage implementation

of interventions with their

children.

14. Parents increase structure within

the family. (31, 32)

31. Assist parents in developing

rituals (e.g., dinner times,

bedtime readings, weekly family

activity times) that will provide

structure and promote bonding.

32. Assist the parents in increasing

structure within the family by

setting times for eating meals

together, limiting number of

visitors, setting a lights-out time,

establishing a phone call cutoff

time, curfew time, “family

meeting” time, and so on.

15. Each family member represents

pictorially and then describes

his/her role in the family. (33, 34)

33. Conduct a family session in

which all members bring self-

produced drawings of themselves

in relationship to the family; ask

each to describe what they’ve

brought and then have the

picture placed in an album.

FAMILY CONFLICT

177

34. Ask the family to make a

collage of pictures cut out from

magazines depicting “family”

through their eyes and/or ask

them to design a coat of arms

that will signify the blended unit.

16. Family members report a desire

for and vision of a new sense of

connectedness. (35, 36, 37)

35. In a family session, assign the

family the task of planning and

going on an outing or activity; in

the following session, process the

experience with the family,

giving positive reinforcement

where appropriate.

36. Conduct a session with all new

family members in which a

genogram is constructed,

gathering the history of both

families and that visually shows

how the new family connection

will be.

37. Assign the parents to read the

book Changing Families by

Fassler, Lash, and Ives at home

with the family and report their

impressions in family therapy

sessions.

17. Identify factors that lead to

dependence on the family and

verbalize steps to overcome

them. (38, 39)

38. Ask the client to make a list of

ways he/she is dependent on

parents.

39. For each factor that promotes

the client’s dependence on

parents, develop a constructive

plan to reduce that dependence

(or assign “Taking Steps toward

Independence” in the Adult

Psychotherapy Homework

Planner by Jongsma).

18. Increase the level of independent

functioning. (40, 41)

40. Confront the client’s emotional

dependence and avoidance of

economic responsibility that

promotes continuing pattern

of living with parents; develop a

plan for the client’s healthy and

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

178

responsible emancipation from

parents that is, if possible,

complete with their blessing (e.g.,

finding and keeping a job, saving

money, socializing with friends,

finding own housing, etc.).

41. Probe the client’s fears

surrounding emancipation;

support the client’s strengths

that can lead to independence

(or assign “Acknowledging

My Strengths” in the Adult

Psychotherapy Homework

Planner by Jongsma) and assist

the client in identifying and

replacing fearful thoughts with

positive messages (or assign

“Replacing Fears With Positive

Messages” in the Adult

Psychotherapy Homework

Planner by Jongsma).

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

313.81 Oppositional Defiant Disorder

312.8 Conduct Disorder

312.9 Disruptive Behavior Disorder NOS

300.4 Dysthymic Disorder

300.00 Anxiety Disorder NOS

312.34 Intermittent Explosive Disorder

303.90 Alcohol Dependence

304.20 Cocaine Dependence

304.80 Polysubstance Dependence

FAMILY CONFLICT

V71.02 Child or Adolescent Antisocial Behavior

V61.20 Parent-Child Relational Problem

V61.10 Partner Relational Problem

V61.8 Sibling Relational Problem

_____

_____________________________________

_____

_____________________________________

Axis II:

301.7 Antisocial Personality Disorder

301.6 Dependent Personality Disorder

301.83 Borderline Personality Disorder

301.9 Personality Disorder NOS

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.4 F34.1 Persistent Depressive Disorder

300.09 F41.8 Other Specified Anxiety Disorder

300.00 F41.9 Unspecified Anxiety Disorder

312.34 F63.81 Intermittent Explosive Disorder

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

304.20 F14.20 Cocaine Use Disorder, Moderate or Severe

301.7 F60.2 Antisocial Personality Disorder

301.6 F60.7 Dependent Personality Disorder

301.83 F60.3 Borderline Personality Disorder

301.9 F60.9 Unspecified Personality Disorder

V61.8 Z63.8 High Expressed Emotion Level Within

Family

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

FEMALE SEXUAL DYSFUNCTION

BEHAVIORAL DEFINITIONS

1. Describes consistently very low or no pleasurable anticipation of or desire

for sexual activity.

2. Strongly avoids and/or is repulsed by any and all sexual contact in spite

of a relationship of mutual caring and respect.

3. Recurrently experiences a lack of the usual physiological response of

sexual excitement and arousal (genital lubrication and swelling).

4. Reports a consistent lack of a subjective sense of enjoyment and pleasure

during sexual activity.

5. Experiences a persistent delay in or absence of reaching orgasm after

achieving arousal and in spite of sensitive sexual pleasuring by a caring

partner.

6. Describes genital pain experienced before, during, or after sexual

intercourse.

7. Reports consistent or recurring involuntary spasm of the vagina that

prohibits penetration for sexual intercourse.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Increase desire for and enjoyment of sexual activity.

2. Attain and maintain physiological excitement response during sexual

intercourse.

FEMALE SEXUAL DYSFUNCTION

3. Reach orgasm with a reasonable amount of time, intensity, and focus to

sexual stimulation.

4. Eliminate pain and achieve a presence of subjective pleasure before,

during, and after sexual intercourse.

5. Eliminate vaginal spasms that prohibit penile penetration during sexual

intercourse and achieve a sense of relaxed enjoyment of coital pleasure.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Provide a detailed sexual history

that explores current problems

and past experiences that have

influenced sexual attitudes,

feelings, and behavior. (1, 2, 3)

1. Conduct a thorough biopsy-

chosocial sexual history that

examines the client’s current

adult sexual functioning as well

as childhood and adolescent

sexual experiences, level and

sources of sexual knowledge,

typical sexual practices and their

frequency, medical history, drug

and alcohol use, and lifestyle

factors.

2. Assess the client’s attitudes and

fund of knowledge regarding sex,

emotional responses to it, and

self-talk that may be contributing

to the dysfunction.

3. Explore the client’s family of

origin for factors that may be

contributing to elements of the

dysfunction such as negative

attitudes regarding sexuality,

feelings of inhibition, low self-

esteem, guilt, fear, or repulsion

(or assign “Factors Influencing

Negative Sexual Attitudes” in

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

182

the Adult Psychotherapy

Homework Planner by Jongsma).

2. Discuss any feelings of and

causes for depression. (4)

4. Assess the role of depression

in possibly causing the client’s

sexual dysfunction and treat if

depression appears causal (see

the Unipolar Depression chapter

in this Planner).

3. Participate in treatment of

depressive feelings that may be

causing sexual difficulties. (5)

5. Refer the client for an

antidepressant medication

prescription to alleviate

depression.

4. Honestly report substance

abuse and cooperate with

recommendations by the

therapist for addressing it. (6)

6. Explore the client’s use or abuse

of mood-altering substances and

their effect on sexual functioning;

refer for focused substance abuse

counseling.

5. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (7, 8, 9, 10)

7. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

8. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

FEMALE SEXUAL DYSFUNCTION

suicide risk when comorbid

depression is evident).

9. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

10. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

6. Honestly and openly discuss the

quality of the relationship

including conflicts, unfulfilled

needs, and anger. (11)

11. Assess the quality of the

relationship including couple

satisfaction, distress, attraction,

communication, and sexual

repertoire toward making a

decision to focus treatment on

sexual problems or more broadly

on the relationship (or assign

“Positive and Negative

Contributions to the Relation-

ship: Mine and Yours” in the

Adult Psychotherapy Homework

Planner by Jongsma).

7. Cooperate with a physician’s

complete medical evaluation;

discuss results with therapist.

(12)

12. Refer the client to a physician

for a complete medical

evaluation to rule out any

general medical or substance-

related causes of the sexual

dysfunction (e.g., vascular,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

184

endocrine, medications),

including a gynecological exam

and assessment of pelvic floor

musculature, if indicated (e.g.,

for a sexual pain condition).

8. Cooperate with physician’s

recommendation for addressing

a medical condition or

medication that may be causing

sexual problems. (13)

13. Encourage the client to follow

her physician’s recommendations

regarding treatment of a

diagnosed medical condition or

use of medication that may be

causing the sexual problem.

9. Verbalize an understanding of

the role that physical disease

or medication has on sexual

dysfunction. (14)

14. Discuss the contributory role

that a diagnosed medical

condition or medication use may

be having on the client’s sexual

functioning.

10. Participate in sex therapy with a

partner or individually if the

partner is not available. (15)

15. Encourage couples sex therapy

or treat individually if a partner

is not available (see Enhancing

Sexuality—Therapist Guide by

Wincze).

11. Participate in couples/marital

therapy as part of addressing

sexual problems. (16)

16. For hypoactive desire or if

problem issues go beyond sexual

dysfunction, conduct sex therapy

in the context of couples therapy

(see “Does Marital Therapy

Enhance the Effectiveness

of Treatment for Sexual

Dysfunction?” by Zimmer and

the Intimate Relationship

Conflicts chapter in this

Planner).

12. Demonstrate healthy acceptance

and accurate knowledge of

sexuality by freely learning and

discussing accurate information

regarding sexual functioning.

(17, 18)

17. Disinhibit and educate the

couple by encouraging them

to talk freely and respectfully

regarding her sexual body parts,

sexual thoughts, feelings,

attitudes, and behaviors.

18. Reinforce the client for talking

freely, knowledgeably, and

positively regarding her

sexual thoughts, feelings,

and behavior.

FEMALE SEXUAL DYSFUNCTION

13. State a willingness to explore

new ways to approach sexual

relations. (19, 20)

19. Direct conjoint sessions with the

client and her partner that focus

on conflict resolution, expression

of feelings, and sex education.

20. Assign books (e.g., Sexual

Awareness: Your Guide to

Healthy Couple Sexuality by

McCarthy and McCarthy; The

Gift of Sex by Penner and

Penner; For Each Other: Sharing

Sexual Intimacy by Barbach)

that provide the client with

accurate sexual information

and/or outline sexual exercises

that disinhibit and reinforce

sexual sensate focus.

14. List conditions and factors that

positively affect sexual arousal

such as setting, time of day,

atmosphere. (21)

21. Assign the couple to list

conditions and factors that

positively affect their sexual

arousal; process the list toward

creating an environment

conducive to sexual arousal.

15. Identify and replace negative

cognitive messages that trigger

negative emotional reactions

during sexual activity.

(22, 23, 24)

22. Probe automatic thoughts that

trigger the client’s negative

emotions such as fear, shame,

anger, or grief before, during,

and after sexual activity.

23. Assist the client in identifying

healthy alternative thoughts

that can replace dysfunctional

automatic thoughts and will

mediate pleasure, relaxation,

and disinhibition.

24. Assist the client in making

behavioral changes that chal-

lenge dysfunctional beliefs and

emotions; if necessary, improve

the client’s understanding of

developmental influences that

have led to current dysfunctional

sexual beliefs and/or discuss pros

and cons of change.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

186

16. Practice directed masturbation

and sensate focus exercises alone

and with partner and share

feelings associated with activity.

(25, 26, 27)

25. For anorgasmia, direct the client

in masturbatory exercises

designed to maximize arousal;

assign the client graduated steps

of sexual pleasuring exercises

with partner that reduce her

performance anxiety, and focus

on experiencing bodily arousal

sensations (see Enhancing

Sexuality—Therapist Guide by

Wincze or assign “Journaling the

Response to Nondemand, Sexual

Pleasuring [Sensate Focus]” in the

Adult Psychotherapy Homework

Planner by Jongsma).

26. For hypoactive desire, conduct

Orgasm Consistency Training

involving masturbatory training,

sensate focus, male self-control

techniques, and the coital

alignment technique (see Orgasm

Consistency Training by

Hurlbert, White, and Powell).

27. Assign readings to supplement

education and technique training

done in session (e.g., Enhancing

Sexuality—Client Workbook by

Wincze; Rekindling Desire by

McCarthy and McCarthy;

Becoming Orgasmic: A Sexual

and Personal Growth Program

for Women by Heiman and

LoPiccolo; Because It Feels

Good: A Woman’s Guide to

Sexual Pleasure and Satisfaction

by Herbenick).

17. Report progress on graduated

self-controlled vaginal

penetration with a partner.

(28, 29, 30)

28. Assign the client body

exploration and awareness

exercises that reduce inhibition

and desensitize negative

emotional reactions to sex.

29. Direct the client’s use of

masturbation and/or vaginal

FEMALE SEXUAL DYSFUNCTION

dilator devices to reinforce

relaxation and success

surrounding vaginal

penetration.

30. Direct the client’s partner in

sexual exercises that allow for

client-controlled level of genital

stimulation and gradually

increased vaginal penetration

(or assign “Journaling the

Response to Nondemand, Sexual

Pleasuring [Sensate Focus]” in the

Adult Psychotherapy Homework

Planner by Jongsma).

18. State an understanding of how

family upbringing, including

religious training, negatively

influenced sexual thoughts,

feelings, and behavior. (31, 32)

31. Explore the role of the client’s

family of origin in teaching her

negative attitudes regarding

sexuality (or assign “Factors

Influencing Negative Sexual

Attitudes” in the Adult

Psychotherapy Homework Planner

by Jongsma); process toward the

goal of insight and change.

32. Explore the role of the client’s

religious training in reinforcing

her feelings of guilt and shame

surrounding her sexual behavior

and thoughts; process toward the

goal of insight and change.

19. Verbalize a resolution of feelings

regarding sexual trauma or

abuse experiences. (33, 34)

33. Probe the client’s history for

experiences of sexual trauma

or abuse.

34. Process the client’s emotions

surrounding an emotional

trauma in the sexual arena (see

the Sexual Abuse Victim chapter

in this Planner).

20. Verbalize an understanding of

the influence of childhood sex

role models. (35)

35. Explore sex role models the

client has experienced in

childhood or adolescence and

how they have influenced the

client’s attitudes and behaviors.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

188

21. Verbalize connection between

previously failed intimate

relationships and current fear.

(36)

36. Explore the client’s fears

surrounding intimate

relationships and whether there

is evidence of repeated failure in

this area.

22. Discuss feelings surrounding a

secret affair and make a

termination decision regarding

one of the relationships. (37, 38)

37. Explore for any secret sexual

affairs that may account for the

client’s sexual dysfunction with

her partner.

38. Process a decision regarding

the termination of one of the

relationships that is leading

to internal conflict over the

dishonesty and disloyalty

to a partner.

23. Openly acknowledge and

discuss, if present, homosexual

attraction. (39)

39. Explore for a homosexual

interest that accounts for the

client’s heterosexual disinterest

(or assign “Journal of Sexual

Thoughts, Fantasies, Conflicts”

in the Adult Psychotherapy

Homework Planner by Jongsma).

24. Discuss low self-esteem issues

that impede sexual functioning

and verbalize positive self-image.

(40)

40. Explore the client’s fears of

inadequacy as a sexual partner

that led to sexual avoidance.

25. Communicate feelings of threat

to partner that are based on

perception of partner being too

sexually aggressive or too

critical. (41)

41. Explore the client’s feelings

of threat brought on by the

perception of her partner as

too sexually aggressive.

26. Verbalize a positive body image.

(42, 43)

42. Assign the client to list assets of

her body; confront unrealistic

distortions and critical

comments (or assign “Study

Your Body—Clothed and

Unclothed” in the Adult

Psychotherapy Homework

Planner by Jongsma).

43. Explore the client’s feelings

regarding her body image,

focusing on causes for negativism.

FEMALE SEXUAL DYSFUNCTION

27. Implement new coital positions

and settings for sexual activity

that enhance pleasure and

satisfaction. (44, 45)

44. Assign books (e.g., Sexual

Awareness by McCarthy and

McCarthy; The Gift of Sex by

Penner and Penner; For Each

Other: Sharing Sexual Intimacy

by Barbach) that provide the

client with accurate sexual

information and/or outline

sexual exercises that disinhibit

and reinforce sexual sensate

focus.

45. Suggest experimentation with

coital positions and settings for

sexual play that may increase

the client’s feelings of security,

arousal, and satisfaction.

28. Engage in more assertive

behaviors that allow for sharing

sexual needs, feelings, and

desires, behaving more

sensuously and expressing

pleasure. (46, 47)

46. Give the client permission for

less inhibited, less constricted

sexual behavior by assigning

body-pleasuring exercises with

partner.

47. Encourage the client to gradually

explore the role of being more

sexually assertive, sensuously

provocative, and freely

uninhibited in sexual play with

partner.

29. Resolve conflicts or develop

coping strategies that reduce

stress interfering with sexual

interest or performance. (48)

48. Probe stress in areas such as

work, extended family, and

social relationships that distract

the client from sexual desire or

performance (see Anxiety,

Family Conflict, and Vocational

Stress chapters in this Planner).

30. Verbalize increasing desire for

and pleasure with sexual activity.

(49, 50)

49. Reinforce the client’s expressions

of desire for and pleasure with

sexual activity.

50. Explore if there are areas of

healthy sexual activity that the

client may like to engage in but

has been reluctant to request or

discuss; encourage openness and

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

190

honesty in bringing these

activities up in session and/or

with her partner.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

302.71 Hypoactive Sexual Desire Disorder

302.79 Sexual Aversion Disorder

302.72 Female Sexual Arousal Disorder

302.73 Female Orgasmic Disorder

302.76 Dyspareunia

306.51 Vaginismus

995.53 Sexual Abuse of Child, Victim

625.8 Female Hypoactive Sexual Desire Disorder

Due to Axis III Disorder

625.0 Female Dyspareunia Due to Axis III

Disorder

302.70 Sexual Dysfunction NOS

_____

_________________________________

___

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

302.71 F52.22 Female Sexual Interest/Arousal Disorder

302.73 F52.31 Female Orgasmic Disorder

302.76 F52.6 Genito-Pelvic Pain/Penetration Disorder

995.53 T74.22XA Child Sexual Abuse, Confirmed, Initial

Encounter

995.53 T74.22XD Child Sexual Abuse, Confirmed,

Subsequent Encounter

302.70 F52.9 Unspecified Sexual Dysfunction

FEMALE SEXUAL DYSFUNCTION

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

FINANCIAL STRESS

BEHAVIORAL DEFINITIONS

1. Indebtedness and overdue bills that exceed ability to meet monthly

payments.

2. Loss of income due to unemployment.

3. Reduction in income due to change in employment status.

4. Conflict with spouse over management of money and the definition of

necessary expenditures and savings goals.

5. A feeling of low self-esteem and hopelessness that is associated with the

lack of sufficient income to cover the cost of living.

6. A long-term lack of discipline in money management that has led to

excessive indebtedness.

7. An uncontrollable crisis (e.g., medical bills, job layoff) that has caused

past due bill balances to exceed ability to make payments.

8. Fear of losing housing to foreclosure because of an inability to meet

monthly mortgage payments.

9. A pattern of impulsive spending that does not consider the eventual

financial consequences.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Revise spending patterns to not exceed income.

2. Resolve financial crisis with a path to eliminate debt.

FINANCIAL STRESS

3. Gain a new sense of self-worth in which the substance of one’s value is

not attached to the capacity to do things or own things that cost money.

4. Understand personal desires, insecurities, and anxieties that make

overspending possible.

5. Achieve an inner strength to control personal impulses, cravings, and

desires that directly or indirectly increase debt irresponsibly.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the details of the

current financial situation.

(1, 2, 3)

1. Provide the client a supportive,

nonjudgmental environment by

being empathetic, warm, and

sensitive to the fact that the topic

may elicit guilt, shame, and

embarrassment.

2. Explore the client’s current

financial situation.

3. Assist the client in compiling

a complete list of financial

obligations.

2. Isolate the sources and causes

of the excessive indebtedness.

(4)

4. Assist in identifying, without

projection of blame or holding to

excuses, the causes for the financial

crisis through a review of the

client’s history of spending.

3. Verbalize feelings of

depression, hopelessness,

and/or shame that are related

to financial status. (5, 6)

5. Probe the client’s feelings of

hopelessness or helplessness that

may be associated with the

financial crisis.

6. Assess the depth or seriousness of

the client’s despondency over the

financial crisis.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

194

4. Describe any suicidal impulses

that may accompany financial

stress. (7)

7. Assess the client’s potential risk

for suicidal behavior. If necessary,

take steps to ensure the client’s

safety (see the Suicidal Ideation

chapter in this Planner).

5. Identify personal traits that

make undisciplined spending

possible. (8, 9)

8. Probe the client for evidence of low

self-esteem, need to impress others,

loneliness, or depression that may

accelerate unnecessary,

unwarranted spending.

9. Assess the client for mood swings

that are characteristic of bipolar

disorder and could be responsible

for careless spending due to the

impaired judgment of manic phase

(see the Bipolar Disorder—Mania

chapter in this Planner).

6. Honestly describe any of own

or family members’ substance

abuse problems that contribute

to financial irresponsibility.

(10, 11)

10. Probe the client for excessive

alcohol or other drug use by asking

questions from the CAGE or

Michigan Alcohol Screening

Test screening instruments for

substance abuse (see the Substance

Use chapter in this Planner).

11. Explore the possibility of alcohol

or drug use by the client’s family

members or significant other.

7. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature

of the therapy relationship.

(12, 13, 14, 15)

12. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

FINANCIAL STRESS

13. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

14. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

15. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

8. Identify priorities that should

control how money is spent.

(16, 17)

16. Ask the client to list the priorities

that he/she believes should give

direction to how his/her money is

spent; process those priorities.

17. Review the client’s spending

history to discover what priorities

and values have misdirected

spending.

9. Describe the family-of-origin

pattern of money management.

(18)

18. Explore the client’s family-of-

origin patterns of earning, saving,

and spending money, focusing on

how those patterns are influencing

his/her current financial decisions.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

196

10. Meet with community agency

personnel to apply for welfare

assistance. (19, 20, 21)

19. Review the client’s need for filing

for bankruptcy, applying for

welfare, and/or obtaining credit

counseling.

20. Direct the client to the proper

church or community resources to

seek welfare assistance and support

him/her in beginning the humbling

application process.

21. Refer the client to government

home-buyers/homeowners

assistance programs to avoid

foreclosure (e.g., http://www.

usa.gov/shopping/realestate/

mortgages/mortgages.shtml)

11. Write a budget that balances

income with expenses. (22, 23)

22. If financial planning is needed,

refer to a professional planner or

ask partners to write a current

budget and a long-range savings

and investment plan (consider

assigning “Plan a Budget” from the

Adult Psychotherapy Homework

Planner by Jongsma or The Budget

Kit: The Common Cents Money

Management Workbook by

Lawrence).

23. Review the client’s budget as to

reasonableness and completeness.

12. Attend a meeting with a credit

counselor to gain assistance in

budgeting and contacting

creditors for establishment of

a reasonable repayment plan.

(24, 25)

24. Refer the client to a nonprofit, no-

cost credit counseling service for

the development of a budgetary

plan of debt repayment.

25. Encourage the client’s attendance

at all credit counseling sessions and

his/her discipline of self to control

spending within budgetary

guidelines.

13. Meet with an attorney to help

reach a decision regarding

filing for bankruptcy. (26)

26. Refer the client to an attorney

to discuss the feasibility and

implications of filing for

bankruptcy.

FINANCIAL STRESS

14. Verbalize a plan for seeking

employment to raise level of

income. (27, 28)

27. Review the client’s income from

employment and brainstorm

ways (e.g., additional part-time

employment, better paying job, job

training) to increase this revenue.

28. Assist the client in formulating a

plan for a job search (or assign “A

Vocational Action Plan” from the

Adult Psychotherapy Homework

Planner by Jongsma).

15. Set financial goals and make

budgetary decisions with

partner, allowing for equal

input and balanced control

over financial matters. (29, 30)

29. Encourage financial planning

by the client that is done in

conjunction with his/her partner.

30. Reinforce changes in managing

money that reflect compromise,

responsible planning, and

respectful cooperation with

the client’s partner.

16. Keep weekly and monthly

records of financial income

and expenses. (31, 32)

31. Encourage the client to keep a

weekly and monthly record of

income and outflow; review his/her

records weekly, and reinforce

his/her responsible financial

decision-making.

32. Offer praise and ongoing

encouragement of the client’s

progress toward debt resolution;

recommend the client read The

Total Money Makeover: A Proven

Plan for Financial Fitness by

Ramsey).

17. Use cognitive and behavioral

strategies to control the

impulse to make unnecessary

and unaffordable purchases.

(33, 34, 35, 36)

33. Role-play situations in which

the client must resist the inner

temptation to spend beyond

reasonable limits, emphasizing

positive self-talk that compliments

self for being disciplined.

34. Role-play situations in which the

client must resist external pressure

to spend beyond what he/she can

afford (e.g., friend’s invitation to

golf or go shopping, child’s request

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

198

for a toy), emphasizing being

graciously assertive in refusing

the request.

35. Teach the client the cognitive

strategy of asking self before

each purchase: Is this purchase

absolutely necessary? Can we

afford this? Do we have the cash

to pay for this without incurring

any further debt?

36. Urge the client to avoid all impulse

buying by delaying every purchase

until after 24 hours of thought and

by buying only from a prewritten

list of items to buy (consider

assigning “Impulsive Behavior

Journal” from the Adult

Psychotherapy Homework Planner

by Jongsma).

18. Report instances of successful

control over impulse to spend

on unnecessary expenses.

(37, 38)

37. Reinforce with praise and

encouragement all of the client’s

reports of resisting the urge to

overspend.

38. Hold conjoint or family therapy

session in which controlled

spending is reinforced and

continued cooperation is pledged

by everyone.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

FINANCIAL STRESS

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

309.0 Adjustment Disorder with Depressed Mood

296.4x Bipolar I Disorder, Manic

296.89 Bipolar II Disorder

296.xx Major Depressive Disorder

_____

_____________________________________

_____

_____________________________________

Axis II:

301.83 Borderline Personality Disorder

301.7 Antisocial Personality Disorder

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

309.24 F43.22 Adjustment Disorder, With Anxiety

296.4x F31.1x Bipolar I Disorder, Manic

296.89 F31.81 Bipolar II Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

301.83 F60.3 Borderline Personality Disorder

301.7 F60.2 Antisocial Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

GRIEF / LOSS UNRESOLVED

BEHAVIORAL DEFINITIONS

1. Thoughts dominated by loss coupled with poor concentration, tearful

spells, and confusion about the future.

2. Serial losses in life (i.e., deaths, divorces, jobs) that led to depression and

discouragement.

3. Strong emotional response of sadness exhibited when losses are discussed.

4. Lack of appetite, weight loss, and/or insomnia as well as other depression

signs that occurred since the loss.

5. Feelings of guilt that not enough was done for the lost significant other,

or an unreasonable belief of having contributed to the death of the

significant other.

6. Avoidance of talking on anything more than a superficial level about the

loss.

7. Loss of a positive support network due to a geographic move.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Begin a healthy grieving process around the loss.

2. Develop an awareness of how the avoidance of grieving has affected life

and begin the healing process.

3. Complete the process of letting go of the lost significant other.

4. Resolve the loss, reengaging in old relationships and initiating new

contacts with others.

GRIEF / LOSS UNRESOLVED

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Tell in detail the story of the

current loss that is triggering

symptoms. (1, 2, 3, 4)

1. Create a safe environment for

disclosure and actively build the

level of trust with the client in

individual sessions through

consistent eye contact, active

listening, unconditional positive

regard, and warm acceptance to

help increase his/her ability to

identify and express thoughts and

feelings.

2. Use empathy, compassion, and

support, allowing the client to tell

in detail the story of his/her recent

loss.

3. Ask the client to elaborate in an

autobiography the circumstances,

feelings, and effects of the losses in

him/her; assess the characteristics

of the loss (e.g., type, suddenness,

trauma), previous functioning,

current functioning, and coping

style.

4. Ensure that the client has self-

selected therapy for grief as

opposed to being “forced” into it;

clarify that therapy is the client’s

choice if he/she voices feeling

pushed into it.

2. Participate in a therapy that

addresses issues beyond grief

5. Assess for whether the client

evidences chronic or complicated

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

202

that have arisen as a result of

the loss. (5)

grief or a more severe clinical

syndrome secondary to the loss

(e.g., depression, GAD, PTSD)

and conduct or refer to an

appropriate evidence-based

therapy (see appropriate chapters

in this Planner).

3. Identify how the use of

substances has aided the

avoidance of feelings

associated with the loss. (6, 7)

6. Assess the role that substance

abuse has played as an escape for

the client from the pain or guilt of

loss.

7. Arrange for chemical dependence

treatment so that grief issues can

be faced while the client is clean

and sober (see the Substance Use

chapter in this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(8, 9, 10, 11)

8. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

9. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

10. Assess for any issues of age,

gender, or culture that could help

GRIEF / LOSS UNRESOLVED

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

11. Assess for the severity of the level

of impairment to the client’s

functioning to determine appro-

priate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

5. Read books on the topic of

grief to better understand the

loss experience and to increase

a sense of hope. (12, 13)

12. Ask the client to read books on

grief and loss (e.g., Getting to the

Other Side of Grief: Overcoming the

Loss of a Spouse by Zonnebelt-

Smeenge and De Vries; Good Grief

by Westberg; When Bad Things

Happen to Good People by

Kushner; How Can It Be All Right

When Everything Is All Wrong? by

Smedes); process the content.

13. Ask the parents of a deceased child

to read a book on coping with the

loss (e.g., When the Bough Breaks:

Forever After the Death of a Son or

Daughter by Bernstein; Through

the Eyes of a Dove: A Book for

Bereaved Parents by Courtney);

process the key themes gleaned

from the reading.

6. Identify what stages of grief

have been experienced in the

continuum of the grieving

process. (14, 15, 16)

14. Ask the client to talk to several

people about losses in their lives

and how they felt and coped;

process the findings.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

204

15. Educate the client on the stages of

the grieving process and answer

any questions he/she may have.

16. Assist the client in identifying the

stages of grief that he/she has

experienced and which stage he/she

is presently working through.

7. Watch videos on the theme of

grief and loss to compare own

experience with that of the

characters in the films. (17)

17. Ask the client to watch the films

Terms of Endearment, Dad,

Ordinary People, or a similar film

that focuses on loss and grieving,

then discuss how the characters cope

with loss and express their grief.

8. Begin verbalizing feelings

associated with the loss.

(18, 19, 20)

18. Assign the client to keep a daily

grief journal to be shared in

therapy sessions.

19. Ask the client to bring pictures or

mementos connected with his/her

loss to a session and talk about

them (or assign “Creating a

Memorial Collage” in the Adult

Psychotherapy Homework Planner

by Jongsma).

20. Assist the client in identifying and

expressing feelings connected with

his/her loss.

9. Attend a grief/loss support

group. (21)

21. Ask the client to attend a grief/loss

support group and report to the

therapist how he/she felt about

attending.

10. Identify how avoiding dealing

with loss has negatively

impacted life. (22)

22. Ask the client to list ways that

avoidance of grieving has

negatively impacted his/her life.

11. Acknowledge dependency on

lost loved one and begin to

refocus life on independent

actions to meet emotional

needs. (23, 24)

23. Assist the client in identifying how

he/she depended upon the

significant other, expressing and

resolving the accompanying

feelings of abandonment and of

being left alone.

24. Explore the feelings of anger or

guilt that surround the loss,

GRIEF / LOSS UNRESOLVED

helping the client understand the

sources for such feelings.

12. Verbalize and resolve feelings

of anger or guilt focused on sel

or deceased loved one that

interfere with the grieving

process. (25, 26)

25. Encourage the client to forgive

self and/or deceased to resolve

his/her feelings of guilt or anger;

recommend books on forgiveness

(e.g., Forgive and Forget by

Smedes).

26. Use nondirective techniques

(e.g., active listening, clarification,

summarization, reflection) to allow

the client to express and process

angry feelings connected to his/her

loss.

13. Verbalize resolution of feelings

of guilt and regret associated

with the loss. (27)

27. Assign the client to make a list

of all the regrets associated with

actions toward or relationship

with the deceased; process the list

content toward resolution of these

feelings.

14. Decrease unrealistic thoughts,

statements, and feelings of

being responsible for the loss.

(28)

28. Use a cognitive therapy approach

to identify the client’s bias toward

thoughts of personal responsibility

for the loss and replace them with

factual, reality-based thoughts (or

assign “Negative Thoughts Trigger

Negative Feelings” in the Adult

Psychotherapy Homework Planner

by Jongsma).

15. Express thoughts and feelings

about the deceased that went

unexpressed while the deceased

was alive. (29, 30, 31, 32)

29. Conduct an empty-chair exercise

with the client where he/she focuses

on expressing to the lost loved one

imagined in the chair what he/she

never said while that loved one was

alive.

30. Assign the client to visit the grave

of the lost loved one to “talk to”

the deceased and express his/her

feelings.

31. Ask the client to write a letter to the

lost person describing his/her fond

memories and/or painful and

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

206

regretful memories, and how he/she

currently feels life (or assign “Dear

_____: A Letter to a Lost Loved

One” in the Adult Psychotherapy

Homework Planner by Jongsma);

process the letter in session.

32. Assign the client to write to the

deceased loved one with a special

focus on his/her feelings associated

with the last meaningful contact

with that person.

16. Identify and voice positives

about the deceased loved one

including previous positive

experiences, positive

characteristics, positive aspects

of the relationship, and how

these things may be

remembered. (33, 34)

33. Ask the client to discuss and/or

list the positive aspects of

and memories about his/her

relationship with the lost loved

one; reinforce the client’s

expression of positive memories

and emotions (e.g., smiling,

laughing); encourage the client

to share these thoughts with

supportive loved ones.

34. Assist the client in engaging in

behaviors that celebrate the

positive memorable aspects of the

loved one and his/her life (e.g.,

placing memoriam in newspaper

on anniversary of death,

volunteering time to a favorite

cause of the deceased person).

17. Attend and participate in a

family therapy session focused

on each member sharing

his/her experience with grief.

(35)

35. Conduct a family and/or group

session with the client participating,

where each member talks about

his/her experience related to the loss;

encourage supportive interactions

among family members.

18. Reengage in activities with

family, friends, coworkers, and

others. (36, 37)

36. Assist the client in recommitting

and reengaging in the primary

social positive roles in which he/she

has functioned prior to the loss.

37. Promote behavioral activation by

assisting the client in listing

activities which he/she previously

enjoyed but has not engaged in

GRIEF / LOSS UNRESOLVED

since experiencing the loss and then

encourage reengagement in these

activities (or assign “Identify and

Schedule Pleasant Activities” in the

Adult Psychotherapy Homework

Planner by Jongsma).

19. Report decreased time spent

each day focusing on the loss.

(38, 39)

38. Develop a grieving ritual with an

identified feeling state (e.g., dress in

dark colors, preferably black, to

indicate deep sorrow) which the

client may focus on near the

anniversary of the loss. Process what

he/she received from the ritual.

39. Suggest that the client set aside a

specific time-limited period each

day to focus on mourning his/her

loss. After each day’s time is up,

the client will resume regular

activities and postpone grieving

thoughts until the next scheduled

time. For example, mourning times

could include putting on dark

clothing and/or sad music; clothing

would be changed when the

allotted time is up.

20. Develop and enact act(s) of

penitence. (40)

40. Encourage the parents to allow the

client to participate in a memorial

service, funeral service, or other

grieving rituals.

21. Implement acts of spiritual

faith as a source of comfort

and hope. (41)

41. Encourage the client to rely upon

his/her spiritual faith promises,

activities (e.g., prayer, meditation,

worship, music), and fellowship as

sources of support.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

208

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

296.2x Major Depressive Disorder, Single Episode

296.3x Major Depressive Disorder, Recurrent

V62.82 Bereavement

309.0 Adjustment Disorder With Depressed Mood

309.3 Adjustment Disorder With Disturbance of

Conduct

300.4 Dysthymic Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

296.2x F32.x Major Depressive Disorder, Single Episode

296.3x F33.x Major Depressive Disorder, Recurrent

Episode

V62.82 Z63.4 Uncomplicated Bereavement

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

309.24 F43.22 Adjustment Disorder, With Anxiety

309.28 F43.23 Adjustment Disorder, With Mixed Anxiety

and Depressed Mood

309.3 F43.24 Adjustment Disorder, With Disturbance of

Conduct

309.4 F43.25 Adjustment Disorder, With Mixed

Disturbance of Emotions and Conduct

300.4 F34.1 Persistent Depressive Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

IMPULSE CONTROL DISORDER

BEHAVIORAL DEFINITIONS

1. A tendency to act too quickly without careful deliberation, resulting in

numerous negative consequences.

2. Loss of control over aggressive impulses resulting in assault, self-

destructive behavior, or damage to property.

3. Deliberate and purposeful fire-setting on more than one occasion.

4. Persistent and recurrent maladaptive gambling behavior.

5. Recurrent failure to resist impulses to steal objects that are not needed

for personal use or for their monetary value.

6. Recurrent pulling out of one’s hair resulting in noticeable hair loss.

7. Desire to be satisfied almost immediately and a decreased ability to delay

pleasure or gratification.

8. A history of acting out in at least two areas that are potentially self-

damaging (e.g., spending money, sexual activity, reckless driving,

addictive behavior).

9. Overreactivity to mildly aversive or pleasure-oriented stimulation.

10. A sense of tension or affective arousal before engaging in the impulsive

behavior (e.g., kleptomania, pyromania).

11. A sense of pleasure, gratification, or release at the time of committing

the ego-dystonic, impulsive act.

12. Difficulty waiting for things—that is, restless standing in line, talking

out over others in a group, and the like.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

210

LONG-TERM GOALS

1. Reduce the frequency of impulsive behavior and increase the frequency

of behavior that is carefully thought out.

2. Reduce thoughts that trigger impulsive behavior and increase self-talk

that controls behavior.

3. Learn to stop, listen, and think before acting.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Identify the impulsive

behaviors that have been

engaged in over the last six

months. (1)

1. Review the client’s behavior

pattern to assist him/her in clearly

identifying, without minimization,

denial, or projection of blame,

his/her pattern of impulsivity.

2. List the reasons or rewards

that lead to continuation of an

impulsive pattern. (2, 3)

2. Explore whether the client’s

impulsive behavior is triggered by

anxiety and maintained by anxiety

relief rewards; assess for bipolar

manic disorder or ADHD.

3. Ask the client to make a list of the

positive things he/she gets from

impulsive actions and process it

with the therapist.

3. Disclose any history of

substance use that may

contribute to and complicate

the treatment of Impulse

Control Disorder. (4)

4. Arrange for a substance abuse

evaluation and refer the client for

treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

5. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into the

IMPULSE CONTROL DISORDER

211

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(5, 6, 7, 8)

problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

7. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the level

of impairment to the client’s

functioning to determine appro-

priate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

212

5. List the negative consequences

that accrue to self and others as

a result of impulsive behavior.

(9, 10, 11)

9. Assign the client to write a list

of the negative consequences

that have occurred because of

impulsivity (or assign “Recognizing

the Negative Consequences of

Impulsive Behavior” from the

Adult Psychotherapy Homework

Planner by Jongsma).

10. Assist the client in making

connections between his/her

impulsivity and the negative

consequences for himself/herself

and others.

11. Confront the client’s denial of

responsibility for the impulsive

behavior or the negative

consequences (or assign “Accept

Responsibility for Illegal

Behavior” from the Adult

Psychotherapy Homework Planner

by Jongsma).

6. Identify impulsive behavior’s

antecedents, mediators, and

consequences. (12, 13)

12. Ask the client to keep a log

of impulsive acts (time, place,

feelings, thoughts, what was going

on prior to the act, and what was

the result); process log content to

discover triggers and reinforcers

(or assign “Impulsive Behavior

Journal” from the Adult Psycho-

therapy Homework Planner by

Jongsma).

13. Explore the client’s past

experiences to uncover his/her

cognitive, emotional, and

situational triggers to impulsive

episodes.

7. Participate in imaginal

exposure sessions to decrease

the urge to act impulsively.

(14, 15)

14. Assist the client in composing a

script describing a typical situation

in which impulsive behavior

occurs, the urge to act, physical

symptoms, expected negative

consequences, and, finally,

resisting the urge.

IMPULSE CONTROL DISORDER

15. Use the client’s script in an

imaginal exposure session in which

the client is relaxed and the script is

read repeatedly.

8. Participate in an in vivo

exposure treatment procedure.

(16, 17, 18, 19)

16. Direct and assist the client in

construction of a hierarchy of

feared internal and external

impulsive behavior cues.

17. Assess the nature of any external

cues (e.g., persons, objects, and

situations) and internal cues

(thoughts, images, and impulses)

that precipitate the client’s

impulsive actions.

18. Select initial exposures (imaginal

or in vivo) to the internal and/or

external impulsive behavior cues

that have a high likelihood of being

a successful experience for the

client; include response prevention

and do cognitive restructuring

within and after the exposure (see

Mastery of Obsessive-Compulsive

Disorder by Kozak and Foa; or

Treatment of Obsessive-Compulsive

Disorder by McGinn and

Sanderson).

19. Assign the client a homework

exercise in which he/she repeats

the exposure to the internal and/or

external impulsive behavior cues

using response prevention and

restructured cognitions between

sessions and records responses

(or assign “Reducing the Strength

of Compulsive Behaviors” in the

Adult Psychotherapy Homework

Planner by Jongsma); review

during next session, reinforcing

success and providing corrective

feedback toward improvement (see

Mastery of Obsessive-Compulsive

Disorder by Kozak and Foa).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

214

9. Verbalize a clear connection

between impulsive behavior

and negative consequences to

self and others. (10, 20)

10. Assist the client in making

connections between his/her

impulsivity and the negative

consequences for himself/herself

and others.

20. Reinforce the client’s verbalized

acceptance of responsibility for

and connection between impulsive

behavior and negative

consequences.

10. Before acting on behavioral

decisions, frequently review

them with a trusted friend or

family member for feedback

regarding possible

consequences. (21, 22)

21. Conduct a session with the client

and his/her partner to develop a

contract for receiving feedback

prior to impulsive acts.

22. Brainstorm with the client who

he/she could rely on for trusted

feedback regarding action

decisions; use role-play and

modeling to teach how to ask

for and accept this help.

11. Utilize cognitive methods to

control trigger thoughts and

reduce impulsive reactions

to those trigger thoughts.

(13, 23, 24)

13. Explore the client’s past

experiences to uncover his/her

cognitive, emotional, and

situational triggers to impulsive

episodes.

23. Teach the client cognitive methods

(thought-stopping, thought

substitution, reframing, etc.) for

gaining and improving control

over impulsive urges and actions.

24. Use the cognitive restructuring

process (i.e., teaching the

connection between thoughts,

feelings, and actions; identifying

relevant automatic thoughts and

their underlying beliefs or biases;

challenging the biases; developing

alternative positive perspectives;

testing biased and alternative

beliefs through behavioral

experiments) to assist the client

in replacing negative automatic

IMPULSE CONTROL DISORDER

thoughts associated with education

and his/her ability to learn.

12. Use relaxation exercises to

control anxiety, urges, and

reduce consequent impulsive

behavior. (25, 26, 27)

25. Teach the client relaxation skills

(e.g., progressive muscle

relaxation, imagery, diaphragmatic

breathing, verbal cues for deep

relaxation), how to discriminate

better between relaxation and

tension, as well as how to apply

these skills to coping with

situations associated with

impulsive urges (e.g., see

Progressive Relaxation Training

by Bernstein and Borkovec).

26. Assign the client homework each

session in which he or she practices

relaxation exercises daily for at

least 15 minutes and applies the

technique to impulsive trigger

situations; review the exercises,

reinforcing success while providing

corrective feedback toward

improvement.

27. Assign the client to read about

progressive muscle relaxation and

other calming strategies in relevant

books or treatment manuals (e.g.,

The Relaxation and Stress Reduction

Workbook by Davis, Robbins-

Eshelman, and McKay; Mastery

of Your Anxiety and Worry—

Workbook by Craske and Barlow).

13. Utilize behavioral strategies to

manage urges for impulsive

action. (28, 29, 30)

28. Teach the use of positive

behavioral alternatives to cope

with impulsive urges (e.g., talking

to someone about the urge, taking

a time out to delay any reaction,

calling a friend or family member,

engaging in physical exercise,

leaving credit cards with a family

member, creating needed item

shopping lists to avoid impulsive

buying, avoiding use of police and

fire scanners, etc.).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

216

29. Review the client’s implementation

of behavioral coping strategies to

reduce urges and tension; reinforce

success and redirect for failure.

30. Teach the client covert sensitization

in which he/she imagines a negative

consequence (e.g., going to jail)

whenever the desire to act

impulsively appears (e.g., the desire

to steal); assign as homework;

review, reinforcing success and

problem-solving obstacles until

internalized by the client.

14. List instances where “stop,

listen, think, and act” has been

implemented, citing the

positive consequences. (31, 32)

31. Using modeling, role-playing, and

behavior rehearsal, teach the client

how to use “stop, listen, and think”

before acting in several current

situations.

32. Review and process the client’s use

of “stop, listen, think, and act” in

day-to-day living and identify the

positive consequences.

15. Describe any history of manic

or hypomanic behavior related

to a mood disorder. (33)

33. Assess the client for a mood

disorder that includes manic

episodes with a lack of judgment

over impulsive behavior and its

consequences (see the Bipolar

Disorder—Mania chapter in this

Planner).

16. Identify situations in which

there has been a loss of control

over aggressive impulses

resulting in destructive or

assaultive behavior. (34)

34. Explore the client’s history of

explosive anger management

problems; include this as

presenting problem if there have

been several such episodes of

aggressiveness grossly out of

proportion to any precipitating

psychosocial stressor (see the

Anger Control Problems chapter

in this Planner).

17. Comply with the recommen-

dations from a physician

evaluation regarding the

35. Refer the client to a physician for

an evaluation for a psychotropic

medication prescription.

IMPULSE CONTROL DISORDER

217

necessity for psychopharma-

cological intervention. (35, 36)

36. Monitor the client for psychotropic

medication prescription

compliance, side effects, and

effectiveness; consult with the

prescribing physician at regular

intervals.

18. Implement a reward system

for replacing impulsive

actions with reflection on

consequences and choosing

wise alternatives. (37, 38)

37. Assist the client in identifying

rewards that would be effective

in reinforcing himself/herself for

suppressing impulsive behavior.

38. Assist the client and significant

others in developing and putting

into effect a reward system for

deterring the client’s impulsive

actions.

19. Learn and implement problem-

solving skills to reduce

impulsive behavior. (39, 40)

39. Teach the client problem-

resolution skills (e.g., defining the

problem clearly, brainstorming

multiple solutions, listing the pros

and cons of each solution, seeking

input from others, selecting and

implementing a plan of action,

evaluating outcome, and

readjusting plan as necessary).

40. Use modeling and role-playing

with the client to apply the

problem-solving approach to

his/her urge for impulsive action

(or assign “Problem-Solving: An

Alternative to Impulsive Action”

from the Adult Psychotherapy

Homework Planner by Jongsma);

encourage implementation of

action plan, reinforcing success

and redirecting for failure.

20. Read recommended material

on overcoming impulsive

behavior. (41)

41. Recommend the client read

material on coping with impulsive

urges (e.g., Stop Me Because I

Can't Stop Myself: Taking Control

of Impulsive Behavior by Grant and

Fricchione; Overcoming Impulse

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

218

Control Problems: A Cognitive-

Behavioral Therapy Program—

Workbook by Grant, Donahue,

and Odlaug).

21. Attend a self-help recovery

group. (42)

42. Refer the client to a self-help

recovery group (e.g., 12-step

program, ADHD group, Rational

Recovery, etc.) designed to help

terminate self-destructive

impulsivity; process his/her

experience in the group.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

312.34 Intermittent Explosive Disorder

312.32 Kleptomania

312.31 Pathological Gambling

312.39 Trichotillomania

312.30 Impulse Control Disorder NOS

312.33 Pyromania

310.1 Personality Change Due to Axis III Disorder

_____

_____________________________________

_____

______

______________________________

Axis II:

301.7 Antisocial Personality Disorder

301.83 Borderline Personality Disorder

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

______________________

______________

IMPULSE CONTROL DISORDER

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

312.34 F63.81 Intermittent Explosive Disorder

312.32 F63.81 Kleptomania

312.31 F63.0 Gambling Disorder

312.39 F63.2 Trichotillomania

312.9 F91.9 Unspecified Disruptive, Impulse Control,

and Conduct Disorder

312.89 F91.8 Other Specified Disruptive, Impulse

Control, and Conduct Disorder

312.33 F63.1 Pyromania

310.1 F07.0 Personality Change Due to Another

Medical Condition

301.7 F60.2 Antisocial Personality Disorder

301.83 F60.3 Borderline Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

INTIMATE RELATIONSHIP CONFLICTS

BEHAVIORAL DEFINITIONS

1. Frequent or continual arguing with the partner.

2. Lack of communication with the partner.

3. A pattern of angry projection of responsibility for the conflicts onto the

partner.

4. Marital separation.

5. Pending divorce.

6. Involvement in multiple intimate relationships at the same time.

7. Physical and/or verbal abuse in a relationship.

8. A pattern of superficial or no communication, infrequent or no sexual

contact, excessive involvement in activities (work or recreation) that

allows for avoidance of closeness to the partner.

9. A pattern of repeated broken, conflictual relationships due to personal

deficiencies in problem-solving, maintaining a trust relationship, or

choosing abusive or dysfunctional partners.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Develop the necessary skills for effective, open communication, mutually

satisfying sexual intimacy, and enjoyable time for companionship within

the relationship.

2. Increase awareness of own role in the relationship conflicts.

INTIMATE RELATIONSHIP CONFLICTS

221

3. Learn to identify escalating behaviors that lead to abuse.

4. Make a commitment to one intimate relationship at a time.

5. Accept the termination of the relationship.

6. Rebuild positive self-image after acceptance of the rejection associated

with the broken relationship.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Attend and actively participate

in conjoint sessions with the

partner. (1)

1. Develop a level of trust with the

couple by creating a therapeutic

environment in which each can

express problems, wants, and

goals; clarify ground rules;

establish oneself as a neutral

moderator.

2. Identify problems and

strengths in the relationship,

including one’s own role in

each. (2, 3, 4)

2. Assess current, ongoing problems

in the relationship, including

possible abuse/neglect, substance

use, communication, conflict

resolution, as well as home

environment

(if domestic violence

is present, plan for safety and

avoid early use of conjoint

sessions; see the Physical

Abuse chapter in The Couples

Psychotherapy Treatment Planner

by O’Leary, Heyman, and

Jongsma).

3. Assess strengths in the relationship

that could be enhanced during

the therapy to facilitate the

accomplishment of therapeutic

goals.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

222

4. Assign the couple a between-

sessions task recording in journals

the positive and negative things

about the significant other and the

relationship (or assign “Positive

and Negative Contributions to the

Relationship: Mine and Yours” in

the Adult Psychotherapy Home-

work Planner by Jongsma); ask the

couple not to show their journal

material to each other until the

next session, when the material will

be processed.

3. Acknowledge the connection

between substance abuse and

the conflicts present within the

relationship. (5)

5. Explore with the couple the role of

substance abuse in precipitating

conflict and/or abuse within the

relationship.

4. Chemically dependent partner

agrees to pursue substance

treatment individually or with

partner. (6)

6. Solicit an agreement for substance

abuse treatment for the chemically

dependent partner and refer to an

evidence-based individual therapy

or to Behavioral Couples Therapy

for substance abuse treatment (see

the Substance Use chapter in this

Planner).

5. Complete psychological testing

designed to assess the marital

relationship and track

treatment progress. (7)

7. Administer a measure of overall

marital adjustment (e.g., The

Dyadic Adjustment Scale), and/or

satisfaction (e.g., Marital

Satisfaction Inventory-Revised) to

supplement interview as needed;

readminister as indicated to assess

treatment progress.

6. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(8, 9, 10, 11)

8. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue as a

INTIMATE RELATIONSHIP CONFLICTS

concern; or demonstrates resis-

tance regarding acknowledgment

of the “problem described,” is not

concerned, and has no motivation

to change).

9. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

10. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

11. Assess for the severity of the level

of impairment to the client’s

functioning to determine appro-

priate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

7. Make a commitment to change

specific behaviors that have

been identified by self or the

partner. (12)

12. Process the list of positive and

problematic features of each

partner and the relationship; ask

couple to agree to work on changes

he/she needs to make to improve

the relationship, generating a list o

targeted changes (or assign “How

Can We Meet Each Other’s Needs

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

224

and Desires?” in the Adult

Psychotherapy Homework Planner

by Jongsma).

8. Each partner negotiates and

signs a contract to agree to

increase positive behaviors that

each partner desires. (13)

13. Develop a contract identifying

negotiated behavioral changes that

each partner desires within the

relationship; ask the couple to sign

the contract.

9. Increase the frequency of the

direct expression of honest,

respectful, and positive feelings

and thoughts within the

relationship. (14, 15, 16)

14. Assist the couple in identifying

conflicts that can be addressed

using communication, conflict-

resolution, and/or problem-solving

skills (see “Behavioral Marital

Therapy” by Holtzworth-Munroe

and Jacobson).

15. Use behavioral techniques

(education, modeling, role-playing,

corrective feedback, and positive

reinforcement) to teach

communication skills including

assertive communication, offering

positive feedback, active listening,

making positive requests of others

for behavior change, and giving

negative feedback in an honest and

respectful manner.

16. Assign the couple a homework

exercise to use and record newly

learned communication skills;

process results in session, providing

corrective feedback toward

improvement.

10. Learn and implement problem-

solving and conflict resolution

skills. (17, 18, 19)

17. Review how newly learned

communication skills can be

applied to conflict resolution

through calm, respectful, effective

dialogue; role-play application of

this skill to a present conflict

situation.

18. Use behavioral techniques

(education, modeling, role-playing,

corrective feedback, and positive

reinforcement) to teach the couple

INTIMATE RELATIONSHIP CONFLICTS

problem-solving and conflict

resolution skills including defining

the problem constructively and

specifically, brainstorming options,

evaluating options, compromise,

choosing options and

implementing a plan, evaluating

the results.

19. Assign the couple a homework

exercise to use and record newly

learned problem-solving and

conflict resolution skills (or assign

“Applying Problem-Solving to

Interpersonal Conflict” in the

Adult Psychotherapy Homework

Planner by Jongsma); process

results in session.

11. Learn and implement cognitive

therapy techniques to replace

unrealistic, maladaptive

thoughts, feelings, and actions

with those facilitative of the

relationship. (20, 21)

20. Use cognitive therapy techniques

to restructure the clients’ biased

cognitions (e.g., mind-reading,

blaming), modify maladaptive

emotional responses (e.g., rage)

and inappropriate behaviors

(e.g., verbal aggression) within

the relationship (see Enhanced

Cognitive Behavioral Therapy

for Couples by Epstein and

Baucom)

21. Identify the couple’s irrational

beliefs and unrealistic expectations

regarding relationships and then

assist them in adopting more

realistic beliefs and expectations of

each other and of the relationship

(or assign “Journal and Replace

Self-Defeating Thoughts” in the

Adult Psychotherapy Homework

Planner by Jongsma).

12. Accept partner’s existing

characteristics that are unlikely

to change but do not

jeopardize the relationship.

(22)

22. Help the couple build tolerance of

each other’s differences by seeing

the positive side of such differences

to balance their awareness of

drawbacks (see Integrative Couple

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

226

Therapy by Jacobson and

Christensen).

13. Increase flexibility of

expectations, willingness to

compromise, and acceptance of

irreconcilable differences. (23)

23. Teach both partners the key

concepts of flexibility,

compromise, sacrifice of wants,

and acceptance of differences

toward increased understanding,

empathy, intimacy, and

compassion for each other

(see Integrative Couple Therapy

by Jacobson and Christensen).

14. Understand the origin of each

other’s negative emotions and

reactions and develop more

constructive interactions that

fill needs. (24, 25, 26)

24. For mild to moderately distressed

couples, convey a model to the

clients that conceptualizes negative

emotions and behavioral reactions

as reflecting vulnerability and

attachment insecurities (see

Emotion-Focused Couples Therapy

by Greenberg and Goldman;

“Emotionally Focused Couples

Therapy” by Johnson).

25. Encourage the clients to recognize,

reframe, and express these

insecurities toward resolving

negative emotional and behavioral

reactions.

26. Assist the clients in developing

more constructive interactions that

satisfy attachment needs such as

increased intimacy and expressions

of love (or assign “How Can We

Meet Each Other’s Needs and

Desires?” in the Adult Psycho-

therapy Homework Planner by

Jongsma).

15. Gain insight into how past

relationship experiences

influence current relationship

problems. (27)

27. Conduct an insight-oriented

couples therapy identifying how

past relationship injuries (e.g.,

betrayal of trust) create current

vulnerabilities that cause

relationship conflicts (e.g., fear

of intimacy); help the couple to

separate the past from the present

INTIMATE RELATIONSHIP CONFLICTS

227

(see Insight Oriented Marital

Therapy by Wills).

16. Identify any patterns of

destructive and/or abusive

behavior in the relationship.

(28, 29)

28. Assess current patterns of

destructive and/or abusive behavior

for each partner, including those

that existed in each family of origin

(if domestic violence is present, plan

for safety and avoid early use of

conjoint sessions; see the Physical

Abuse chapter in The Couples

Psychotherapy Treatment Planner

by O’Leary, Heyman, and

Jongsma).

29. Ask each partner to make a list of

escalating behaviors that occur

prior to abusive behavior.

17. Implement a “time out” signal

that either partner may give to

stop interaction that may

escalate into abuse. (30, 31, 32)

30. Assist the partners in identifying a

clear verbal or behavioral signal to

be used by either partner to

terminate interaction immediately

if either fears impending abuse.

31. Solicit a firm agreement from both

partners that the “time out” signal

will be responded to favorably

without debate.

32. Assign implementation and

recording the use of the “time out”

signal and other conflict resolution

skills in daily interaction (or assign

“Alternatives to Destructive

Anger” in the Adult Psychotherapy

Homework Planner by Jongsma).

18. Initiate verbal and physical

affection behaviors toward the

partner. (33)

33. Encourage each partner to increase

the use of verbal and physical

affection; address resistance

surrounding initiating affectionate

or sexual interactions with the

partner.

19. Increase time spent in

enjoyable contact with the

partner. (34)

34. Assist the couple in identifying and

planning rewarding social/

recreational activities that can be

shared with the partner (or assign

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

228

“Identify and Schedule Pleasant

Activities” in the Adult

Psychotherapy Homework Planner

by Jongsma).

20. Participate in an evaluation to

identify or rule out sexual

dysfunction and participate in

appropriate treatment, if

indicated. (35, 36)

35. Gather from each partner a

thorough sexual history to

determine areas of strength and to

identify areas of dysfunction (see

the Female Sexual Dysfunction

and Male Sexual Dysfunction

chapters in this Planner).

36. Refer the client to a specialist for

a diagnostic evaluation of sexual

dysfunction (e.g., rule-out of

medical or substance etiology),

with recommendation for

appropriate evidence-based

treatment (e.g., medication, sex

therapy, surgery).

21. Commit to the establishment

of healthy, mutually satisfying

sexual attitudes and behavior

that is not a reflection of

destructive earlier experiences.

(37, 38)

37. In a conjoint session identify sexual

behavior, patterns, activities, and

beliefs of each partner and the

extended family (or assign

“Factors Influencing Negative

Sexual Attitudes” in the Adult

Psychotherapy Homework Planner

by Jongsma).

38. Assist each partner in committing

to attempt to develop healthy,

mutually satisfying sexual beliefs,

attitudes, and behavior that are

independent of previous childhood,

personal, or family training or

experience.

22. Identify the cause and

consequences of the partner’s

infidelity, as well as each

other’s goals of therapy.

(39, 40)

39. Assist the couple in identifying the

cause(s) and consequences of the

infidelity; clarify the couple’s

motivation and goals of therapy.

40. Assign the clients to read After the

Affair by Spring, or Getting Past

the Affair: A Program to Help You

Cope, Heal, and Move On—

Together or Apart by Synder,

INTIMATE RELATIONSHIP CONFLICTS

Baucom, and Gordon; process key

concepts gathered from the reading

in conjoint sessions with the

therapist.

23. Verbalize acceptance of the loss

of the relationship. (41, 42, 43)

41. Explore and clarify feelings

associated with loss of the

relationship.

42. Refer the client to a support group

or divorce seminar to assist in

resolving the loss and in adjusting

to the new life.

43. Assign the client to read Rebuilding:

When Your Relationship Ends by

Fisher, or Surviving Separation and

Divorce: A Woman’s Guide by

Oberlin; process key concepts.

24. Implement increased

socialization activities to cope

with loneliness. (44, 45)

44. Support the client in his/her

adjustment to living alone and

being single; encourage him/her in

accepting some time in being alone

and in making concrete plans for

social contact.

45. Inform the client of opportunities

within the community that assist

him/her in building new social

relationships.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

312.34 Intermittent Explosive Disorder

309.0 Adjustment Disorder With Depressed Mood

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

230

309.24 Adjustment Disorder With Anxiety

300.4 Dysthymic Disorder

300.00 Anxiety Disorder NOS

311 Depressive Disorder NOS

309.81 Posttraumatic Stress Disorder

V61.10 Partner Relational Problem

_____

_____________________________________

_____

_____________________________________

Axis II:

301.20 Schizoid Personality Disorder

301.81 Narcissistic Personality Disorder

301.9 Personality Disorder NOS

_____

________________

____________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

312.34 F63.81 Intermittent Explosive Disorder

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

309.24 F43.22 Adjustment Disorder, With Anxiety

300.4 F34.1 Persistent Depressive Disorder

300.09 F41.8 Other Specified Anxiety Disorder

300.00 F41.9 Unspecified Anxiety Disorder

311 F32.9 Unspecified Depressive Disorder

311 F32.8 Other Specified Depressive Disorder

309.81 F43.10 Posttraumatic Stress Disorder

301.20 F60.1 Schizoid Personality Disorder

301.81 F60.81 Narcissistic Personality Disorder

301.9 F60.9 Unspecified Personality Disorder

V61.03 Z63.5 Disruption of Family by Separation or

Divorce

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

LEGAL CONFLICTS

BEHAVIORAL DEFINITIONS

1. Legal charges pending.

2. On parole or probation subsequent to legal charges.

3. Legal pressure has been central to the decision to enter treatment.

4. A history of criminal activity leading to numerous incarcerations.

5. Most arrests are related to alcohol or drug abuse.

6. Pending divorce accompanied by emotional turmoil.

7. Fear of loss of freedom due to current legal charges.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Accept and responsibly respond to the mandates of court.

2. Understand how chemical dependence has contributed to legal problems

and accept the need for recovery.

3. Accept responsibility for decisions and actions that have led to arrests

and develop higher moral and ethical standards to govern behavior.

4. Internalize the need for treatment so as to change values, thoughts,

feelings, and behavior to a more prosocial position.

5. Become a responsible citizen in good standing within the community.

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

232

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the behavior that led

to current involvement with the

court system. (1)

1. Explore the client’s behavior that

led to legal conflicts and assess

whether it fits a pattern of antisocial

behavior (see the Antisocial

Behavior chapter in this Planner).

2. Verbalize the role drug and/or

alcohol abuse has played in

legal problems. (2, 3)

2. Explore how chemical dependence

may have contributed to the

client’s legal conflicts.

3. Confront the client’s denial of

chemical dependence by reviewing

the various negative consequences

of addiction that have occurred in

his/her life.

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(4, 5, 6, 7)

4. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

5. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

LEGAL CONFLICTS

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

6. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

7. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

4. Maintain sobriety in

accordance with rules of

probation/parole. (8, 9)

8. Reinforce the client’s need for a

plan for recovery and sobriety as a

means of improving judgment and

control over behavior (see the

Substance Use chapter in this

Planner).

9. Monitor and reinforce the client’s

sobriety, using physiological

measures to confirm, if advisable.

5. Obtain counsel and meet to

make plans for resolving legal

conflicts. (10)

10. Encourage and facilitate the client

in meeting with an attorney to

discuss plans for resolving legal

issues.

6. Make regular contact with

court officers to fulfill

sentencing requirements. (11)

11. Monitor and encourage the client

to keep appointments with court

officers.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

234

7. Verbalize and accept

responsibility for the series

of decisions and actions that

eventually led to illegal activity.

(12)

12. Confront the client’s denial and

projection of responsibility onto

others for his/her own illegal

actions (or assign “Accept

Responsibility for Illegal

Behavior” from the Adult Psycho-

therapy Homework Planner by

Jongsma).

8. State values that affirm

behavior within the boundaries

of the law. (13, 14)

13. Assist the client in clarification of

values that allow him/her to act

illegally.

14. Teach the values associated with

respecting legal boundaries and

the rights of others as well as the

consequences of crossing these

boundaries.

9. Verbalize how the emotional

state of anger, frustration,

helplessness, or depression has

contributed to illegal behavior.

(15, 16, 17)

15. Probe the client’s negative

emotional states that could

contribute to his/her illegal

behavior.

16. Refer the client for ongoing

counseling to deal with emotional

conflicts and antisocial impulses

(see Antisocial Behavior, Anger

Control Problems, or Unipolar

Depression chapters in this

Planner).

17. Recommend that the client read

material on controlling emotions

(e.g., Thoughts and Feelings:

Taking Control of Your Moods and

Your Life by McKay, Davis, and

Fanning; The Anger Control

Workbook by McKay and Rogers;

A Cognitive Behavioral Workbook

for Depression: A Step-by-Step

Program by Knaus; Overcoming

Impulse Control Problems: A

Cognitive-Behavioral Therapy

Program–Workbook by Grant,

Donahue, and Odlaug).

LEGAL CONFLICTS

10. Identify the causes for the

negative emotional state that

was associated with illegal

actions. (18, 19)

18. Explore causes for the client’s

underlying negative emotions that

consciously or unconsciously

fostered his/her criminal behavior.

19. Interpret the client’s antisocial

behavior that is linked to current

or past emotional conflicts to

foster insights and resolution.

11. Identify and replace cognitive

distortions that foster

antisocial behavior. (20, 21, 22)

20. Use the cognitive restructuring

process (i.e., teaching the

connection between thoughts,

feelings, and actions; identifying

relevant automatic thoughts and

their underlying beliefs or biases;

challenging the biases; developing

alternative positive perspectives;

testing biased and alternative

beliefs through behavioral

experiments) to assist the client in

replacing negative automatic

thoughts associated with illegal

behavior.

21. Reinforce the client for developing

and implementing positive, reality-

based messages to replace the

distorted, negative self-talk

associated with illegal behavior.

22. Assign the client a homework

exercise (e.g., “Crooked Thinking

Leads to Crooked Behavior”

from the Adult Psychotherapy

Homework Planner by Jongsma)

in which he/she identifies negative

self-talk, identifies biases in the

self-talk, generates alternatives,

and tests through behavioral

experiments; review and reinforce

success, providing corrective

feedback toward improvement.

12. Attend an anger control group.

(23)

23. Refer the client to an impulse

control or anger management

group.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

236

13. Identify ways to meet life needs

(i.e., social and financial)

without resorting to illegal

activities. (24, 25)

24. Explore with the client ways he/she

can meet social and financial needs

without involvement with illegal

activity (e.g., employment, further

education or skill training, spiritual

enrichment group).

25. Educate the client on the difference

between antisocial and prosocial

behaviors; assist him/her in writing

a list of ways to show respect for

the law, help others, and work

regularly.

14. Attend class to learn how to

successfully seek employment.

(26)

26. Refer the client to an ex-offender

center for assistance in obtaining

employment.

15. Verbalize an understanding of

the importance of honesty in

earning the trust of others and

esteem for self. (27)

27. Help the client understand the

importance of honesty in earning

the trust of others and self-respect.

16. Develop and implement a plan

for restitution for illegal

activity. (28, 29)

28. Assist the client in seeing the

importance of restitution to self-

worth; help him/her develop a plan

to provide restitution for the

results of his/her behavior (or

assign “How I Have Hurt Others”

and/or “Letter of Apology” from

the Adult Psychotherapy

Homework Planner by Jongsma).

29. Review the client’s implementation

of his/her restitution plan;

reinforce success and redirect for

failure.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

LEGAL CONFLICTS

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

304.30 Cannabis Dependence

304.20 Cocaine Dependence

303.90 Alcohol Dependence

304.80 Polysubstance Dependence

312.32 Kleptomania

V71.01 Adult Antisocial Behavior

309.3 Adjustment Disorder With Disturbance of

Conduct

_____

_____________________________________

_____

_____________________________________

Axis II:

301.7 Antisocial Personality Disorder

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

304.30 F12.20 Cannabis Use Disorder, Moderate or

Severe

304.20 F14.20 Cocaine Use Disorder, Moderate or Severe

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

312.32 F63.81 Kleptomania

V71.01 Z72.811 Adult Antisocial Behavior

309.3 F43.24 Adjustment Disorder, With Disturbance of

Conduct

301.7 F60.2 Antisocial Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

LOW SELF-ESTEEM

BEHAVIORAL DEFINITIONS

1. Inability to accept compliments.

2. Makes self-disparaging remarks; sees self as unattractive, worthless, a

loser, a burden, unimportant; takes blame easily.

3. Lack of pride in grooming.

4. Difficulty in saying no to others; assumes not being liked by others.

5. Fear of rejection by others, especially peer group.

6. Lack of any goals for life and setting of inappropriately low goals for

self.

7. Inability to identify positive characteristics of self.

8. Anxious and uncomfortable in social situations.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Elevate self-esteem.

2. Develop a consistent, positive self-image.

3. Demonstrate improved self-esteem through more pride in appearance,

more assertiveness, greater eye contact, and identification of positive

traits in self-talk messages.

4. Establish an inward sense of self-worth, confidence, and competence.

LOW SELF-ESTEEM

5. Interact socially without undue distress or disability.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Acknowledge feeling less

competent than most others.

(1, 2)

1. Actively build the level of trust

with the client in individual

sessions through consistent

eye contact, active listening,

unconditional positive regard, and

warm acceptance to help increase

his/her ability to identify and

express feelings.

2. Explore the client’s assessment

of himself/herself and what is

verbalized as the basis for negative

self-perception.

2. Participate in a therapy for

issues beyond self-esteem. (3)

3. Assess whether the client’s low self-

esteem is occurring within a clinical

syndrome (e.g., social anxiety

disorder, depression), and, if so,

conduct or refer to an appropriate

evidence-based treatment (e.g., see

the Social Anxiety and/or Unipolar

Depression chapters in this

Planner).

3. Disclose any history of

substance use that may

contribute to and complicate

the treatment of bipolar

depression. (4)

4. Arrange for a substance abuse

evaluation and refer the client for

treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

5. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems”

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

240

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(5, 6, 7, 8)

(e.g., demonstrates good insight

into the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

7. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

LOW SELF-ESTEEM

241

5. Increase insight into the

historical and current sources

of low self-esteem. (9, 10)

9. Help the client become aware of

his/her fear of rejection and its

connection with past rejection or

abandonment experiences; begin to

contrast past experiences of pain

with present experiences of

acceptance and competence.

10. Discuss, emphasize, and interpret

the client’s incidents of abuse

(emotional, physical, and sexual)

and how they have impacted

his/her feelings about himself/

herself.

6. Decrease the frequency of

negative self-descriptive

statements and increase

frequency of positive self-

descriptive statements.

(11, 12, 13)

11. Assist the client in becoming aware

of how he/she expresses or acts out

negative feelings about himself/

herself.

12. Help the client reframe his/her

negative assessment of himself/

herself.

13. Assist the client in developing

positive self-talk as a way of

boosting his/her confidence and

self-image (or assign “Positive Self-

Talk” in the Adult Psychotherapy

Homework Planner by Jongsma).

7. Identify and replace negative

self-talk messages used to

reinforce low self-esteem.

(14, 15)

14. Help the client identify his/her

distorted, negative beliefs about

self and the world and replace

these messages with more realistic,

affirmative messages (or assign

“Journal and Replace Self-

Defeating Thoughts” in the Adult

Psychotherapy Homework Planner

by Jongsma or read What to Say

When You Talk to Yourself by

Helmstetter).

15. Ask the client to complete and

process self-esteem-building

exercises from recommended self-

help books (e.g., Ten Days to Self

Esteem! by Burns; The Self-Esteem

Companion by McKay, Fanning,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

242

Honeychurch, and Sutker; 10

Simple Solutions for Building Self-

Esteem by Schialdi).

8. Identify any secondary gain

that is received by speaking

negatively about self and

refusing to take any risks.

(16, 17)

16. Teach the client the meaning and

power of secondary gain in

maintaining negative behavior

patterns.

17. Assist the client in identifying how

self-disparagement and avoidance

of risk-taking could bring

secondary gain (e.g., praise from

others, others taking over

responsibilities).

9. Decrease the verbalized fear of

rejection while increasing

statements of self-acceptance.

(18, 19)

18. Ask the client to make one positive

statement about himself/herself

daily and record it on a chart or in

a journal) or assign “Replacing

Fears with Positive Messages”

in the Adult Psychotherapy

Homework Planner by Jongsma).

19. Verbally reinforce the client’s

use of positive statements of

confidence and accomplishments.

10. Identify and engage in

activities that would improve

self-image by being consistent

with one’s values. (20, 21)

20. Help the client analyze his/her

values and the congruence or

incongruence between them and

the client’s daily activities.

21. Identify and assign activities

congruent with the client’s values;

process them toward improving

self-concept and self-esteem.

11. Increase eye contact and

interaction with others.

(22, 23, 24)

22. Assign the client to make eye

contact with whomever he/she is

speaking to; process the feelings

associated with eye contact (or

assign “Restoring Socialization

Comfort” in the Adult Psycho-

therapy Homework Planner by

Jongsma).

23. Provide feedback to the client

when he/she is observed avoiding

LOW SELF-ESTEEM

eye contact with others toward

increasing the behavior and

extinguishing anxiety associated

with it.

24. Use role-playing and behavioral

rehearsal to improve the client’s

social skills in greeting people and

carrying a conversation (suggest

the client read Shyness: What It

Is and What to Do About It by

Zimbardo).

12. Take responsibility for daily

grooming and personal

hygiene. (25)

25. Monitor and give feedback to the

client on his/her grooming and

hygiene.

13. Identify positive traits and

talents about self. (26, 27)

26. Assign the client the exercise of

identifying his/her positive physical

characteristics in a mirror to help

him/her become more comfortable

with himself/herself.

27. Ask the client to keep building a

list of positive traits and have

him/her read the list at the

beginning and end of each session

(or assign “Acknowledging My

Strengths” or “What Are My

Good Qualities?” in the

Adult Psychotherapy Homework

Planner by Jongsma); reinforce the

client’s positive self-descriptive

statements.

14. Demonstrate an increased

ability to identify and express

personal feelings. (28, 29)

28. Assign the client to keep a journal

of feelings on a daily basis.

29. Assist the client in identifying and

labeling emotions.

15. Articulate a plan to be

proactive in trying to get

identified needs met.

(30, 31, 32)

30. Assist the client in identifying and

verbalizing his/her needs, met and

unmet.

31. Conduct a conjoint or family

therapy session in which the client

is supported in expression of unmet

needs.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

244

32. Assist the client in developing a

specific action plan to get each

need met (or assign “Satisfying

Unmet Emotional Needs” in the

Adult Psychotherapy Homework

Planner by Jongsma).

16. Positively acknowledge verbal

compliments from others. (33)

33. Assign the client to be aware of

and acknowledge graciously

(without discounting) praise and

compliments from others.

17. Increase the frequency of

assertive behaviors. (34)

34. Train the client in assertiveness or

refer him/her to a group that will

educate and facilitate assertiveness

skills via lectures and assignments.

18. Form realistic, appropriate,

and attainable goals for self in

all areas of life. (35, 36)

35. Help the client analyze his/her

goals to make sure they are

realistic and attainable.

36. Assign the client to make a list of

goals for various areas of life and a

plan for steps toward goal

attainment.

19. Take verbal responsibility for

accomplishments without

discounting. (37)

37. Ask the client to list

accomplishments; process the

integration of these into his/her

self-image.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

LOW SELF-ESTEEM

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.23 Social Phobia (Social Anxiety Disorder)

300.4 Dysthymic Disorder

296.xx Major Depressive Disorder

296.xx Bipolar I Disorder

296.89 Bipolar II Disorder

309.9 Adjustment Disorder Unspecified

_____

_____________________________________

_____

__________________

Axis II:

301.82 Avoidant Personality Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.23 F40.10 Social Anxiety Disorder (Social Phobia)

300.4 F34.1 Persistent Depressive Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

296.xx F31.xx Bipolar I Disorder

296.89 F31.81 Bipolar II Disorder

300.02 F41.1 Generalized Anxiety Disorder

319 F70 Intellectual Disability, Mild

V62.89 R41.83 Borderline Intellectual Functioning

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

MALE SEXUAL DYSFUNCTION

BEHAVIORAL DEFINITIONS

1. Describes consistently very low or no pleasurable anticipation of or

desire for sexual activity.

2. Strongly avoids and/or is repulsed by any and all sexual contact in spite

of a relationship of mutual caring and respect.

3. Recurrently experiences a lack of the usual physiological response of

sexual excitement and arousal (attaining and/or maintaining an

erection).

4. Reports a consistent lack of a subjective sense of enjoyment and pleasure

during sexual activity.

5. Experiences a persistent delay in or absence of reaching ejaculation after

achieving arousal and in spite of sensitive sexual pleasuring by a caring

partner.

6. Describes genital pain experienced before, during, or after sexual

intercourse.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Increase desire for and enjoyment of sexual activity.

2. Attain and maintain physiological excitement response during sexual

intercourse.

MALE SEXUAL DYSFUNCTION

247

3. Reach ejaculation with a reasonable amount of time, intensity, and

focus to sexual stimulation.

4. Eliminate pain and achieve a presence of subjective pleasure before,

during, and after sexual intercourse.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Provide a detailed sexual

history that explores current

problems and past experiences

that have influenced sexual

attitudes, feelings, and

behavior. (1, 2, 3)

1. Obtain a detailed sexual history

that examines the client’s current

adult sexual functioning as well as

his childhood and adolescent

sexual experiences, level and

sources of sexual knowledge,

typical sexual practices and their

frequency, medical history, drug

and alcohol use, and lifestyle

factors.

2. Assess the client’s attitudes and

fund of knowledge regarding sex,

emotional responses to it, and self-

talk that may be contributing to

the dysfunction.

3. Explore the client’s family-of-

origin for factors that may be

contributing to the dysfunction

such as negative attitudes

regarding sexuality, feelings of

inhibition, low self-esteem, guilt,

fear, or repulsion (or assign

“Factors Influencing Negative

Sexual Attitudes” in the Adult

Psychotherapy Homework Planner

by Jongsma).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

248

2. Report any signs of depression;

participate in treatment of

depressive feelings that may be

causing sexual difficulties.

(4, 5)

4. Assess the role of depression in

possibly causing the client’s sexual

dysfunction and treat if depression

appears causal (see the Unipolar

Depression chapter in this

Planner).

5. Refer the client for antidepressant

medication prescription to alleviate

depression that underlies the sexual

dysfunction.

3. Honestly report substance

abuse and cooperate with

recommendations by the

therapist for addressing it. (6)

6. Explore the client’s use or abuse of

mood-altering substances and their

effect on sexual functioning; refer

him for focused substance abuse

counseling, if indicated.

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(7, 8, 9, 10)

7. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

8. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

9. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

MALE SEXUAL DYSFUNCTION

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

10. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

5. Honestly and openly discuss

the quality of the relationship

including conflicts, unfulfilled

needs, and anger. (11, 12)

11. Assess the quality of the

relationship including couple

satisfaction, distress, attraction,

communication, and sexual

repertoire toward making a

decision to focus treatment on

sexual problems or more broadly

on the relationship (or assign

“Positive and Negative

Contributions to the Relationship:

Mine and Yours” in the Adult

Psychotherapy Homework Planner

by Jongsma).

12. If relationship problem issues

go beyond sexual dysfunction,

conduct sex therapy in the context

of couples therapy (see the

Intimate Relationship Conflicts

chapter in this Planner).

6. Cooperate with a physician’s

complete examination and

follow through on any

treatment recommendations.

(13, 14)

13. Refer the client to a physician

for a complete exam to rule out

any organic or medication related

basis for the sexual dysfunction

(e.g., vascular, endocrine,

medications).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

250

14. Encourage the client to follow

physician’s recommendations

regarding treatment of a diagnosed

medical condition or use of

medication that may be causing

the sexual problem.

7. Verbalize an understanding of

the role that physical disease or

medication has on sexual

dysfunction. (15)

15. Discuss the contributory role that a

diagnosed medical condition or

medication use may be having on

the client’s sexual functioning.

8. Take medication for impotence

as ordered and report as to

effectiveness and side effects.

(16)

16. Refer the client to a physician for

an evaluation regarding a prescrip-

tion of medication to overcome

impotence (e.g., Viagra).

9. Participate in sex therapy with

a partner or individually if the

partner is not available.

(17, 18)

17. Encourage couples sex therapy or

treat individually if a partner is not

available (see Enhancing Sexuality

by Wincze).

18. Direct conjoint sessions with the

client and his partner that focus on

conflict resolution, expression of

feelings, and sex education.

10. Verbalize an understanding of

normal sexual functioning and

contributors to sexual

dysfunction. (19, 20)

19. Educate the client and partner

about normal sexual functioning,

sexual dysfunction, and cognitive,

emotional, behavioral, and

interpersonal factors that contribute

to function or dysfunction.

20. Assign the client to read books

(e.g., Sexual Awareness by

McCarthy and McCarthy; The Gift

of Sex by Penner and Penner; The

New Male Sexuality by Zilbergeld)

that provide accurate sexual

information and/or outline sexual

practices that disinhibit and

reinforce sexual sensate focus.

11. Demonstrate healthy

acceptance by freely discussing

accurate knowledge of sexual

functioning. (21, 22)

21. Desensitize and educate the couple

by encouraging them to talk freely

and respectfully regarding sexual

body parts, sexual thoughts,

feelings, attitudes, and behaviors.

MALE SEXUAL DYSFUNCTION

22. Reinforce the couple for talking

freely, knowledgeably, and

positively regarding sexual

thoughts, feelings, and behavior.

12. Discuss low self-esteem issues

that impede sexual functioning

and verbalize a positive self-

image. (23)

23. Explore the client’s fears of

inadequacy as a sexual partner that

led to sexual avoidance; encourage

realistic, positive thoughts regard-

ing self as a sexual partner (or

assign “Positive Self-Talk” in the

Adult Psychotherapy Homework

Planner by Jongsma).

13. Verbalize a positive body

image. (24, 25)

24. Assign the client to list assets of

his body; confront unrealistic

distortions and critical comments

(or assign “Study Your Body—

Clothed and Unclothed” in the

Adult Psychotherapy Homework

Planner by Jongsma).

25. Explore the client’s feelings

regarding his body image, focusing

on causes for negativism.

14. Communicate feelings of threat

to partner that are based on

perception of partner being too

sexually aggressive or too

critical. (26)

26. Explore the client’s feelings of

threat brought on by the

perception of his partner as being

too sexually aggressive or too

critical of his sexual performance.

15. Identify challenge, and replace

self-defeating thoughts and

beliefs with positive, reality-

based thoughts and beliefs.

(27, 28, 29)

27. Probe automatic thoughts that

trigger the client’s negative

emotions such as fear, shame,

anger, or grief before, during,

and after sexual activity.

28. Train the client in healthy

alternative thoughts that will

mediate pleasure, relaxation, and

disinhibition (or assign “Journal

and Replace Self-Defeating

Thoughts” in the Adult Psycho-

therapy Homework Planner by

Jongsma).

29. Use cognitive therapy techniques

to help the client counter

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

252

self-defeating thoughts; identify

and challenge self-talk, attentional

focus (e.g., spectatoring),

misinformation, and beliefs that

perpetuate the dysfunction and

replace with those facilitative of

sexual functioning.

16. List conditions and factors that

positively affect sexual arousal,

such as setting, time of day, or

atmosphere. (30)

30. Assign the couple to list conditions

and factors that positively affect

their sexual arousal; process the list

toward creating an environment

conducive to sexual arousal.

17. Practice directed masturbation

and sensate focus exercises

alone and with partner and

share feelings associated with

activity. (31, 32)

31. Assign the client body exploration

and awareness exercises that

reduce inhibition and desensitize

him to sexual aversion.

32. Direct the client in masturbatory

exercises designed to maximize

arousal; assign the client graduated

steps of sexual pleasuring exercises

with partner that reduce his

performance anxiety and focus on

experiencing bodily arousal

sensations (or assign “Journaling

the Response to Nondemand,

Sexual Pleasuring [Sensate Focus]”

in the Adult Psychotherapy Home-

work Planner by Jongsma).

18. Participate in graduated

exposure (desensitization) to

sexual exercises that have

gradually increasing anxiety

attached to them. (33, 34)

33. Direct and assist the client in

construction of a hierarchy of

anxiety-producing sexual situations

associated with performance

anxiety.

34. Select initial in vivo or imaginal

exposures that have a high

likelihood of being a successful

experience for the client and

instruct him on attentional

strategies (e.g., focus on partner,

avoid spectatoring); review with the

client and/or couple, moving up the

hierarchy until associated anxiety

has waned (or assign “Gradually

MALE SEXUAL DYSFUNCTION

Reducing Your Phobic Fear” in the

Adult Psychotherapy Homework

Planner by Jongsma).

19. Engage in more assertive

behaviors that allow for

sharing sexual needs, feelings,

and desires, behaving more

sensuously, and expressing

pleasure. (35, 36)

35. Give the client permission for less

inhibited, less constricted sexual

behavior by assigning body-

pleasuring exercises with partner.

36. Encourage the client to gradually

explore the role of being more

sexually assertive, sensuously

provocative, and freely uninhibited

in sexual play with partner.

20. Implement new coital positions

and settings for sexual activity

that enhance pleasure and

satisfaction. (37, 38)

37. Assign the client to read books

(e.g., Sexual Awareness by

McCarthy and McCarthy; The Gift

of Sex by Penner and Penner; In

the Mood, Again: A Couple’s Guide

to Reawakening Sexual Desire by

Cervenka; The Joy of Sex by

Comfort) that outline sexual

practices that disinhibit and allow

for sexual experimentation.

38. Suggest experimentation with

coital positions and settings for

sexual play that may increase the

client’s feelings of security, arousal,

and satisfaction.

21. Male partner implement

masturbation prior to

intercourse and/or the squeeze

technique during sexual

intercourse and report on

success in slowing premature

ejaculation. (39)

39. Prescribe pre-intercourse

masturbation for the male partner

to make use of the refractory

period and/or instruct the client

and partner in use of the squeeze

technique to prevent premature

ejaculation; use illustrations if

needed (e.g., see The Illustrated

Manual of Sex Therapy by

Kaplan); process the procedure

and feelings about it, providing

corrective feedback toward

successful use (recommend Coping

with Premature Ejaculation by

Metz and McCarthy).

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254

22. State an understanding of how

religious training negatively

influenced sexual thoughts,

feelings, and behavior. (40, 41)

40. Explore the role of the client’s

religious training in reinforcing

his feelings of guilt and shame

surrounding his sexual behavior

and thoughts; process toward the

goal of change.

41. Assist the client in developing

insight into the role of unhealthy

sexual attitudes and experiences

of childhood in the development

of current adult dysfunction; press

for a commitment to try to put

negative attitudes and experiences

in the past while making a

behavioral effort to become

free from those influences.

23. Verbalize a resolution of

feelings regarding sexual

trauma or abuse experiences.

(42, 43)

42. Probe the client’s history for

experiences of sexual trauma or

abuse.

43. Process the client’s emotions

surrounding an emotional trauma

in the sexual arena (see the Sexual

Abuse Victim chapter in this

Planner).

24. Verbalize an understanding of

the influence of childhood sex

role models. (44)

44. Explore sex role models the client

has experienced in childhood or

adolescence and how they have

influenced the client’s attitudes and

behaviors.

25. Verbalize connection between

previously failed intimate

relationships and current fear.

(45)

45. Explore the client’s fears

surrounding intimate relationships

and whether there is evidence of

repeated failure in this area.

26. Discuss feelings surrounding a

secret affair and make a

termination decision regarding

one of the relationships.

(46, 47)

46. Explore for any secret sexual

affairs that may account for the

client’s sexual dysfunction with his

partner.

47. Process a decision regarding

the termination of one of the

relationships that is leading

to internal conflict over the

dishonesty and disloyalty to a

partner.

MALE SEXUAL DYSFUNCTION

27. Openly acknowledge and

discuss, if present, homosexual

attraction. (48)

48. Explore for a homosexual interest

that accounts for the client’s

heterosexual disinterest (or assign

“Journal of Sexual Thoughts,

Fantasies, Conflicts” in the Adult

Psychotherapy Homework Planner

by Jongsma).

28. Resolve conflicts or develop

coping strategies that reduce

stress interfering with sexual

interest or performance. (49)

49. Probe stress in areas such as work,

extended family, and social

relationships that distract the client

from sexual desire or performance

(see the Anxiety, Family Conflict,

and Vocational Stress chapters in

this Planner).

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

302.71 Hypoactive Sexual Desire Disorder

302.79 Sexual Aversion Disorder

302.72 Male Erectile Disorder

302.74 Male Orgasmic Disorder

302.76 Dyspareunia

302.75 Premature Ejaculation

608.89 Male Hypoactive Sexual Desire Disorder

Due to Axis III Disorder

607.84 Male Erectile Disorder Due to Axis III

Disorder

608.89 Male Dyspareunia Due to Axis III Disorder

302.70 Sexual Dysfunction NOS

995.53 Sexual Abuse of Child, Victim

_____

_____________________________________

_____

_____________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

256

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

302.71 F52.0 Male Hypoactive Sexual Desire Disorder

302.72 F52.21 Erectile Disorder

302.74 F52.32 Delayed Ejaculation

302.75 F52.4 Premature Ejaculation

302.70 F52.9 Unspecified Sexual Dysfunction

995.53 T74.22XA Child Sexual Abuse, Confirmed, Initial

Encounter

995.53 T74.22XD Child Sexual Abuse, Confirmed,

Subsequent Encounter

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

MEDICAL ISSUES

BEHAVIORAL DEFINITIONS

1. A diagnosis of a chronic illness that is not life-threatening, but necessitates

changes in living.

2. A diagnosis of an acute, serious illness that is life-threatening.

3. A diagnosis of a chronic illness that eventually will lead to an early death.

4. Sad affect, social withdrawal, anxiety, loss of interest in activities, and

low energy.

5. Suicidal ideation.

6. Denial of the seriousness of the medical condition.

7. Refusal to cooperate with recommended medical treatments.

8. A positive test for human immunodeficiency virus (HIV).

9. Acquired immune deficiency syndrome (AIDS).

10. Medical complications secondary to chemical dependence.

11. Psychological or behavioral factors that influence the course of the

medical condition.

12. History of neglecting physical health.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Medically stabilize physical condition.

2. Work through the grieving process and face with peace the reality of

own death.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

258

3. Accept emotional support from those who care, without pushing them

away in anger.

4. Live life to the fullest extent possible, even though remaining time may

be limited.

5. Cooperate with the medical treatment regimen without passive-

aggressive or active resistance.

6. Become as knowledgeable as possible about the diagnosed condition and

about living as normally as possible.

7. Reduce fear, anxiety, and worry associated with the medical condition.

8. Accept the illness, and adapt life to the necessary limitations.

9. Accept the role of psychological or behavioral factors in development of

the medical condition and focus on resolution of these factors.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe history, symptoms,

and treatment of the medical

condition. (1, 2)

1. In a collaborative fashion, develop

a therapeutic alliance while

gathering a history of the

condition, including symptoms,

client’s reactions to the diagnosis,

treatments of the condition, and

prognosis.

2. With the client’s informed consent,

contact treating physician and

family members for additional

medical information regarding the

client’s diagnosis, treatment, and

prognosis.

2. Disclose any history of or

current involvement with

substance abuse. (3, 4)

3. Explore and assess the role of

chemical abuse on the client’s

medical condition.

4. Recommend that the client pursue

treatment for his/her chemical

MEDICAL ISSUES

dependence (see the Substance Use

chapter in this Planner).

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature

of the therapy relationship.

(5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

7. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

260

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

4. Identify feelings associated

with the medical condition. (9)

9. Assist the client in identifying,

sorting through, and verbalizing

the various feelings generated by

his/her medical condition.

5. Family members share with

each other feelings that are

triggered by the client’s medical

condition. (10)

10. Meet with family members to

facilitate their clarifying and

sharing possible feelings of guilt,

anger, helplessness, and/or sibling

attention jealousy associated with

the client’s medical condition.

6. Identify the losses or

limitations that have been

experienced due to the medical

condition. (11)

11. Ask the client to list the changes,

losses, or limitations that have

resulted from the medical

condition (or assign “The Impact

of My Illness” in the Adult

Psychotherapy Homework Planner

by Jongsma).

7. Verbalize an increased

understanding of the steps to

grieving the losses brought on

by the medical condition.

(12, 13)

12. Educate the client on the stages of

the grieving process and answer

any questions that he/she may

have.

13. Suggest that the client read a book

on grief and loss (e.g., Good Grief

by Westberg; How Can It Be Right

When Everything Is All Wrong? by

Smedes; When Bad Things Happen

to Good People by Kushner).

8. Verbalize acceptance of the

reality of the medical condition

and the need for treatment.

(14, 15, 16, 17)

14. Gently confront the client’s denial

of the seriousness of his/her

condition and need for compliance

with medical treatment procedures;

reinforce the client’s acceptance of

his/her medical condition and

compliance with treatment.

15. Explore and process the client’s

fears associated with medical

treatment, deterioration of physical

MEDICAL ISSUES

health, and subsequent death

(or assign “How I Feel About

My Medical Treatment” in the

Adult Psychotherapy Homework

Planner by Jongsma).

16. Normalize the client’s feelings of

grief, sadness, or anxiety associated

with medical condition; encourage

verbal expression of these emotions

to significant others and medical

personnel.

17. Assess the client for and treat

his/her depression and anxiety

(see the Unipolar Depression and

Anxiety chapters in this Planner).

9. Commit to learning and

implementing a proactive

approach to managing

personal stresses introduced

by the medical condition/

diagnosis. (18)

18. Use a Stress Inoculation Training

approach to help the client develop

knowledge and skills for managing

stressful reactions to the medical

condition/diagnosis; begin by using

results of the assessment to identify

the client’s stressful reactions,

identify internal and external

triggers of the reactions, as well as

any current coping “strengths”

(see Stress Inoculation Training by

Meichenbaum).

10. Journal thoughts, feelings,

actions, and circumstances

related to stressful reactions.

(19)

19. Ask the client to self-monitor and

collect data that identifies both

internal and external triggers for

his/her stressful reactions, as well

as coping “strengths.”

11. Verbalize an understanding of

the medical condition/diagnosis

and managing the stress it can

create. (20, 21)

20. Collaboratively teach a

conceptualization of stress that

highlights the different “phases”

of stress reactions including:

anticipating, management/coping,

handling feelings generated by the

stress, and reflecting on one’s

coping efforts (recommend The

Relaxation and Stress Reduction

Workbook by Davis, Robbins-

Eshelman, and McKay); provide

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

262

accurate information about the

medical condition and stress

management, correcting

misinformation and debunking any

myths the client may have (e.g.,

venting negative emotions makes

them go away).

21. Refer the client and his/her family

to reading material and reliable

Internet resources for accurate

information regarding the medical

condition and the effect stress may

have on the condition (consider

assigning “Pain and Stress

Journal” in the Adult Psycho-

therapy Homework Planner by

Jongsma).

12. Work with therapist to develop

a plan for coping with stress.

(22)

22. Assist the client in developing a

tailored coping action plan for

preventing and/or managing

identified stressful reactions using

skills such as relaxation, exercise,

cognitive reframing, and problem-

solving.

13. Learn and implement skills for

managing stress. (23, 24, 25)

23. Conduct skills training, building

upon effective coping strategies the

client possesses, and teaching new

skills tailored to the specific

stressor.

24. Train problem-focused personal

and interpersonal coping skills (e.g.,

problem-solving, communication,

conflict resolution, accessing social

supports).

25. Train emotionally focused coping

skills (e.g., calming skills,

perspective taking, emotional

regulation, cognitive reframing).

14. Demonstrate mastery of coping

skills by applying them to daily

life situations. (26, 27, 28)

26. Encourage skill development by

having the client rehearse and

practice coping skills in session

through imaginal and/or

behavioral rehearsal.

MEDICAL ISSUES

27. Facilitate generalization of skills

into everyday life by assigning

homework (e.g., “Plan Before

Acting” or “Journal and Replace

Self-Defeating Thoughts” in the

Adult Psychotherapy Homework

Planner by Jongsma) in which the

patient applies coping skills in

graduating more demanding

stressful situations; review,

reinforcing success and problem-

solving obstacles toward effective

use of skills.

28. Help the client internalize his/her

new skill set and build self-efficacy

by ensuring that the client “takes

credit” for improvement and

makes self-attributions for

change.

15. Learn and implement skills for

preventing lapses back into

more stressful reactions. (29)

29. Teach the client relapse prevention

skills including distinguishing

between a lapse and relapse,

identifying and rehearsing the

management of high-risk situations

using skills learned in therapy,

building a less stressful lifestyle,

and periodically attending

“booster” sessions of therapy.

16. Share with significant others

efforts to adapt successfully

to the medical condition/

diagnosis. (30)

30. Where appropriate, include

significant others in the

intervention plan to help create a

reinforcing social system and social

support.

17. Comply with the medication

regimen and necessary medical

procedures, reporting any side

effects or problems to

physicians or therapists.

(2, 31, 32, 33)

2. With the client’s informed consent,

contact treating physician and

family members for additional

medical information regarding the

client’s diagnosis, treatment, and

prognosis.

31. Monitor and reinforce the client’s

compliance with the medical

treatment regimen.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

264

32. Explore and address the client’s

misconceptions, fears, and

situational factors that interfere

with medical treatment compliance

(or assign “How I Feel About My

Medical Treatment” in the Adult

Psychotherapy Homework Planner

by Jongsma).

33. Confront any manipulative,

passive-aggressive, and denial

mechanisms that block the client’s

compliance with the medical

treatment regimen.

18. Engage in social, productive,

and recreational activities that

are possible in spite of medical

condition. (34, 35)

34. Sort out with the client activities

that he/she can still enjoy either

alone or with others (or assign

“Identify and Schedule Pleasant

Activities” in the Adult Psycho-

therapy Homework Planner by

Jongsma).

35. Solicit a commitment from the

client to increase his/her activity

level by engaging in enjoyable and

challenging activities; reinforce

such engagement.

19. Engage in faith-based activities

as a source of comfort and

hope. (36)

36. Encourage the client to rely upon

his/her spiritual faith promises,

activities (e.g., prayer, meditation,

worship, music), and fellowship as

sources of support.

20. Attend a support group of

others diagnosed with a similar

illness. (37)

37. Refer the client to a support group

of others living with a similar

medical condition.

21. Partner and family members

attend a support group. (38)

38. Refer family members to a

community-based support group

associated with the client’s medical

condition.

22. Implement positive imagery as

a means of triggering peace of

mind and reducing tension.

(39, 40)

39. Teach the client the use of positive,

relaxing, healing imagery to reduce

stress and promote peace of mind.

MEDICAL ISSUES

40. Encourage the client to rely on

faith-based promises of God’s love,

presence, caring, and support to

bring peace of mind.

23. Identify the coping skills and

sources of emotional support

that have been beneficial in the

past. (41, 42)

41. Probe and evaluate the client’s and

family members’ resources of

emotional support and coping

skills that have been beneficial in

the past (or assign “Past Successful

Anxiety Coping” in the Adult

Psychotherapy Homework Planner

by Jongsma).

42. Encourage the client and his/her

family members to reach out for

support from church leaders,

extended family, hospital social

services, community support

groups, and God.

24. Client’s partner and family

members verbalize their fears

regarding the client’s severely

disabled life or possible death.

(43)

43. Draw out from the client’s partner

and family members their

unspoken fears about his/her

possible death; empathize with

their feelings of panic, helpless

frustration, and anxiety; if

appropriate, reassure them of

God’s presence as the giver and

supporter of life.

25. Acknowledge any high-risk

behaviors associated with

sexually transmitted disease

(STD). (44)

44. Assess the client’s behavior for the

presence of high-risk behaviors

(e.g., IV drug use, unprotected sex,

gay lifestyle, promiscuity) related

to STD and HIV.

26. Accept the presence of an STD

or HIV and follow through

with medical treatment.

(45, 46)

45. Refer the client to public health or

a physician for STD and/or HIV

testing, education, and treatment.

46. Encourage and monitor the client’s

follow-through on pursuing

medical treatment for STD and

HIV at a specialized treatment

program, if necessary.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

266

27. Identify sources of emotional

distress that could have a

negative impact on physical

health. (47, 48)

47. Teach the client how lifestyle and

emotional distress can have

negative impacts on medical

condition; review his/her lifestyle

and emotional status to identify

negative factors for physical

health.

48. Assign the client to make a list of

lifestyle changes he/she could make

to help maintain physical health;

process list.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

316 Psychological Symptoms Affecting Axis III

Disorder

309.0 Adjustment Disorder With Depressed Mood

309.24 Adjustment Disorder With Anxiety

309.28 Adjustment Disorder With Mixed Anxiety

and Depressed Mood

309.3 Adjustment Disorder With Disturbance of

Conduct

309.4 Adjustment Disorder With Mixed

Disturbance of Emotions and Conduct

309.9 Adjustment Disorder Unspecified

296.xx Major Depressive Disorder

311 Depressive Disorder NOS

300.02 Generalized Anxiety Disorder

301.01 Panic Disorder Without Agoraphobia

301.21 Panic Disorder With Agoraphobia

309.81 Posttraumatic Stress Disorder

MEDICAL ISSUES

300.00 Anxiety Disorder NOS

V71.09 No Diagnosis or Condition on Axis I

_____

_____________________________________

_____

_____________________________________

Axis II:

799.9 Diagnosis Deferred

_____

_____________________________________

_____

_________________________

___________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

316 F54 Psychological Factors Affecting Other

Medical Conditions

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

309.24 F43.22 Adjustment Disorder, With Anxiety

309.28 F43.23 Adjustment Disorder, With Mixed Anxiety

and Depressed Mood

309.3 F43.24 Adjustment Disorder, With Disturbance of

Conduct

309.4 F43.25 Adjustment Disorder, With Mixed

Disturbance of Emotions and Conduct

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

311 F32.9 Unspecified Depressive Disorder

311 F32.8 Other Specified Depressive Disorder

300.02 F41.1 Generalized Anxiety Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

OBSESSIVE-COMPULSIVE

DISORDER (OCD)

BEHAVIORAL DEFINITIONS

1. Intrusive, recurrent, and unwanted thoughts, images, or impulses that

distress and/or interfere with the client’s daily routine, job performance,

or social relationships.

2. Failed attempts to ignore or control these thoughts, images, or impulses

or neutralize them with other thoughts and actions.

3. Recognition that obsessive thoughts are a product of his/her own mind.

4. Repetitive and/or excessive mental or behavioral actions are done to

neutralize or prevent discomfort or some dreaded outcome.

5. Recognition of repetitive thoughts and/or behaviors as being excessive

and unreasonable, not realistic worries about life’s problems.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Reduce the frequency, intensity, and duration of obsessions and/or

compulsions.

2. Reduce time involved with or interference from obsessions and

compulsions.

3. Function daily at a consistent level with minimal interference from

obsessions and compulsions.

OBSESSIVE-COMPULSIVE DISORDER (OCD)

4. Resolve key life conflicts and the emotional stress that fuels obsessive-

compulsive behavior patterns.

5. Let go of key thoughts, beliefs, and past life events in order to maximize

time free from obsessions and compulsions.

6. Accept the presence of obsessive thoughts without acting on them and

commit to a value-driven life.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the history and nature

of obsessions and compulsions.

(1, 2)

1. Establish rapport with the client

toward building a therapeutic

alliance.

2. Assess the frequency, intensity,

duration, and history of the client’s

obsessions and compulsions

(consider using a structured

interview such as The Anxiety

Disorders Interview Schedule-Adult

Version).

2. Obtain a complete medical

evaluation to rule out medical

and substance-related causes

for anxiety symptoms. (3, 4)

3. Refer the client to a general

physician for a complete medical

examination to rule out medical or

substance-related etiology for the

anxiety.

4. Assist the client in following up

on the recommendations from a

physical evaluation, including

medications, lab work, or specialty

assessments.

3. Complete psychological tests

designed to assess and track

the nature and severity of

obsessions and compulsions. (5)

5. Administer an objective measure

of OCD to further assess its depth

and breadth (e.g., The Yale-Brown

Obsessive-Compulsive Scale;

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

270

Obsessive-Compulsive Inventory-

Revised); readminister as indicated

to assess treatment progress.

4. Disclose any history of

substance use that may

contribute to and complicate

the treatment of OCD. (6)

6. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

5. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(7, 8, 9, 10)

7. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

8. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

9. Assess for any issues of age, gender,

or culture that could help explain

the client’s currently defined

“problem behavior” and factors

that could offer a better under-

standing of the client’s behavior.

10. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

OBSESSIVE-COMPULSIVE DISORDER (OCD)

271

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

6. Cooperate with an evaluation

by a physician for psychotropic

medication. (11, 12)

11. Arrange for an evaluation for a

prescription of psychotropic

medications (e.g., serotonergic

medications).

12. Monitor the client for prescription

compliance, side effects, and

overall effectiveness of the

medication; consult with the

prescribing physician at regular

intervals.

7. Keep a daily journal of

obsessions, compulsions, and

triggers; record thoughts,

feelings, and actions taken. (13)

13. Ask the client to self-monitor

obsessions, compulsions, and

triggers; record thoughts, feelings,

and actions taken; routinely process

the data to facilitate the

accomplishment of therapeutic

objectives (or assign “Analyze the

Probability of a Feared Event” in

the Adult Psychotherapy Homework

Planner by Jongsma).

8. Verbalize an accurate

understanding of OCD, how it

develops, and how it is

maintained. (14)

14. Convey a biopsychosocial model

for the development and

maintenance of OCD highlighting

the role of unwarranted fear and

avoidance in its maintenance (see

Mastery of Obsessive-Compulsive

Disorder by Kozak and Foa).

9. Verbalize an understanding of

the treatment rationale for

OCD. (15, 16)

15. Provide a rationale for treatment

to the client, discussing how

treatment serves as an arena to

desensitize learned fear, reality-test

obsessional fears and underlying

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

272

beliefs, and build confidence in

managing fears without

compulsions (see Mastery of

Obsessive-Compulsive Disorder

by Kozak and Foa).

16. Assign the client to read

psychoeducational chapters of

books or treatment manuals or

consult other recommended

sources for information on the

rationale for exposure and ritual

prevention therapy and/or

cognitive restructuring for OCD

(e.g., Mastery of Obsessive-

Compulsive Disorder by Kozak and

Foa; Getting Over OCD by

Abramowitz; The OCD Workbook:

Your Guide to Breaking Free from

Obsessive-Compulsive Disorder by

Hyman and Pedrick).

10. Identify and replace biased,

fearful self-talk and beliefs.

(17, 18)

17. Explore the client’s biased schema

and self-talk that mediate his/her

obsessional fears and compulsions;

assist him/her in generating

thoughts that correct for the biases;

use rational disputation and

behavioral experiments to test

fearful versus alternative

predictions (see “Obsessive-

Compulsive Disorder” by

Salkovskis and Kirk).

18. Assign the client a homework

exercise in which he/she identifies

fearful self-talk, identifies biases in

the self-talk, generates alternatives,

and tests though behavioral

experiments (or assign “Journal and

Replace Self-Defeating Thoughts”

or “Reducing the Strength of

Compulsive Behaviors” in the Adult

Psychotherapy Homework Planner

by Jongsma); review and reinforce

success, providing corrective

feedback toward improvement.

OBSESSIVE-COMPULSIVE DISORDER (OCD)

11. Participate in imaginal or

in vivo exposure to feared

internal and/or external cues.

(19, 20, 21, 22)

19. Assess the nature of any internal

cues (thoughts, images, and

impulses) and external cues (e.g.,

persons, objects, and situations)

that precipitate the client’s

obsessions and compulsions.

20. Assist the client in the construction

of hierarchies of feared internal

and external fear cues.

21. Conduct exposure (imaginal

and/or in vivo) to the internal

and/or external OCD cues; begin

with exposures that have a high

likelihood of being a successful

experience for the client; include

response prevention and do

cognitive restructuring within and

after the exposure (see Mastery of

Obsessive-Compulsive Disorder by

Kozak and Foa; or Understanding

and Treating Obsessive-Compulsive

Disorder by Abramowitz).

22. Assign the client homework

exercises in which he/she repeats

the exposure to the internal and/or

external OCD cues, using response

prevention and restructured

cognitions, and records responses

(or assign “Making Use of the

Thought-Stopping Technique”

in the Adult Psychotherapy

Homework Planner by Jongsma);

review during subsequent sessions,

reinforcing success, problem-

solving obstacles, and providing

corrective feedback toward

improvement (see Mastery of

Obsessive-Compulsive Disorder

by Kozak and Foa).

12. Verbalize an understanding of

relapse prevention. (23, 24)

23. Provide a rationale for relapse

prevention that discusses the risk

and introduces strategies for

preventing it.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

274

24. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with a

temporary setback and relapse

with a return to a sustained pattern

of thinking, feeling and behaving

that is characteristic of OCD.

13. Identify situations at risk

for a lapse and strategies for

managing these risk situations.

(25, 26, 27, 28)

25. Identify high-risk situations and

rehearse the management of future

situations or circumstances in

which lapses could occur.

26. Instruct the client to routinely

use strategies learned in therapy

(e.g., continued everyday exposure,

cognitive restructuring, problem-

solving), building them into his/her

life as much as possible.

27. Develop a “coping card” or

other reminder on which coping

strategies and other helpful

information can be kept and

consulted by the client as needed

(e.g., steps in problem-solving,

positive coping statements, other

strategies that were helpful to the

client during therapy).

28. Schedule periodic maintenance

or “booster” sessions to help the

client maintain therapeutic gains

and problem-solve challenges.

14. Participate in Acceptance and

Commitment Therapy (ACT)

for OCD. (29, 30, 31, 32)

29. Use an ACT approach to OCD to

help the client accept and openly

experience obsessive thoughts,

images, and impulses without

being overly impacted by them,

and committing his/her time and

efforts to activities that are

consistent with identified,

personally meaningful values

(see Acceptance and Commitment

Therapy for Anxiety Disorders by

Eifert, Forsyth, and Hayes).

OBSESSIVE-COMPULSIVE DISORDER (OCD)

30. Teach mindfulness meditation

to help the client recognize the

negative thought processes

associated with OCD and change

his/her relationship with these

thoughts by accepting thoughts,

images, and impulses that are

reality-based while noticing, but

not reacting to, non-reality-based

mental phenomena (see Guided

Mindfulness Meditation [Audio

CD] by Zabat-Zinn).

31. Assign the client homework in

which he/she practices lessons

from mindfulness meditation and

ACT in order to consolidate the

approach into in everyday life.

32. Assign the client reading consistent

with the mindfulness and ACT

approach to supplement work

done in session (see The

Mindfulness and Acceptance

Workbook for Anxiety by Forsyth

and Eifert).

15. Identify and discuss unresolved

life conflicts. (33, 34)

33. Explore the client’s life circum-

stances to help identify key

unresolved conflicts that may

underlie OCD.

34. Read with the client the fable

“The Friendly Forest” or “Round

in Circles” from Friedman’s Fables

by Friedman, and then process

using discussion questions.

16. Verbalize and clarify feelings

connected to key life conflicts.

(35, 36)

35. Encourage, support, and assist the

client in identifying and expressing

feelings related to key unresolved

life issues.

36. Assess for secondary gains the

client may be receiving by

remaining disordered with OCD

(e.g., attention, care-receiving,

avoidance of activity); directly

address gains, if evident.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

276

17. Accept or work to resolve

identified life conflicts. (37)

37. Explore the resolution of identified

interpersonal or other identified

life conflicts; assist the client with

acceptance of those that cannot be

changed or use a conflict-

resolution approach to address

those that can.

18. Gain insight into how

childhood experiences might

influence current struggles with

OCD and take appropriate

actions. (38)

38. Use an insight-oriented approach

to explore how current obsessive

themes (e.g., cleanliness, symmetry,

aggressive impulses) may be related

to unresolved developmental

conflicts (e.g., psychosexual,

interpersonal); process toward the

goal of insight and change.

19. Implement the Ericksonian

task designed to interfere with

OCD. (39)

39. Develop and assign an Ericksonian

task (see Ericksonian Approaches

by Battino and South) that is

consistent with the theme of the

client’s obsession or compulsion

(i.e., “symptom as task”); process

the results with the client. (e.g., if

obsessed with a loss, give the client

the task to visit, send a card, or

bring flowers to someone who has

lost someone).

20. Engage in a strategic ordeal to

overcome OCD impulses. (40)

40. Create and sell a strategic ordeal

that offers a guaranteed cure to

the client for the obsession or

compulsion. (Note at the beginning

of the therapy that Haley empha-

sizes that the “cure” offers an

intervention to achieve a goal and is

not a promise to cure the client; see

Ordeal Therapy by Haley).

21. Develop and implement a daily

ritual that interrupts the

current pattern of compulsions.

(41)

41. Help the client create and

implement a ritual (e.g., find a job

that the client finds necessary but

very unpleasant, and have him/her

do this job each time he/she finds

thoughts becoming obsessive);

follow up with the client on the

outcome of its implementation and

make necessary adjustments.

OBSESSIVE-COMPULSIVE DISORDER (OCD)

277

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.3 Obsessive-Compulsive Disorder

300.00 Anxiety Disorder NOS

296.xx Major Depressive Disorder

_____

_____________________________________

_____

_____________________________________

Axis II:

301.4 Obsessive-Compulsive Personality Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.3 F42 Obsessive-Compulsive Disorder

300.09 F41.8 Other Specified Anxiety Disorder

300.00 F41.9 Unspecified Anxiety Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

301.4 F60.5 Obsessive-Compulsive Personality

Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

PANIC/AGORAPHOBIA

BEHAVIORAL DEFINITIONS

1. Complains of unexpected, sudden, debilitating panic symptoms (e.g.,

shallow breathing, sweating, heart racing or pounding, dizziness,

depersonalization or derealization, trembling, chest tightness, fear of

dying or losing control, nausea) that have occurred repeatedly, resulting

in persisting concern about having additional attacks.

2. Demonstrates marked avoidance of activities or environments due to

fear of triggering intense panic symptoms, resulting in interference with

normal routine.

3. Demonstrates marked fear and avoidance of bodily sensations associated

with panic attacks, resulting in interference with normal routine.

4. Has to have a “safe person” accompany him/her to be able to do certain

activities (e.g., travel, shop).

5. Increasingly isolates self due to fear of traveling or leaving a “safe

environment,” such as home.

6. Avoids environments from which escape is not readily available (e.g.,

public transportation, in large groups of people, malls or big stores).

7. Displays no evidence of agoraphobia.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

PANIC/AGORAPHOBIA

LONG-TERM GOALS

1. Reduce the frequency, intensity, and duration of panic attacks.

2. Reduce the fear that panic symptoms will recur without the ability to

manage them.

3. Reduce the fear of triggering panic and eliminate avoidance of activities

and environments thought to trigger panic.

4. Increase comfort in freely leaving home and being in a public environment.

5. Learn to accept occasional panic symptoms and fearful thoughts without

it affecting actions.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the history and nature

of the panic symptoms. (1, 2)

1. Establish rapport with the client

toward building a therapeutic

alliance.

2. Assess the client’s frequency,

intensity, duration, and history of

panic symptoms and the type and

severity of avoidance (e.g., The

Anxiety Disorders Interview

Schedule–Adult Version).

2. Complete psychological tests

designed to assess the depth

and breadth of fear and

avoidance. (3)

3. Administer surveys to assess the

depth and breadth of fears and

avoidance (e.g., The Mobility

Inventory for Agoraphobia; The

Anxiety Sensitivity Index); discuss

results with client; readminister as

indicated to assess treatment

progress.

3. Disclose any history of

substance use that may

contribute to and complicate

4. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

280

the treatment of panic or

agoraphobia. (4)

recommends it (see the Substance

Use chapter in this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

7. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

PANIC/AGORAPHOBIA

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

5. Cooperate with an evaluation

by a physician for psychotropic

medication. (9)

9. Arrange for an evaluation for a

prescription of psychotropic

medications to alleviate the client’s

symptoms (e.g., serotonergic

medication).

6. Take prescribed psychotropic

medications consistently. (10)

10. Monitor the client for prescription

compliance, side effects, and

overall effectiveness of the

medication; consult with the

prescribing physician at regular

intervals.

7. Complete a daily journal of

experiences with panic and

agoraphobia. (11)

11. Ask the client to self-monitor panic

and avoidance including cues, level

of distress, symptoms, thoughts,

and behaviors (or assign

“Monitoring My Panic Attack

Experiences” in the Adult

Psychotherapy Homework Planner

by Jongsma); use data throughout

therapy to support therapeutic

interventions (e.g.,

psychoeducation, cognitive

restructuring).

8. Verbalize an accurate

understanding of panic attacks

and agoraphobia and their

treatment. (12, 13)

12. Discuss how panic attacks are

“false alarms” of danger, not

medically dangerous, not a sign of

weakness or craziness, common

but often lead to unnecessary fear

and avoidance; correct myths and

misconceptions about panic

symptoms (e.g., going crazy, dying,

losing control) that contribute to

fear and avoidance.

13. Assign the client to read

psychoeducational chapters of

books or treatment manuals on

panic disorders and agoraphobia

(e.g., Mastery of Your Anxiety and

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

282

Panic—Workbook by Barlow and

Craske; Don’t Panic: Taking

Control of Anxiety Attacks by

Wilson; Living with Fear by Marks;

Thoughts and Feelings: Taking

Control of Your Moods and Your

Life by McKay, Davis, and

Fanning).

9. Verbalize an understanding of

the rationale for treatment of

panic. (14)

14. Discuss how exposure serves as an

arena to desensitize learned fear,

build confidence, and feel safer by

building a new history of successful

experiences.

10. Implement calming and coping

strategies to reduce overall

anxiety and to cope with the

experience of panic. (15, 16, 17)

15. Teach the client progressive muscle

relaxation as a daily exercise for

general relaxation and train

him/her in the use of coping

strategies (e.g., staying focused on

behavioral goals, muscular

relaxation, evenly paced

diaphragmatic breathing, positive

self-talk) to manage symptom

attacks.

16. Assign capnometry-assisted

respiratory training (CART) to

teach the client, by providing CO

level biofeedback, how to gain

control over dysfunctional

respiratory patterns and associated

panic symptoms (e.g.,

lightheadedness, shortness of

breath) through reducing

hyperventilation and breathing

more slowly and more shallow (see

Therapeutic Use of Ambulatory

Capnography by Meuret et al.).

17. Teach the client cognitive coping

strategies such as encouraging

positive self-talk and/or keeping

focused on external stimuli and

behavioral responsibilities

during panic rather than being

preoccupied with internal focus on

feared physiological changes.

PANIC/AGORAPHOBIA

11. Identify, challenge, and replace

biased, fearful self-talk with

reality-based, positive self-talk.

(18, 19)

18. Explore the client’s schema and

self-talk that mediate his/her fear

response, identify and challenge

biases; assist him/her in replacing

the distorted messages with

alternatives that correct for the

biases such as overestimating

the likelihood of catastrophic

outcomes and underestimating

one’s ability to cope with panic

symptoms.

19. Assign the client a homework

exercise in which he/she identifies

fearful self-talk and creates reality-

based alternatives (or assign

“Journal and Replace Self-

Defeating Thoughts” in the Adult

Psychotherapy Homework Planner

by Jongsma); test fear-based

predictions against alternatives

using behavioral experiments;

review; reinforce success, problem-

solve obstacles toward

accomplishing objective (see

10 Simple Solutions to Panic by

Antony and McCabe; Mastery

of Your Anxiety and Panic—

Workbook by Barlow and

Craske).

12. Participate in gradual exposure

to feared physical sensations

until they are no longer

frightening to experience.

(20, 21)

20. Teach the client a sensation

exposure technique in which

he/she generates feared physical

sensations through exercise (e.g.,

breathes rapidly until slightly

lightheaded, spins in chair briefly

until slightly dizzy), then records

and allows sensations and anxiety

associated with them to calm (e.g.,

using cognitive and/or somatic

coping strategies; repeat exercise

until anxiety associated with

physical sensations wanes (see

10 Simple Solutions to Panic by

Antony and McCabe; Mastery of

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

284

Your Anxiety and Panic—Therapist

Guide by Craske and Barlow).

21. Assign the client a homework

exercise in which he/she does

sensation exposures and records

(e.g., Mastery of Your Anxiety and

Panic—Workbook by Barlow and

Craske; 10 Simple Solutions to

Panic by Antony and McCabe);

review; reinforce success, problem-

solve obstacles toward

accomplishing objective.

13. Undergo gradual repeated

exposure to feared or avoided

situations. (22, 23, 24)

22. Direct and assist the client in

construction of a hierarchy of

anxiety-producing situations

associated with agoraphobia

in which a symptom attack and

its negative consequences are

feared.

23. Select initial exposures that have

a high likelihood of being a

successful experience for the client;

develop a plan for managing the

symptoms and rehearse the plan in

imagination.

24. Assign the client a homework

exercise in which he/she does

situational exposures and records

responses (e.g., “Gradually

Reducing Your Phobic Fear”

in the Adult Psychotherapy

Homework Planner by Jongsma;

Mastery of Your Anxiety and

Panic—Workbook by Barlow and

Craske; 10 Simple Solutions to

Panic by Antony and McCabe);

review; reinforce success, problem-

solve obstacles toward

accomplishing objective.

14. Implement relapse prevention

strategies for managing

possible future anxiety

symptoms. (25, 26, 27, 28, 29)

25. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with an

initial and reversible return of

PANIC/AGORAPHOBIA

symptoms, fear, or urges to avoid

and relapse with the decision to

return to fearful and avoidant

patterns.

26. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur.

27. Instruct the client to routinely use

strategies learned in therapy (e.g.,

cognitive restructuring, exposure),

building them into his/her life as

much as possible.

28. Develop a “coping card” on which

coping strategies and other

important information (e.g., “Pace

your breathing,” “Focus on the

task at hand,” “You can manage

it,” and “It will go away”) are

recorded for the client’s later use.

29. Schedule a “booster session” for

the client for 1 to 3 months after

therapy ends to track progress,

reinforce gains, and problem-solve

barriers.

15. Participate in Acceptance and

Commitment Therapy (ACT)

for panic disorder.

(30, 31, 32, 33)

30. Use an ACT approach to help the

client accept and openly experience

anxious thoughts and feelings

without being overly impacted by

them, and committing his/her time

and efforts to activities that are

consistent with identified,

personally meaningful values

(see Acceptance and Commitment

Therapy for Anxiety Disorders by

Eifert, Forsyth, and Hayes).

31. Teach mindfulness meditation

to help the client recognize the

negative thought processes

associated with panic and change

his/her relationship with these

thoughts by accepting thoughts,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

286

images, and impulses that are

reality-based while noticing, but

not reacting to, non-reality-based

mental phenomena (see Guided

Mindfulness Meditation [Audio

CD] by Zabat-Zinn).

32. Assign the client homework in

which he/she practices lessons from

mindfulness meditation and ACT

in order to consolidate the

approach into everyday life.

33. Assign the client reading consistent

with the mindfulness and ACT

approach to supplement work done

in session (see The Mindfulness and

Acceptance Workbook for Anxiety

by Forsyth and Eifert).

16. Work through developmental

conflicts that may be

influencing current struggles

with fear and avoidance and

take appropriate actions. (34)

34. Use an insight-oriented approach

to explore how psychodynamic

conflicts (e.g., separation/autonomy;

anger recognition, management,

and coping) may be manifesting

as fear and avoidance; address

transference; work through

separation and anger themes during

therapy and upon termination

toward developing a new ability to

manage separations and autonomy.

17. Identify and discuss unresolved

life conflicts. (35)

35. Explore the client’s life circum-

stances to help identify key

unresolved conflicts that may

underlie panic disorder.

18. Verbalize and clarify feelings

connected to key life conflicts.

(36, 37)

36. Encourage, support, and assist the

client in identifying and expressing

feelings related to key unresolved

life issues.

37. Assess for secondary gains the

client may be receiving by

remaining disordered with panic

and/or agoraphobia (e.g.,

attention, care-receiving,

avoidance of activity); directly

address gains, if evident.

PANIC/AGORAPHOBIA

19. Accept or work to resolve

identified life conflicts. (38)

38. Explore the resolution of identified

interpersonal or other identified life

conflicts; assist the client with

acceptance of those that cannot be

changed or use a conflict-resolution

approach to address those that can.

20. Implement the Ericksonian

task designed to face fear. (39)

39. Develop and assign an Ericksonian

task (see Ericksonian Approaches

by Battino and South) that is

consistent with the theme of the

client’s fears (e.g., the client fears

traveling past a certain boundary,

so ask him/her to go to it, walk a

certain number of steps past it,

stop, allow anxiety to come and go,

and repeat); process the results

with the client

21. Commit self to not allowing

the threat of panic symptoms

to control decisions in life; take

actions based on personal goals

rather than fear and avoidance.

(40)

40. Support the client in following

through with work, family, and

social activities rather than

escaping or avoiding them to focus

on panic symptoms.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.01 Panic Disorder Without Agoraphobia

300.21 Panic Disorder With Agoraphobia

300.22 Agoraphobia Without History of Panic

Disorder

_____

_____________________________________

_____

_____________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

288

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.01 F41.0 Panic Disorder

300.22 F40.00 Agoraphobia

300.02 F41.1 Generalized Anxiety Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

PARANOID IDEATION

BEHAVIORAL DEFINITIONS

1. Extreme or consistent distrust of others generally or someone specifically,

without sufficient basis.

2. Expectation of being exploited or harmed by others.

3. Misinterpretation of benign events as having threatening personal

significance.

4. Hypersensitivity to hints of personal critical judgment by others.

5. Inclination to keep distance from others out of fear of being hurt or

taken advantage of.

6. Tendency to be easily offended and quick to anger; defensiveness is

common.

7. A pattern of being suspicious of the loyalty or fidelity of spouse or

significant other without reason.

8. Level of mistrust is obsessional to the point of disrupting daily functioning.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Show more trust in others by speaking positively of them and reporting

comfort in socializing.

2. Interact with others without defensiveness or anger.

3. Verbalize trust of significant other and eliminate accusations of disloyalty.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

290

4. Report reduced vigilance and suspicion around others as well as more

relaxed, trusting, and open interaction.

5. Concentrate on important matters without interference from suspicious

obsessions.

6. Function appropriately at work, in social activities, and in the community

with only minimal interference from distrustful obsessions.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Demonstrate a level of trust

with therapist by disclosing

feelings and beliefs. (1, 2)

1. Actively build level of trust

with the client by explicitly

acknowledging the client’s

difficulty, allowing him/her to lead

discussions and establishing one’s

role as the therapist, whose interest

in the client is strictly professional.

2. Use good eye contact, active

listening, unconditional positive

regard, and warm acceptance to

help increase the client’s ability

to identify and express feelings;

demonstrate a calm, tolerant

demeanor in sessions to decrease

the client’s fears.

2. Identify those people or

agencies that are distrusted

and why. (3, 4)

3. Assess the nature, extent, and

severity of the client’s paranoia,

probing for delusional beliefs and

conviction in them.

4. Explore the client’s basis for

fears; assess his/her degree of

irrationality and ability to

acknowledge that he/she is

thinking irrationally.

PARANOID IDEATION

3. Complete a psychological

evaluation to assess the depth

of paranoia. (5)

5. Refer or conduct psychological

and/or neuropsychological testing

including assessment of a possible

psychotic process (e.g., Minnesota

Multiphasic Personality Inventory-

2, NEO Personality Inventory-

Revised, The Schedule for

Nonadaptive and Adaptive

Personality-2, give relevant

feedback of results to the client.

4. Disclose any history of

substance use that may

contribute to and complicate

the treatment of paranoid

ideation. (6)

6. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

5. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature

of the therapy relationship.

(7, 8, 9, 10)

7. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the “problem

described” and is reluctant to

address the issue as a concern; or

demonstrates resistance regarding

acknowledgment of the “problem

described,” is not concerned, and

has no motivation to change).

8. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

9. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

292

factors that could offer a better

understanding of the client’s

behavior.

10. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

6. Comply with a medical

evaluation to assess medical

health. (11)

11. Refer the client to a physician for a

medical evaluation to rule out a

possible medical and/or substance-

related etiology.

7. Comply with a psychiatric

evaluation and take

psychotropic medication as

prescribed. (12, 13, 14)

12. Assess the necessity for anti-

psychotic medication and the

client’s willingness to explore the

option.

13. Refer the client to a psychiatrist

for a medication evaluation to

assess the need for a psychotropic

medication prescription.

14. Monitor the client’s psychotropic

medication prescription for

compliance, effectiveness, and side

effects; report to the prescribing

physician and directly address

noncompliance, if present.

8. Participate in a comprehensive

rehabilitation program for the

presenting problem. (15)

15. Assess whether the client’s paranoid

ideation is occurring within a

clinical syndrome (e.g., paranoid

schizophrenia, delusional disorders),

and if so, conduct or refer to an

appropriate evidence-based

treatment that is delivered as part of

PARANOID IDEATION

a comprehensive rehabilitation

program (e.g., see the Psychoticism

chapter in this Planner).

9. Identify feelings associated

with the distrust. (16, 17, 18)

16. Probe feelings that may underlie

paranoia including inferiority,

shame, humiliation, rejection.

17. Explore historical sources of the

client’s feelings of vulnerability in

family-of-origin experiences.

18. Interpret the client’s paranoia as a

defense against his/her expressed

feelings including inferiority,

shame, humiliation, rejection.

10. Identify core belief that others

are untrustworthy and

malicious. (19, 20)

19. Explore the client’s self-talk and

maladaptive beliefs that underlie

paranoia (e.g., people cannot be

trusted, getting close to people will

result in hurt).

20. Review the client’s social

interactions to explore his/her

distorted cognitive beliefs operative

during interactions.

11. Explore the positive and

negative impact of beliefs that

others are untrustworthy and

malicious. (21)

21. Facilitate a cost-benefit analysis

around the client’s specific fears; or

assign the client to complete a cost-

benefit analysis exercise (see The

Feeling Good Handbook by Burns);

process the results toward

continuing movement toward

therapeutic goals.

12. Acknowledge other feelings

that may underlie distrust of

others. (22, 23)

22. Assess for the client’s ability to

acknowledge that his/her thinking

is maladaptive; work to improve

acknowledgement.

23. Assist the client in seeing the

pattern of distrusting others as

being related to his/her own fears

of inadequacy.

13. Acknowledge that the belief

about others being threatening

is based more on subjective

24. Assist the client in generating

alternatives to distorted thoughts

and beliefs that correct for the

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

294

interpretation than on

objective data. (24, 25)

biases; use role reversal to allow

the client to argue for and against

biased and alternative beliefs

toward facilitating cognitive

restructuring.

25. Assign the client to test distorted

and alternative beliefs through

behavioral experiments in which

both are converted to predictions

and tested through homework

exercises.

14. Verbalize trust in significant

other and feel relaxed when not

in his/her presence. (26, 27)

26. Conduct conjoint sessions to

assess and reinforce the client’s

verbalizations of trust toward

significant other.

27. Provide alternative explanations

for significant other’s behavior

that counters the client’s pattern

of assumption of other’s malicious

intent.

15. Learn and implement skills

that facilitate increased

satisfying social interaction

without fear or suspicion.

(28, 29)

28. Encourage the client not to jump

to conclusions about others but

rather check out his/her beliefs

regarding others by respectfully

and assertively verifying

conclusions with others.

29. Use instruction, role-playing,

behavioral rehearsal, and role

reversal to increase the client’s

empathy for others, his/her

understanding of the impact that

his/her distrustful defensive

behavior has on others, and develop

effective relevant social skills.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

PARANOID IDEATION

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.23 Social Phobia

310.1 Personality Change Due to Axis III Disorder

295.30 Schizophrenia, Paranoid Type

297.1 Delusional Disorder

_____

_____________________________________

_____

_____________________________________

Axis II:

301.0 Paranoid Personality Disorder

310.22 Schizotypal Personality Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.23 F40.10 Social Anxiety Disorder (Social Phobia)

310.1 F07.0 Personality Change Due to Another

Medical Condition

295.30 F20.9 Schizophrenia

298.8 F28 Other Specified Schizophrenia Spectrum

and Other Psychotic Disorder

298.9 F29 Unspecified Schizophrenia Spectrum and

Other Psychotic Disorder

297.1 F22 Delusional Disorder

298.8 F23 Brief Psychotic Disorder

295.4 F20.40 Schizophreniform Disorder

301.0 F60.0 Paranoid Personality Disorder

310.22 F21 Schizotypal Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

PARENTING

BEHAVIORAL DEFINITIONS

1. Expresses feelings of inadequacy in setting effective limits with their

child.

2. Reports difficulty in managing the challenging problem behavior of their

child.

3. Frequently struggles to control their emotional reactions to their child’s

misbehavior.

4. Exhibits increasing conflict between spouses over how to parent/

discipline their child.

5. Displays deficits in parenting knowledge and skills.

6. Displays inconsistent parenting styles.

7. Demonstrates a pattern of lax supervision and inadequate limit-setting.

8. Regularly overindulges their child’s wishes and demands.

9. Displays a pattern of harsh, rigid, and demeaning behavior toward their

child.

10. Shows a pattern of physically and emotionally abusive parenting.

11. Lacks knowledge regarding reasonable expectations for a child’s behavior

at a given developmental level.

12. Have exhausted their ideas and resources in attempting to deal with their

child’s behavior.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

PARENTING

LONG-TERM GOALS

1. Achieve a level of competent, effective parenting.

2. Effectively manage challenging problem behavior of the child.

3. Reach a realistic view and approach to parenting, given the child’s

developmental level.

4. Terminate ineffective and/or abusive parenting and implement positive,

effective techniques.

5. Strengthen the parental team by resolving marital conflicts.

6. Achieve a greater level of family connectedness.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Identify major concerns

regarding the child’s

misbehavior and the associated

parenting approaches that have

been tried. (1)

1. Using empathy and normalization

of the parents’ struggles, conduct

a clinical interview focused on

pinpointing the nature and severity

of the child’s misbehavior; assess

parenting styles used to respond to

the child’s misbehavior, and what

triggers and reinforcements may be

contributing to the behavior.

2. Describe any conflicts that

result from the different

approaches to parenting that

each partner has. (2)

2. Assess the parents’ consistency in

their approach to the child and

whether they have experienced

conflicts between them over how

to react to the child.

3. Parents and child cooperate

with psychological testing

designed to enhance

understanding of the family.

(3, 4)

3. Administer psychological

instruments designed to objectively

assess parent-child relational

conflict (e.g., the Parenting Stress

Index; the Parent-Child

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

298

Relationship Inventory), traits of

oppositional defiance or conduct

disorder (e.g., Adolescent Psycho-

pathology Scale-Short Form [APS-

SF]; the Millon Adolescent Clinical

Inventory [MACI]); discuss results

with clients toward increasing

understanding of the problems and

engage in treatment; readminister

as indicated to assess treatment

progress.

4. Conduct or arrange for

psychological testing to help in

assessing for comorbid conditions

(e.g., depression, ADHD)

contributing to disruptive behavior

problems; follow up accordingly

with client and parents regarding

treatment options; readminister as

indicated to assess treatment

progress.

4. Disclose any significant marital

conflicts and work toward their

resolution. (5, 6)

5. Analyze the data received from the

parents about their relationship

and parenting and establish or rule

out the presence of superseding

marital conflicts.

6. Conduct or refer the parents to

marital/relationship therapy to

resolve the conflicts that are

preventing them from being

effective parents (see the Intimate

Relationship Conflicts chapter in

this Planner).

5. Disclose any history of

substance use that may

contribute to and complicate

the treatment of parenting

issues. (7)

7. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

6. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

8. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

PARENTING

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(8, 9, 10, 11)

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

9. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

10. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

11. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

300

7. Cooperate with an evaluation

for possible treatment with

psychotropic medications to

assist in anger and behavioral

control and take medications

consistently, if prescribed. (12)

12. Assess the client for the need for

psychotropic medication to assist

in control of anger and other

misbehaviors; refer him/her to a

physician for an evaluation for

prescription medication; monitor

prescription compliance,

effectiveness, and side effects;

provide feedback to the prescribing

physician.

8. Freely express feelings of

frustration, helplessness,

and inadequacy that each

experiences in the parenting

role. (13, 14, 15)

13. Create a compassionate, empa-

thetic environment where the

parents become comfortable

enough to let their guard down

and express the frustrations of

parenting.

14. Educate the parents on the full

scope of parenting by using humor

and normalization.

15. Help the parents reduce their

unrealistic expectations of their

parenting performance, identify

parental strengths, and begin to

build the confidence and

effectiveness level of the parental

team.

9. Verbalize a commitment to

learning and using alternative

ways to think about and

manage anger and

misbehavior. (16, 17)

16. Assist the parent in re-

conceptualizing anger as involving

different components (cognitive,

physiological, affective, and

behavioral) that go through

predictable phases (e.g.,

demanding expectations not being

met leading to increased arousal

and anger leading to acting out)

that can be managed.

17. Assist the parent in identifying the

positive consequences of managing

anger and misbehavior (e.g.,

respect from others and self,

cooperation from others, improved

physical health, etc.); ask the client

to agree to learn new ways to

PARENTING

conceptualize and manage anger

and misbehavior.

10. Verbalize an understanding of

the numerous key differences

between boys and girls at

different levels of development

and adjust expectations and

parenting practices

accordingly. (18)

18. Educate the parents on key

developmental differences between

boys and girls, such as rate of

development, perspectives, impulse

control, temperament, and how

these influence the parenting

process.

11. Verbalize an increased

awareness and understanding

of the unique issues and trials

of parenting adolescents.

(19, 20, 21)

19. Educate the parents about the

various biopsychosocial influences

on adolescent behavior including

biological changes, peer influences,

self-concept, identity, and

parenting styles.

20. Teach the parents the concept

that adolescence is a time in which

the parents need to “ride the

adolescent rapids” (see Positive

Parenting for Teenagers:

Empowering Your Teen and

Yourself through Kind and Firm

Parenting by Nelson and Lott;

Turning Points by Pittman;

Preparing for Adolescence: How

to Survive the Coming Years of

Change by Dobson) until both

survive.

21. Assist the parents in coping with

the issues and reducing their fears

regarding negative peer groups,

negative peer influences, and losing

their influence to these groups.

12. Verbalize an understanding of

the impact of their reaction on

their child’s behavior. (22, 23)

22. Use a Parent Management

Training approach beginning with

teaching the parents how parent

and child behavioral interactions

can encourage or discourage

positive or negative behavior and

that changing key elements of

those interactions (e.g., prompting

and reinforcing positive behaviors)

can be used to promote positive

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

302

change (e.g., Parenting the Strong-

Willed Child by Forehand and

Long).

23. Assign the parents to implement

key parenting practices

consistently, including establishing

realistic age-appropriate rules for

acceptable and unacceptable

behavior, prompting of positive

behavior in the environment,

use of positive reinforcement to

encourage behavior (e.g., praise

and clearly established rewards),

use of calm clear direct instruction,

time out, and other loss-of-

privilege practices for problem

behavior.

13. Learn and implement

parenting practices that have

demonstrated effectiveness.

(24, 25, 26, 27)

24. Teach the parents how to

implement key parenting practices

consistently, including establishing

realistic age-appropriate rules for

acceptable and unacceptable

behavior, prompting of positive

behavior in the environment,

use of positive reinforcement to

encourage behavior (e.g., praise),

use of clear direct instruction, time

out and other loss-of-privilege

practices for problem behavior,

negotiation, and renegotiation—

usually with older children and

adolescents (see Defiant Teens: A

Clinician’s Manual for Assessment

and Family Intervention by Barkley,

Edwards, and Robin; Defiant

Children: A Clinician’s Manual for

Parent Training by Barkley).

25. Assign the parents home exercises

in which they implement parenting

skills and record results of

implementation (or assign “Using

Reinforcement Principles in

Parenting” in the Adult Psycho-

therapy Homework Planner by

PARENTING

303

Jongsma); review in session,

providing corrective feedback

toward improved, appropriate, and

consistent use of skills.

26. Ask the parents to read parent-

training manuals consistent with

the therapy (e.g., Parents and

Adolescents Living Together: The

Basics by Patterson and Forgatch;

Parents and Adolescents Living

Together: Family Problem Solving

by Forgatch and Patterson; The

Kazdin Method for Parenting the

Defiant Child by Kazdin).

27. Refer parents to an Incredible

Years program, a group parent

training program that teaches

positive child management

practices and stress management

techniques (see www.incredible

years.com)

14. Interact with children under

the supervision of the therapist

to improve parenting

knowledge and skills and

the quality of parent-child

interactions. (28)

28. Use a Parent-Child Interaction

Therapy approach involving Child-

Directed Interaction in which

parents engage their child in a play

situation that the child directs as

well as Parent Directed Interaction

where parents are taught how to

use specific behavior management

techniques as they play with their

child (see Parent-Child Interaction

Therapy by McNeil and Humbree-

Kigin).

15. Verbalize a sense of increased

skill, effectiveness, and

confidence in parenting. (29)

29. Support, empower, monitor,

and encourage the parents in

implementing new strategies for

parenting their child; reinforce

successes; problem-solve obstacles

toward consolidating a

coordinated, consistent, and

effective parenting style.

16. Older children and adolescents

learn and implement skills for

30. Use a Cognitive-Behavioral

Therapy approach with older

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

304

managing self and interactions

with others. (30, 31)

children and adolescents using

several techniques such as

instruction, modeling, role-playing,

feedback, and practice to teach the

child how to manage his/her

emotional reactions, manage

interpersonal interactions, and

problem-solving conflicts.

31. Use structured tasks involving

games, stories, and other activities

in session to develop personal and

interpersonal skills, then carry

them into real-life situations

through homework exercises;

review; reinforce successes;

problem-solve obstacles toward

integration into the child’s life.

17. Develop skills to talk openly

and effectively with the

children. (32, 33)

32. Use instruction, modeling, and role-

play to teach the parents how to

communicate effectively with their

child including use open-ended

questions, active listening, and

respectful assertive communication

that encourage openness, sharing,

and ongoing dialogue.

33. Ask the parents to read material

on parent-child communication

(e.g., How to Talk So Kids Will

Listen and Listen So Kids Will Talk

by Faber and Mazlish; Parent

Effectiveness Training by Gordon);

help them implement the new

communication style in daily

dialogue with their children and

to see the positive responses each

child had to it.

18. Parents expand repertoire of

parenting options (34, 35)

34. Expand the parents’ repertoire of

intervention options by having

them read material on parenting

difficult children (e.g., The Difficult

Child by Turecki and Tonner; The

Explosive Child by Greene; How to

Handle a Hard-to-Handle Kid by

Edwards).

PARENTING

305

35. Support, empower, monitor,

and encourage the parents in

implementing new strategies for

parenting their child, giving

feedback and redirection as

needed.

19. Identify unresolved childhood

issues that affect parenting and

work toward their resolution.

(36, 37)

36. Explore each parent’s story of

his/her childhood to identify any

unresolved issues that are present

(e.g., abusive or neglectful parents,

substance abuse by parents, etc.)

and to identify how these issues are

now affecting the ability to

effectively parent.

37. Assist the parents in working

through issues from their own

childhood that are unresolved.

20. Partners express verbal support

of each other in the parenting

process. (38, 39)

38. Assist the parental team in

identifying areas of parenting

weaknesses; help the parents

improve their skills and boost their

confidence and follow-through.

39. Help the parents identify and

implement specific ways they

can support each other as parents

and in realizing the ways children

work to keep the parents from

cooperating in order to get their

way (or assign “Learning to

Parent as a Team” in the Adult

Psychotherapy Homework Planner

by Jongsma).

21. Decrease outside pressures,

demands, and distractions that

drain energy and time from the

family. (40, 41)

40. Give the parents permission to not

involve their child and themselves

in too numerous activities,

organizations, or sports.

41. Ask the parents to provide a

weekly schedule of their entire

family’s activities and then

evaluate the schedule with them,

looking for which activities are

valuable and which can possibly be

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

306

eliminated to create a more focused

and relaxed time to parent.

22. Increase the gradual letting

go of their adolescent in

constructive, affirmative ways.

(42)

42. Guide the parents in identifying

and implementing constructive,

affirmative ways they can allow

and support the healthy separation

of their adolescent.

23. Parents and child report an

increased feeling of

connectedness between them.

(43, 44)

43. Assist the parents in removing and

resolving any barriers that prevent

or limit connectedness between

family members and in identifying

activities that will promote

connectedness (e.g., games, one-to-

one time).

44. Encourage the parents to see that

just “hanging out at home” or

being around/available is quality

time.

24. Verbalize an understanding of

relapse prevention and the

difference between a lapse and

a relapse. (45, 46, 47)

45. Provide a rationale for relapse

prevention that discusses the risk

and introduces strategies for

preventing it.

46. Discuss with the parent/child the

distinction between a lapse and

relapse, associating a lapse with a

temporary setback and relapse

with a return to a sustained pattern

of conflict.

47. Identify and rehearse with the

parent/child the management of

future situations or circumstances

in which lapses could occur.

25. Learn and implement strategies

to prevent relapse of disruptive

behavior. (48, 49, 50)

48. Instruct the parent/child to

routinely use strategies learned in

therapy (e.g., parent training

techniques, problem-solving, anger

management), building them into

his/her life as much as possible.

49. Develop a “coping card” or other

recording on which coping

strategies and other important

information can be kept (e.g., steps

PARENTING

in problem-solving, positive coping

statements, reminders that were

helpful to the client during

therapy).

50. Schedule periodic maintenance or

“booster” sessions to help the

parent/child maintain therapeutic

gains and problem-solve

challenges.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

309.3 Adjustment Disorder With Disturbance of

Conduct

309.4 Adjustment Disorder With Mixed

Disturbances of Emotions and Conduct

V61.21 Neglect of Child

V61.20 Parent-Child Relational Problem

V61.10 Partner Relational Problem

V61.21 Physical Abuse of Child

V61.21 Sexual Abuse of Child

313.81 Oppositional Defiant Disorder

312.9 Disruptive Behavior Disorder NOS

312.8 Conduct Disorder, Adolescent-Onset Type

314.01 Attention-Deficit/Hyperactivity Disorder,

Combined Type

_____

_____________________________________

_____

_____________________________________

Axis II:

301.7 Antisocial Personality Disorder

301.6 Dependent Personality Disorder

301.81 Narcissistic Personality Disorder

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

308

799.9 Diagnosis Deferred

V71.09 No Diagnosis on Axis II

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

309.3 F43.24 Adjustment Disorder, With Disturbance of

Conduct

309.4 F43.25 Adjustment Disorder, With Mixed

Disturbance of Emotions and Conduct

V61.21 Z69.011 Encounter for Mental Health Services for

Perpetrator of Parental Child Neglect

V61.20 Z62.820 Parent-Child Relational Problem

V61.10 Z63.0 Relationship Distress with Spouse or

Intimate Partner

V61.22 Z69.011 Encounter for Mental Health Services for

Perpetrator of Parental Child Abuse

V61.22 Z69.011 Encounter for Mental Health Services for

Perpetrator of Parental Child Sexual Abuse

313.81 F91.3 Oppositional Defiant Disorder

312.9 F91.9 Unspecified Disruptive, Impulse Control,

and Conduct Disorder

312.89 F91.8 Other Specified Disruptive, Impulse

Control, and Conduct Disorder

312.82 F91.2 Conduct Disorder, Adolescent-Onset Type

312.81 F91.1 Conduct Disorder, Childhood-Onset Type

314.01 F90.2 Attention-Deficit/Hyperactivity Disorder,

Combined Presentation

301.7 F60.2 Antisocial Personality Disorder

301.6 F60.7 Dependent Personality Disorder

301.81 F60.81 Narcissistic Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

309

PHASE OF LIFE PROBLEMS

BEHAVIORAL DEFINITIONS

1. Difficulty adjusting to the accountability and interdependence of a new

marriage.

2. Anxiety and depression related to the demands of being a new parent.

3. Grief related to children emancipating from the family (“empty nest

stress”).

4. Restlessness and feelings of lost identity and meaning due to retirement.

5. Feelings of isolation, sadness, and boredom related to quitting employ-

ment to be a full-time homemaker and parent.

6. Frustration and anxiety related to providing oversight and caretaking to

an aging, ailing, and dependent parent.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Resolve conflicted feelings and adapt to the new life circumstances.

2. Reorient life view to recognize the advantages of the current situation.

3. Find satisfaction in serving, nurturing, and supporting significant others

who are dependent and needy.

4. Balance life activities between consideration of others and development

of own interests.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

310

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the circumstances

of life that are contributing

to stress, anxiety, or lack of

fulfillment. (1, 2, 3)

1. Explore the client’s current life

circumstances that are causing

frustration, anxiety, depression,

or lack of fulfillment.

2. Assign the client to write a list

of those circumstances that are

causing concern and how or why

each is contributing to his/her

dissatisfaction (or assign “What

Needs to Be Changed in My Life?”

from the Adult Psychotherapy

Homework Planner by Jongsma).

3. Assist the client in listing those

desirable things that are missing

from his/her life that could increase

his/her sense of fulfillment.

2. Disclose any history of

substance use that may

contribute to and complicate

the treatment of phase of life

problems. (4)

4. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

PHASE OF LIFE PROBLEMS

“problem described” and is

reluctant to address the issue as a

concern; or demonstrates

resistance regarding

acknowledgment of the “problem

described,” is not concerned, and

has no motivation to change).

6. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

7. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

4. Identify values that guide life’s

decisions and determine

fulfillment. (9, 10)

9. Assist the client in clarifying and

prioritizing his/her values (consider

assigning “Developing

Noncompetitive Values” from the

Adult Psychotherapy Homework

Planner by Jongsma).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

312

10. Assign the client to read books on

values clarification (e.g., Values

Clarification by Simon, Howe, and

Kirschenbaum; In Search of

Values: 31 Strategies for Finding

Out What Really Matters Most to

You by Simon); process the content

and list values that he/she holds as

important.

5. Implement new activities that

increase a sense of satisfaction.

(11, 12)

11. Develop a plan with the client to

include activities that will increase

his/her satisfaction, fulfill his/her

values, and improve the quality of

his/her life.

12. Review the client’s attempts to

modify his/her life to include self-

satisfying activities; reinforce

success and redirect for failure.

6. Identify and implement

changes that will reduce

feelings of being overwhelmed

by caretaking responsibilities.

(13, 14)

13. Brainstorm with the client possible

sources of support or respite (e.g.,

parent support group, engaging

spouse in more child care, respite

care for elderly parent, sharing

parent-care responsibilities with a

sibling, utilizing home health-care

resources, taking a parenting class)

from the responsibilities that are

overwhelming him/her.

14. Encourage the client to implement

the changes that will reduce the

burden of responsibility felt;

monitor progress, reinforcing

success and redirecting for failure.

7. Implement increased

assertiveness to take control of

conflicts. (15, 16, 17)

15. Use role-playing, modeling, and

behavior rehearsal to teach the

client assertiveness skills that can

be applied to reducing conflict or

dissatisfaction.

16. Refer the client to an assertiveness

training class.

17. Encourage the client to read books

on assertiveness and boundary

PHASE OF LIFE PROBLEMS

setting (e.g., The Assertiveness

Workbook: How to Express Your

Ideas and Stand Up for Yourself at

Work and in Relationships by

Paterson; Asserting Yourself by

Bower and Bower; When I Say No,

I Feel Guilty by Smith; Your

Perfect Right by Alberti and

Emmons); process the content and

its application to the client’s daily

life.

8. Apply problem-solving skills to

current circumstances. (18, 19)

18. Teach the client problem-

resolution skills (e.g., defining the

problem clearly, brainstorming

multiple solutions, listing the pros

and cons of each solution, seeking

input from others, selecting and

implementing a plan of action,

evaluating outcome, and

readjusting plan as necessary).

19. Use modeling and role-playing

with the client to apply the

problem-solving approach to

his/her current circumstances (or

assign “Applying Problem-Solving

to Interpersonal Conflict” from the

Adult Psychotherapy Homework

Planner by Jongsma); encourage

implementation of action plan,

reinforcing success and redirecting

for failure.

9. Increase communication with

significant others regarding

current life stress factors.

(20, 21)

20. Teach the client communication

skills (e.g., “I messages,” active

listening, eye contact) to apply to

his/her current life stress factors.

21. Invite the client’s partner and/or

other family members for conjoint

sessions to address the client’s

concerns; encourage open

communication and group

problem solving.

10. Identify five advantages of

current life situation. (22)

22. Assist the client in identifying at

least five advantages to his/her

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

314

current life circumstance that

may have been overlooked or

discounted (e.g., opportunity to

make own decisions, opportunity

for intimacy and sharing with a

partner, a time for developing

personal interests or meeting the

needs of a significant other).

11. Implement changes in time and

effort allocation to restore

balance to life. (23)

23. Assist the client in identifying areas

of life that need modification in

order to restore balance in his/her

life (e.g., adequate exercise, proper

nutrition and sleep, socialization

and reaction activities, spiritual

development, conjoint activities

with partner as well as individual

activities and interests, service to

others as well as self-indulgence);

develop a plan of implementation

(or assign “What Needs to be

Changed in My Life?” from the

Adult Psychotherapy Homework

Planner by Jongsma).

12. Increase activities that

reinforce a positive self-

identity. (24, 25)

24. Assist the client in clarifying

his/her identity and meaning in life

by listing his/her strengths, positive

traits and talents, potential ways to

contribute to society, and areas of

interest and ability that have not

yet been developed (or assign

“What’s Good About Me and

My Life?” from the Adult Psycho-

therapy Homework Planner by

Jongsma).

25. Develop an action plan with the

client to increase activities that give

meaning and expand his/her sense

of identity at a time of transition in

life phases (e.g., single to married,

employed to homemaker, childless

to parent, employed to retired);

monitor implementation; suggest

the client read material on

transitioning in life (e.g., Managing

PHASE OF LIFE PROBLEMS

Transitions: Making the Most of

Change or Transitions: Making

Sense of Life’s Changes by

Bridges).

13. Increase social contacts to

reduce sense of isolation.

(26, 27)

26. Explore opportunities for the client

to overcome his/her sense of

isolation (e.g., joining a community

recreational or educational group,

becoming active in church or

synagogue activities, taking formal

education classes, enrolling in an

exercise group, joining a hobby

support group); encourage

implementation of these activities.

27. Use role-playing and modeling to

teach the client social skills needed

to reach out to build new relation-

ships (e.g., starting conversations,

introducing self, asking questions

of others about themselves, smiling

and being friendly, inviting new

acquaintances to his/her home,

initiating a social engagement or

activity with a new acquaintance).

14. Share emotional struggles

related to current adjustment

stress. (28, 29)

28. Explore the client’s feelings, coping

mechanisms, and support system

as he/she tries to adjust to the

current life stress factors; assess

for depth of depression, anxiety, or

grief and recommend treatment

focused on these problems if

warranted (see the Unipolar

Depression, Anxiety, and Grief/

Loss Unresolved chapters in this

Planner).

29. Assess the client for suicide

potential if feelings of depression,

helplessness, and isolation are

present; initiate suicide prevention

precautions, if necessary (see the

Suicidal Ideation chapter in this

Planner).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

316

15. Significant others offer support

to reduce the client’s stress.

(30)

30. Hold family therapy sessions in

which significant others are given

the opportunity to support the

client and offer suggestions for

reducing his/her stress; challenge

the client to share his/her needs

assertively and challenge

significant others to take

responsibility for support (e.g.,

partner to increasing parenting

involvement, partner to support

the client’s need for affirmation

and stimulation outside the home,

family members to take more

responsibility for elderly parent’s

care).

16. Read self-help book on the

difficult transition life is

presenting currently. (31)

31. Suggest reading material to the

client on making the transition that

is stressful (e.g., new marriage, new

parent, becoming full-time

homemaker, providing care to an

aging parent, retirement, or

adjusting to an “empty nest”);

consult the Bibliotherapy

Appendix for selected titles.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

V62.89 Phase of Life Problem

313.82 Identity Problem

V61.10 Partner Relational Problem

V61.20 Parent-Child Relational Problem

309.0 Adjustment Disorder With Depressed Mood

PHASE OF LIFE PROBLEMS

309.28 Adjustment Disorder With Mixed Anxiety

and Depressed Mood

309.24 Adjustment Disorder With Anxiety

_____

_____________________________________

_____

_______________

_____________________

Axis II:

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

V62.89 Z60.0 Phase of Life Problem

V61.10 Z63.0 Relationship Distress With Spouse or

Intimate Partner

V61.20 Z62.820 Parent-Child Relational Problem

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

309.28 F43.23 Adjustment Disorder, With Mixed Anxiety

and Depressed Mood

309.24 F43.22 Adjustment Disorder, With Anxiety

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

PHOBIA

BEHAVIORAL DEFINITIONS

1. Describes a persistent and unreasonable fear of a specific object or

situation that promotes avoidance behaviors because an encounter with

the phobic stimulus provokes an immediate anxiety response.

2. Fears and avoids the phobic stimulus/feared environment or endures it

with distress, resulting in interference with normal routines.

3. Acknowledges a persistence of fear despite recognition that the fear is

unreasonable.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Reduce fear of the specific phobic object or situation.

2. Reduce avoidance of the specific phobic object or situation, leading to

comfort and independence in moving around in a public environment.

3. Eliminate fear of the specific phobic object or situation.

4. Eliminate avoidance of the specific phobic object or situation, leading to

comfort and independence in moving around in a public environment.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

PHOBIA

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the history and nature

of the phobia(s), complete with

impact on functioning and

attempts to overcome it. (1, 2)

1. Establish rapport with the client

toward building a therapeutic

alliance; explore and identify

the objects or situations that

precipitate the client’s phobic fear.

2. Assess the client’s fear and

avoidance, including the focus of

the fear, types of avoidance (e.g.,

distraction, escape, dependence on

others), development of the fear,

and disability resulting from the

fear (consider using The Anxiety

Disorders Interview Schedule-Adult

Version).

2. Complete psychological tests

designed to assess features of

the phobia. (3)

3. Administer a client-report measure

(e.g., Measures for Specific Phobia

by Antony; the Fear Survey

Schedule-III) to further assess the

depth and breadth of phobic

responses; readminister as needed

to assess treatment outcome.

3. Participate in a behavioral

assessment task. (4)

4. Conduct a behavioral assessment

task in which the client is asked

to approach, under his/her own

direction, the feared object or

situation while reporting relevant

cognitive and emotional

experiences; readminister as needed

to assess treatment outcome.

4. Disclose any history of

substance use that may

contribute to and complicate

the treatment of the phobia. (5)

5. Arrange for a substance abuse

evaluation and refer the client for

treatment for if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

320

5. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of

the therapy relationship.

(6, 7, 8, 9)

6. Assess the client’s level of insight

(syntonic versus dystonic) toward

the “presenting problems” (e.g.,

demonstrates good insight into

the problematic nature of the

“described behavior,” agrees with

others’ concern, and is motivated

to work on change; demonstrates

ambivalence regarding the

“problem described” and is

reluctant to address the issue

as a concern; or demonstrates

resistance regarding acknowledg-

ment of the “problem described,”

is not concerned, and has no

motivation to change).

7. Assess the client for evidence of

research-based correlated disorders

(e.g., oppositional defiant behavior

with ADHD, depression secondary

to an anxiety disorder) including

vulnerability to suicide, if appro-

priate (e.g., increased suicide risk

when comorbid depression is

evident).

8. Assess for any issues of age,

gender, or culture that could help

explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

9. Assess for the severity of the level

of impairment to the client’s

functioning to determine

appropriate level of care (e.g., the

behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as well

as the efficacy of treatment (e.g.,

the client no longer demonstrates

PHOBIA

severe impairment but the

presenting problem now is causing

mild or moderate impairment).

6. Cooperate with an evaluation

by a physician for psychotropic

medication. (10, 11)

10. Arrange for a medication

evaluation to determine the need

for a prescription of psychotropic

medications if the client requests it

or if the client is likely to be

noncompliant with gradual

exposure.

11. Monitor the client for prescription

compliance, side effects, and

overall effectiveness of the

medication; consult with the

prescribing physician at regular

intervals.

7. Verbalize an accurate

understanding of information

about phobias and their

treatment. (12, 13, 14)

12. Discuss how phobias are a

common but irrational expression

of our fight or flight response, are

not a sign of weakness, but cause

unnecessary distress and

disability.

13. Discuss how phobic fear is

maintained by a “phobic cycle” of

unwarranted fear and avoidance

that precludes positive, corrective

experiences with the feared object

or situation, and how treatment

breaks the cycle by encouraging

exposure to these experiences (see

Mastery of Your Specific Phobia—

Therapist Guide by Craske, Antony,

and Barlow; Specific Phobias by

Bruce and Sanderson).

14. Assign the client to read

psychoeducational chapters of

books or treatment manuals on

specific phobias (e.g., The Anxiety

and Phobia Workbook by Bourne;

Living with Fear by Marks;

Mastering Your Fears and

Phobia—Workbook by Antony,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

322

Craske, and Barlow; Anxiety,

Phobias, and Panic: A Step-by-Step

Program for Regaining Control of

your Life by Peurifoy; Face Your

Fears: A Proven Plan to Beat

Anxiety, Panic, Phobias, and

Obsessions by Tolin).

8. Verbalize an understanding of

the cognitive, physiological,

and behavioral components

of anxiety and its treatment.

(15, 16)

15. Discuss how phobias involve

perceiving unrealistic threats,

bodily expressions of fear, and

avoidance of what is threatening

that interact to maintain the

problem; discuss how treatment

targets change in each domain

(see Mastery of Your Specific

Phobia—Therapist Guide by

Craske, Antony, and Barlow;

Specific Phobias by Bruce and

Sanderson).

16. Discuss how exposure serves as an

arena to desensitize learned fear,

build confidence, and feel safer by

building a new history of success

experiences (see Mastery of Your

Specific Phobia—Therapist Guide

by Craske, Antony, and Barlow;

Specific Phobias by Bruce and

Sanderson).

9. Learn and implement calming

skills to reduce and manage

anxiety symptoms that may

emerge during encounters with

phobic objects or situations.

(17, 18, 19)

17. Teach the client anxiety

management skills (e.g., staying

focused on behavioral goals,

muscular relaxation, evenly paced

diaphragmatic breathing, positive

self-talk) to address anxiety

symptoms that may emerge during

encounters with phobic objects or

situations.

18. Assign the client a homework

exercise in which he/she practices

daily calming skills; review and

reinforce success, problem-solve

obstacles toward mastery of the

skill.

PHOBIA

19. Use biofeedback techniques to

facilitate the client’s success at

learning calming skills.

10. Learn and implement applied

muscle tension skills. (20, 21)

20. Teach the client applied tension in

which he/she tenses neck and upper

torso muscles to curtail blood flow

out of the brain to help prevent

fainting during encounters with

phobic objects or situations

involving blood, injection, or

injury (consult “Applied Tension”

by Öst and Sterner).

21. Assign the client a homework

exercise in which he/she practices

daily applied tension skills; review

and reinforce success, problem-

solve obstacles toward mastery of

the skill.

11. Identify, challenge, and replace

biased, fearful self-talk with

positive, realistic, and

empowering self-talk.

(22, 23, 24)

22. Explore the client’s self-talk and

schema that mediate his/her fear

response; assist in identify biases,

generate alternatives that correct

for the biases; and replacing

distorted messages with reality-

based alternatives.

23. Assign the client a homework

exercise in which he/she identifies

fearful self-talk and creates reality-

based alternatives (or assign

“Journal and Replace Self-

Defeating Thoughts” in the Adult

Psychotherapy Homework Planner

by Jongsma); review and reinforce

success, problem-solve obstacles

toward mastery of the skill.

24. Use behavioral techniques (e.g.,

modeling, corrective feedback,

imaginal rehearsal, social

reinforcement) to train the client

in positive self-talk that prepares

him/her to endure anxiety

symptoms without serious

consequences.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

324

12. Participate in repeated

exposure to feared or avoided

phobic objects or situations.

(25, 26, 27, 28)

25. Direct and assist the client in

construction of a hierarchy of

anxiety-producing situations

associated with the phobic

response; include imaginal

situations if needed to

accommodate excessive fear.

26. Select initial exposures that

have a high likelihood of being

a successful experience for the

client; develop a plan for managing

the symptoms and rehearse the

plan.

27. Assign the client a homework

exercise in which he/she does

imaginal and/or situational

exposures and records responses

(see “Gradually Reducing Your

Phobic Fear” in the Adult

Psychotherapy Homework Planner

by Jongsma; Mastering Your Fears

and Phobia—Workbook by

Antony, Craske, and Barlow;

Living with Fear by Marks); review

and reinforce success, problem-

solve obstacles toward the

extinction of fear and elimination

of phobic avoidance.

28. Assign the client behavioral

experiments in which biased, fear-

based predictions are tested against

alternatives that correct for the

biases during exposure exercises;

review and reinforce success,

problem-solve obstacles toward

belief in the alternatives and the

elimination of phobic avoidance.

13. Implement relapse prevention

strategies for preventing and/or

managing possible future

anxiety symptoms.

(29, 30, 31, 32, 33)

29. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with a

temporary and reversible return of

symptoms, fear, or urges to avoid

PHOBIA

and relapse with the decision to

return to fearful and avoidant

patterns.

30. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur.

31. Instruct the client to routinely use

strategies learned in therapy (e.g.,

cognitive restructuring, exposure),

building them into his/her life as

much as possible.

32. Develop a “coping card” or other

recording on which coping

strategies and other therapeutic

important information that the

client found useful (e.g., coping

strategies, cognitive messages) are

made available for the client’s later

use.

33. Schedule a “booster session” for

the client 1 to 3 months after

therapy ends to reinforce gains and

problem-solve any obstacles to

progress.

14. Learn to accept anxious

thinking and tolerate, rather

than avoid, unpleasant

emotions while accomplishing

meaningful goals. (34, 35, 36)

34. Use an Acceptance and Commit-

ment Therapy approach including

mindfulness strategies to help the

client decrease experiential

avoidance, disconnect thoughts

from actions, accept one’s

experience rather than change or

control symptoms, and behave

according to his/her broader life

values; assist the client in clarifying

his/her values and goals and

commit to behaving accordingly

(see Acceptance and Commitment

Therapy for Anxiety Disorders by

Eifert, Forsyth, and Hayes).

35. Recommend that the client read

self-help books consistent with the

ACT approach to help supplement

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

326

therapy and foster better

understanding of it (e.g., see The

Mindfulness and Acceptance

Workbook for Anxiety by Forsyth

and Eifert); process material read.

36. Support the client in following

through with his/her commitments

toward having a meaningful and

fulfilling work, family, and social

life.

15. Verbalize the costs and benefits

of remaining fearful and

avoidant. (37)

37. Probe for the presence of

secondary gain that reinforces the

client’s phobic actions through

escape or avoidance mechanisms;

address gain directly if evident;

encourage and support change.

16. Verbalize the separate realities

of the irrationally feared

object or situation and the

emotionally painful experience

from the past that has been

evoked by the phobic stimulus.

(38, 39, 40)

38. Clarify and differentiate between

the client’s current irrational fear

and past emotional pain.

39. Encourage the client’s sharing

of feelings associated with past

traumas through active listening,

positive regard, and questioning.

40. Work through past pain with the

client toward insight into its

relationship with the present fear.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

PHOBIA

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.29 Specific Phobia

_____

_________________________

___________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.29 F40.xxx Specific Phobia

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

POSTTRAUMATIC STRESS

DISORDER (PTSD)

BEHAVIORAL DEFINITIONS

1. Has been exposed to a traumatic event involving actual or perceived

threat of death or serious injury.

2. Reports response of intense fear, helplessness, or horror to the traumatic

event.

3. Experiences disturbing and persistent thoughts, images, and/or perceptions

of the traumatic event.

4. Experiences frequent nightmares.

5. Describes a reliving of the event, particularly through dissociative

flashbacks.

6. Displays significant psychological and/or physiological distress resulting

from internal and external clues that are reminiscent of the traumatic

event.

7. Intentionally avoids thoughts, feelings, or discussions related to the

traumatic event.

8. Intentionally avoids activities, places, people, or objects (e.g., up-armored

vehicles) that evoke memories of the event.

9. Displays a significant decline in interest and engagement in activities.

10. Experiences disturbances in sleep.

11. Reports difficulty concentrating as well as feelings of guilt.

12. Reports hypervigilance

13. Demonstrates an exagger0061ted startle response.

14. Symptoms present more than one month.

15. Impairment in social, occupational, or other areas of functioning.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

POSTTRAUMATIC STRESS DISORDER (PTSD)

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Eliminate or reduce the negative impact trauma related symptoms have

on social, occupational, and family functioning.

2. Returns to the level of psychological functioning prior to exposure to the

traumatic event.

3. No longer experiences intrusive event recollections, avoidance of event

reminders, intense arousal, or disinterest in activities or relationships.

4. Thinks about or openly discusses the traumatic event with others

without experiencing psychological or physiological distress.

5. No longer avoids persons, places, activities, and objects that are

reminiscent of the traumatic event.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe in as much detail as

comfort allows the nature and

history of the PTSD symptoms.

(1, 2)

1. Establish rapport with the client

toward building a therapeutic

alliance.

2. Gently and sensitively explore

the client’s recollection of the

facts of the traumatic incident

and his/her cognitive and

emotional reactions at the time;

assess frequency, intensity,

duration, and history of the

client’s PTSD symptoms and

their impact on functioning (see

“How the Trauma Affects Me”

in the Adult Psychotherapy

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

330

Homework Planner by Jongsma);

supplement with semi-structured

assessment instrument if desired

(see The Anxiety Disorders

Interview Schedule–Adult

Version).

2. Cooperate with psychological

testing. (3)

3. Administer or refer the client for

administration of psychological

testing or objective measures

of the PTSD symptoms

and/or other comorbidity

(e.g., Minnesota Multiphasic

Personality Inventory–2; Impact

of Events Scale-Revised; PTSD

Symptom Scale; Posttraumatic

Stress Diagnostic Scale);

discuss results with the client;

readminister as indicated to

assess treatment progress).

3. Acknowledge any substance use.

(4, 5)

4. Assess the client for the presence

and degree of substance abuse or

dependence.

5. Refer the client for a more

comprehensive substance use

evaluation and treatment.

4. Verbalize any symptoms of

depression, including any

suicidal thoughts. (6)

6. Assess the client’s depth of

depression and suicide potential

and treat appropriately, taking

the necessary safety precautions

as indicated (see the Suicidal

Ideation chapter in this Planner).

5. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (7, 8, 9, 10)

7. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

POSTTRAUMATIC STRESS DISORDER (PTSD)

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

8. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

9. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

10. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

6. Cooperate with a psychiatric

evaluation to assess for the need

for psychotropic medication.

(11, 12)

11. Assess the client’s need for

medication (e.g., selective

serotonin reuptake inhibitors)

and arrange for prescription,

if appropriate.

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332

12. Monitor and evaluate the client’s

psychotropic medication

prescription compliance and the

effectiveness of the medication

on his/her level of functioning.

7. Verbalize an accurate

understanding of PTSD and how

it develops. (13)

13. Discuss how PTSD results from

exposure to trauma; results

in intrusive recollection,

unwarranted fears, anxiety, and

a vulnerability to other negative

emotions such as shame, anger,

and guilt; and results in

avoidance of thoughts, feelings,

and activities associated with

the trauma.

8. Verbalize an understanding of

the treatment rationale for

PTSD. (14, 15)

14. Educate the client about how

effective treatments for PTSD

help address the cognitive,

emotional, and behavioral

consequences of PTSD using

cognitive and behavioral therapy

approaches.

15. Assign the client to read

psychoeducational chapters

of books or treatment manuals

on PTSD that explain its

features and development (e.g.,

Overcoming Posttraumatic Stress

Disorder by Smyth; Reclaiming

Your Life from a Traumatic

Experience by Rothbaum, Foa,

and Hembree).

9. Learn and implement calming

skills. (16)

16. Teach the client calming skills

(e.g., breathing retraining,

relaxation, calming self-talk) to

use in and between sessions when

feeling overly distressed.

10. Participate in Cognitive

Processing Therapy to process

the trauma and reduce its

impact. (17, 18, 19, 20)

17. Use a Cognitive Processing

Therapy approach beginning with

assigning the client to write a

description of the meaning of the

traumatic event (i.e., the impact

POSTTRAUMATIC STRESS DISORDER (PTSD)

333

statement); ask the client to read

and discuss the impact statement

(see Posttraumatic Stress Disorder

by Resick, Monson, and Rizvi;

Cognitive Processing Therapy for

Rape Victims by Resick and

Schnicke).

18. Teach the client the relationship

between thoughts, behaviors,

and emotions associated with the

trauma.

19. Ask the client to write a detailed

description of the traumatic

event and read the statement in

session (or assign “Share the

Painful Memory” in the Adult

Psychotherapy Homework

Planner by Jongsma); use

cognitive therapy techniques to

question biased thoughts and

beliefs and explore unbiased

alternatives; repeat this process

until a shift from biased to

unbiased thinking is evident.

20. Ask the client to rewrite a

description of the event, but now

reflecting new thoughts and

beliefs; discuss this restructured

version of the event reinforcing

the new beliefs; assess and

address themes common to

PTSD (e.g., safety, trust, power,

control, esteem, and intimacy).

11. Participate in Cognitive Therapy

to help identify, challenge, and

replace biased, negative, and

self-defeating thoughts resulting

from the trauma. (21, 22, 23)

21. Using Cognitive Therapy

techniques, explore the client’s

self-talk and beliefs about self,

others, and the future that are a

consequence of the trauma (e.g.,

themes of safety, trust, power,

control, esteem, and intimacy);

identify and challenge biases;

assist him/her in generating

appraisals that correct for the

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

334

biases; test biased and

alternatives predictions through

behavioral experiments.

22. Assign the client to keep a daily

log of automatic thoughts (e.g.,

“Negative Thoughts Trigger

Negative Feelings” in the Adult

Psychotherapy Homework

Planner by Jongsma); process

the journal material to challenge

distorted thinking patterns with

reality-based thoughts and to

generate predictions for

behavioral experiments.

23. Assign the client a homework

exercise in which he/she identifies

fearful self-talk; tests, through

behavioral experiments, the

predictions from these

dysfunctional thoughts; and

creates reality-based alternatives.

Review and reinforce success

while problem-solving obstacles

toward sustaining positive

change (see Overcoming

Posttraumatic Stress Disorder

by Smyth).

12. Participate in Prolonged

Exposure Therapy to reduce fear

and avoidance associated with

the trauma. (24, 25, 26, 27, 28)

24. Direct and assist the client in

constructing a fear and

avoidance hierarchy of trauma-

related stimuli.

25. Utilize in vivo exposure in which

the client gradually exposes

himself/herself to objects,

situations, places negatively

associated with the trauma.

26. Assign the client a homework

exercise in which he/she does an

exposure exercise and records

responses (see “Gradually

Reducing Your Phobic Fear”

in the Adult Psychotherapy

Homework Planner by Jongsma

POSTTRAUMATIC STRESS DISORDER (PTSD)

335

or Overcoming Posttraumatic

Stress Disorder by Smyth);

review and reinforce progress,

problem-solve obstacles.

27. Utilize imaginal exposure to

process memories of the trauma,

at a client-chosen level of detail,

for an extended period of time

(e.g., 90 minutes); repeat in

future sessions until distress

reduces and stabilizes (see

Prolonged Exposure Therapy for

PTSD by Foa, Hembree, and

Rothbaum; or Posttraumatic

Stress Disorder by Resick,

Monson, and Rizvi).

28. Assign the client a homework

exercise in which he or she does

self-directed exposure to the

memory of the trauma.

13. Learn and implement personal

skills to manage challenging

situations related to trauma. (29)

29. Use techniques from Stress

Inoculation Training (e.g., covert

modeling [i.e., imagining the

successful use of the strategies],

role-play, practice, and

generalization training) to teach

the client tailored skills (e.g.,

calming and coping skills) for

managing fears, overcoming

avoidance, and increasing

present-day adaptation (see

Clinical Handbook/Practical

Therapist Manual for Assessing

and Treating Adults with

Posttraumatic Stress Disorder

(PTSD) by Meichenbaum).

14. Learn and implement guided

self-dialogue to manage

thoughts, feelings, and urges

brought on by encounters with

trauma-related situations. (30)

30. Teach the client a guided self-

dialogue procedure in which

he/she learns to recognize

maladaptive self-talk, challenges

its biases, copes with engendered

feelings, overcomes avoidance,

and reinforces his/her

accomplishments; review and

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

336

reinforce progress, problem-

solve obstacles.

15. Participate in Eye Movement

Desensitization and

Reprocessing (EMDR) to reduce

emotional distress related to

traumatic thoughts, feelings,

and images. (31)

31. Utilize Eye Movement

Desensitization and

Reprocessing (EMDR) to reduce

the client’s emotional reactivity

to the traumatic event and

reduce PTSD symptoms.

16. Participate in Acceptance and

Commitment Therapy (ACT) to

reduce the impact of the

traumatic event. (32, 33, 34, 35)

32. Use an ACT approach to PTSD

to help the client experience and

accept the presence of troubling

thoughts and images without

being overly impacted by them,

and committing his/her time and

efforts to activities that are

consistent with identified,

personally meaningful values

(see Acceptance and Commitment

Therapy for Anxiety Disorders by

Eifert, Forsyth, and Hayes).

33. Teach mindfulness meditation

to help the client recognize the

negative thought processes

associated with PTSD and

change his/her relationship with

these thoughts by accepting

thoughts, images, and impulses

that are reality-based while

noticing, but not reacting to,

non-reality-based mental

phenomena (see Guided

Mindfulness Meditation [Audio

CD] by Zabat-Zinn).

34. Assign the client homework in

which he/she practices lessons

from mindfulness meditation

and ACT in order to consolidate

the approach into everyday life.

35. Assign the client reading

consistent with the mindfulness

and ACT approach to

supplement work done in session

(see Finding Life Beyond

POSTTRAUMATIC STRESS DISORDER (PTSD)

Trauma: Using Acceptance and

Commitment Therapy to Heal

from Post-Traumatic Stress and

Trauma-Related Problems by

Follette and Pistorello).

17. Acknowledge the need to

implement anger control

techniques; learn and implement

anger management techniques.

(36, 37)

36. Assess the client for instances of

poor anger management that

have led to threats or actual

violence that caused damage to

property and/or injury to people

(or assign “Anger Journal” in the

Adult Psychotherapy Homework

Planner by Jongsma).

37. Teach the client anger manage-

ment techniques (see the Anger

Control Problems chapter in this

Planner).

18. Learn and implement

approaches for addressing shame

and self-disparagement. (38)

38. Use a Compassionate Mind

Training to help the client

identify and change self-

attacking and personal shaming

resulting from the trauma

(see Focused Therapies and

Compassionate Mind Training

for Shame and Self-Attacking

by Gilbert and Irons).

19. Implement a regular exercise

regimen as a stress release

technique. (39, 40)

39. Develop and encourage a routine

of physical exercise for the client.

40. Recommend that the client read

and implement programs from

Exercising Your Way to Better

Mental Health by Leith.

20. Sleep without being disturbed by

dreams of the trauma. (41)

41. Monitor the client’s sleep pattern

(or assign “Sleep Pattern

Record” in the Adult

Psychotherapy Homework

Planner by Jongsma) and

encourage use of relaxation,

positive imagery, and sleep

hygiene as aids to sleep (see the

Sleep Disturbance chapter in this

Planner).

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338

21. Participate in conjoint and/or

family therapy sessions. (42)

42. Conduct family and conjoint

sessions to facilitate healing of

hurt caused by the client’s

symptoms of PTSD.

22. Participate in group therapy

sessions focused on PTSD. (43)

43. Refer the client to or conduct

group therapy sessions

emphasizing the sharing of

traumatic events and their effects

with other PTSD survivors.

23. Verbalize an understanding of

relapse prevention. (44, 45, 46)

44. Provide the client with a

rationale for relapse prevention

that discusses the risk and

introduces strategies for

preventing it.

45. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

a temporary setback and relapse

with a return to a sustained

pattern of thinking, feeling, and

behaving that is characteristic of

PTSD.

46. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur.

24. Learn and implement strategies

to prevent relapse of PTSD.

(47, 48, 49)

47. Instruct the client to routinely

use strategies learned in therapy

(e.g., continued everyday

exposure, cognitive

restructuring, problem-solving),

building them into his/her life as

much as possible.

48. Develop a “coping card” or

other reminder on which coping

strategies and other important

information can be recorded

(e.g., steps in problem-solving,

positive coping statements,

reminders that were helpful to

the client during therapy).

POSTTRAUMATIC STRESS DISORDER (PTSD)

339

49. Schedule periodic maintenance

or “booster” sessions to help the

client maintain therapeutic gains

and problem-solve challenges.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

309.81 Posttraumatic Stress Disorder

300.14 Dissociative Identity Disorder

300.6 Depersonalization Disorder

300.15 Dissociative Disorder NOS

995.54 Physical Abuse of Child, Victim

995.81 Physical Abuse of Adult, Victim

995.53 Sexual Abuse of Child, Victim

995.83 Sexual Abuse of Adult, Victim

308.3 Acute Stress Disorder

304.80 Polysubstance Dependence

305.00 Alcohol Abuse

303.90 Alcohol Dependence

304.30 Cannabis Dependence

304.20 Cocaine Dependence

304.00 Opioid Dependence

296.xx Major Depressive Disorder

_____

_____________________________________

_____

_____________________________________

Axis II:

301.83 Borderline Personality Disorder

301.9 Personality Disorder NOS

_____

_____________________________________

_____

_____________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

340

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

309.81 F43.10 Posttraumatic Stress Disorder

300.14 F44.81 Dissociative Identity Disorder

300.6 F48.1 Depersonalization/Derealization Disorder

300.15 F44.89 Other Specified Dissociative Disorder

300.15 F44.9 Unspecified Dissociative Disorder

995.54 T74.12XA Child Physical Abuse, Confirmed, Initial

Encounter

995.54 T74.12XD Child Physical Abuse, Confirmed,

Subsequent Encounter

995.81 T74.11XA Spouse or Partner Violence, Physical,

Confirmed, Initial Encounter

995.81 T74.11XD Spouse or Partner Violence, Physical,

Confirmed, Subsequent Encounter

995.53 T74.22XA Child Sexual Abuse, Confirmed, Initial

Encounter

995.53 T74.22XD Child Sexual Abuse, Confirmed,

Subsequent Encounter

995.83 T74.21XA Spouse or Partner Violence, Sexual,

Confirmed, Initial Encounter

995.83 T74.21XD Spouse or Partner Violence, Sexual,

Confirmed, Subsequent Encounter

995.83 T74.21XA Adult Sexual Abuse by Nonspouse or

Nonpartner, Confirmed, Initial Encounter

995.83 T74.21XD Adult Sexual Abuse by Nonspouse or

Nonpartner, Confirmed, Subsequent

Encounter

308.3 F43.0 Acute Stress Disorder

305.00 F10.10 Alcohol Use Disorder, Mild

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

304.30 F12.20 Cannabis Use Disorder, Moderate or

Severe

304.20 F14.20 Cocaine Use Disorder, Moderate or Severe

304.00 F11.20 Opioid Use Disorder, Moderate or Severe

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

301.83 F60.3 Borderline Personality Disorder

301.9 F60.9 Unspecified Personality Disorder

POSTTRAUMATIC STRESS DISORDER (PTSD)

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

PSYCHOTICISM

BEHAVIORAL DEFINITIONS

1. Verbalizes bizarre content of thought (delusions of grandeur, persecution,

reference, influence, control, somatic sensations, or infidelity).

2. Demonstrates abnormal speech patterns including tangential replies,

incoherence, perseveration, and moving quickly from subject to subject.

3. Describes perceptual disturbance or hallucinations (auditory, visual,

tactile, or olfactory).

4. Exhibits disorganized behavior, such as confusion, severe lack of goal

direction, impulsiveness, or repetitive behaviors.

5. Expresses paranoid thoughts and exhibits paranoid reactions, including

extreme distrust, fear, and apprehension.

6. Exhibits psychomotor abnormalities such as a marked decrease in

reactivity to environment; catatonic patterns such as stupor, rigidity,

excitement, posturing, or negativism as well as unusual mannerisms or

grimacing.

7. Displays extreme agitation, including a high degree of irritability, anger,

unpredictability, or impulsive physical acting out.

8. Exhibits bizarre dress or grooming.

9. Demonstrates disturbed affect (blunted, none, flattened, or inappropriate).

10. Demonstrates relationship withdrawal (withdrawal from involvement

with the external world and preoccupation with egocentric ideas and

fantasies, feelings of alienation).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

PSYCHOTICISM

LONG-TERM GOALS

1. Control or eliminate active psychotic symptoms so that functioning is

positive and medication is taken consistently.

2. Eliminate acute, reactive, psychotic symptoms and return to normal

functioning.

3. Increase goal-directed behaviors.

4. Focus thoughts on reality.

5. Normalize speech patterns, which can be evidenced by coherent

statements, attentions to social cues, and remaining on task.

6. Interact with others without defensiveness or anger.

7. Achieve and maintain an active, personally effective recovery approach.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Provide the history and the

current status of psychotic

symptoms. (1, 2)

1. Demonstrate acceptance to the

client through a calm, nurturing

manner, good eye contact, and

active listening; approach an

acutely psychotic client in a

calm, confident, open, direct, yet

soothing manner (e.g., approach

slowly, face toward the client

with open body language, speak

slowly and clearly).

2. Assess the client’s history of

psychotic symptoms including

current symptoms and the impact

they have had on functioning.

2. Participate in psychological

testing that will help increase

understanding of the condition.

(3)

3. Coordinate psychological and/or

neuropsychological testing to

assess the extent and the severity

of the client’s psychotic

symptoms.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

344

3. Allow family members to

participate in the assessment

of the condition. (4)

4. Request that a family member

provide information about the

client’s history of psychotic

behaviors.

4. Cooperate with a physician’s

evaluation of medical health. (5)

5. Refer the client for a complete

medical evaluation to rule out

possible general medical and

substance-related etiologies.

5. Disclose substance abuse as a

precipitating trigger for

psychotic symptoms. (6, 7)

6. Use a Motivational Interviewing

approach toward engaging

the client in the process of

discontinuing substance use,

including drugs, alcohol,

nicotine, and caffeine (see the

Substance Use chapter in this

Planner).

7. Refer the client to a substance

abuse treatment program.

6. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature

of the therapy relationship.

(8, 9, 10, 11)

8. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

9. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

PSYCHOTICISM

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

10. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

11. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

7. Cooperate with services focused

on stabilizing the current acute

psychotic episode.

(12, 13, 14, 15)

12. Refer the client for an immediate

evaluation by a psychiatrist

regarding his/her psychotic

symptoms and a possible

prescription for antipsychotic

medication.

13. Coordinate voluntary or

involuntary psychiatric

hospitalization if the client is a

threat to himself/herself or others

and/or is unable to provide for

his/her own basic needs.

14. Arrange for the client to remain

in a stable, supervised situation

(e.g., adult foster care [AFC]

placement or a friend’s/family

member’s home).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

346

15. Coordinate mobile crisis

response services (e.g., physical

exam, psychiatric evaluation,

medication access, triage to

impatient care, etc.) in the

client’s home environment

(including jail, personal

residence, homeless shelter,

or street setting).

8. Decrease the risk of suicide.

(16, 17)

16. Perform a suicide assessment and

take all necessary precautionary

steps (see the Suicidal Ideation

chapter in this Planner).

17. Remove potentially hazardous

materials, such as firearms or

excess medication, if indicated.

9. Obtain immediate, temporary

support or supervision from

friends, peers, or family

members. (18, 19)

18. Develop a crisis plan to provide

supervision and support to the

client on an intensive basis.

19. Coordinate access to round-the-

clock, professional consultation

(e.g., a 24-hour professionally

staffed crisis line) to caregivers

and the client.

10. Report a decrease in psychotic

symptoms through the consistent

use of psychotropic medications.

(20, 21)

20. Educate the client about the

use and expected benefits of

psychotropic medications;

encourage consistent taking of

prescribed medications (or assign

“Why I Dislike Taking My

Medication” in the Adult

Psychotherapy Homework

Planner by Jongsma).

21. Monitor the client’s medication

compliance, effectiveness, and

side-effect risk (e.g., tardive

dyskinesia, muscle rigidity,

dystonia, metabolic effects such

as weight gain).

11. Participate with family and/or

significant others in a therapy

designed to improve quality of

22. Conduct a family-based

intervention beginning with

psychoeducation emphasizing

PSYCHOTICISM

life for all members and facilitate

personal recovery. (22)

the biological nature of

psychosis, the need for

medication and medication

adherence, risk factors for

relapse such as personal and

interpersonal triggers, and the

importance of effective

communication, problem-

solving, early episode

intervention, and social

support (see Family Care of

Schizophrenia by Falloon, Boyd,

and McGill).

12. Learn and implement effective

communication skills with family

and/or significant others. (23, 24)

23. Assess and educate the client and

family about the role of aversive

communication (e.g., high

expressed emotion) in family

distress and the risk for the

client’s relapse; emphasize the

positive role of social support.

24. Use cognitive-behavioral

techniques (education, modeling,

role-playing, corrective feedback,

and positive reinforcement)

to teach family members

communication skills (e.g.,

offering positive feedback; active

listening; making positive

requests of others for behavior

change; and giving constructive

feedback in an honest and

respectful manner).

13. Implement problem-solving

skills with family and/or

significant others to address

problems that arise. (25, 26)

25. Assist the client and family in

identifying conflicts that can be

addressed with problem-solving

techniques.

26. Use cognitive-behavioral

techniques (education, modeling,

role-playing, corrective feedback,

and positive reinforcement) to

teach the client and family

problem-solving skills (i.e.,

defining the problem

constructively and specifically;

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

348

brainstorming solution options;

evaluating the pros and cons of

the options; choosing an option

and implementing a plan;

evaluating the results; and

adjusting the plan).

14. Complete exercises between

sessions to practice newly

learned personal and

interpersonal skills. (27)

27. Assign the client and family

homework exercises to use and

record use of newly learned

communication and problem-

solving skills; process results

in session toward effective

use; problem-solve obstacles;

(assign “Plan Before Acting”

or “Problem-Solving: An

Alternative to Impulsive Action”

in the Adult Psychotherapy

Homework Planner by Jongsma);

process results in session.

15. Develop and participate in a

family relapse prevention and

management plan in the event

that psychotic symptoms return.

(28)

28. Help the client and family draw

up a “relapse drill” detailing

roles and responsibilities

(e.g., who will call a meeting

of the family to problem-solve

potential relapse; who will call

the client’s physician, schedule a

serum level to be taken, or

contact emergency services, if

needed); problem-solve obstacles

and work toward a commitment

to adherence with the plan.

16. Participate in a

psychoeducational program with

other families. (29)

29. Refer the family to a multigroup

family psychoeducational

program (see Multifamily Groups

in the Treatment of Severe

Psychiatric Disorders by

McFarland).

17. Identify internal and

environmental triggers of

psychotic symptoms. (30)

30. Help the client identify specific

behaviors, situations, thoughts,

and feelings associated with

symptom exacerbations.

PSYCHOTICISM

18. Identify current reactions to

symptoms and their impact on

self and others. (31, 32)

31. Help the client identify his/her

emotional and behavioral

reactions as well as other

consequences of psychotic

symptoms toward the goal of

increasing his/her understanding

of these reactions and how they

impact functioning adaptively or

maladaptively (e.g., withdrawal

leading to isolation and

loneliness; paranoid accusations

leading to negative reactions of

others that falsely support the

delusion).

32. Assess adaptive and maladaptive

strategies that the client is using

to cope with psychotic

symptoms; reinforce adaptive

strategies.

19. Learn and implement skills that

increase personal effectiveness

and resistance to subsequent

psychotic episodes. (33, 34, 35)

33. Tailor cognitive behavioral

strategies so the client can

restructure psychotic cognition,

learn effective personal and

interpersonal skills, and develop

coping and compensation

strategies for managing

psychotic symptoms (see

Treating Complex Cases: The

Cognitive Behavioural Therapy

Approach by Tarrier, Wells, and

Haddock).

34. Desensitize the client’s fear of

his/her hallucinations by allowing

or encouraging him/her to talk

about them, their frequency, their

intensity, and their meaning (or

assign “What Do You Hear and

See?” in the Adult Psychotherapy

Homework Planner by Jongsma);

provide a reality alternative view

of the world.

35. Use education, modeling, role-

play, reinforcement, and other

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

350

cognitive-behavioral strategies

to teach the client coping and

compensation strategies for

managing psychotic symptoms

(e.g., calming techniques;

attention switching and

narrowing; realistic self-talk;

realistic attribution of the source

of the symptom; and increased

adaptive personal and social

activity).

20. Identify and change self-talk and

beliefs that interfere with

recovery. (36, 37)

36. Use Cognitive Therapy

techniques to explore biased self-

talk and beliefs that contribute

to delusional thinking; assist the

client in identifying and

challenging the biases,

generating alternative appraisals

that correct biases, building

confidence, and improving

adaptation.

37. Assign the client homework

exercises in which he/she

identifies biased self-talk, creates

reality-based alternatives, and

tests them in his/her experience;

review and reinforce success,

providing corrective feedback

toward facilitating sustained,

positive change (or assign

“Journal and Replace Self-

Defeating Thoughts” in the

Adult Psychotherapy Homework

Planner by Jongsma).

21. Verbalize an understanding of

the need to learn new and

improved social skills. (38)

38. Provide a rationale for social

skills training that communicates

the benefits of improved social

interactions and decreased

negative social actions.

22. Participate in individual or

group therapy focused on

improving social effectiveness.

(39)

39. Provide or refer the client to

individual or group social skills

training that employs cognitive-

behavioral strategies (e.g.,

education, modeling, role-play,

PSYCHOTICISM

practice, reinforcement, and

generalization) to teach the client

relevant social skills (e.g.,

conversation, assertiveness,

conflict resolution) to improve

his/her ability to attain and

maintain social relationships (or

assign “Restoring Socialization

Comfort” in the Adult

Psychotherapy Homework

Planner by Jongsma).

23. Read about social skills training

in books or manuals

recommended by the therapist.

(40)

40. Use prescribed reading

assignments from books or

treatment manuals consistent

with therapeutic skill being

taught to facilitate the client’s

acquisition of it (e.g., Your

Perfect Right by Alberti and

Emmons for assertiveness skills;

Conversationally Speaking

by Garner for conversational

skills).

24. Practice and strengthen skills

learned in therapy. (41)

41. Prescribe in- and between-session

exercises that allow the client to

practice new skills, reality test

and challenge his/her maladaptive

beliefs, and consolidate a new

approach to adaptive functioning

and symptom management;

review; reinforce positive change;

problem-solve obstacles toward

consolidating the client’s skills.

25. Participate in a therapy to

practice mental tasks and learn

strategies to improve mental,

emotional, and social

functioning. (42)

42. Provide or refer the client

to a Cognitive Remediation/

Neurocognitive Therapy

program that uses repeated

practice of cognitive tasks and/or

strategy training to restore

cognitive function and/or teach

compensatory strategies for

cognitive impairments and

improve cognitive, emotional,

and social functioning (see

Cognitive Remediation Therapy

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

352

for Schizophrenia by Wykes and

Reeder).

26. Participate in a training program

to build job skills. (43)

43. Refer the client to a Supported

Employment program to build

occupational skills and improve

overall functioning and quality

of life.

27. Verbalize the acceptance of

mental illness and willingness to

engage in recovery, decreasing

feelings of stigmatization. (44)

44. Encourage the client to express

his/her feelings related to

acceptance of the mental illness

and engagement in recovery;

reinforce thoughts and actions

that strengthen the client’s

engagement in the recovery

process.

28. Attend a support group for

others with severe mental illness.

(45)

45. Refer the client to a support

group for individuals with a

mental illness with the goal of

helping consolidate their new

approach to recovery and gain

social support for it.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

297.1 Delusional Disorder

298.8 Brief Psychotic Disorder

295.xx Schizophrenia

295.30 Schizophrenia, Paranoid Type

295.70 Schizoaffective Disorder

295.40 Schizophreniform Disorder

296.xx Bipolar I Disorder

296.89 Bipolar II Disorder

PSYCHOTICISM

353

296.xx Major Depressive Disorder

310.1 Personality Change Due to Axis III Disorder

_____

_________________

___________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

297.1 F22 Delusional Disorder

298.8 F23 Brief Psychotic Disorder

295.30 F20.9 Schizophrenia

295.70 F25.0 Schizoaffective Disorder, Bipolar Type

295.70 F25.1 Schizoaffective Disorder, Depressive Type

295.40 F20.40 Schizophreniform Disorder

296.xx F31.xx Bipolar I Disorder

296.89 F31.81 Bipolar II Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

310.1 F07.0 Personality Change Due to Another

Medical Condition

298.8 F28 Other Specified Schizophrenia Spectrum

and Other Psychotic Disorder

298.9 F29 Unspecified Schizophrenia Spectrum and

Other Psychotic Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

SEXUAL ABUSE VICTIM

BEHAVIORAL DEFINITIONS

1. Vague memories of inappropriate childhood sexual contact that can be

corroborated by significant others.

2. Self-report of being sexually abused with clear, detailed memories.

3. Inability to recall years of childhood.

4. Extreme difficulty becoming intimate with others.

5. Inability to enjoy sexual contact with a desired partner.

6. Unexplainable feelings of anger, rage, or fear when coming into contact

with a close family relative.

7. Pervasive pattern of promiscuity or the sexualization of relationships.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Resolve the issue of being sexually abused with an increased capacity for

intimacy in relationships.

2. Begin the healing process from sexual abuse with resultant enjoyment of

appropriate sexual contact.

3. Work successfully through the issues related to being sexually abused

with consequent understanding and control of feelings.

4. Recognize and accept the sexual abuse without inappropriate

sexualization of relationships.

5. Establish whether sexual abuse occurred.

SEXUAL ABUSE VICTIM

355

6. Begin the process of moving away from being a victim of sexual abuse

and toward becoming a survivor of sexual abuse.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Tell the story of the nature,

frequency, and duration of the

abuse. (1, 2, 3)

1. Actively build the level of trust

with the client in individual

sessions through consistent eye

contact, unconditional positive

regard, and warm acceptance to

help increase his/her ability to

identify and express feelings.

2. Gently explore the client’s sexual

abuse experience without

pressing early for unnecessary

details.

3. Ask the client to draw a diagram

of the house in which he/she was

raised, complete with where

everyone slept.

2. Disclose any emotional problems

resulting from the sexual abuse.

(4)

4. Assess the client for psycho-

logical problems secondary to

the sexual abuse; if the client’s

experiences with sexual abuse are

currently manifesting as a

clinical syndrome (e.g., PTSD,

depression), conduct or refer to

an evidence-based intervention

for the disorder (see, for

example, PTSD or Unipolar

Depression chapters in this

Planner).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

356

3. Disclose any history of substance

use that may contribute to and

complicate the treatment of

sexual abuse. (5)

5. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (6, 7, 8, 9)

6. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

7. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

8. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

9. Assess for the severity of the

level of impairment to the

SEXUAL ABUSE VICTIM

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Identify a support system of key

individuals who will be

encouraging and helpful in

aiding the process of resolving

the issue. (10, 11)

10. Help the client identify those

individuals who would be

compassionate and encourage

him/her to enlist their support.

11. Encourage the client to attend a

support group for survivors of

sexual abuse.

6. Verbalize an increased

knowledge of sexual abuse and

its effects. (12, 13)

12. Assign the client to read material

on sexual abuse (e.g., The

Courage to Heal by Bass and

Davis; Betrayal of Innocence by

Forward and Buck; Outgrowing

the Pain by Gil; Reclaiming Your

Life After Rape: Cognitive-

Behavioral Therapy for

Posttraumatic Stress Disorder—

Client Workbook by Rothbaum

and Foa); process key concepts.

13. Assign and process a written

exercise from Healing the

Trauma of Abuse: A Women’s

Workbook by Copeland and

Harris.

7. Identify and express the feelings

connected to the abuse. (14, 15)

14. Explore, encourage, and support

the client in verbally expressing

and clarifying feelings associated

with the abuse.

15. Encourage the client to be open

in talking of the abuse without

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

358

shame or embarrassment as if

he/she was responsible for the

abuse.

8. Decrease the secrecy in the

family by informing key

nonabusive members regarding

the abuse. (16, 17, 18)

16. Guide the client in an empty

chair conversation exercise with

a key figure connected to the

abuse (e.g., perpetrator, sibling,

parent) telling them of the sexual

abuse and its effects.

17. Hold a conjoint session where

the client tells his/her spouse of

the abuse.

18. Facilitate a family session with

the client, assisting and

supporting him/her in revealing

the abuse to parent(s).

9. Describe how a sex abuse

experience is part of a family

pattern of broken boundaries.

(19)

19. Develop with the client a

genogram and assist in

illuminating key family patterns

of broken boundaries related

to sex and intimacy through

physical contact or verbal

suggestiveness.

10. Verbalize the ways the sexual

abuse has had an impact on life.

(20, 21)

20. Ask the client to make a list of

the ways sexual abuse has

impacted his/her life; process the

list content.

21. Develop with the client a

symptom line connected to

the abuse.

11. Clarify memories of the abuse.

(22, 23)

22. Refer or conduct hypnosis with

the client to further uncover or

clarify the nature and extent of

the abuse.

23. Facilitate the client’s recall of the

details of the abuse by asking

him/her to keep a journal and

talk and think about the

incidents (or assign “Picturing

the Place of the Abuse” or

“Describe the Trauma” in the

Adult Psychotherapy Homework

SEXUAL ABUSE VICTIM

359

Planner by Jongsma). Caution

him/her against embellishment

based on book, video, or drama

material, and be very careful not

to lead the client into only

confirming therapist-held

suspicions.

12. Decrease statements of shame,

being responsible for the abuse,

or being a victim, while

increasing statements that reflect

personal empowerment.

(24, 25, 26, 27)

24. Assign the client to read material

on overcoming shame (e.g.,

Healing the Shame That Binds

You by Bradshaw; Facing Shame

by Fossum and Mason); process

key concepts.

25. Encourage, support, and assist

the client in identifying,

expressing, and processing any

feelings of guilt related to

feelings of physical pleasure,

emotional fulfillment, or

responsibility connected with

the events.

26. Confront and process with the

client any statements that reflect

taking responsibility for the

abuse or indicating he/she is a

victim; assist the client in feeling

empowered by working through

the issues and letting go of the

abuse.

27. Assign the client to complete a

cost-benefit exercise (see Ten

Days to Self-Esteem! by Burns),

or a similar exercise, on being a

victim versus a survivor or on

holding on versus forgiving;

process completed exercises.

13. Identify the positive benefits for

self of being able to forgive all

those involved with the abuse.

(28, 29, 30)

28. Read and process the story from

Stories for the Third Ear by

Wallas entitled “The Seedling”

(a story for a client who has been

abused as a child).

29. Assist the client in removing any

barriers that prevent him/her

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

360

from being able to identify the

benefits of forgiving those

responsible for the abuse.

30. Recommend that the client read

Forgive and Forget by Smedes;

process the content of the book

after the reading is completed.

14. Express feelings to and about the

perpetrator, including the impact

the abuse has had both at the

time of occurrence and currently.

(31, 32, 33)

31. Assign the client to write an

angry letter to the perpetrator

of the sexual abuse; process the

letter within the session.

32. Prepare the client for a face-to-

face meeting with the perpetrator

of the abuse by processing the

feelings that arise around the

event and role-playing the

meeting.

33. Hold a conjoint session where

the client confronts the

perpetrator of the abuse;

afterward, process his/her

feelings and thoughts related to

the experience.

15. Increase level of forgiveness of

self, perpetrator, and others

connected with the abuse. (34)

34. Assign the client to write a

forgiveness letter and/or

complete a forgiveness exercise

(or assign “A Blaming Letter

and a Forgiving Letter to

Perpetrator” in the Adult

Psychotherapy Homework

Planner by Jongsma); process

each with therapist.

16. Increase level of trust of others

as shown by more socialization

and greater intimacy tolerance.

(35, 36)

35. Teach the client the share-check

method of building trust in

relationships (i.e., share only a

little of self and then check to be

sure that the shared data is

treated respectfully, kindly, and

confidentially; as proof of

trustworthiness is verified, share

more freely).

SEXUAL ABUSE VICTIM

36. Use role-playing and modeling

to teach the client how to

establish reasonable personal

boundaries that are neither too

porous nor too restrictive.

17. Report increased ability to

accept and initiate appropriate

physical contact with others.

(37, 38)

37. Encourage the client to give

and receive appropriate touches;

help him/her define what is

appropriate.

38. Ask the client to practice one or

two times a week initiating

appropriate touching or a

touching activity (i.e., giving a

back rub to spouse, receiving a

professional massage, hugging a

friend, etc.).

18. Verbally identify self as a

survivor of sexual abuse. (39, 40)

39. Reinforce with the client the

benefits of seeing himself/herself

as a survivor rather than the

victim and work to remove any

barriers that remain in the way

of him/her doing so (or assign

“Changing from Victim to

Survivor” in the Adult

Psychotherapy Homework

Planner by Jongsma).

40. Give positive verbal

reinforcement when the client

identifies himself/herself as a

survivor.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

362

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

303.90 Alcohol Dependence

304.80 Polysubstance Dependence

300.4 Dysthymic Disorder

296.xx Major Depressive Disorder

300.02 Generalized Anxiety Disorder

300.14 Dissociative Identity Disorder

300.15 Dissociative Disorder NOS

995.53 Sexual Abuse of Child, Victim

995.83 Sexual Abuse of Adult, Victim

_____

_____________________________________

_____

_________

___________________________

Axis II:

301.82 Avoidant Personality Disorder

301.6 Dependent Personality Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

300.4 F34.1 Persistent Depressive Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

300.02 F41.1 Generalized Anxiety Disorder

300.14 F44.81 Dissociative Identity Disorder

300.15 F44.89 Other Specified Dissociative Disorder

300.15 F44.9 Unspecified Dissociative Disorder

995.53 T74.22XA Child Sexual Abuse, Confirmed, Initial

Encounter

995.53 T74.22XD Child Sexual Abuse, Confirmed,

Subsequent Encounter

995.83 T74.21XA Spouse or Partner Violence, Sexual,

Confirmed, Initial Encounter

995.83 T74.21XD Spouse or Partner Violence, Sexual,

Confirmed, Subsequent Encounter

995.83 T74.21XA Adult Sexual Abuse by Nonspouse or

Nonpartner, Confirmed, Initial Encounter

995.83 T74.21XD Adult Sexual Abuse by Nonspouse or

Nonpartner, Confirmed, Subsequent

Encounter

SEXUAL ABUSE VICTIM

363

301.82 F60.6 Avoidant Personality Disorder

301.6 F60.7 Dependent Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

SEXUAL IDENTITY CONFUSION*

BEHAVIORAL DEFINITIONS

1. Uncertainty about basic sexual orientation.

2. Difficulty in enjoying sexual activities with opposite sex partner because

of low arousal.

3. Sexual fantasies and desires about same-sex partners, which causes

distress.

4. Sexual activity with person of same sex that has caused confusion, guilt,

and anxiety.

5. Depressed mood, diminished interest in activities.

6. Marital conflicts caused by uncertainty about sexual orientation.

7. Feelings of guilt, shame, and/or worthlessness.

8. Concealing sexual identity from significant others (e.g., friends, family,

spouse).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Identify sexual identity and engage in a wide range of relationships that

are supportive of that identity.

Most of the content of this chapter (with only slight revisions) originates from J. M. Evosevich

and M. Avriette, The Gay and Lesbian Psychotherapy Treatment Planner (Hoboken, NJ: Wiley,

SEXUAL IDENTITY CONFUSION

365

2. Reduce overall frequency and intensity of the anxiety associated with

sexual identity so that daily functioning is not impaired.

3. Disclose sexual orientation to significant others.

4. Return to previous level of emotional, psychological, and social

functioning.

5. Eliminate all feelings of depression (e.g., depressed mood, guilt,

worthlessness).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe fear, anxiety, and

distress about confusion over

sexual identity. (1)

1. Actively build trust with the

client and encourage his/her

expression of fear, anxiety, and

distress over sexual identity

confusion.

2. Disclose any history of substance

use that may contribute to and

complicate the treatment of

sexual identity confusion. (2)

2. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (3, 4, 5, 6)

3. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

366

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

4. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

5. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

6. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

4. Identify sexual experiences

that have been a source of

excitement, satisfaction, and

emotional gratification.

(7, 8, 9, 10)

7. Assess the client’s current sexual

functioning by asking him/her

about previous sexual history,

fantasies, and thoughts.

SEXUAL IDENTITY CONFUSION

8. Assist the client in identifying

sexual experiences that have

been a source of excitement,

satisfaction, and emotional

gratification.

9. To assist the client in increasing

his/her awareness of sexual

attractions and conflicts, assign

him/her to write a journal

describing sexual thoughts,

fantasies, and conflicts that

occur throughout the week

(or assign “Journal of Sexual

Thoughts, Fantasies, Conflicts”

from the Adult Psychotherapy

Homework Planner by Jongsma).

10. Have the client rate his/her

sexual attraction to both men

and women on a scale of 1 to 10

(with 10 being extremely

attracted and 1 being not at all

attracted).

5. Verbalize an understanding of

how cultural, racial, and/or

ethnic identity factors contribute

to confusion about sexual

identity. (11)

11. Explore with the client how

cultural, racial, and/or ethnic

factors contribute to confusion

about homosexual behavior

and/or identity.

6. Write a “future” biography

detailing life as a heterosexual

and as a homosexual to assist in

identifying primary orientation.

(12)

12. Assign the client the homework

of writing a “future” biography

describing his/her life 20 years

in the future, once as a

heterosexual, another as a

homosexual; read and process in

session (e.g., ask him/her which

life was more satisfying, which

life had more regret).

7. Verbalize an understanding of

the range of sexual identities

possible. (13, 14)

13. Educate the client about the

range of sexual identities possible

(i.e., heterosexual, homosexual,

bisexual).

14. Have the client read The

Invention of Heterosexuality

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

368

by Katz; process the client’s

thoughts and feelings about its

content.

8. Identify the negative emotions

experienced by hiding sexuality.

(15, 16)

15. Explore the client’s negative

emotions (e.g., shame, guilt,

anxiety, loneliness) related to

hiding/denying his/her sexuality.

16. Explore the client’s religious

convictions and how these may

conflict with identifying

himself/herself as homosexual

and cause feelings of shame or

guilt (see the Spiritual Confusion

chapter in this Planner); consider

suggesting that the client read

The Bible, Christianity, &

Homosexuality by Cannon that

argues the Bible does not

condemn faithful gay

relationships.

9. Verbalize an understanding of

safer-sex practices. (17)

17. Teach the client the details of

safer-sex guidelines and

encourage him/her to include

them in all future sexual activity.

10. Verbalize an increased

understanding of homosexuality.

(13, 18, 19)

13. Educate the client about the

range of sexual identities possible

(i.e., heterosexual, homosexual,

bisexual).

18. Assign the client homework

to identify 10 myths about

homosexuals and assist him/her

in replacing them with more

realistic, positive beliefs.

19. Assign the client to read books

that provide accurate, positive

messages about homosexuality

(e.g., Is it a Choice? by Marcus;

Outing Yourself by Signorile;

Coming Out: An Act of Love

by Eichberg).

11. List the advantages and

disadvantages of disclosing

20. Assign the client to list

advantages and disadvantages of

SEXUAL IDENTITY CONFUSION

369

sexual orientation to significant

people in life. (20)

disclosing sexual orientation to

significant others; process the list

content.

12. Watch films/videos that depict

lesbian women/gay men in

positive ways. (21)

21. Ask the client to watch movies/

videos that depict lesbians/gay

men as healthy and happy (e.g.,

Desert Hearts; In and Out;

Jeffrey; When Night is Falling);

process his/her reactions to the

films.

13. Attend a support group for those

who want to disclose themselves

as homosexual. (22)

22. Refer the client to a coming out

support group (e.g., at Gay and

Lesbian Community Service

Center or AIDS Project).

14. Identify gay/lesbian people to

socialize with or to obtain

support from. (23, 24, 25)

23. Assign the client to read

lesbian/gay magazines and

newspapers (e.g., The Advocate).

24. Encourage the client to gather

information and support from

the Internet (e.g., coming-out

bulletin boards on AOL and

Facebook, lesbian/gay

organizations’ web sites).

25. Encourage the client to identify

gay men or lesbians to interact

with by reviewing people he/she

has met in support groups, at

work, and so on, and encourage

him/her to initiate social

activities.

15. Develop a plan detailing when,

where, how, and to whom sexual

orientation is to be disclosed.

(26, 27)

26. Have the client role-play

disclosure of sexual orientation

to significant others (e.g., family,

friends, coworkers; see the

Family Conflict chapter in this

Planner).

27. Assign the client homework to

write a detailed plan to disclose

his/her sexual orientation,

including to whom it will be

disclosed, where, when, and

possible questions and reactions

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

370

recipient(s) might have (or assign

“To Whom and How to Reveal

My Homosexuality” from the

Adult Psychotherapy Homework

Planner by Jongsma).

16. Identify one friend who is likely

to have a positive reaction to

homosexuality disclosure.

(28, 29)

28. Encourage the client to identify

one friend who is likely

to be accepting of his/her

homosexuality.

29. Suggest the client have casual

talks with a friend about

lesbian/gay rights, or some item

in the news related to lesbians

and gay men to “test the water”

before disclosing sexual

orientation to that friend.

17. Reveal sexual orientation to

significant others according to

written plan. (30, 31)

30. Encourage the client to disclose

sexual orientation to friends/

family according to the written

plan.

31. Probe the client about reactions

of significant others to disclosure

of homosexuality (e.g.,

acceptance, rejection, shock);

provide encouragement and

positive feedback.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

309.0 Adjustment Disorder With Depressed Mood

309.28 Adjustment Disorder With Mixed Anxiety

and Depressed Mood

SEXUAL IDENTITY CONFUSION

309.24 Adjustment Disorder With Anxiety

300.4 Dysthymic Disorder

302.85 Gender Identity Disorder in Adolescents or

Adults

300.02 Generalized Anxiety Disorder

313.82 Identity Problem

296.2x Major Depressive Disorder, Single Episode

296.3x Major Depressive Disorder, Recurrent

302.9 Sexual Disorder NOS

_____

_____________________________________

_____

_____________________________________

Axis II:

301.82 Avoidant Personality Disorder

301.83 Borderline Personality Disorder

301.81 Narcissistic Personality Disorder

_____

_____________________________________

_____

_________________

___________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

309.28 F43.23 Adjustment Disorder, With Mixed Anxiety

and Depressed Mood

300.09 F41.8 Other Specified Anxiety Disorder

300.00 F41.9 Unspecified Anxiety Disorder

309.24 F43.22 Adjustment Disorder, With Anxiety

300.4 F34.1 Persistent Depressive Disorder

302.85 F64.1 Gender Dysphoria in Adolescents and

Adults

300.02 F41.1 Generalized Anxiety Disorder

296.2x F32.x Major Depressive Disorder, Single Episode

296.3x F33.x Major Depressive Disorder, Recurrent

Episode

301.82 F60.6 Avoidant Personality Disorder

301.83 F60.3 Borderline Personality Disorder

301.81 F60.81 Narcissistic Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

SLEEP DISTURBANCE

BEHAVIORAL DEFINITIONS

1. Complains of difficulty falling asleep.

2. Complains of difficulty remaining asleep.

3. Reports sleeping adequately, but not feeling refreshed or rested after

waking.

4. Exhibits daytime sleepiness or falling asleep too easily during daytime.

5. Insomnia or hypersomnia complaints due to a reversal of the normal

sleep-wake schedule.

6. Reports distress resulting from repeated awakening with detailed recall

of extremely frightening dreams involving threats to self.

7. Experiences abrupt awakening with a panicky scream followed by

intense anxiety and autonomic arousal, no detailed dream recall, and

confusion or disorientation.

8. Others report repeated incidents of sleepwalking accompanied by

amnesia for the episode.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Restore restful sleep pattern.

2. Feel refreshed and energetic during wakeful hours.

3. Terminate anxiety-producing dreams that cause awakening.

SLEEP DISTURBANCE

4. End abrupt awakening in terror and return to peaceful, restful sleep

pattern.

5. Restore restful sleep with reduction of sleepwalking incidents.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the history and details

of sleep pattern. (1, 2)

1. Assess the client’s sleep history

including sleep pattern, bedtime

routine, activities associated

with the bed, activity level

while awake, nutritional habits

including stimulant use, napping

practice, actual sleep time,

rhythm of time for being awake

versus sleeping, and so on.

2. Assign the client to keep a

journal of sleep patterns,

stressors, thoughts, feelings, and

activities associated with going

to bed, and other relevant client-

specific factors possibly

associated with sleep problems;

process the material for details

of the sleep-wake cycle.

2. Share history of substance abuse

or medication use. (3)

3. Assess the contribution of the

client’s medication or substance

abuse to his/her sleep disorder;

refer him/her for chemical

dependence treatment, if

indicated (see the Substance Use

chapter in this Planner).

3. Verbalize depressive or anxious

feelings and share possible

causes. (4)

4. Assess the role of depression or

anxiety as the cause of the

client’s sleep disturbance (see the

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

374

Unipolar Depression or Anxiety

chapters in this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

SLEEP DISTURBANCE

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Keep physician appointment

to assess possible medical

contributions to sleep disorder

and the need for psychotropic

medications. (9)

9. Refer the client to a physician

to rule out medical or pharma-

cological causes for sleep

disturbance and to consider

sleep lab studies and/or need for

a prescription of psychotropic

medications.

6. Take psychotropic medication as

prescribed to assess the effect on

sleep. (10)

10. Monitor the client for

psychotropic medication

prescription compliance,

effectiveness, and side effects.

7. Verbalize an understanding of

normal sleep, sleep disturbances,

and their treatment. (11, 12, 13)

11. Provide the client with basic

sleep education (e.g., normal

length of sleep, normal

variations of sleep, normal time

to fall asleep, and normal mid-

night awakening; recommend

The Insomnia Workbook: A

Comprehensive Guide to Getting

the Sleep You Need by

Silberman); help the client

understand the exact nature

of his/her “abnormal” sleeping

pattern.

12. Provide the client with a

rationale for the therapy,

explaining the role of cognitive,

emotional, physiological, and

behavioral contributions to good

and poor sleep.

13. Ask the client to read material

consistent with the therapeutic

approach to facilitate his/her

progress through therapy

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

376

(e.g., Say Good Night to Insomnia

by Jacobs; The Harvard Medical

School Guide to a Good Night’s

Sleep by Epstein and Mardon).

8. Learn and implement calming

skills for use at bedtime. (14, 15)

14. Teach the client relaxation skills

(e.g., progressive muscle

relaxation, guided imagery, slow

diaphragmatic breathing); teach

the client how to apply these

skills to facilitate relaxation and

sleep at bedtime (see “Bedtime

Relaxation Techniques” by

Hauri and Linde).

15. Refer the client for or conduct

biofeedback training to

strengthen the client’s successful

relaxation response.

9. Practice good sleep hygiene. (16) 16. Instruct the client in sleep

hygiene practices such as

restricting excessive liquid

intake, spicy late night snacks, or

heavy evening meals; exercising

regularly, but not within 3–4

hours of bedtime; minimizing

or avoiding caffeine, alcohol,

tobacco, and stimulant intake

(or assign “Sleep Pattern

Record” in the Adult

Psychotherapy Homework

Planner by Jongsma).

10. Learn and implement stimulus

control strategies to establish a

consistent sleep-wake rhythm.

(17, 18, 19, 20)

17. Discuss with the client the

rationale for stimulus control

strategies to establish a

consistent sleep-wake cycle

(see Behavioral Treatments for

Sleep Disorders by Perlis, Aloia,

and Kuhn).

18. Teach the client stimulus control

techniques (e.g., lie down to

sleep only when sleepy; do not

use the bed for activities like

watching television, reading,

listening to music, but only for

SLEEP DISTURBANCE

sleep or sexual activity; get out

of bed if sleep doesn’t arrive

soon after retiring; lie back down

when sleepy; set alarm to the

same wake-up time every

morning regardless of sleep time

or quality; do not nap during

the day); assign consistent

implementation.

19. Instruct the client to move

activities associated with arousal

and activation from the bedtime

ritual to other times during the

day (e.g., reading stimulating

content, reviewing day’s events,

planning for next day, watching

disturbing television).

20. Monitor the client’s sleep

patterns and compliance with

stimulus control instructions;

problem-solve obstacles and

reinforce successful, consistent

implementation.

11. Learn and implement a sleep

restriction method to increase

sleep efficiency. (21)

21. Use a sleep restriction therapy

approach in which the amount o

time in bed is reduced to match

the amount of time the patient

typically sleeps (e.g., from

8 hours to 5), thus inducing

systematic sleep deprivation;

periodically adjust sleep time

upward until an optimal sleep

duration is reached.

12. Identify, challenge, and replace

self-talk contributing to sleep

disturbance with positive,

realistic, and reassuring self-talk.

(22, 23)

22. Explore the client’s schema and

self-talk that mediate his/her

emotional responses

counterproductive to sleep (e.g.,

fears, worries of sleeplessness),

challenge the biases; assist him/her

in replacing the distorted

messages with reality-based

alternatives and positive self-talk

that will increase the likelihood of

establishing a sound sleep pattern

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

378

(see Insomnia: A Clinical Guide to

Assessment and Treatment by

Morin and Espie).

23. Assign the client a homework

exercise in which he/she identifies

targeted self-talk and creates

reality-based alternatives (or

assign “Negative Thoughts

Trigger Negative Feelings” in the

Adult Psychotherapy Homework

Planner by Jongsma); review and

reinforce success, providing

corrective feedback toward

improvement.

13. Implement a paradoxical

instruction to stay awake as a

means to counter anxiety

interfering with sleep onset. (24)

24. Assign a paradoxical

intervention in which the client

tries to stay awake for as long as

possible to diminish performance

anxiety interfering with sleep;

review implementation,

reinforcing success; problem-

solve obstacles.

14. Learn and implement skills for

managing stresses contributing

to the sleep problem. (25)

25. Use cognitive behavioral skills

training techniques (e.g.,

instruction, covert modeling [i.e.,

imagining the successful use of the

strategies], role-play, practice, and

generalization training) to teach

the client tailored skills (e.g.,

calming and coping skills,

conflict-resolution, problem-

solving) for managing stressors

related to the sleep disturbance

(e.g., interpersonal conflicts that

carry over and cause nighttime

wakefulness); routinely review,

reinforce successes, problem-solve

obstacles toward effective

everyday use (see Insomnia: A

Clinical Guide to Assessment and

Treatment by Morin and Espie;

Treating Sleep Disorders by

Goetting, Perlis and Lichstein).

SLEEP DISTURBANCE

15. Verbalize an understanding of

the cognitive-behavioral

approach to treating

sleeplessness. (26)

26. Assign the client to read material

on the cognitive-behavioral

treatment approach to

sleeplessness (e.g., Overcoming

Insomnia: A Cognitive-Behaviora

Therapy Approach Workbook by

Edinger and Carney; Say Good

Night to Insomnia by Jacobs).

16. Participate in a scheduled

awakening procedure to reduce

the frequency of night wakening.

(27)

27. Use a scheduled awakening

procedure in which the client is

gently and only slightly

awakened 30 minutes prior to

the typical time of the first night

wakening, sleep terror, or

sleepwalking incident; phase out

the awakening as sleep terrors

decrease (see When Children

Don’t Sleep Well by Durand).

17. Learn and implement relapse

prevention practices.

(28, 29, 30, 31, 32)

28. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

an occasional and reversible slip

into old habits and relapse with

the decision to return to old

habits that risk sleep disturbance

(e.g., poor sleep hygiene, poor

stimulus control practices).

29. Identify and rehearse with the

client the management of future

lapses.

30. Instruct the client to routinely

use strategies learned in therapy

(e.g., good sleep hygiene and

stimulus control) to prevent

relapse into habits associated

with sleep disturbance.

31. Develop a “coping card” or

other reminder where relapse

prevention practices are recorded

for the client’s later use.

32. Schedule periodic “maintenance

sessions” to help the client

maintain therapeutic gains.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

380

18. Discuss experiences of emotional

traumas that may disturb sleep.

(33)

33. Explore recent traumatic events

that may be interfering with the

client’s sleep.

19. Discuss fears regarding

relinquishing control. (34)

34. Probe the client’s fears related to

letting go of control.

20. Disclose fears of death that may

contribute to sleep disturbance.

(35)

35. Probe a fear of death that may

contribute to the client’s sleep

disturbance.

21. Share childhood traumatic

experiences associated with sleep

experience. (36, 37)

36. Explore traumas of the client’s

childhood that surround the

sleep experience.

37. Probe the client for the presence

and nature of disturbing dreams

and explore their possible

relationship to present or past

trauma.

22. Reveal sexual abuse incidents

that continue to be disturbing.

(38)

38. Explore for possible sexual abuse

to the client that has not been

revealed (see the Sexual Abuse

Victim chapter in this Planner).

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

307.42 Primary Insomnia

307.44 Primary Hypersomnia

307.45 Circadian Rhythm Sleep Disorder

307.47 Nightmare Disorder

307.46 Sleep Terror Disorder

307.46 Sleepwalking Disorder

309.81 Posttraumatic Stress Disorder

SLEEP DISTURBANCE

296.xx Major Depressive Disorder

300.4 Dysthymic Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

307.42 G47.00 Insomnia

307.44 G47.10 Hypersomnolence Disorder

307.45 G47.xx Circadian Rhythm Sleep-Wake Disorder

307.47 F51.5 Nightmare Disorder

307.46 F51.4 Non-Rapid Eye Movement Sleep Arousal

Disorder, Sleep Terror Type

307.46 F51.3 Non-Rapid Eye Movement Sleep Arousal

Disorder, Sleepwalking Type

309.81 F43.10 Posttraumatic Stress Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

300.4 F34.1 Persistent Depressive Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

SOCIAL ANXIETY

BEHAVIORAL DEFINITIONS

1. Overall pattern of social anxiety, shyness, or timidity that presents itself

in most social situations.

2. Hypersensitivity to the criticism or disapproval of others.

3. No close friends or confidants outside of first-degree relatives.

4. Avoidance of situations that require a degree of interpersonal contact.

5. Reluctant involvement in social situations out of fear of saying or doing

something foolish or of becoming emotional in front of others.

6. Debilitating performance anxiety and/or avoidance of required social

performance demands.

7. Increased heart rate, sweating, dry mouth, muscle tension, and shakiness

in social situations.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Interact socially without undue fear or anxiety.

2. Participate in social performance requirements without undue fear or

anxiety.

3. Develop the essential social skills that will enhance the quality of

relationship life.

4. Develop the ability to form relationships that will enhance recovery

support system.

SOCIAL ANXIETY

383

5. Reach a personal balance between solitary time and interpersonal

interaction with others.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the history and nature

of social fears and avoidance.

(1, 2)

1. Establish rapport with the client

toward building a therapeutic

alliance.

2. Assess the client’s history of

social anxiety and avoidance

including frequency, intensity,

and duration of anxiety

symptoms, triggers, and the

nature and extent of avoidance

(e.g., The Anxiety Disorders

Interview Schedule–Adult

Version).

2. Complete psychological tests

designed to assess the nature and

severity of social anxiety and

avoidance. (3)

3. Administer a measure of social

anxiety to further assess the

depth and breadth of social fears

and avoidance (e.g., the

Liebowitz Social Anxiety Scale;

Social Interaction Anxiety Scale;

Social Phobia Inventory);

readminister as indicated to

assess treatment progress.

3. Disclose any history of substance

use that may contribute to and

complicate the treatment of

social anxiety. (4)

4. Arrange for a substance abuse

evaluation and refer the client

for treatment for if the

evaluation recommends it

(see the Substance Use chapter

in this Planner).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

384

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

SOCIAL ANXIETY

385

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Cooperate with an evaluation by

a physician for psychotropic

medication. (9)

9. Arrange for the client to have an

evaluation for a prescription of

psychotropic medications.

6. Take prescribed psychotropic

medications consistently. (10)

10. Monitor the client for

prescription compliance, side

effects, and overall effectiveness

of the medication; consult with

the prescribing physician at

regular intervals.

7. Participate in a small group

therapy for social anxiety. (11)

11. Enroll client in a small (closed

enrollment) cognitive-behavioral

group therapy for social anxiety

(see Cognitive-Behavioral Group

Therapy for Social Phobia by

Heimberg and Becker; Social

Anxiety Disorder by Turk,

Heimberg, and Magee).

8. Verbalize an accurate

understanding of the vicious

cycle of social anxiety and

avoidance. (12, 13)

12. Discuss how social anxiety

derives from cognitive biases

that overestimate negative

evaluation by others, undervalue

the self, distress, and often lead

to unnecessary avoidance.

13. Assign the client to read

psychoeducational chapters of

books or treatment manuals on

social anxiety that explain the

cycle of social anxiety and

avoidance and the rationale for

cognitive behavioral treatment

(e.g., Overcoming Social Anxiety

and Shyness by Butler; The

Shyness and Social Anxiety

Workbook by Antony and

Swinson; Managing Social

Anxiety by Hope, Heimberg,

and Turk).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

386

9. Verbalize an understanding of

the rationale for cognitive-

behavioral treatment of social

anxiety. (14)

14. Discuss how therapy based on

cognitive-behavioral principles

targets fear and avoidance to

desensitize learned fear, build

social skills, reality-test anxious

thoughts, and increase

confidence and social

effectiveness.

10. Learn and implement calming

and coping strategies to manage

anxiety symptoms during

moments of social anxiety and

lead to a more relaxed state in

general. (15)

15. Teach and ask the client to

practice relaxation and

attentional focusing skills (e.g.,

staying focused externally and

on behavioral goals, muscular

relaxation, evenly paced

diaphragmatic breathing, ride

the wave of anxiety) for

managing social anxiety

symptoms and maintaining a

more relaxed approach to life;

review, reinforce successes;

provide corrective feedback

toward effective use.

11. Identify, challenge, and replace

biased, fearful self-talk with

reality-based, positive self-talk.

(16, 17)

16. Explore the client’s and self-talk

and underlying beliefs that

mediate his/her social fears,

challenge the biases (or assign

“Journal and Replace Self-

Defeating Thoughts” in the

Adult Psychotherapy Homework

Planner by Jongsma); assist

him/her in generating appraisals

that correct for the biases and

build confidence.

17. Assign the client a homework

exercise in which he/she identifies

fearful self-talk and creates

reality-based alternatives; test

fear-based predictions against

alternatives using behavioral

experiments; review; reinforce

success, problem-solve obstacles

toward accomplishing objective

(see “Restoring Socialization

Comfort” in the Adult

SOCIAL ANXIETY

Psychotherapy Homework

Planner by Jongsma; The

Shyness and Social Anxiety

Workbook by Antony and

Swinson).

12. Participate in gradual repeated

exposure to feared social

situations within and outside of

therapy. (18, 19, 20)

18. Direct and assist the client in

construction of a hierarchy of

anxiety-producing situations

associated with the phobic

response.

19. Select initial in vivo or role-

played exposures that have a

high likelihood of being a

successful experience for the

client; do cognitive restructuring

within and after the exposure,

use behavioral strategies (e.g.,

modeling, rehearsal, social

reinforcement) to facilitate

progress through the hierarchy

(see Cognitive-Behavioral Group

Therapy for Social Phobia by

Heimberg and Becker; Managing

Social Anxiety by Hope,

Heimberg, and Turk).

20. Assign the client a homework

exercise in which he/she does an

exposure exercise and records

responses (or assign “Gradually

Reducing Your Phobic Fear”

in the Adult Psychotherapy

Homework Planner by Jongsma;

also see The Shyness and Social

Anxiety Workbook by Antony

and Swinson; review and

reinforce success, providing

corrective feedback toward

improvement.

13. Learn and implement social

skills to reduce anxiety and build

confidence in social interactions.

(21, 22)

21. Use instruction, modeling,

and role-playing to build the

client’s general social and/or

communication skills (Cognitive

Behavioral Group Therapy for

Social Phobia by Heimberg

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

388

and Becker; Managing Social

Anxiety by Hope, Heimberg,

and Turk).

22. Assign the client to read about

general social and/or commu-

nication skills in books or

treatment manuals on building

social skills (e.g., Your Perfect

Right by Alberti and Emmons;

Conversationally Speaking by

Garner).

14. Implement relapse prevention

strategies for managing possible

future anxiety symptoms.

(23, 24, 25, 26)

23. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

an initial and reversible return

of symptoms, fear, or urges

to avoid and relapse with the

decision to return to fearful and

avoidant patterns.

24. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur.

25. Instruct the client to routinely

use strategies learned in

therapy (e.g., using cognitive

restructuring, social skills, and

exposure) while building social

interactions and relationships.

26. Develop a “coping card” on

which coping strategies and

other important information

(e.g., “Pace your breathing,”

“Focus on the task at hand,”

“You can manage it,” and

“It will go away”) are recorded

for the client’s later use.

15. Participate in Acceptance and

Commitment Therapy (ACT) for

social anxiety. (27, 28, 29, 30)

27. Use an ACT approach to help

the client accept and openly

experience anxious thoughts and

feelings without being overly

impacted by them, and

committing his/her time and

SOCIAL ANXIETY

389

efforts to activities that are

consistent with identified,

personally meaningful values

(see Acceptance and Commitment

Therapy for Anxiety Disorders by

Eifert, Forsyth, and Hayes).

28. Teach mindfulness meditation

to help the client recognize the

negative thought processes

associated with social anxiety

and change his/her relationship

with these thoughts by accepting

thoughts, images, and impulses

that are reality-based while

noticing, but not reacting to,

non-reality-based mental

phenomena (see Guided

Mindfulness Meditation [Audio

CD] by Zabat-Zinn).

29. Assign the client homework in

which he/she practices lessons

from mindfulness meditation and

ACT in order to consolidate the

approach into in everyday life.

30. Assign the client reading

consistent with the mindfulness

and ACT approach to supple-

ment work done in session (see

The Mindfulness and Acceptance

Workbook for Anxiety by

Forsyth and Eifert).

16. Identify important people in life,

past and present, and describe

the quality, good and poor, of

those relationships. (31)

31. Conduct Interpersonal Therapy

(apply Comprehensive Guide to

Interpersonal Psychotherapy by

Weissman, Markowitz, and

Klerman) beginning with the

assessment of the client’s

“interpersonal inventory” of

important past and present

relationships; develop a case

formulation linking social

anxiety grief, interpersonal role

disputes, role transitions, and/or

interpersonal deficits).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

390

17. Verbalize and demonstrate an

understanding and resolution of

current interpersonal problems.

(32, 33, 34, 35)

32. For grief, facilitate mourning

and gradually help client

discover new activities and

relationships to compensate

for the loss.

33. For interpersonal disputes,

help the client explore the

relationship, the nature of the

dispute, whether it has reached

an impasse, and available

options to resolve it including

learning and implementing

conflict-resolution skills; if the

relationship has reached an

impasse, consider ways to

change the impasse or to end the

relationship.

34. For role transitions (e.g.,

beginning or ending a

relationship or career, moving,

promotion, retirement,

graduation), help the client

mourn the loss of the old role

while recognizing positive and

negative aspects of the new role,

and taking steps to gain mastery

over the new role.

35. For interpersonal deficits,

help the client develop new

interpersonal skills and

relationships.

18. Explore past experiences that

may be the source of low self-

esteem and social anxiety

currently. (36, 37)

36. Probe childhood experiences

of criticism, abandonment, or

abuse that would foster low self-

esteem and shame; process these.

37. Assign the client to read the

books Healing the Shame That

Binds You by Bradshaw and

Facing Shame by Fossum and

Mason, and process key ideas.

19. Work through developmental

conflicts that may be influencing

current struggles with fear and

38. Use an insight-oriented

approach to explore how

psychodynamic conflicts

SOCIAL ANXIETY

avoidance and take appropriate

actions. (38)

(e.g., separation/autonomy;

anger recognition, management,

and coping) may be manifesting

as social fear and avoidance;

address transference; work

through separation and anger

themes during therapy and upon

termination toward developing a

new ability to manage

separations and autonomy.

20. Verbally describe the defense

mechanisms used to avoid close

relationships. (39)

39. Assist the client in identifying

defense mechanisms that keep

others at a distance and prevent

him/her from developing trusting

relationships; identify ways to

minimize defensiveness.

21. Return for a follow-up session to

track progress, reinforce gains,

and problem-solve barriers. (40)

40. Schedule a follow-up or “booster

session” for the client for 1 to 3

months after therapy ends to

track progress.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.23 Social Phobia

300.4 Dysthymic Disorder

296.xx Major Depressive Disorder

300.7 Body Dysmorphic Disorder

_____

____________________________________

_____

_____________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

392

Axis II:

301.82 Avoidant Personality Disorder

301.0 Paranoid Personality Disorder

310.22 Schizotypal Personality Disorder

_____

_________________________

___________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.23 F40.10 Social Anxiety Disorder (Social Phobia)

300.4 F34.1 Persistent Depressive Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

300.7 F45.22 Body Dysmorphic Disorder

301.82 F60.6 Avoidant Personality Disorder

301.0 F60.0 Paranoid Personality Disorder

310.22 F21 Schizotypal Personality Disorder

301.20 F60.1 Schizoid Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

393

SOMATIZATION

BEHAVIORAL DEFINITIONS

1. Complains of a physical malady that seems to be caused by a

psychosocial stressor triggering a psychological conflict.

2. Preoccupied with the fear of having serious physical disease, without any

medical basis for concern.

3. Exhibits a multitude of physical complaints that have no organic

foundation but have led to life changes (e.g., seeing doctors often, taking

prescriptions, withdrawing from responsibilities).

4. Preoccupied with chronic pain beyond what is expected for a physical

malady or in spite of no known organic cause.

5. Complains of one or more physical problems (usually vague) that have

no known organic basis, resulting in impairment in life functioning in

excess of what is expected.

6. Preoccupied with pain in one or more anatomical sites with both

psychological factors and a medical condition as a basis for the pain.

7. Preoccupied with an imagined physical defect in appearance or a vastly

exaggerated concern about a minimal defect (Body Dysmorphic

Disorder).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

394

LONG-TERM GOALS

1. Reduce frequency of physical complaints and improve the level of

independent functioning.

2. Reduce verbalizations focusing on pain while increasing productive

activities.

3. Accept body appearance as normal even with insignificant flaws.

4. Accept self as relatively healthy with no known medical illness or

defects.

5. Improve physical functioning due to development of adequate coping

mechanisms for stress management.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Verbalize health concerns and/or

negative feelings regarding body

as well as feared consequences of

perceived body abnormality.

(1, 2, 3)

1. Build a level of trust and

understanding with the client

by listening to his/her initial

complaints without rejection

or confrontation.

2. Nurture a trusting relationship

throughout therapy by not

dismissing or trivializing health

complaints while simultaneously

advancing a psychosocial

treatment approach.

3. Assess the history of the client’s

complaints including symptoms,

fears, effect on functioning,

stressors, and goals of treatment.

2. Complete psychological tests

designed to assess the depth

and breadth of the presenting

problem(s). (4)

4. Administer surveys tailored to

the presenting complaint to

assess its nature and severity

(e.g., the Body Dysmorphic

SOMATIZATION

395

Disorder Examination; the

Whiteley Index; the Illness

Attitude Scale for health

anxiety); discuss results with

client; readminister as needed

to assess progress.

3. Disclose any history of substance

use that may contribute to and

complicate the treatment of

somatization. (5)

5. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the Substance

Use chapter in this Planner).

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (6, 7, 8, 9)

6. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

7. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

8. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

396

understanding of the client’s

behavior.

9. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Cooperate with an evaluation by

a physician for psychotropic

medication. (10)

10. Arrange for the client to have an

evaluation by a physician for a

prescription of psychotropic

medications (e.g., SSRIs).

6. Take psychotropic medications

consistently. (11)

11. Monitor the client for

prescription compliance, side

effects, and overall effectiveness

of the medication; consult with

the prescribing physician at

regular intervals.

7. Participate in individual or

group Cognitive-Behavioral

Therapy. (12)

12. Use a cognitive-behavioral/Stress

Inoculation Training approach

to help the client conceptualize

the stress-somatization

relationship and learn and

implement tailored skills

(e.g., calming and coping skills,

communication, problem-

solving, exposure) for managing

stressors, decreasing fears,

overcoming avoidance, and

increasing present-day

adaptation through problem-

focused coping (see Stress

Inoculation Training by

Meichenbaum; Treating Health

SOMATIZATION

Anxiety by Taylor and

Asmundson; Body Dysmorphic

Disorder by Veale and

Neziroglu).

8. Verbalize an understanding of

the rationale for treatment. (13)

13. Educate the client, with

sensitivity to defensiveness,

about the role of biased fears

and avoidance in maintaining

the disorder; about the role of

stress in exacerbating symptoms;

discuss how treatment serves as

an arena to desensitize fears, to

reality-test fears and underlying

beliefs, build skills in managing

stress, and build confidence and

self-acceptance regarding

appearance, health, and/or other

concerns.

9. Identify and replace biased,

fearful self-talk and beliefs with

realistic, accepting self-talk and

beliefs. (14, 15)

14. Use Cognitive Restructuring

techniques to explore the client’s

self-talk and underlying beliefs

that mediate his/her fears and

related avoidance or reassurance

seeking (e.g., “I have never been

a healthy person,” “These

sensations indicate a problem,”

“My receding hairline is

repulsive”); assist him/her in

generating thoughts that

challenge and correct for the

biases (see Treating Health

Anxiety by Taylor and

Asmundson; assign “Negative

Thoughts Trigger Negative

Feelings” in the Adult

Psychotherapy Homework

Planner by Jongsma).

15. Conduct behavioral experiments

that repeatedly test biased and

alternative beliefs; review;

reinforce successes; problem-

solve obstacles toward a shift in

fearful beliefs.

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398

10. Discuss current stresses that may

influence physical complaints.

(16)

16. Discuss how stress may be

exacerbating the focus and/or

experience of physical symptoms

to a degree that the client can

accept it and provide a rationale

for learning personalized stress

management skills.

11. Participate in repeated imaginal

and/or live exposure to feared

external and/or internal cues.

(17, 18, 19)

17. Assess external triggers for fears

(e.g., persons, situations,

sensations) and subtle and

obvious avoidant strategies (e.g.,

wearing concealing clothing for

BDD, reassurance-seeking for

hypochondriasis).

18. Direct and assist the client in

construction of a hierarchy of

fear triggers; incorporate

exposures that gradually increase

the client to what he/she fears

while reducing subtle and

obvious avoidant habits.

19. Select initial exposures that have

a high likelihood of being a

successful experience for the

client; be a participant model,

do cognitive restructuring

within and after the exposure;

incorporate response prevention

if needed (e.g., asking the client

with BDD to refrain from

concealing the undesirable

physical feature, agreeing not to

seek reassurance; adhering to a

reasonable schedule of medical

evaluations).

12. Learn and implement calming

skills to reduce overall anxiety

and manage anxiety symptoms.

(20, 21, 22)

20. Teach the client calming/

relaxation skills (e.g., applied

relaxation, progressive muscle

relaxation, cue controlled

relaxation; mindful breathing;

biofeedback) and how to

discriminate better between

relaxation and tension; teach the

SOMATIZATION

399

client how to apply these skills to

his/her daily life (e.g., Progressive

Relaxation Training by Bernstein

and Borkovec; The Relaxation

and Stress Reduction Workbook

by Davis, Robbins-Eshelman,

and McKay).

21. Assign the client homework each

session in which he/she practices

relaxation exercises daily,

gradually applying them

progressively from non-anxiety-

provoking to anxiety-provoking

situations; review and reinforce

success while providing

corrective feedback toward

improvement.

22. Assign the client to read about

progressive muscle relaxation

and other calming strategies in

relevant books or treatment

manuals (e.g., New Directions in

Progressive Muscle Relaxation

by Bernstein, Borkovec, and

Hazlett-Stevens; Mastery of Your

Anxiety and Worry—Workbook

by Craske and Barlow).

13. Learn and implement problem-

solving strategies for realistically

addressing worries. (23)

23. Teach the client problem-solving

strategies involving specifically

defining a problem, generating

options for addressing it,

evaluating the pros and cons of

each option, selecting and

implementing an optional action,

and re-evaluating and refining

the action (or assign “Plan

Before Acting” in the Adult

Psychotherapy Homework

Planner by Jongsma).

14. Complete homework

assignments involving exposure

to feared external and/or internal

cues. (24)

24. Assign the client homework

exercises in which he/she

strengthens new skills through

repeated exposures between

sessions while recording

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

400

responses (or assign “Gradually

Reducing Your Phobic Fear”

in the Adult Psychotherapy

Homework Planner by Jongsma);

review during next session,

reinforcing success and problem-

solving obstacles toward

improvement.

15. Implement the use of the

“thought-stopping” technique to

reduce the frequency of obsessive

thoughts. (25, 26)

25. Teach the client to interrupt

critical self-conscious thoughts

using the “thought-stopping”

technique of shouting “STOP”

to himself/herself silently while

picturing a red traffic signal and

then thinking about a calming

scene.

26. Assign the client to implement

the “thought-stopping”

technique on a daily basis

between sessions (or assign

“Making Use of the Thought-

Stopping Technique” in the

Adult Psychotherapy Homework

Planner by Jongsma); review.

16. Express thoughts and feelings

assertively and directly.

(27, 28, 29)

27. Using instruction, role-playing,

and behavioral rehearsal, teach

the client assertive, respectful

expression of thoughts and

feelings.

28. Train the client in assertiveness

or refer him/her to an

assertiveness training class

(recommend Your Perfect Right:

Assertiveness and Equality in

Your Life and Relationships

by Alberti and Emmons).

29. Reinforce the client’s

assertiveness as a means of

him/her attaining healthy need

satisfaction in contrast to passive

helplessness.

17. Learn and implement guided

self-dialogue to manage

30. Teach the client a guided self-

dialogue procedure in which

SOMATIZATION

thoughts, feelings, and urges

brought on by encounters with

trauma-related situations. (30)

he/she learns to recognize

maladaptive self-talk, challenges

its biases, copes with engendered

feelings, overcomes avoidance,

and reinforces his/her

accomplishments; review and

reinforce progress, problem-

solve obstacles toward

developing an effective

consolidated approach.

18. Learn about health/appearance

anxiety through completion of

prescribed reading. (31)

31. Assign the client who has

accepted the role of anxiety in

their health/appearance concerns

to read about health anxiety in

self-help books consistent with

the therapeutic model (e.g., Stop

Worrying About Your Health by

Zgourides; The BDD Workbook

by Claiborne and Pedrick;

Managing Chronic Pain: A

Cognitive-Behavioral Therapy

Approach Workbook by Otis).

19. Implement maintenance

strategies for managing possible

future lapses. (32, 33, 34, 35)

32. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

a temporary setback and relapse

with a return to a sustained

pattern thinking, feeling, and

behaving that is characteristic of

the disorder.

33. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur.

34. Instruct the client to routinely

use strategies learned in therapy

(e.g., continued exposure to

previously feared external or

internal cues that arise) to

prevent lapses into former

patterns of internal focus on

physical complaints, self-

conscious fears, and/or

avoidance patterns.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

402

35. Schedule periodic “maintenance

sessions” to help the client

maintain therapeutic gains.

20. Discuss causes for emotional

stress in life that underlie the

focus on physical complaints.

(36, 37, 38)

36. Refocus the client’s discussion

from physical complaints to

emotional conflicts and

expression of feelings.

37. Explore the client’s sources of

emotional pain—feelings of fear,

inadequacy, rejection, or abuse.

38. Assist the client in acceptance of

connection between physical

focus and avoidance of facing

emotional conflicts.

21. Identify family patterns that

exist around exaggerated focus

on physical maladies. (39)

39. Explore the client’s family

history for modeling and

reinforcement of physical

complaints.

22. Verbalize the secondary gain

that results from physical

complaints. (40)

40. Assist the client in developing

insight into the secondary gain

received from physical illness,

complaints, and the like.

23. Participate in Acceptance and

Commitment Therapy (ACT) for

health/appearance worries.

(41, 42, 43)

41. Use an ACT approach to help

the client experience and accept

the presence of worrisome

thoughts and images without

being overly impacted by them,

and committing his/her time and

efforts to activities that are

consistent with identified,

personally meaningful values

(see Acceptance and Commitment

Therapy by Hayes, Strosahl, and

Wilson).

42. Teach mindfulness meditation to

help the client recognize the

negative thought processes

associated with PTSD and

change his/her relationship with

these thoughts by accepting

thoughts, images, and impulses

that are reality-based while

SOMATIZATION

noticing, but not reacting to,

non-reality-based mental

phenomena (see Guided

Mindfulness Meditation [Audio

CD] by Zabat-Zinn).

43. Assign the client homework in

which he/she practices lessons

from mindfulness meditation

and ACT in order to consolidate

the approach into everyday life

(or assign Living Beyond Your

Pain: Using Acceptance and

Commitment Therapy to Ease

Chronic Pain by Dahl and

Lundgren).

24. Increase social and productive

activities rather than being

preoccupied with self and

physical complaints. (44, 45)

44. Assist the client in developing a

list of pleasurable activities that

can serve as rewards and

diversions from bodily focus

(or assign “Identify and Schedule

Pleasant Activities” in the Adult

Psychotherapy Homework

Planner by Jongsma).

45. Assign diversion activities

that take the client’s focus off

himself/herself and redirect it

toward hobbies, social activities,

assisting others, completing

projects, or returning to work.

25. Decrease physical complaints,

doctor visits, and reliance on

medication while increasing

verbal assessment of self as able

to function normally and

productively. (46, 47)

46. Challenge the client to endure

pain and carry on with

responsibilities so as to build

self-esteem and a sense of

contribution.

47. Structure specific times each day

for the client to think about, talk

about, and write down his/her

physical problems while outside

of those times the client will not

focus on his/her physical

condition; monitor and process

the intervention’s effectiveness

(or assign “Controlling the

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

404

Focus on Physical Problems”

in the Adult Psychotherapy

Homework Planner by Jongsma).

26. Engage in normal responsibilities

vocationally and socially without

complaining or withdrawing into

avoidance while using physical

problems as an excuse. (48, 49)

48. Give positive feedback when

the client is not focusing on and

talking about symptoms but is

accepting of his/her body as

normal and is performing

daily work, family, and social

activities without avoidance or

excuse.

49. Discuss with the client the

destructive social impact that

consistent complaining and/or

negative body focus have on

relationships with friends and

family; ask him/her to reflect on

this and recall how others have

reacted negatively to complaints.

27. Make and attend an

appointment at a pain clinic. (50)

50. Refer the client to a pain clinic to

learn pain management

techniques.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.7 Body Dysmorphic Disorder

300.11 Conversion Disorder

300.7 Hypochondriasis

300.81 Somatization Disorder

307.80 Pain Disorder Associated With Psychological

Factors

SOMATIZATION

307.89 Pain Disorder Associated With Both

Psychological Factors and a General Medical

Condition

300.81 Undifferentiated Somatoform Disorder

300.4 Dysthymic Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.7 F45.22 Body Dysmorphic Disorder

300.11 F44.x Conversion Disorder

300.7 F45.21 Illness Anxiety Disorder

300.81 F45.1 Somatic Symptom Disorder

307.80 F45.1 Somatic Symptom Disorder, With

Predominant Pain

307.89 F54 Psychological Factors Affecting Other

Medical Conditions

300.4 F34.1 Persistent Depressive Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

SPIRITUAL CONFUSION

BEHAVIORAL DEFINITIONS

1. Verbalization of a desire for a closer relationship to a higher power.

2. Feelings and attitudes about a higher power that are characterized by

fear, anger, and distrust.

3. Verbalization of a feeling of emptiness in his/her life, as if something was

missing.

4. A negative, bleak outlook on life and regarding others.

5. A felt need for a higher power, but because upbringing contained no

religious education or training, does not know where or how to begin.

6. An inability to connect with a higher power due to anger, hurt, and

rejection from religious upbringing.

7. A struggle with understanding and accepting Alcoholics Anonymous

(AA) Steps Two and Three (i.e., difficulty in believing in a higher power).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Clarify spiritual concepts and instill a freedom to approach a higher

power as a resource for support.

2. Increase belief in and development of a relationship with a higher power.

3. Begin a faith in a higher power and incorporate it into support system.

4. Resolve issues that have prevented faith or belief from developing and

growing.

SPIRITUAL CONFUSION

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Summarize the highlights of own

spiritual quest or journey to this

date. (1)

1. Ask the client to talk about or

write the story of his/her spiritual

quest/journey (or assign “My

History of Spirituality” from the

Adult Psychotherapy Homework

Planner by Jongsma); process the

journey material.

2. Describe beliefs and feelings

around the idea of a higher

power. (2, 3, 4)

2. Assign the client to list all of

his/her beliefs related to a higher

power; process the beliefs.

3. Assist the client in processing

and clarifying his/her feelings

regarding a higher power.

4. Explore the causes for the

emotional components (e.g.,

fear, rejection, peace, acceptance,

abandonment) of the client’s

reaction to a higher power.

3. Provide behavioral, emotional

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of in-

sight (syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

408

address the issue as a concern;

or demonstrates resistance

regarding acknowledgement

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence of

research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

4. Describe early life training in

spiritual concepts and identify its

impact on current religious

beliefs. (9)

9. Review the client’s early life

experiences surrounding belief in

a higher power and explore how

this affects current beliefs.

SPIRITUAL CONFUSION

5. Verbalize an increased

knowledge and understanding

of concept of a higher power.

(10, 11)

10. Ask the client to talk with a

chaplain, pastor, rabbi, or priest

regarding the client’s spiritual

struggles, issues, or questions,

and record the feedback.

11. Assign the client to read The

Case for Faith by Strobel, Mere

Christianity by Lewis, or The

Case for God byArmstrong to

build knowledge and a concept

of a higher power.

6. Identify specific blocks to

believing in a higher power.

(12, 13)

12. Assist the client in identifying

specific issues or blocks that

prevent the development of

his/her spirituality.

13. Encourage the client to read

books dealing with conversion

experiences (e.g., Surprised by

Joy by Lewis; The Confessions of

St. Augustine by Augustine; The

Seven Storey Mountain by

Merton).

7. Identify the difference between

religion and faith. (14)

14. Educate the client on the

difference between religion and

spirituality.

8. Replace the concept of a higher

power as harsh and judgmental

with a belief in a higher power as

forgiving and loving. (13, 15)

13. Encourage the client to read

books dealing with conversion

experiences (e.g., Surprised by

Joy by Lewis; Confessions of St.

Augustine by Augustine; The

Seven Storey Mountain by

Merton).

15. Emphasize that the higher power

is characterized by love and

gracious forgiveness for anyone

with remorse and who seeks

forgiveness.

9. Implement daily attempts to be

in contact with higher power.

(16, 17, 18)

16. Recommend that the client

implement daily meditations

and/or prayer; process the

experience.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

410

17. Assign the client to write a daily

note to his/her higher power.

18. Encourage and assist the client in

developing and implementing a

daily devotional time or other

ritual that will foster his/her

spiritual growth.

10. Verbalize separation of beliefs

and feelings regarding one’s

earthly father from those

regarding a higher power.

(19, 20)

19. Assist the client in comparing

his/her beliefs and feelings about

his/her earthly father with those

about a higher power.

20. Urge separating the feelings and

beliefs regarding the earthly

father from those regarding

a higher power to allow for

spiritual growth and maturity.

11. Acknowledge the need to

separate negative past

experiences with religious people

from the current spiritual

evaluation. (21, 22)

21. Assist the client in evaluating

religious tenets separated from

painful emotional experiences

with religious people in his/her

past.

22. Explore the religious distortions

and judgmentalism that the

client has been subjected to

by others.

12. Verbalize acceptance of

forgiveness from a higher power.

(23, 24)

23. Ask the client to read Serenity: A

Companion for 12 Step Recovery

by Helmfelt and Fowler—all

readings related to AA Steps Two

and Three, The Road Less

Traveled by Peck, or Shame and

Grace: Healing the Shame We

Don’t Deserve by Smedes; process

the concept of forgiveness.

24. Explore the client’s feelings

of shame and guilt that led to

him/her feeling unworthy before

a higher power and others.

13. Ask a respected person who has

apparent spiritual depth to serve

as a mentor. (25)

25. Help the client find a mentor

to guide his/her spiritual

development.

SPIRITUAL CONFUSION

411

14. Attend groups dedicated to

enriching spirituality. (26, 27)

26. Make the client aware of

opportunities for spiritual

enrichment (e.g., Bible studies,

study groups, fellowship groups);

process the experiences he/she

decides to pursue.

27. Suggest that the client attend a

spiritual retreat (e.g., DeColores

or Course in Miracles) and report

to therapist what the experience

was like for him/her and what

he/she gained from the

experience.

15. Read books that focus on

furthering a connection with a

higher power. (28)

28. Ask the client to read books to

cultivate his/her spirituality (e.g.,

The Cloister Walk by Norris;

The Purpose-driven Life by

Warren; The Care of the Soul by

Moore).

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.4 Dysthymic Disorder

311 Depressive Disorder NOS

300.00 Anxiety Disorder NOS

296.xx Major Depressive Disorder

_____

_____________________________________

_____

_____________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

412

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.4 F34.1 Persistent Depressive Disorder

311 F32.9 Unspecified Depressive Disorder

311 F32.8 Other Specified Depressive Disorder

300.09 F41.8 Other Specified Anxiety Disorder

300.00 F41.9 Unspecified Anxiety Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

V62.89 Z65.8 Religious or Spiritual Problem

Note: The ICD-9-CM codes are to be used for coding purposes in the United Sates through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

SUBSTANCE USE

BEHAVIORAL DEFINITIONS

1. Consistently uses alcohol or other mood-altering drugs until high,

intoxicated, or passed out.

2. Unable to stop or cut down use of mood-altering drug once started,

despite the verbalized desire to do so and the negative consequences

continued use brings.

3. Produces blood study results that reflect a pattern of heavy substance

use (e.g., elevated liver enzymes).

4. Denies that chemical dependence is a problem despite direct feedback

from spouse, relatives, friends, and employers that the use of the

substance is negatively affecting him/her and others.

5. Describes amnestic blackouts that occur when abusing alcohol.

6. Continues drug and/or alcohol use despite experiencing persistent or

recurring physical, legal, vocational, social, or relationship problems

that are directly caused by the use of the substance.

7. Exhibits increased tolerance for the drug as evidenced by the need to use

more to become intoxicated or to attain the desired effect.

8. Exhibits physical symptoms (i.e., shaking, seizures, nausea, headaches,

sweating, anxiety, insomnia, depression) when withdrawing from the

substance.

9. Suspends important social, recreational, or occupational activities

because they interfere with using the mood-altering drug.

10. Makes a large time investment in activities to obtain the substance, to

use it, or to recover from its effects.

11. Consumes mood-altering substances in greater amounts and for longer

periods than intended.

12. Continues abuse of a mood-altering chemical after being told by a

physician that it is causing health problems.

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

414

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Accept the fact of chemical dependence and begin to actively participate

in a recovery program.

2. Establish a sustained recovery, free from the use of all mood-altering

substances.

3. Establish and maintain total abstinence while increasing knowledge of

the disease and the process of recovery.

4. Acquire the necessary skills to maintain long-term sobriety from all

mood-altering substances.

5. Withdraw from mood-altering substance, stabilize physically and

emotionally, and then establish a supportive recovery plan.

6. Utilize behavioral and cognitive coping skills to help maintain sobriety.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the type, amount,

frequency, and history of

substance abuse. (1)

1. Gather a complete drug/alcohol

history from the client, including

the amount and pattern of

his/her use, signs and symptoms

of use, and negative life

consequences (e.g., social, legal,

familial, vocational).

2. Complete psychological tests

designed to assess the nature and

severity of substance abuse. (2)

2. Administer to the client an

objective test of drug and/or

alcohol abuse (e.g., the Addiction

SUBSTANCE USE

Severity Index, the Michigan

Alcohol Screening Test); process

the results with the client.

3. Participate in a medical

evaluation to assess the effects

of chemical dependence. (3)

3. Refer the client for a thorough

physical examination to

determine any physical/medical

consequences of chemical

dependence.

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (4, 5, 6, 7)

4. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

5. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

6. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

416

7. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Cooperate with an evaluation by

a physician for psychotropic

medication. (8, 9)

8. Assess the need for psychotropic

medication for any mental/

emotional comorbidities, and

discuss the use of acamprosate

(Campral), naltrexone (Vivitrol),

or disulfiram (Antabuse) where

applicable to discourage

chemical abuse and strengthen

recovery.

9. Monitor the client for

prescription compliance, side

effects, and overall effectiveness

of the medication; consult with

the prescribing physician at

regular intervals.

6. Explore and resolve ambivalence

associated with commitment to

change behaviors related to

substance use and addiction.

(10, 11, 12, 13)

10. Using a nondirective, client-

centered, empathic style derived

from motivational enhancement

therapy (see Motivational

Interviewing by Miller and

Rollnick; Motivational

Interviewing and Enhancement

by DiClemente, Van Orden, and

Wright), establish rapport with

the client and listen reflectively,

asking permission before

providing information or

advice.

SUBSTANCE USE

417

11. Ask the client to make a list of

the ways substance abuse has

negatively impacted his/her life

(e.g., medically, relationally,

legally, vocationally, and

socially) and the positive impact

nonuse may have (or assign

“Substance Abuse Negative

Impact versus Sobriety’s

Positive Impact” in the Adult

Psychotherapy Homework

Planner by Jongsma).

12. Ask open-ended questions

to explore the client’s own

motivations for change,

affirming his/her change-related

statements and efforts (see

Substance Abuse Treatment

and the Stages of Change by

Connors, Donovan, and

DiClemente).

13. Elicit recognition of the

discrepancy gap between current

behavior and desired life goals,

reflecting resistance without

direct confrontation or

argumentation.

7. Commit self to an action plan

directed toward termination of

substance use. (14, 15)

14. Encourage and support the

client’s self-efficacy for change

toward the goal of developing an

action plan for termination of

substance use to which the client

is willing to commit.

15. Develop an abstinence contract

with the client regarding the

termination of the use of his/her

drug of choice; process client’s

feelings related to the

commitment.

8. Attend Alcoholics

Anonymous/Narcotics

Anonymous (AA/NA) meetings

as frequently as necessary to

support sobriety. (16)

16. Recommend that the client

attend AA or NA meetings and

report on the impact of the

meetings; process messages the

client is receiving.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

418

9. Agree to make amends to

significant others who have been

hurt by the life dominated by

substance abuse. (17, 18)

17. Discuss the negative effects the

client’s substance abuse has had

on family, friends, and work

relationships and encourage a

plan to make amends for such

hurt.

18. Elicit from the client a verbal

commitment to make initial

amends now to key individuals

and further amends when

working Steps 8 and 9 of the

AA program.

10. Verbalize increased knowledge

of alcoholism and the process of

recovery. (19, 20)

19. Conduct or assign the client to

attend a chemical dependence

didactic series to increase his/her

knowledge of the patterns and

effects of chemical dependence;

ask him/her to identify several

key points attained from each

didactic and process these

points.

20. Assign the client to read a

workbook describing evidence-

based treatment approaches

to addiction recovery (e.g.,

Overcoming Your Alcohol or

Drug Problem by Daley and

Marlatt); use the readings to

reinforce key concepts and

practices throughout therapy.

11. Verbalize an understanding of

factors that can contribute to

development of chemical

dependence and pose risks for

relapse. (21, 22)

21. Assess the client’s intellectual,

personality, and cognitive

vulnerabilities, family history,

and life stresses that contribute to

his/her chemical dependence.

22. Facilitate the client’s

understanding of his/her genetic,

personality, social, and family

factors, including childhood

experiences, that led to the

development of chemical

dependency and serve as risk

factors for relapse.

SUBSTANCE USE

12. Identify level of happiness in

various areas of life. (23)

23. Approaching the client with

empathy and genuine caring,

administer The Happiness Scale

(see A Community Reinforcement

Approach to Addiction Treatment

by Meyers and Miller); review

results in session.

13. Develop goals to increase

satisfaction and pleasure in

unsatisfactory, nondrinking

areas of life. (24)

24. Assist the client in defining

specific goals and strategies for

achieving increased happiness in

problematic, nondrinking areas

of life, so that the role of alcohol

and/or drugs as the major

determinant of an individual’s

happiness is diminished

(consider assigning “Setting and

Pursuing Goals in Recovery”

in the Addiction Treatment

Homework Planner by Finley

and Lenz).

14. Learn and implement

communication and problem-

solving skills toward achieving

goals. (25, 26, 27, 28, 29)

25. Using modeling, role-playing

and behavioral rehearsal,

teach the client communication

skills including how to make

statements that convey under-

standing, accepting partial

responsibility for problems,

and offering to help solve the

problem.

26. Teach the client problem-solving

skills (identify and pinpoint the

problem, brainstorm possible

solutions, list and evaluate the

pros and cons of each solution,

select and implement a solution,

evaluate all parties’ satisfaction

with the action, adjust action if

necessary); use role-playing to

assist the client in applying these

steps to life issues to increase

happiness (or assign “Plan

Before Acting” in the Adult

Psychotherapy Homework

Planner by Jongsma).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

420

27. Teach the client assertiveness

skills that can be used to support

drink refusal.

28. Assign the client to read

about general social and/or

assertiveness skills in books or

treatment manuals on building

social skills (e.g., Your Perfect

Right by Alberti and Emmons;

Conversationally Speaking by

Garner).

29. Assign homework to encourage

the client to apply the newly

learned behavioral skills to

achieving the happiness goals

identified (see “Applying

Problem-Solving to Inter-

personal Conflict” in the Adult

Psychotherapy Homework

Planner by Jongsma); review

progress, reinforcing success

and redirecting for failure.

15. Cooperate with exploration of

increasing satisfaction in areas

of life that can support sobriety

such as employment, recreation,

and relationships.

(30, 31, 32, 33, 34)

30. Evaluate the role of the client’s

living situation in fostering a

pattern of chemical dependence;

process with the client.

31. Facilitate development of a plan

for the client to change his/her

living situation to foster recovery

(or assign “Assessing My Needs”

in the Addiction Treatment

Homework Planner by Finley

and Lenz); revisit routinely and

facilitate toward accomplishing a

positive change in living

situation.

32. Teach the client skills necessary

for finding a job, keeping a job,

and improving satisfaction in a

job setting.

33. Assist the client in identifying

new sources of non-drinking

SUBSTANCE USE

421

recreation and social friendships,

using problem-solving and

communication skills to

overcome obstacles.

34. Direct conjoint sessions that

address and resolve issues with a

partner so as to increase the

number of pleasant interactions

and reduce conflicts.

16. Participate in behavioral couples

therapy designed to increase the

non-substance-using partner’s

reinforcement of sobriety and to

reduce relationship conflict.

(35, 36, 37, 38)

35. Develop a sobriety contract with

the couple that stipulates an

agreement to remain abstinent;

limits the focus of partner

discussions to present day issues,

not past hurtful behaviors;

identifies the role of AA

meetings; and schedules a daily

time to share thoughts and

feelings.

36. Ask each partner to make a list

of pleasurable activities that

could be engaged in together to

increase positive feelings toward

each other (or assign “Identify

and Schedule Pleasant

Activities” in the Adult

Psychotherapy Homework

Planner by Jongsma); process the

list and assign implementation of

one or more activities before the

next session.

37. Teach the couple problem-

solving skills (identify and

pinpoint the problem,

brainstorm possible solutions,

list and evaluate the pros and

cons of each solution, select and

implement a solution, evaluate

all parties’ satisfaction with

the action, adjust action if

necessary); role-play the use of

these skills applied to real life

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

422

issues of conflict for the couple

(or assign “Applying Problem-

Solving to Interpersonal

Conflict” in the Adult

Psychotherapy Homework

Planner by Jongsma).

38. In light of the recovery contract,

review the client’s sobriety

experience and the couples’

interaction since the last session;

address any relationship

conflicts, assisting the couple in

improving their communication

skills (e.g., “I messages,”

reflective listening, eye contact,

respectful responding, etc.) by

using role-play in the session.

17. Identify, challenge, and replace

destructive, high-risk self-talk

with positive, strength-building

self-talk. (39, 40, 41)

39. Explore the client’s schema and

high-risk self-talk that weaken

his/her resolve to remain

abstinent; challenge the biases;

assist him/her in generating

realistic self-talk that corrects

for the biases and builds

resilience.

40. Rehearse situations in which the

client identifies his/her negative

self-talk and generates

empowering alternatives (or

assign “Negative Thoughts

Trigger Negative Feelings” in the

Adult Psychotherapy Homework

Planner by Jongsma); review and

reinforce success.

41. Assign the client a homework

exercise in which he/she identifies

high-risk self-talk, identifies

biases in the self-talk, generates

alternatives, and tests through

behavioral experiments (consider

assigning “Replacing Fears With

Positive Messages” in the Adult

Psychotherapy Homework

SUBSTANCE USE

Planner by Jongsma); review and

reinforce success, providing

corrective feedback toward

improvement.

18. Earn rewards by submitting

drug-negative urine samples. (42)

42. Implement a prize-based

contingency management system

by rewarding the client with

desired prizes starting at the low

end of a $1–100 range and

increasing with continued

abstinence.

19. Earn rewards by maintaining

attendance in treatment. (43)

43. Implement a prize-based

contingency management system

by rewarding the client with

desired prizes starting at the low

end of a $1–100 range and

increasing with continued

attendance.

20. Participate in EEG biofeedback

treatment to reduce fear of

bodily sensations that can trigger

substance abuse. (44)

44. Administer to the client or

refer the client to a certified

biofeedback practitioner for

training in using EEG relaxation

feedback to cope with arousal-

related bodily sensations that

may trigger substance abuse.

21. Verbalize an understanding of

lapse and relapse. (45, 46)

45. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

an initial, temporary, and

reversible use of a substance and

relapse with the decision to

return to a repeated pattern

of abuse.

46. Evaluate past lapses and

prescribe self-monitoring to

assess current risk factors for

lapses (or assign “Relapse

Triggers” in the Adult

Psychotherapy Homework

Planner by Jongsma and/or the

Alcoholism and Drug Abuse

Patient Workbook by

Perkinson).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

424

22. Implement relapse prevention

strategies for managing possible

future situations with high-risk

for relapse. (47, 48, 49, 50)

47. Use stimulus control techniques

such as avoidance of specific

triggers to reduce exposure to

high-risk situations.

48. Use instruction, modeling,

imaginal rehearsal, role-play,

and cognitive restructuring to

teach the client cognitive-

behavioral skills (e.g., relaxation,

problem-solving, social and

communication skills,

recognition and management

of rationalization, denial, and

apparently irrelevant decisions)

for managing urges and other

high risk situations.

49. Instruct the client to routinely

use strategies learned in therapy

(e.g., problem-solving, stimulus

control, social skills, and

assertiveness) while managing

high-risk trigger situations (or

assign “Aftercare Plan

Components” in the Adult

Psychotherapy Homework

Planner by Jongsma).

50. Supplement relapse prevention

work done in session by

recommend that the client read

material on how to avoid relapse

(e.g., Staying Sober: A Guide to

Relapse Prevention by Gorski

and Miller; The Staying Sober

Workbook by Gorski;

Overcoming Your Alcohol or

Drug Problem: Effective

Recovery Strategies—Workbook

by Daley and Marlatt).

SUBSTANCE USE

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

303.90 Alcohol Dependence

305.00 Alcohol Abuse

304.30 Cannabis Dependence

304.20 Cocaine Dependence

305.60 Cocaine Abuse

304.80 Polysubstance Dependence

291.2 Alcohol-Induced Persisting Dementia

291.1 Alcohol-Induced Persisting Amnestic

Disorder

V71.01 Adult Antisocial Behavior

300.4 Dysthymic Disorder

312.34 Intermittent Explosive Disorder

309.81 Posttraumatic Stress Disorder

304.10 Sedative, Hypnotic, or Anxiolytic

Dependence

_____

_____________________________________

_____

___________

_________________________

Axis II:

301.7 Antisocial Personality Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

305.00 F10.10 Alcohol Use Disorder, Mild

304.30 F12.20 Cannabis Use Disorder, Moderate or

Severe

304.20 F14.20 Cocaine Use Disorder, Moderate or Severe

305.60 F14.10 Cocaine Use Disorder, Mild

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

426

291.2 F10.27 Moderate or Severe Alcohol Use Disorder

With Alcohol-Induced Major

Neurocognitive Disorder, Nonamnestic-

Confabulatory Type

291.1 F10.26 Moderate or Severe Alcohol Use Disorder

With Alcohol-Induced Major

Neurocognitive Disorder, Amnestic-

Confabulatory Type

V71.01 Z72.811 Adult Antisocial Behavior

300.4 F34.1 Persistent Depressive Disorder

312.34 F63.81 Intermittent Explosive Disorder

309.81 F43.10 Posttraumatic Stress Disorder

304.10 F13.20 Sedative, Hypnotic, or Anxiolytic Use

Disorder, Moderate or Severe

301.7 F60.2 Antisocial Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

427

SUICIDAL IDEATION

BEHAVIORAL DEFINITIONS

1. Recurrent thoughts of or preoccupation with death.

2. Recurrent or ongoing suicidal ideation without any plans.

3. Ongoing suicidal ideation with a specific plan.

4. Recent suicide attempt.

5. History of suicide attempts that required professional or family/friend

intervention on some level (e.g., inpatient, safe house, outpatient,

supervision).

6. Positive family history of depression and/or a preoccupation with

suicidal thoughts.

7. A bleak, hopeless attitude regarding life coupled with recent life events

that support this (e.g., divorce, death of a friend or family member, loss

of job).

8. Social withdrawal, lethargy, and apathy coupled with expressions of

wanting to die.

9. Sudden change from being depressed to upbeat and at peace, while

actions indicate the client is “putting his/her house in order” and there

has been no genuine resolution of conflict issues.

10. Engages in self-destructive or dangerous behavior (e.g., chronic drug or

alcohol abuse; promiscuity, unprotected sex; reckless driving) that appears

to invite death.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

428

LONG-TERM GOALS

1. Alleviate the suicidal impulses/ideation and return to the highest level of

previous daily functioning.

2. Stabilize the suicidal crisis.

3. Placement in an appropriate level of care to safely address the suicidal

crisis.

4. Reestablish a sense of hope for self and the future.

5. Cease the perilous lifestyle and resolve the emotional conflicts that

underlie the suicidal pattern.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. State the strength of the suicidal

feelings, the frequency of the

thoughts, and the detail of the

plans. (1, 2, 3, 4)

1. Assess the client’s suicidal risk

including the extent of his/her

ideation, the presence and

feasibility of a plan, past

attempts, substance use,

availability of means, and

family history.

2. Assess and monitor the client’s

suicidal potential on an ongoing

basis.

3. Notify the client’s family and

significant others of his/her

suicidal ideation; ask them to

form a 24-hour suicide watch

until the crisis subsides.

4. Arrange or conduct psycho-

metric testing to further assess

suicidal behavior and/or related

conditions (e.g., The Suicidal

Thinking and Behaviors

SUICIDAL IDEATION

Questionnaire; The Beck

Hopelessness Scale; The Reasons

for Living Scale); evaluate the

results for the client’s degree of

depression and suicide risk.

2. Disclose any history of substance

use that may contribute to and

complicate the treatment of

suicidal ideation. (5)

5. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

3. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (6, 7, 8, 9)

6. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

7. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

8. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

430

understanding of the client’s

behavior.

9. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

4. Verbalize a promise to contact

the therapist or some other

emergency helpline if a serious

urge to self-harm arises.

(10, 11, 12, 13)

10. Elicit a promise from the client

that he/she will initiate contact

with the therapist or a helpline if

the suicidal urge becomes strong

and before any self-injurious

behavior.

11. Provide the client with a “crisis

card” with emergency help

telephone numbers making help

available 24 hours a day.

12. Develop a plan with the client,

identifying what he/she will and

won’t do when experiencing

suicidal thoughts or impulses;

encourage the client to be open

and honest regarding suicidal

urges, reassuring him/her

regularly of caring concern by

therapist and significant others.

13. Offer to be available to the client

through telephone contact if a

life-threatening urge develops.

5. Client and/or significant others

increase the safety of the home

by removing firearms or other

14. Encourage the client and/or

significant others to remove

firearms or other lethal means to

SUICIDAL IDEATION

potentially lethal means to

suicide from easy access. (14)

suicide from easy access; process

the client’s feelings about this

prevention measure.

6. Cooperate with hospitalization if

the suicidal urge becomes

uncontrollable. (15)

15. Arrange for hospitalization

when the client is judged to be

uncontrollably harmful to self;

arrange for a hospital legal

commitment if necessary to

protect the client from harm

to himself/herself.

7. Participate in a therapy for an

identified emotional problem

resulting in suicidal thoughts.

(16)

16. Assess whether suicidality is

functionally related to an active

clinical syndrome (e.g., unipolar

or bipolar depression) or

personality disorder (e.g.,

borderline personality disorder);

conduct or refer to an evidence-

based intervention for the

disorder (see, for example,

interpersonal therapy for unipolar

depression, interpersonal and

social rhythm therapy for bipolar

depression, or dialectical behavior

therapy for borderline personality

disorders in appropriate chapters

in this Planner).

8. Cooperate with a referral to a

physician for an evaluation for

antidepressant medication. (17)

17. Assess the client’s need for

psychotropic medication and

arrange for a prescription, if

necessary.

9. Take psychotropic medications

as prescribed and report all side

effects. (18)

18. Monitor the client for

effectiveness, side effects, and

compliance with prescribed

psychotropic medication; confer

with prescribing physician on a

regular basis.

10. Identify life factors that preceded

the suicidal ideation. (19, 20, 21)

19. Explore the client’s sources of

emotional pain and hopelessness.

20. Encourage the client to express

feelings related to his/her suicidal

ideation in order to clarify them

and increase insight as to the

causes for them.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

432

21. Assist the client in becoming

aware of life factors that were

significant precursors to the

beginning of his/her suicidal

ideation.

11. Increase communication with

significant others, resulting in

a feeling of understanding,

empathy, and being attended to.

(22, 23, 24)

22. Probe the client’s feelings of

despair related to his/her

conflicted family relationships.

23. Hold family therapy sessions to

promote communication of the

client’s feelings of sadness, hurt,

and anger.

24. Meet with significant others to

assess their understanding of the

causes for the client’s distress.

12. Identify how previous attempts

to solve interpersonal problems

have failed, leading to feelings of

abject loneliness and rejection.

(25, 26)

25. Encourage the client to share

feelings of grief related to broken

close relationships.

26. Review with the client previous

problem-solving attempts and

discuss new alternatives that are

available.

13. Learn and implement problem-

solving and decision-making

skills. (27, 28)

27. Use a Problem-Solving Therapy

approach (see Problem-Solving

Therapy by D’Zurilla and Nezu

under Unipolar Depression)

involving psychoeducation,

modeling, and role-playing to

teach client personal problem-

solving skills (i.e., defining a

problem specifically, generating

possible solutions, evaluating the

pros and cons of each solution,

selecting and implementing a

plan of action, evaluating the

efficacy of the plan, accepting

or revising the plan); role-play

application of the problem-

solving skill to a real life issue

(or assign “Applying Problem-

Solving to Interpersonal

Conflict” in the Adult

SUICIDAL IDEATION

Psychotherapy Homework

Planner by Jongsma).

28. Encourage in the client the

development of a positive

problem orientation in which

problems and solving them are

viewed as a natural part of life

and not something to be

despaired, approached passively,

or avoided.

14. Reestablish a consistent eating

and sleeping pattern. (29)

29. Encourage normal eating and

sleeping patterns by the client

and monitor his/her compliance.

15. Commit to the use of coping

strategies for suicidal urges. (30)

30. Assist the client in developing

coping strategies for suicidal

ideation (e.g., more physical

exercise, less internal focus,

increased social involvement,

more expression of feelings, and

contact with therapist).

16. Identify the positive aspects,

relationships, and achievements

in his/her life. (31, 32)

31. Ask the client to write a list of

positive aspects of his/her life

(or assign “What’s Good About

Me and My Life” in the Adult

Psychotherapy Homework

Planner by Jongsma).

32. Review with the client the

success he/she has had and the

sources of love and concern

that exist in his/her life.

17. Learn and implement behavioral

strategies designed to increase

engagement in rewarding

activities. (33, 34)

33. Engage the client in “behavioral

activation,” increasing his/her

activity level and contact with

sources of reward, while

identifying processes that inhibit

activation (see Behavioral

Activation for Depression by

Martell, Dimidjian, and

Herman-Dunn under Unipolar

Depression in Appendix B; or

assign “Identify and Schedule

Pleasant Activities” in the Adult

Psychotherapy Homework

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

434

Planner by Jongsma); use

behavioral techniques such as

instruction, rehearsal, role-

playing, or role reversal, as

needed, to facilitate activity in

the client’s daily life; reinforce

success.

34. Assist the client in developing

skills that increase the likelihood

of deriving pleasure from

behavioral activation (e.g.,

assertiveness skills, developing

an exercise plan, less

internal/more external focus,

increased social involvement);

reinforce success.

18. Identify and replace negative

thinking patterns that mediate

feelings of hopelessness and

helplessness. (35, 36, 37, 38)

35. Assist the client in developing

an awareness of the cognitive

messages that reinforce

hopelessness and helplessness.

36. Assist the client in identifying,

challenging, and changing biased

cognition, allowing for a more

realistic perspective conducive

to hope (or assign “Journal of

Distorted, Negative Thoughts”

in the Adult Psychotherapy

Homework Planner by Jongsma).

37. Address underlying assumptions

to self-talk that may be con-

tributing to biases (e.g., beliefs

about self-worthlessness,

hopelessness).

38. Ask the client to keep a daily

record of self-defeating thoughts

(thoughts of hopelessness,

helplessness, worthlessness,

catastrophizing, negatively

predicting the future, etc.); chal-

lenge each thought for accuracy,

then replace each dysfunctional

thought with one that is positive

and self-enhancing; review;

SUICIDAL IDEATION

reward successes; problem-solve

obstacles toward positive

cognitive change.

19. Verbalize the devastating effects

that suicide can have on

significant others. (39)

39. Assist the client in reviewing the

effects that the client’s suicide

would have on loved ones

(or assign “The Aftermath

of Suicide” in the Adult

Psychotherapy Homework

Planner by Jongsma).

20. Verbalize a feeling of support

that results from spiritual faith.

(40, 41)

40. Explore the client’s spiritual

belief system as to it being a

source of acceptance and peace

(or assign “My History of

Spirituality” in the Adult

Psychotherapy Homework

Planner by Jongsma).

41. Arrange for the client’s spiritual

leader to meet with and support

the client.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

296.xx Bipolar I Disorder

300.4 Dysthymic Disorder

296.2x Major Depressive Disorder, Single Episode

296.3x Major Depressive Disorder, Recurrent

296.89 Bipolar II Disorder

_____

_____________________________________

_____

___________

_________________________

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436

Axis II:

301.83 Borderline Personality Disorder

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

296.xx F31.xx Bipolar I Disorder

300.4 F34.1 Persistent Depressive Disorder

296.2x F32.x Major Depressive Disorder, Single Episode

296.3x F33.x Major Depressive Disorder, Recurrent

Episode

296.89 F31.81 Bipolar II Disorder

301.83 F60.3 Borderline Personality Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

TYPE A BEHAVIOR

BEHAVIORAL DEFINITIONS

1. A pattern of pressuring self and others to accomplish more because there

is never enough time.

2. A spirit of intense competition in all activities.

3. Intense compulsion to win at all costs regardless of the activity or co-

competitor.

4. Inclination to dominate all social or business situations, being too direct

and overbearing.

5. Propensity to become irritated by the action of others who do not

conform to own sense of propriety or correctness.

6. A state of perpetual impatience with any waiting, delays, or interruptions.

7. Difficulty in sitting and quietly relaxing or reflecting.

8. Psychomotor facial signs of intensity and pressure (e.g., muscle tension,

scowling, glaring, or tics).

9. Psychomotor voice signs (e.g., irritatingly forceful speech or laughter,

rapid and intense speech, and frequent use of obscenities).

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Formulate and implement a new life attitudinal pattern that allows for a

more relaxed pattern of living.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

438

2. Reach a balance between work/competitive and social/noncompetitive

time in daily life.

3. Achieve an overall decrease in pressured, driven behaviors.

4. Develop social and recreational activities as a routine part of life.

5. Alleviate sense of time urgency, free-floating anxiety, anger, and self-

destructive behaviors.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the pattern of

pressured, driven living. (1, 2)

1. Assess examples of pressured

lifestyle including associated

situations, cognition, emotion,

actions, and impact on client and

others.

2. Assist the client to see self as

others do.

2. Comply with psychological

assessment. (3, 4)

3. Administer measure to assess

and track the breadth and depth

of Type A behavior (e.g., Jenkins

Activity Survey).

4. Review and process results of

testing with the client toward

increasing motivation for

change.

3. Disclose any history of substance

use that may contribute to and

complicate the treatment of

Type A behavior. (5)

5. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

4. Provide behavioral, emotional,

and attitudinal information

6. Assess the client’s level of insight

(syntonic versus dystonic)

TYPE A BEHAVIOR

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (6, 7, 8, 9)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

7. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

8. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

9. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

440

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Identify the beliefs that support

driven, overachieving behavior.

(10, 11, 12)

10. Probe personal history including

family of origin history for role

models of and/or pressure for

high achievement and

compulsive drive.

11. Ask the client to make a list of

his/her beliefs about self-worth

and the worth of others; process

it with the therapist.

12. Assist the client in making key

connections between his/her

overachieving/driven behavior

and the desire to please key

parental figures.

6. Verbalize a desire to reprioritize

values toward less self-focus,

more inner and other

orientation. (13, 14)

13. Explore and clarify the client’s

value system and assist in

developing new priorities on the

importance of relationships,

recreation, spiritual growth,

reflection time, giving to others

(or assign “Developing

Noncompetitive Values” in the

Adult Psychotherapy Homework

Planner by Jongsma).

14. Ask the client to read

biographies or autobiographies

of spiritual people (e.g., St.

Augustine, Thomas Merton,

Albert Schweitzer, C. S. Lewis);

process the key beliefs they

lived by.

7. Verbalize a commitment to

learning new approaches

managing self, time, and

relationships that emphasize the

values of inner and other

orientation. (15)

15. Ask the client to commit to

attempting attitude and behavior

changes to promote a healthier,

less Type A lifestyle; explore

with him/her what changes need

to be made to become less

Type A.

TYPE A BEHAVIOR

441

8. Develop the pattern of doing one

task at a time with less emphasis

on pressure to complete it

quickly. (16)

16. Encourage and reinforce the

client, focusing on one activity at

a time without a sense of

urgency; direct him/her to calmly

complete the task before moving

on to another task.

9. Decrease the number of hours

worked daily and the frequency

of taking work home. (17)

17. Review the client’s pattern of

hours spent working (at home

and office) and recommend

selected reductions; explore how

these reductions could be

accomplished (what specifically

needs to change?).

10. Learn and implement calming

skills as a lifestyle change and to

manage pressure situations.

(18, 19)

18. Teach the client calming

techniques (e.g., muscle

relaxation, paced breathing,

calming imagery) as part of a

tailored strategy for responding

appropriately to feelings of

pressure when they occur

(recommend The Relaxation and

Stress Reduction Workbook by

Davis, Robbins-Eshelman, and

McKay).

19. Assign the client to implement

calming techniques in his/her

daily life in general and when

facing trigger situations; process

the results, reinforcing success

and provide corrective feedback

toward improvement.

11. Increase daily time involved in

relaxing activities.

(20, 21, 22, 23)

20. Assign the client to do at least

one noncompetitive activity each

day for a week; process this

experience.

21. Ask the client to try at least one

area of interest outside of his/her

vocation that he/she will do two

times weekly for one month (or

assign “Identify and Schedule

Pleasant Activities” in the Adult

Psychotherapy Homework

Planner by Jongsma).

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442

22. Assign the client to watch

comedy movies or other pleasant

activities and identify the

positive aspects and

consequences of them.

23. Reinforce all the client changes

that reflect a greater sense of life

balance.

12. Identify and replace distorted

automatic thoughts that

motivate pressured living. (24)

24. Assist the client in identifying

distorted automatic thoughts

that lead to feeling pressured

to achieve; assist him/her in

replacing these distortions with

positive, realistic cognitions.

13. Verbalize a recognition of

hostility toward and impatience

with others. (25, 26)

25. Explore the client’s pattern of

intolerant, impatient interaction

with others.

26. Assist the client in identifying

his/her critical beliefs about

other people and connecting

them to hostile verbal and

behavior patterns in daily life;

challenge him/her to develop

alternative thoughts that mediate

tolerance and acceptance of

others.

14. Learn and implement respectful

assertive communication

knowledge and skills to replace

insensitive directness or verbal

aggression that is controlling.

(27, 28)

27. Train the client in assertive

communication with emphasis

on recognizing and refraining

from aggressive communication

(e.g., ignoring of the rights of

others) to respectful, assertive

communication.

28. Monitor, point out, and

reframe the client’s actions or

verbalizations that reflect a self-

centered or critical approach to

others; practice alternatives

using behavioral strategies such

as modeling, role-playing, and/or

role reversal.

TYPE A BEHAVIOR

15. Learn problem-solving and/or

conflict resolution skills to

manage interpersonal problems.

(29, 30)

29. Teach the client conflict

resolution skills (e.g., empathy,

active listening, “I messages,”

respectful communication,

assertiveness without aggression,

compromise); use role- play and

modeling to apply these skills to

current conflicts.

30. Teach the client problem-solving

skills (e.g., define the problem

specifically, brainstorm options,

list the pros and cons of each

option, chose and implement an

option, evaluate the outcome);

use modeling, role-playing, and

behavior rehearsal to apply this

skill to several current conflicts

(or assign “Plan Before Acting”

in the Adult Psychotherapy

Homework Planner by

Jongsma).

16. Practice using new calming,

cognitive, communication, and

problem-solving skills in session

with the therapist and during

homework exercises. (31, 32, 33)

31. Assist the client in constructing

a client-tailored strategy for

managing pressure that

combines any of the somatic,

cognitive, communication,

problem-solving, and/or conflict

resolution skills relevant to

his/her needs.

32. Select situations in which the

client will be increasingly

challenged to apply his/her new

strategies for managing stress.

33. Use any of several techniques,

including relaxation, imagery,

behavioral rehearsal, modeling,

role-playing, in vivo exposure, or

behavioral experiments to help

the client consolidate the use of

his/her new stress management

skills.

17. Demonstrate decreased

impatience with others by

talking of appreciating and

34. Assign the client to talk to an

associate or child, focusing on

listening to the other person and

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

444

understanding the good qualities

in others. (34, 35, 36, 37)

learning several good things

about that person; process the

experience.

35. Assign the client and family to

attend an experiential weekend

that promotes self-awareness

(e.g., high/low ropes course or

cooperative tasks); process the

experience afterwards.

36. Assign the client to go with a

group on a wilderness camping

and canoeing trip, on a work

camp project, or with the Red

Cross as a disaster worker;

process the experience.

37. Encourage the client to volunteer

for a nonprofit social agency,

school, or the like for one year,

doing direct work with people

(i.e., serving food at a soup

kitchen or tutoring an inner-city

child); process the positive

consequences.

18. Increase interest in the lives of

others as evidenced by listening

to others talk of their life

experiences, and by engaging in

one act of kindness per day.

(38, 39, 40)

38. Encourage and monitor the

client in doing one random,

spontaneous act of kindness on a

daily basis and explore the

positive results.

39. Encourage the client to express

warmth, appreciation, affection,

and gratitude to others.

40. Assign the client to read the

book The Road Less Traveled by

Peck and to process key ideas

with therapist.

19. Develop a daily routine that

reflects a balance between the

quest for achievement and

appreciation of aesthetic things.

(41, 42)

41. Assign the client to read “List of

Aphorisms” in Treating Type A

Behavior and Your Heart by

Friedman and Ulmer three times

daily for one or two weeks; then

to pick several to incorporate

into his/her life.

TYPE A BEHAVIOR

42. Ask the client to list activities

he/she could engage in for purely

aesthetic enjoyment (e.g., visit an

art museum, attend a symphony

concert, hike in the woods, take

painting lessons, etc.) and

incorporate these into his/her

life.

20. Participate in Acceptance and

Commitment Therapy (ACT) to

learn a new approach to life and

its stresses. (43, 44, 45, 46)

43. Use an ACT approach to help

the client accept and openly

experience anxious thoughts and

feelings without being overly

impacted by them, and

committing his/her time and

efforts to activities that are

consistent with identified,

personally meaningful values (see

Learning ACT: An Acceptance

and Commitment Therapy Skills-

Training Manual for Therapists

by Luoma, Hayes, and Walser).

44. Teach mindfulness meditation to

help the client recognize the

negative thought processes

associated with panic and change

his/her relationship with these

thoughts by accepting thoughts,

images, and impulses that are

reality-based while noticing, but

not reacting to, non-reality-

based mental phenomena (see

Guided Mindfulness Meditation

[Audio CD] by Zabat-Zinn).

45. Assign the client homework in

which he/she practices lessons

from mindfulness meditation

and ACT in order to consolidate

the approach into in everyday

life.

46. Assign the client reading

consistent with the mindfulness

and ACT approach to supple-

ment work done in session (see

Get Out of Your Mind and Into

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446

Your Life: The New Acceptance

and Commitment Therapy by

Hayes).

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

300.3 Obsessive-Compulsive Disorder

300.02 Generalized Anxiety Disorder

296.89 Bipolar II Disorder, Hypomanic

_____

_____________________________________

_____

_____________________________________

Axis II:

301.4 Obsessive-Compulsive Personality Disorder

_____

_____________________________________

_____

_________________________________

___

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

300.3 F42 Obsessive-Compulsive Disorder

300.02 F41.1 Generalized Anxiety Disorder

296.89 F31.81 Bipolar II Disorder

301.4 F60.5 Obsessive-Compulsive Personality

Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

447

UNIPOLAR DEPRESSION

BEHAVIORAL DEFINITIONS

1. Depressed or irritable mood.

2. Decrease or loss of appetite.

3. Diminished interest in or enjoyment of activities.

4. Psychomotor agitation or retardation.

5. Sleeplessness or hypersomnia.

6. Lack of energy.

7. Poor concentration and indecisiveness.

8. Social withdrawal.

9. Suicidal thoughts and/or gestures.

10. Feelings of hopelessness, worthlessness, or inappropriate guilt.

11. Low self-esteem.

12. Unresolved grief issues.

13. Mood-related hallucinations or delusions.

14. History of chronic or recurrent depression for which the client has taken

antidepressant medication, been hospitalized, had outpatient treatment,

or had a course of electroconvulsive therapy.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Alleviate depressive symptoms and return to previous level of effective

functioning.

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448

2. Recognize, accept, and cope with feelings of depression.

3. Develop healthy thinking patterns and beliefs about self, others, and the

world that lead to the alleviation and help prevent the relapse of

depression.

4. Develop healthy interpersonal relationships that lead to the alleviation

and help prevent the relapse of depression.

5. Appropriately grieve the loss in order to normalize mood and to return

to previously adaptive level of functioning.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe current and past

experiences with depression

including their impact on

functioning and attempts to

resolve it. (1, 2)

1. Encourage the client to share

his/her thoughts and feelings of

depression; express empathy and

build rapport while identifying

primary cognitive, behavioral,

interpersonal, or other

contributors to depression.

2. Assess current and past mood

episodes including their features,

frequency, severity, and duration

(e.g., clinical interview

supplemented by the Inventory

to Diagnose Depression).

2. Complete psychological testing

to assess the depth of depression,

the need for anti-depressant

medication, and suicide

prevention measures. (3)

3. Arrange for the administration

of an objective assessment

instrument for evaluating the

client’s depression and suicide

risk (e.g., Beck Depression

Inventory-II; the Beck

Hopelessness Scale); evaluate

results and give feedback to the

client; readminister as indicated

to assess treatment progress.

UNIPOLAR DEPRESSION

3. Verbalize any history of past and

present suicidal thoughts and

actions. (4)

4. Assess the client’s history of

suicidality and current state of

suicide risk (see the Suicidal

Ideation chapter in this Planner

if suicide risk is present).

4. State no longer having thoughts

of self-harm. (5, 6)

5. Continuously assess and monitor

the client’s suicide risk.

6. Arrange for hospitalization, as

necessary, when the client is

judged to be a danger to self.

5. Complete a medical evaluation

to assess for possible

contribution of medical or

substance-related conditions to

the depression. (7)

7. Refer the client to a physician

for a medical evaluation to

rule out general medical or

substance-related causes of

the depression.

6. Disclose any history of substance

use that may contribute to and

complicate the treatment of

unipolar depression. (8)

8. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in this

Planner).

7. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature

of the therapy relationship.

(9, 10, 11, 12)

9. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

10. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

450

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

11. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

12. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

8. Cooperate with a medication

evaluation by a physician.

(13, 14)

13. Evaluate the client’s need and

desire for psychotropic

medication and, if indicated,

arrange for a medication

evaluation by a physician.

14. Monitor and evaluate the client’s

psychotropic medication

compliance, effectiveness, and

side effects; communicate with

prescribing physician.

9. Verbalize an accurate

understanding of depression.

(15, 16)

15. Consistent with the treatment

model, discuss how cognitive,

behavioral, interpersonal, and/or

UNIPOLAR DEPRESSION

other factors (e.g., family history)

contribute to depression.

16. Assign the client to read chapters,

books, treatment manuals, or

other resources that convey

psychoeducational concepts

regarding depression.

10. Verbalize an understanding of

the rationale for treatment of

depression. (17, 18)

17. Consistent with the treatment

model, discuss how change in

cognitive, behavioral,

interpersonal, and other factors

can help the client alleviate

depression and return to

previous level of effective

functioning.

18. Assign the client to read

chapters, books, or use other

resources to help the client learn

more about the therapy and its

rationale.

11. Identify and replace thoughts

and beliefs that support

depression. (19, 20, 21, 22, 23)

19. Conduct Cognitive-Behavioral

Therapy (see Cognitive Behavior

Therapy by Beck; Overcoming

Depression by Gilson, et al.),

beginning with helping the client

learn the connection among

cognition, depressive feelings,

and actions.

20. Assign the client to self-monitor

thoughts, feelings, and actions in

daily journal (e.g., “Negative

Thoughts Trigger Negative

Feelings” in the Adult Psycho-

therapy Homework Planner by

Jongsma; “Daily Record of

Dysfunctional Thoughts” in

Cognitive Therapy of Depression

by Beck, Rush, Shaw, and

Emery); process the journal

material to challenge depressive

thinking patterns and replace

them with reality-based

thoughts.

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452

21. Assign “behavioral experiments”

in which depressive automatic

thoughts are treated as

hypotheses/prediction,

reality-based alternative

hypotheses/prediction are

generated, and both are tested

against the client’s past, present,

and/or future experiences.

22. Facilitate and reinforce the

client’s shift from biased

depressive self-talk and beliefs to

reality-based cognitive messages

that enhance self-confidence and

increase adaptive actions (see

“Positive Self-Talk” in the Adult

Psychotherapy Homework

Planner by Jongsma).

23. Explore and restructure

underlying assumptions and

beliefs reflected in biased self-

talk that may put the client at

risk for relapse or recurrence.

12. Learn and implement behavioral

strategies to overcome

depression. (24, 25)

24. Engage the client in “behavioral

activation,” increasing his/her

activity level and contact with

sources of reward, while

identifying processes that inhibit

activation (see Behavioral

Activation for Depression by

Martell, Dimidjian, and

Herman-Dunn; or assign

“Identify and Schedule Pleasant

Activities” in the Adult

Psychotherapy Homework

Planner by Jongsma); use

behavioral techniques such as

instruction, rehearsal, role-

playing, role reversal, as needed,

to facilitate activity in the client’s

daily life; reinforce success.

25. Assist the client in developing

skills that increase the likelihood

of deriving pleasure from

UNIPOLAR DEPRESSION

behavioral activation (e.g.,

assertiveness skills, developing

an exercise plan, less

internal/more external focus,

increased social involvement);

reinforce success.

13. Identify important people in life,

past and present, and describe

the quality, good and poor, of

those relationships. (26)

26. Conduct Interpersonal Therapy

(see Interpersonal Psychotherapy

of Depression by Klerman

et al.), beginning with the

assessment of the client’s

“interpersonal inventory” of

important past and present

relationships; develop a case

formulation linking depression

to grief, interpersonal role

disputes, role transitions, and/or

interpersonal deficits).

14. Verbalize an understanding and

resolution of current

interpersonal problems.

(27, 28, 29, 30)

27. For grief, facilitate mourning

and gradually help client

discover new activities and

relationships to compensate

for the loss.

28. For interpersonal disputes,

help the client explore the

relationship, the nature of the

dispute, whether it has reached

an impasse, and available

options to resolve it including

learning and implementing

conflict-resolution skills; if the

relationship has reached an

impasse, consider ways to

change the impasse or to end

the relationship.

29. For role transitions (e.g.,

beginning or ending a

relationship or career, moving,

promotion, retirement,

graduation), help the client

mourn the loss of the old role

while recognizing positive and

negative aspects of the new role,

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454

and taking steps to gain mastery

over the new role.

30. For interpersonal deficits,

help the client develop new

interpersonal skills and

relationships.

15. Learn and implement problem-

solving and decision-making

skills. (31, 32)

31. Conduct Problem-Solving

Therapy (see Problem-Solving

Therapy by D’Zurilla and Nezu)

using techniques such as

psychoeducation, modeling, and

role-playing to teach client

problem-solving skills (i.e.,

defining a problem specifically,

generating possible solutions,

evaluating the pros and cons

of each solution, selecting and

implementing a plan of action,

evaluating the efficacy of the

plan, accepting or revising the

plan); role-play application of

the problem-solving skill to a

real life issue (or assign

“Applying Problem-Solving to

Interpersonal Conflict” in the

Adult Psychotherapy Homework

Planner by Jongsma).

32. Encourage in the client the

development of a positive

problem orientation in which

problems and solving them are

viewed as a natural part of life

and not something to be feared,

despaired, or avoided.

16. Learn and implement conflict

resolution skills to resolve

interpersonal problems. (33, 34)

33. Teach conflict resolution skills

(e.g., empathy, active listening,

“I messages,” respectful

communication, assertiveness

without aggression, compromise);

use psychoeducation, modeling,

role-playing, and rehearsal to

work through several current

conflicts; assign homework

exercises; review and repeat so as

UNIPOLAR DEPRESSION

to integrate their use into the

client’s life.

34. Help the client resolve

depression related to

interpersonal problems through

the use of reassurance and

support, clarification of

cognitive and affective triggers

that ignite conflicts, and active

problem-solving (or assign

“Applying Problem-Solving to

Interpersonal Conflict” in the

Adult Psychotherapy Homework

Planner by Jongsma).

17. Learn and implement relapse

prevention skills. (35, 36, 37)

35. Discuss with the client the

distinction between a lapse and

relapse, associating a lapse with

a rather common, temporary

setback that may involve, for

example, reexperiencing a

depressive thought and/or urge

to withdraw or avoid (perhaps as

related to some loss or conflict)

and a relapse as a sustained

return to a pattern of depressive

thinking and feeling usually

accompanied by interpersonal

withdrawal and/or avoidance.

36. Identify and rehearse with the

client the management of future

situations or circumstances in

which lapses could occur.

37. Build the client’s relapse

prevention skills by helping

him/her identify early warning

signs of relapse and rehearsing

the use of skills learned during

therapy to manage them.

18. Implement mindfulness

techniques for relapse

prevention. (38, 39)

38. Use mindfulness meditation and

cognitive therapy techniques to

help the client learn to recognize

and regulate the negative

thought processes associated

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

456

with depression and to change

his/her relationship with these

thoughts (see Mindfulness-Based

Cognitive Therapy for Depression

by Segal, Williams, and

Teasdale).

39. Work to increase the client’s new

sense of well-being by building

his/her personal strengths

evident in their progress

through therapy (or assign

“Acknowledging My Strengths”

and/or “What Are My Good

Qualities?” in the Adult

Psychotherapy Homework

Planner by Jongsma).

19. Participate in couples therapy to

decrease depression and improve

the relationship. (40)

40. Conduct Behavioral Couples

Therapy using behavioral

interventions focused on

exchanges between partners

including assertive communi-

cation, and problem-solving/

conflict resolution; focus on

consistent use of respectful

assertive communication,

increasing caring exchanges

between partners, and fostering

collaborative problem-solving

(see Integrative Couples Therapy

by Jacobson and Christensen).

20. Verbalize an understanding of

healthy and unhealthy emotions

with the intent of increasing the

use of healthy emotions to guide

actions. (41)

41. Use a process-experiential

approach consistent with

Emotion-Focused Therapy to

create a safe, nurturing

environment in which the client

can process emotions, learning to

identify and regulate unhealthy

feelings and to generate more

adaptive ones that then guide

actions (see Emotion-Focused

Therapy for Depression by

Greenberg and Watson).

21. Verbalize insight into how past

relationships may be influencing

42. Conduct Brief Psychodynamic

Therapy for depression to help

UNIPOLAR DEPRESSION

current experiences with

depression. (42, 43, 44, 45)

the client increase insight into

the role that past relational

patterns may be influencing

current vulnerabilities to

depression; identify core

conflictual themes; process

with the client toward making

changes in current relational

patterns (see Supportive-

Expressive Dynamic Psycho-

therapy of Depression

by Luborsky et al.).

43. Explore experiences from the

client’s childhood that contribute

to current depressed state.

44. Encourage the client to share

feelings of anger regarding pain

inflicted on him/her in childhood

that contributed to current

depressed state.

45. Explain a connection between

previously unexpressed

(repressed) feelings of anger

(and helplessness) and current

state of depression.

22. Use mindfulness and acceptance

strategies to reduce experiential

and cognitive avoidance and

increase value-based behavior.

(46)

46. Conduct Acceptance and

Commitment Therapy (see ACT

for Depression by Zettle)

including mindfulness strategies

to help the client decrease

experiential avoidance,

disconnect thoughts from

actions, accept one’s experience

rather than change or control

symptoms, and behave according

to his/her broader life values;

assist the client in clarifying

his/her goals and values and

commit to behaving accordingly

(or assign “Developing

Noncompetitive Values” in the

Adult Psychotherapy Homework

Planner by Jongsma).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

458

23. Read books on overcoming

depression. (47)

47. Recommend that the client read

self-help books consistent with

the therapeutic approach used

in therapy to help supplement

therapy and foster better

understanding of it (e.g., A

Cognitive Behavioral Workbook

for Depression: A Step-by-Step

Program by Knaus; Solving

Life’s Problems by Nezu, Nezu,

and D’Zurilla; The Interpersonal

Solution to Depression: A

Workbook for Changing How

You Feel by Changing How You

Relate by Pettit and Joiner; The

Mindfulness and Acceptance

Workbook for Depression by

Strosahl and Robinson); process

material read.

24. Increasingly verbalize hopeful

and positive statements

regarding self, others, and the

future. (48, 49)

48. Assign the client to write at least

one positive affirmation

statement daily regarding

himself/herself and the future (or

assign “Positive Self-Talk” in the

Adult Psychotherapy Homework

Planner by Jongsma).

49. Teach the client more about

depression and how to recognize

and accept some sadness as a

normal variation in feeling.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

UNIPOLAR DEPRESSION

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

309.0 Adjustment Disorder With Depressed Mood

300.4 Dysthymic Disorder

296.2x Major Depressive Disorder, Single Episode

296.3x Major Depressive Disorder, Recurrent

310.1 Personality Change Due to Axis III Disorder

311 Depressive Disorder NOS

V62.82 Bereavement

_____

_____________________________________

_____

_____________________________________

Axis II:

301.9 Personality Disorder NOS

799.9 Diagnosis Deferred

V71.09 No Diagnosis

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

296.xx F31.xx Bipolar I Disorder

296.89 F31.81 Bipolar II Disorder

300.4 F34.1 Persistent Depressive Disorder

301.13 F34.0 Cyclothymic Disorder

296.2x F32.x Major Depressive Disorder, Single Episode

296.3x F33.x Major Depressive Disorder, Recurrent

Episode

295.70 F25.0 Schizoaffective Disorder, Bipolar Type

295.70 F25.1 Schizoaffective Disorder, Depressive Type

310.1 F07.0 Personality Change Due to Another

Medical Condition

V62.82 Z63.4 Uncomplicated Bereavement

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

VOCATIONAL STRESS

BEHAVIORAL DEFINITIONS

1. Feelings of anxiety and depression secondary to interpersonal conflict in

the work setting.

2. Feelings of inadequacy, fear, and failure secondary to severe business

losses.

3. Fear of failure secondary to success or promotion that increases perceived

expectations for greater success.

4. Rebellion against and/or conflicts with authority figures in the

employment situation.

5. Feelings of anxiety and depression secondary to being fired or laid off,

resulting in unemployment.

6. Anxiety related to perceived or actual job jeopardy.

7. Feelings of depression and anxiety related to complaints of job

dissatisfaction or the stress of employment responsibilities.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

LONG-TERM GOALS

1. Improve satisfaction and comfort surrounding coworker relationships.

2. Increase sense of confidence and competence in dealing with work

responsibilities.

3. Be cooperative with and accepting of supervision of direction in the work

setting.

VOCATIONAL STRESS

4. Increase sense of self-esteem and elevation of mood in spite of

unemployment.

5. Increase job security as a result of more positive evaluation of

performance by a supervisor.

6. Pursue employment consistency with a reasonably hopeful and positive

attitude.

7. Increase job satisfaction and performance due to implementation of

assertiveness and stress management strategies.

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

__. _____________________________________________________________

_____________________________________________________________

SHORT-TERM

OBJECTIVES

THERAPEUTIC

INTERVENTIONS

1. Describe the nature and history

of the vocational stress. (1, 2)

1. Establish rapport with the client

toward building a therapeutic

alliance.

2. Assess the client’s history of

vocational stress including

perceived sources, client distress

and disability, adaptive and

maladaptive coping actions,

and goals of treatment.

2. Complete psychological tests

designed to assess the nature and

severity of social anxiety and

avoidance. (3)

3. Administer a measure assessing

the client’s stressors and/or

appraisals of stress and/or

general sources of stress (e.g.,

The Derogatis Stress Profile; The

Daily Hassles and Uplifts Scale).

3. Disclose any history of substance

use that may contribute to and

complicate the treatment of

vocational stress. (4)

4. Arrange for a substance abuse

evaluation and refer the client

for treatment if the evaluation

recommends it (see the

Substance Use chapter in

this Planner).

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

462

4. Provide behavioral, emotional,

and attitudinal information

toward an assessment of

specifiers relevant to a DSM

diagnosis, the efficacy of

treatment, and the nature of the

therapy relationship. (5, 6, 7, 8)

5. Assess the client’s level of insight

(syntonic versus dystonic)

toward the “presenting

problems” (e.g., demonstrates

good insight into the

problematic nature of the

“described behavior,” agrees

with others’ concern, and is

motivated to work on change;

demonstrates ambivalence

regarding the “problem

described” and is reluctant to

address the issue as a concern;

or demonstrates resistance

regarding acknowledgment

of the “problem described,”

is not concerned, and has no

motivation to change).

6. Assess the client for evidence

of research-based correlated

disorders (e.g., oppositional

defiant behavior with ADHD,

depression secondary to an

anxiety disorder) including

vulnerability to suicide, if

appropriate (e.g., increased

suicide risk when comorbid

depression is evident).

7. Assess for any issues of age,

gender, or culture that could

help explain the client’s currently

defined “problem behavior” and

factors that could offer a better

understanding of the client’s

behavior.

8. Assess for the severity of the

level of impairment to the

client’s functioning to determine

appropriate level of care (e.g.,

the behavior noted creates mild,

moderate, severe, or very severe

impairment in social, relational,

vocational, or occupational

endeavors); continuously assess

VOCATIONAL STRESS

this severity of impairment as

well as the efficacy of treatment

(e.g., the client no longer

demonstrates severe impairment

but the presenting problem now

is causing mild or moderate

impairment).

5. Cooperate with an evaluation by

a physician for psychotropic

medication. (9)

9. Arrange for a medication

evaluation by a psychiatrist to

assess the potential usefulness

of a medication intervention.

6. Take prescribed psychotropic

medication on a consistent basis.

(10)

10. Monitor the client for

prescription compliance, side

effects, and overall effectiveness

of the medication; consult with

the prescribing physician at

regular intervals.

7. Participate in Stress Inoculation

Training to alleviate stress and

achieve personal goals.

(11, 12, 13, 14, 15)

11. Use a Stress Inoculation

Training approach beginning

with a functional assessment of

the stress problem including

the contribution of the work

environment, the client, and

their interaction (see Stress

Inoculation Training by

Meichenbaum).

12. Assist the client in conceptualiz-

ing stress including the role of

cognitive appraisals, personal

and interpersonal skills, and

skills deficits, tying the

conceptualization into the

rationale for treatment.

13. Use cognitive-behavioral

techniques (e.g., instruction,

modeling, practice, rehearsal,

graduated application, and

generalization) to train tailored

personal and interpersonal

skills (e.g., calming/relaxation,

cognitive, coping, social/

communication, problem-solving,

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

464

etc.) to facilitate adaptation and

management of stress.

14. Assign the client exercises in

which he/she applies newly

learned skills in increasingly

challenging stressful situations;

review; reinforce successes;

problem-solve obstacles toward

effective use.

15. Do relapse prevention training

using common considerations

such as differentiating a lapse

from relapse, identifying and

rehearsing the management of

high-risk situations; and

continued, everyday application

of skills learned in therapy.

8. Identify and implement

behavioral changes that could be

made in workplace interactions

to help resolve conflicts with

coworkers or supervisors.

(16, 17)

16. Assign the client to write a plan

for constructive action (e.g.,

polite compliance with

directedness, initiate a smiling

greeting, compliment others’

work, avoid critical judgments)

that contains various alternatives

to coworker or supervisor

conflict.

17. Use role-playing, behavioral

rehearsal, and role rehearsal to

increase the client’s probability

of positive encounters and to

reduce anxiety with others in

employment situation or job

search (recommend Working

Anger: Preventing and Resolving

Conflict on the Job by Potter-

Effron).

9. Implement assertiveness skills.

(18)

18. Train the client in assertiveness

skills or refer to assertiveness

training class that teaches

effective communication of

needs and feelings without

aggression or defensiveness.

VOCATIONAL STRESS

10. Learn and implement problem-

solving skills. (19)

19. Conduct Problem-Solving

Therapy (see Problem-Solving

Therapy by D’Zurilla and Nezu)

using techniques such as

psychoeducation, modeling, and

role-playing to teach the client

problem-solving skills (i.e.,

defining a problem specifically,

generating possible solutions,

evaluating the pros and cons

of each solution, selecting and

implementing a plan of action,

evaluating the efficacy of the

plan, accepting or revising the

plan); role-play application

of the problem-solving skill

to a real life issue (or assign

“Applying Problem-Solving to

Interpersonal Conflict” in the

Adult Psychotherapy Homework

Planner by Jongsma).

11. Verbalize healthy, realistic

cognitive messages that promote

harmony with others, self-

acceptance, and self-confidence.

(20, 21)

20. Teach the client the connection

between thoughts, feelings, and

behavior; train the client in the

development of more realistic,

healthy cognitive messages that

relieve anxiety and depression.

21. Require the client to keep a daily

record of self-defeating thoughts

(e.g., thoughts of hopelessness,

worthlessness, rejection,

catastrophizing, negatively

predicting the future); challenge

each thought for accuracy, then

replace each dysfunctional

thought with one that is positive

and self-enhancing (or assign

“Journal and Replace Self-

Defeating Thoughts” in the

Adult Psychotherapy Homework

Planner by Jongsma).

12. Identify and replace distorted

cognitive messages associated

with feelings of job stress.

(22, 23, 24)

22. Probe and clarify the client’s

emotions surrounding his/her

vocational stress.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

466

23. Assess the client’s distorted

cognitive messages and schema

that foster his/her vocational

stress; replace these messages

with positive cognitions (or

assign “Negative Thoughts

Trigger Negative Feelings” in the

Adult Psychotherapy Homework

Planner by Jongsma).

24. Confront the client’s pattern

of catastrophizing situations

leading to immobilizing anxiety;

replace these messages with

realistic thoughts.

13. Learn and implement calming

skills to reduce overall anxiety

and manage anxiety symptoms.

(25, 26, 27)

25. Teach the client calming/

relaxation skills (e.g., applied

relaxation, progressive muscle

relaxation, cue controlled

relaxation, mindful breathing,

biofeedback) and how to

discriminate better between

relaxation and tension; teach

the client how to apply these

skills to his/her daily life (e.g.,

New Directions in Progressive

Muscle Relaxation by Bernstein,

Borkovec, and Hazlett-Stevens;

The Relaxation and Stress

Reduction Workbook by Davis,

Robbins-Eshelman, and

McKay).

26. Assign the client homework

each session in which he/she

practices relaxation exercises

daily, gradually applying them

progressively from non-anxiety-

provoking to anxiety-provoking

situations; review and reinforce

success while providing

corrective feedback toward

improvement.

27. Assign the client to read about

progressive muscle relaxation

and other calming strategies in

VOCATIONAL STRESS

relevant books or treatment

manuals (e.g., Mastery of Your

Anxiety and Worry—Workbook

by Craske and Barlow; The

Daily Relaxer: Relax Your Body,

Calm Your Mind, and Refresh

Your Spirit by McKay and

Fanning).

14. Identify own role in the conflict

with coworkers or supervisor.

(28, 29)

28. Clarify the nature of the client’s

conflicts in the work setting.

29. Help the client identify his/her

own role in the conflict,

attempting to represent the

other party’s point of view.

15. Identify any personal problems

that may be causing conflict in

the employment setting. (30)

30. Explore the client’s transfer

of personal problems to the

employment situation.

16. Review family-of-origin history

to determine roots for

interpersonal conflict. (31)

31. Probe the client’s family-of-

origin history for causes of

current interpersonal conflict

patterns that are being reenacted

in the work setting.

17. Identify patterns of similar

conflict with people outside the

work environment. (32)

32. Explore the client’s patterns of

interpersonal conflict that occur

beyond the work setting but are

repeated in the work setting.

18. Replace projection of

responsibility for the conflict

with acceptance of responsibility

for own role in conflict. (33, 34)

33. Confront the client’s projection

of responsibility for his/her

behavior and feelings onto

others; emphasize his/her need to

examine his/her own role in the

conflict.

34. Reinforce the client’s acceptance

of responsibility for personal

feelings and behavior as they

contribute to the conflict in the

work setting.

19. Identify the effect that

vocational stress has on feelings

toward self and relationships

with significant others. (35, 36)

35. Explore the effect of the client’s

vocational stress on his/her intra-

and interpersonal dynamics with

friends and family.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

468

36. Facilitate a family therapy

session in which feelings of

family members can be aired and

clarified regarding the client’s

vocational situation.

20. Develop and verbalize a plan for

constructive action to reduce

vocational stress. (37)

37. Assist the client in developing a

plan to react positively to his/her

vocational situation (or assign

“My Vocational Action Plan”

in the Adult Psychotherapy

Homework Planner by Jongsma);

process the proactive plan and

assist in its implementation.

21. Verbalize an understanding of

circumstances that led up to

being terminated from

employment. (38)

38. Explore the causes for the

client’s termination of

employment that may have been

beyond his/her control.

22. Cease self-disparaging comments

that are based on perceived

failure at workplace.

(39, 40, 41, 42)

39. Probe childhood history for

roots of feelings of inadequacy,

fear of failure, or fear of success.

40. Assist the client in developing

a list of realistic, positive

statements about himself/herself

(or assign “Positive Self-Talk”

in the Adult Psychotherapy

Homework Planner by Jongsma);

reinforce the client’s realistic self-

appraisal of successes and failures

at workplace (recommend The

Self-Esteem Companion: Simple

Exercises to Help You Challenge

Your Inner Critic & Celebrate

Your Personal Strengths by

McKay et al.).

41. Assign the client to separately

list his/her positive traits, talents,

and successful accomplishments,

and then the people who care

for, respect, and value him/her

(or assign “What Are My

Good Qualities?” in the Adult

Psychotherapy Homework

Planner by Jongsma); process

VOCATIONAL STRESS

these lists as a basis for genuine

gratitude and self-worth.

42. Teach the client that the ultimate

worth of an individual is not

measured in material or

vocational success but in service

to a higher power and others.

23. Outline plan for job search.

(43, 44, 45)

43. Help the client develop a written

job plan that contains specific

attainable objectives for job

search (recommend What Color

Is Your Parachute?: A Practical

Manual for Job-Hunters and

Career-Changers by Bolles).

44. Assign the client to choose jobs

for follow up in the want ads and

to ask friends and family about

job opportunities (recommend

Fearless Job Hunting: Powerful

Psychological Strategies for

Getting the Job You Want by

Knaus et al.).

45. Assign the client to attend a job

search class or resumé-writing

seminar.

24. Report on job search experiences

and feelings surrounding these

experiences. (46)

46. Monitor, encourage, and process

the client’s search for

employment.

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

__ . ___________________________

___________________________

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

470

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I:

309.0 Adjustment Disorder With Depressed Mood

300.4 Dysthymic Disorder

296.xx Major Depressive Disorder

V62.2 Occupational Problem

309.24 Adjustment Disorder With Anxiety

303.90 Alcohol Dependence

304.20 Cocaine Dependence

304.80 Polysubstance Dependence

_____

_____________________________________

_____

_____________________________________

Axis II:

301.0 Paranoid Personality Disorder

301.81 Narcissistic Personality Disorder

301.7 Antisocial Personality Disorder

301.9 Personality Disorder NOS

_____

_____________________________________

_____

_____________________________________

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM

ICD-10-CM DSM-5 Disorder, Condition, or Problem

309.0 F43.21 Adjustment Disorder, With Depressed

Mood

300.4 F34.1 Persistent Depressive Disorder

296.xx F32.x Major Depressive Disorder, Single Episode

296.xx F33.x Major Depressive Disorder, Recurrent

Episode

V62.2 Z56.9 Other Problem Related to Employment

309.24 F43.22 Adjustment Disorder, With Anxiety

303.90 F10.20 Alcohol Use Disorder, Moderate or Severe

304.20 F14.20 Cocaine Use Disorder, Moderate or Severe

301.0 F60.0 Paranoid Personality Disorder

301.81 F60.81 Narcissistic Personality Disorder

301.7 F60.2 Antisocial Personality Disorder

301.9 F60.9 Unspecified Personality Disorder

VOCATIONAL STRESS

471

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through

September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-

CM codes are associated with more than one ICD-10-CM and DSM-5 Disorder, Condition,

or Problem. In addition, some ICD-9-CM disorders have been discontinued resulting in

multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-

9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental

Disorders (2013) for details.

indicates that the Objective/Intervention is consistent with those found in evidence-based

treatments.

472

Appendix A

BIBLIOTHERAPY SUGGESTIONS

General

Many references are made throughout the chapters to a therapeutic

homework resource that was developed by the authors as a corollary to this

Complete Adult Psychotherapy Treatment Planner, Fifth Edition (Jongsma,

Peterson, and Bruce). This frequently cited homework resource book is:

Jongsma, A. E. (2014). Adult psychotherapy homework planner (5th ed.). Hoboken,

NJ: Wiley.

Jongsma, A., Peterson, L., & McInnis, W. (2014). Adolescent psychotherapy homework

planner. Hoboken, NJ: Wiley.

O’Leary, K., Heyman, R., & Jongsma, A. (2011). The couples psychotherapy treatment

planner. Hoboken, NJ: Wiley.

Anger Control Problems

Cannon, M. (2011). The gift of anger: Seven steps to uncover the meaning of anger

and gain awareness, true strength, and peace. Oakland, CA: New Harbinger.

Carter, L. (2003). The anger trap. San Francisco, CA: Jossey-Bass.

Deffenbacher, J. L., & McKay, M. (2000). Overcoming situational and general anger:

Client manual (Best practices for therapy). Oakland, CA: New Harbinger.

Fanning, P., & McKay, M. (2008). The relaxation and stress reduction audio series.

Oakland, CA: New Harbinger Publications.

Hayes, S. C. (2005). Get out of your mind and into life: The new acceptance and

commitment therapy. Oakland, CA: New Harbinger Publications.

Kassinove, H., & Tafrate, R. C. (2009). Anger management for everyone: Seven

proven methods to control anger. Atascadero, CA: Impact.

BIBLIOTHERAPY SUGGESTIONS

Lerner, H. (2005). The dance of anger: A woman’s guide to changing the patterns of

intimate relationships. New York, NY: Perennial Currents.

McKay, M., & Rogers, P. (2000). The anger control workbook. Oakland, CA: New

Harbinger.

McKay, M., Rogers, P., & McKay, J. (2003). When anger hurts. Oakland, CA: New

Harbinger.

Nay, W. R. (2012). Taking charge of anger. New York, NY: Guilford Press.

Petracek, L. (2004). The anger workbook for women: How to keep your anger from

undermining your self-esteem, your emotional balance, and your relationships.

Oakland, CA: New Harbinger.

Potter-Efron, R. T. (2005). Angry all the time: An emergency guide to anger control.

Oakland, CA: New Harbinger.

Potter-Efron, R. T., & Potter-Efron, P. S. (2006). Letting go of anger: The eleven

most common anger styles and what to do about them. Oakland, CA: New

Harbinger.

Rosellini, G., & Worden, M. (1997). Of course you’re angry. San Francisco, CA:

Harper Hazelden.

Rubin, T. I. (1998). The angry book. New York: Touchstone.

Smedes, L. (2007). Forgive and forget: Healing the hurts we don’t deserve. San

Francisco, CA: HarperOne.

Tavris, C. (1989). Anger: The misunderstood emotion. New York: Touchstone Books.

Weisinger, H. (1985). Dr. Weisinger’s anger work-out book. New York: Quill.

Antisocial Behavior

Carnes, P. (2001). Out of the shadows: Understanding sexual addiction. Minneapolis,

MN: Hazelden.

Katherine, A. (1994). Boundaries: Where you end and I begin. Minneapolis, MN:

Hazelden.

Pittman, F. (1998). Grow up! New York: Golden Books.

Williams, R., & Williams, V. (1998). Anger kills. New York: HarperTorch.

Anxiety

Benson, H. (2000). The relaxation response. New York, NY: Morrow.

Bourne, E. (2011). The anxiety and phobia workbook. Oakland, CA: New Harbinger.

Burns, D. (1999). Ten days to self-esteem. New York, NY: Morrow.

Clark, D. A., & Beck, A. T. (2012). The anxiety and worry workbook: The cognitive

and behavioral solution. New York, NY: Guilford Press.

Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry:

Workbook. New York, NY: Oxford University Press.

Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

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Fanning, P., & McKay, M. (2008). Applied relaxation training (Relaxation and stress

reduction audio series). Oakland, CA: New Harbinger.

Forsyth, J., & Eifert, G. (2008). The mindfulness and acceptance workbook for anxiety:

A guide to breaking free from anxiety, phobias, and worry using acceptance and

commitment therapy. Oakland, CA: New Harbinger.

Freeston, M., & Meares, K. (2008). Overcoming worry: A self-help guide using

cognitive behavioral techniques. New York: Basic Books.

Jeffers, S. (2006). Feel the fear . . . and do it anyway. New York: Ballantine Books.

Knaus, W. (2008). The cognitive behavioral workbook for anxiety: A step-by-step

program. Oakland, CA: New Harbinger.

Leahy, R. (2006). The worry cure: Seven steps to stop worry from stopping you. New

York, NY: Three Rivers.

Marks, I. (2005). Living with fear: Understanding and coping with anxiety. New

York, NY: McGraw-Hill.

Marra, T. (2004). Depressed and anxious: The dialectical behavior therapy workbook

for overcoming depression and anxiety. Oakland, CA: New Harbinger.

McKay, M., Davis, M., & Fanning, P. (2011). Thoughts and feelings: Taking control

of your moods and your life. Oakland, CA: New Harbinger.

McKay, M., & White. J. (1999). Overcoming generalized anxiety disorder—Client

manual: A relaxation, cognitive restructuring, and exposure-based protocol for the

treatment of GAD. Oakland, CA: New Harbinger.

Orsillo, S. M., & Roemer, L. (2011). The mindful way through anxiety: Break free

from chronic worry and reclaim your life. New York, NY: Guilford Press.

Tolin, D. (2012). Face your fears: A proven plan to beat anxiety, panic, phobias, and

obsessions. Hoboken, NJ: Wiley.

White, J. (2008). Overcoming generalized anxiety disorder—client manual: A

relaxation, cognitive restructuring, and exposure-based protocol for the treatment

of GAD. Oakland, CA: New Harbinger.

Attention Deficit Disorder (ADD)—Adult

Davis, M., Robbins-Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Hallowell, E., & Ratey, J. (2011). Driven to distraction. New York: Anchor.

Kelly, K., & Ramundo, P. (1993). You mean I’m not lazy, stupid, or crazy?! The

classic self-help book for adults with attention deficit disorder. New York:

Scribner.

Nadeau, K. (1996). Adventures in fast forward. Levittown, PA: Brunner/Mazel.

Quinn, P., & Stern, J. (2008). Putting on the brakes. New York, NY: Magination

Press.

Safren, S., Sprich, S., Perlman, C., & Otto, M. (2005). Mastering your adult ADHD:

A cognitive-behavioral treatment program—Client workbook. New York, NY:

Oxford.

BIBLIOTHERAPY SUGGESTIONS

Weiss, L. (2005). The attention deficit disorder in adults workbook. Dallas, TX:

Taylor Publishing.

Wender, P. (2001). ADHD: Attention-deficit hyperactivity disorder in children,

adolescents, and adults. New York, NY: Oxford University Press.

Bipolar Disorder—Depression

Basco, M. R. (2005). The bipolar workbook: Tools for controlling your mood swings.

New York, NY: Guilford Press.

Bauer, M., Kilbourne, A., Greenwald, D., & Ludman, E. (2009).

Overcoming bipolar

disorder: A comprehensive workbook for managing your symptoms and achieving

your life goals

. Oakland, CA: New Harbinger.

Caponigro, J. M., Lee, E. H., Johnson, S. L., & Kring, A. M. (2012). Bipolar

disorder: A guide for the newly diagnosed. Oakland, CA: New Harbinger.

Copeland, M. (2000). The depression workbook: A guide for living with depression and

manic depression. Oakland, CA: New Harbinger.

Fast, J., & Preston, J. (2012). Loving someone with bipolar disorder: Understanding

and helping your partner. Oakland, CA: New Harbinger.

Last, C. G. (2009). When someone you love is bipolar: Help and support for you and

your partner. New York, NY: Guilford Press.

Miklowitz, D. (2010). The bipolar disorder survival guide: What you and your family

need to know. New York, NY: Guilford Press.

White, R., & Preston, J. (2009). Bipolar 101: A practical guide to identifying triggers,

managing medications, coping with symptoms, and more. Oakland, CA: New

Harbinger.

Bipolar Disorder—Mania

Basco, M. R. (2005). The bipolar workbook: Tools for controlling your mood swings.

New York, NY: Guilford Press.

Bauer, M., Kilbourne, A., Greenwald, D., & Ludman, E. (2009).

Overcoming bipolar

disorder: A comprehensive workbook for managing your symptoms and achieving

your life goals

. Oakland, CA: New Harbinger.

Bradley, L. (2004). Manic depression: How to live while loving a manic depressive.

Houston, TX: Emerald Ink.

Copeland, M. (2000). The depression workbook: A guide for living with depression and

manic depression. Oakland, CA: New Harbinger.

Fast, J., & Preston, J. (2012). Loving someone with bipolar disorder: Understanding

and helping your partner. Oakland, CA: New Harbinger.

Granet, R., & Ferber, E. (1999). Why am I up, why am I down?: Understanding

bipolar disorder. New York, NY: Dell.

Last, C. G. (2009). When someone you love is bipolar: Help and support for you and

your partner. New York: Guilford Press.

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Miklowitz, D. (2010).

The bipolar disorder survival guide: What you and your family

need to know.

New York: Guilford Press.

Mondimore, F. (2006). Bipolar disorder: A guide for patients and families. Baltimore:

Johns Hopkins University Press.

Price, P. (2005). The cyclothymia workbook: Learn how to manage your mood swings

and lead a balanced life. Oakland, CA: New Harbinger.

White, R., & Preston, J. (2009). Bipolar 101: A practical guide to identifying triggers,

managing medications, coping with symptoms, and more. Oakland, CA: New

Harbinger.

Borderline Personality Disorder

Chapman, A., Getz, K., & Hoffman, P. (2007). The borderline personality disorder

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New Harbinger.

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with skills from DBT and other treatments. Oakland, CA: New Harbinger.

Katherine, A. (1994). Boundaries: Where you end and I begin. Minneapolis, MN:

Hazelden.

Kreisman, J., & Straus, H. (2010). I hate you—Don’t leave me. New York, NY:

Perigee Trade.

McKay, M., & Wood, J. (2011). The dialectical behavior therapy diary: Monitoring

your emotional regulation day by day. Oakland, CA: New Harbinger.

McKay, M., Wood, J., & Brantley, J. (2007). Dialectical behavior therapy skills

workbook. Oakland, CA: New Harbinger.

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Spradlin, S. (2003). Don’t let your emotions run your life: How dialectical behavior

therapy can put you in control. Oakland, CA: New Harbinger.

For more resources related to dialectical behavior therapy and borderline personality

see Behavioraltech, LLC online at http://behavioraltech.org/index.cfm

Childhood Trauma

Adams, C., & Fay, J. (1992). Helping your child recover from sexual abuse. Seattle:

University of Washington Press.

Black, C. (2002). It will never happen to me: Growing up with addiction as youngsters,

adolescents, and adults. Minneapolis, MN: Hazelden.

BIBLIOTHERAPY SUGGESTIONS

477

Bradshaw, J. (1992). Homecoming: Reclaiming and championing your inner child.

New York, NY: Bantam Books.

Bradshaw, J. (2005). Healing the shame that binds you. Deerfield Beach, FL: Health

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behavioral techniques. New York, NY: New York University Press.

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Anchor.

Pittman, F. (1998). Grow up! New York, NY: Golden Books.

Smedes, L. (2007). Forgive and forget: Healing the hurts we don’t deserve. San

Francisco, CA: HarperOne.

Whitfield, C. (1987). Healing the child within. Deerfield Beach, FL: Health

Communications.

Whitfield, C. (1990). A gift to myself. Deerfield Beach, FL: Health Communications.

Chronic Pain

Benson, H. (1997). Timeless healing: The power and biology of belief. New York,

NY: Scribner.

Benson, H. (2000). The relaxation response. New York, NY: Morrow.

Burns, D. (1999). Feeling good: The new mood therapy. New York, NY: Harper.

Burns, D. (1999). The feeling good handbook. New York, NY: Blume.

Burns, D. (1999). Ten days to self-esteem. New York, NY: Morrow.

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step guide for coping with and overcoming pain. Oakland, CA: New Harbinger.

Caudill, M. (2008). Managing pain before it manages you. New York, NY: Guilford

Press.

Cousins, N. (2005). Anatomy of an illness: As perceived by the patient. New York,

NY: Norton.

Dahl, J., & Lundgren, T. (2006). Living beyond your pain: Using acceptance and

commitment therapy to ease chronic pain. Oakland, CA: New Harbinger.

Davis, M., Robbins-Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Duckro, P., Richardson, W., & Marshall, J. (1999). Taking control of your

headaches. New York, NY: Guilford Press.

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Fanning, P., & McKay, M. (2008). Applied relaxation training (Relaxation and stress

reduction audio series). Oakland, CA: New Harbinger.

Gardner-Nix, J. (2009). The mindfulness solution to pain. Oakland, CA: New

Harbinger.

Hayes, S. C. (2005). Get out of your mind and into your life: The new acceptance and

commitment therapy. New York, NY: New Harbinger.

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Fitness Information Technology.

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to pain relief using the Behavioral Assessment of Pain Questionnaire. Oakland,

CA: New Harbinger.

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workbook. New York, NY: Oxford University Press.

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Turk, D., & Winter, F. (2005). The pain survival guide: How to reclaim your life.

Washington, DC: APA Press.

Cognitive Deficits

Alzheimer’s Association: www.alz.org

Alzheimer’s Foundation of America: www.alzfdn.org

American Brain Tumor Association: www.abta.org

American Stroke Association: www.strokeassociation.org

Attention Deficit Disorder Association: www.add.org

Brain Injury Association of America: www.biausa.org

Fraser, R., Kraft, G., Ehde, D., & Johnson, K. (2006). The MS workbook: Living

fully with multiple sclerosis. Oakland, CA: New Harbinger.

Hallowell, E. M., & Ratey, J. J. (2011). Driven to distraction (revised): Recognizing

and coping with attention deficit disorder. New York, NY: Anchor.

Levine, P. (2008).

Stronger after stroke: Your roadmap to recovery.

New York, NY:

Demos Health.

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Oakland, CA: New Harbinger.

Mace, N. L., & Rabins, P. V. (2011). The 36-hour day: A family guide to caring

for people who have Alzheimer’s disease, related dementias, and memory loss

(5th ed.). Baltimore, MD: Johns Hopkins Press Health Book.

Mark, V., & Mark, J. (2000).

Reversing memory loss: Proven methods for regaining,

strengthening, and preserving your memory.

New York, NY: Mariner.

Mason, D. J. (2004). The mild traumatic brain injury workbook. Oakland, CA: New

Harbinger.

Mason, D. J., & Kohn, M. (2001). The memory workbook. Oakland, CA: New

Harbinger.

Mason, D. J., & Smith, S. (2005). The memory doctor: Fun, simple techniques to

improve memory and boost your brain power. Oakland, CA: New Harbinger.

BIBLIOTHERAPY SUGGESTIONS

Multiple Sclerosis Association of America: www.msassociation.org

National Stroke Association: www.stroke.org

Niemeier, J. P., & Karol, R. L. (2011). Overcoming grief and loss after brain injury.

New York, NY: Oxford University Press.

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coaster when someone you love has attention deficit disorder. San Francisco, CA:

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international assimilative system, adapted to all persons, all studies, and all

occupations . . . complete course of instruction. Los Angeles: University of

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Wayman, L. (2011).

A loving approach to dementia care: Making meaningful

connections with the person who has Alzheimer’s disease or other dementia or

memory loss

. Baltimore, MD: Johns Hopkins University Press.

Weiner, W. J., & Shulman, L. M. (2007). Parkinson’s disease: A complete guide for

patients and families (2nd ed.). Baltimore, MD: Johns Hopkins University Press.

Dependency

Alberti, R., & Emmons, M. (2008). Your perfect right: Assertiveness and equality in

your life and relationships. San Luis Obispo, CA: Impact.

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caring for yourself. Minneapolis, MN: Hazelden.

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Beattie, M. (2011). Codependent no more workbook. Minneapolis, MN: Hazelden.

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Katherine, A. (1994). Boundaries: Where you end and I begin. Minneapolis, MN:

Hazelden.

Norwood, R. (2008). Women who love too much. New York, NY: Gallery Books.

Pittman, F. (1998). Grow up! New York, NY: Golden Books.

Smith, M. (1985). When I say no, I feel guilty. New York, NY: Bantam Books.

Whitfield, C. (1990). A gift to myself. Deerfield Beach, FL: Health Communications.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

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Dissociation

Boon, S., Steele, K., & van der Hart, O. (2011). Coping with trauma-related

dissociation: Skills training for patients and therapists. New York, NY: Norton.

Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry:

Workbook. New York, NY: Oxford University Press.

Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Follette, V., & Pistorello, J. (2007). Finding life beyond trauma: Using acceptance and

commitment therapy to heal from post-traumatic stress and trauma-related

problems. Oakland, CA: New Harbinger.

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McGraw-Hill.

Neziroglu, F., & Donnelly, K. (2010). Overcoming depersonalization disorder: A

mindfulness and acceptance guide to conquering feelings of numbness and

unreality. Oakland, CA: New Harbinger.

Eating Disorders and Obesity

Albers, S. (2009). Eat, drink, and be mindful: How to end your struggle with mindless

eating and start savoring food with intention and joy. Oakland, CA: New

Harbinger.

Apple, R., & Agras, W. (2007). Overcoming your eating disorders: A cognitive-

behavioral therapy approach for bulimia nervosa and binge-eating disorder—

Workbook. New York, NY: Oxford University Press.

Brownell, K. (2004). The LEARN program for weight management. Euless, TX:

American Health.

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causes, treatments, and prevention of eating disorders. New York, NY: McGraw-

Hill.

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diet/binge cycle and live a healthier, more satisfying life. Seattle, WA:

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Minneapolis, MN: Hazelden.

Katzman, D. K., & Pinhas, L. (2005). Help for eating disorders: A parent’s guide to

symptoms, causes and treatments. Toronto, Canada: Robert Rose.

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weight management: A step-by-step program. Oakland, CA: New Harbinger.

Lock, J., & le Grange, D. (2005). Help your teenager beat an eating disorder.

New York, NY: Guilford Press.

BIBLIOTHERAPY SUGGESTIONS

Nash, J. (1999). Binge no more: Your guide to overcoming disordered eating. Oakland,

CA: New Harbinger.

Rodin, J. (1993). Body traps: Breaking the binds that keep you from feeling good

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Educational Deficits

Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry:

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Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

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Family Conflict

Alberti, R., & Emmons, M. (2008). Your perfect right: Assertiveness and equality in

your life and relationships. San Luis Obispo, CA: Impact.

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Covey, S. R. (1999). The 7 habits of highly effective families: Building a beautiful

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grown-ups. Burlington, VT: Waterfront Books.

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manage time, build communication, and share responsibility week by week.

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NY: Mariner Books.

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ParentMagic.

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Ellyn, IL: ParentMagic.

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Female Sexual Dysfunction

Barbach, L. (1983). For each other: Sharing sexual intimacy. New York, NY:

Anchor.

Barbach, L. (2000). For yourself: The fulfillment of female sexuality. New York, NY:

Signet.

Cervenka, K. (2003). In the mood, again: A couple’s guide to reawakening sexual

desire. Oakland, CA: New Harbinger.

Comfort, A. (2002). The joy of sex: Fully revised & completely updated for the 21st

century. New York, NY: Crown.

Glazer, H. (2002). The vulvodynia survival guide: How to overcome painful vaginal

symptoms and enjoy an active lifestyle. Oakland, CA: New Harbinger.

Heiman, J., & LoPiccolo, J. (1988). Becoming orgasmic: A sexual and personal

growth program for women. New York, NY: Fireside.

BIBLIOTHERAPY SUGGESTIONS

Herbenick, D. (2009). Because it feels good: A woman’s guide to sexual pleasure and

satisfaction. Emmaus, PA: Rodale Books.

Herbenick, D. (2012). Sex made easy: Your awkward questions answered—for better,

smarter, amazing sex. Philadelphia, PA: Running Press.

Kaplan, H. S. (1988). The illustrated manual of sex therapy. New York, NY:

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Katz, D., & Tabisel, R. L. (2002). Private pain: It’s about life, not just sex. Plainview,

NY: Katz-Tabi.

McCarthy, B., & McCarthy, E. (2003).

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help low-sex and no-sex marriages.

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McCarthy, B., & McCarthy, E. (2012).

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Penner, C., & Penner, J. (2003). The gift of sex: A guide to sexual fulfillment.

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Schnarch, D., & Maddock, J. (2003). Resurrecting sex: Solving sexual problems and

revolutionizing your relationship. New York, NY: HarperCollins.

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Financial Stress

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Burkett, L. (2010). Debt free living: Eliminating debt in a new economy. Chicago, IL:

Moody.

Lawrence, J. (2011). The budget kit: The common cents money management workbook.

New York, NY: Kaplan.

Loungo, T. (1997). 10 minute guide to household budgeting. New York, NY:

Macmillan.

Mundis, J. (2003). How to get out of debt, stay out of debt, and live prosperously. New

York, NY: Bantam Books.

Ramsey, D. (2002). Financial peace revisited. New York, NY: Viking.

Ramsey, D. (2009). The total money makeover: A proven plan for financial fitness.

Nashville, TN: Thomas Nelson.

Vaz-Oxlade, G. (2010). Debt-free forever: Take control of your money and your life.

New York, NY: The Experiment.

Grief/Loss Unresolved

Albom, M. (2002). Tuesdays with Morrie. New York, NY: Broadway.

Bernstein, J. (1998). When the bough breaks: Forever after the death of a son or

daughter. Riverside, NJ: Andrews McMeel.

Courtney, S. (2010). Through the eyes of a dove: A book for bereaved parents. New

York, NY: Eloquent Books.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

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Cross, D. (2010). A new normal: Learning to live with grief and loss. Henderson, NV:

Darlene Cross.

Harris Lord, J. (2006). No time for goodbyes: Coping with sorrow, anger, and injustice

after a tragic death. Burnsville, NC: Compassion Books.

James, J., & Friedman, R. (2009). The grief recovery handbook: The action program for

moving beyond death, divorce, and other losses. New York, NY: HarperCollins.

Kushner, H. (2004). When bad things happen to good people. New York, NY:

Anchor.

Lewis, C. S. (2001). A grief observed. San Francisco, CA: HarperOne.

Moore, T. (2005). Dark nights of the soul: A guide to finding your way through life’s

ordeals. New York, NY: Gotham.

Rando, T. (1995). Grieving: How to go on living when someone you love dies.

Lanham, MD: Lexington Books.

Smedes, L. (2000). How can it be all right when everything is all wrong? New York,

NY: Doubleday.

Smedes, L. (2007). Forgive and forget: Healing the hurts we don’t deserve. San

Francisco, CA: HarperOne.

Tatelbaum, J. (1993). The courage to grieve. New York, NY: Hutchinson.

Westberg, G. (2010). Good grief. Minneapolis, MN: Fortress Press.

Wolterstorff, N. (1987). Lament for a son. Grand Rapids, MI: Eerdmans.

Zonnebelt-Smeenge, S., & DeVries, R. (1998). Getting to the other side of grief:

Overcoming the loss of a spouse. Grand Rapids, MI: Baker Books.

Zonnebelt-Smeenge, S., & DeVries, R. (2004). Living fully in the shadow of death.

Grand Rapids, MI: Baker Books.

Zonnebelt-Smeenge, S., & DeVries, R. (2006). Traveling through grief: Learning to

live again after the death of a loved one. Grand Rapids, MI: Baker Books.

Impulse Control Disorder

Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry:

Workbook. New York, NY: Oxford University Press.

Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Fanning, P., & McKay, M. (2008). Applied relaxation training (Relaxation and stress

reduction audio series). Oakland, CA: New Harbinger.

Grant, J., & Kim, S. (2004). Stop me because I can’t stop myself: Taking control of

impulsive behavior. New York, NY: McGraw-Hill.

Grant, J., Donahue, C., & Odlaug, B. (2011). Overcoming impulse control problems:

A cognitive-behavioral therapy program—Workbook. New York, NY: Oxford

University Press.

Helmstetter, S. (1990). What to say when you talk to yourself. New York, NY:

Pocket Books.

Kelly, K., & Ramundo, P. (1993). You mean I’m not lazy, stupid, or crazy?! A

self-help book for adults with attention deficit disorder. New York, NY: Scribner.

BIBLIOTHERAPY SUGGESTIONS

Keuthen, N. (2001). Help for hair pullers: Understanding and coping with

trichotillomania. Oakland, CA: New Harbinger.

McKay, M., Davis, M., & Fanning, P. (2011). Thoughts and feelings: Taking control

of your moods and your life. Oakland, CA: New Harbinger.

McKay, M., Wood, J., & Brantley, J. (2007). Dialectical behavior therapy skills

workbook. Oakland, CA: New Harbinger.

Miklowitz, D. (2010). The bipolar disorder survival guide: What you and your family

need to know. New York, NY: Guilford Press.

O’Donohue, W., & Sbraga, T. (2004). The sex addiction workbook. Oakland, CA:

New Harbinger.

Spradlin, S. (2003). Don’t let your emotions run your life: How dialectical behavior

therapy can put you in control. Oakland, CA: New Harbinger.

Wender, P. (1987). The hyperactive child, adolescent, and adult. New York, NY:

Oxford University Press.

Intimate Relationship Conflicts

Beck, A. (1989). Love is never enough: How couples can overcome misunderstandings,

resolve conflicts, and solve relationship problems through cognitive therapy. New

York, NY: HarperCollins.

Bernstein, J., & Magee, S. (2007). Why can’t you read my mind? Overcoming the

9 toxic thought patterns that get in the way of a loving relationship. Cambridge,

MA: Da Capo Press.

Burns, D. (2011). Feeling good together: The secret to making troubled relationships

work. New York, NY: Three Rivers Press.

Christensen, A., & Jacobson, N. (2002). Reconcilable differences. New York, NY:

Guilford Press.

Davis, M. (2002). The divorce remedy: The proven 7-step program for saving your

marriage. New York, NY: Simon & Schuster.

Fisher, B. (2005). Rebuilding: When your relationship ends. San Luis Obispo, CA:

Impact.

Fruzzetti, A. (2006). The high-conflict couple: A dialectical behavior therapy guide to

finding peace, intimacy, and validation. Oakland, CA: New Harbinger.

Gray, J. (2001). Men and women and relationships: Making peace with the opposite

sex. New York, NY: MJF Books.

Gray, J. (2004). Men are from Mars, women are from Venus: The classic guide to

understanding the opposite sex. New York, NY: Harper.

Harley, W. (2011). His needs, her needs: Building an affair-proof marriage. Grand

Rapids, MI: Revell.

Hendrix, H. (2007). Getting the love you want: A guide for couples. New York, NY:

Henry Holt.

Johnson, S. M. (2008). Hold me tight: Seven conversations for a lifetime of love.

New York, NY: Little, Brown.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

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McKay, M., Fanning, P., & Paleg, K. (2006). Couple skills: Making your relationship

work. Oakland, CA: New Harbinger.

Markman, H., Stanley S., & Blumberg, S. (2010). Fighting for your marriage. San

Francisco, CA: Jossey-Bass.

Oberlin, L. (2005). Surviving separation and divorce: A woman’s guide. Avon, MA:

Adams Media.

Schnarch, D. (2009). Passionate marriage. New York, NY: Norton.

Spring, J. (1997). After the affair. New York, NY: Morrow.

Synder, D., Baucom, D., & Gordon, K. (2007). Getting past the affair: A program to

help you cope, heal, and move on—Together or apart. New York, NY: Guilford

Press.

Legal Conflicts

Berger, A. (2008). 12 stupid things that mess up recovery: Avoiding relapse through

self-awareness and right action. Minneapolis, MN: Hazelden.

Grant, J., Donahue, C., & Odlaug, B. (2011). Overcoming impulse control problems:

A cognitive-behavioral therapy program—Workbook. New York, NY: Oxford

University Press.

Knaus, B. (2006). A cognitive behavioral workbook for depression: A step-by-step

program. Oakland, CA: New Harbinger.

McKay, M., Davis, M., & Fanning, P. (2011). Thoughts and feelings: Taking control

of your moods and your life. Oakland, CA: New Harbinger.

McKay, M., & Rogers, P. (2000). The anger control workbook. Oakland, CA: New

Harbinger.

McKay, M., Rogers, P., & McKay, J. (2003). When anger hurts. Oakland, CA: New

Harbinger.

McKay, M., Wood, J., & Brantley, J. (2007). Dialectical behavior therapy skills

workbook. Oakland, CA: New Harbinger.

Pittman, F. (1998). Grow up! New York, NY: Golden Books.

Potter-Efron, R. (2001). Stop the anger now: A workbook for the prevention,

containment, and resolution of anger. Oakland, CA: New Harbinger.

Williams, R., & Williams, V. (1998). Anger kills. New York, NY: Time Books.

Low Self-Esteem

Antony, M., & Swinson, R. (2008). Shyness and social anxiety workbook: Proven,

step-by-step techniques for overcoming your fear. Oakland, CA: New Harbinger.

Branden, N. (1995). The six pillars of self-esteem. New York, NY: Bantam Books.

Burns, D. (1999). Ten days to self-esteem. New York, NY: Morrow.

Firestone, R., Firestone, L., & Catlett, J. (2002). Conquer your critical inner voice.

Oakland, CA: New Harbinger Publications.

BIBLIOTHERAPY SUGGESTIONS

Helmstetter, S. (1990). What to say when you talk to yourself. New York, NY:

Pocket Books.

Jeffers, S. (2006). Feel the fear . . . and do it anyway. New York, NY: Ballantine

Books.

McKay, M., & Fanning, P. (2000). Self-esteem: A proven program of cognitive

techniques for assessing, improving, and maintaining your self-esteem. Oakland,

CA: New Harbinger.

McKay, M., Fanning, P., Honeychurch, C., & Sutker, C. (2005). The self-esteem

companion: Simple exercises to help you challenge your inner critic & celebrate

your personal strengths. Oakland, CA: New Harbinger.

Schiraldi, G. (2001). The self-esteem workbook. Oakland, CA: New Harbinger.

Schiraldi, G. (2007). 10 simple solutions for building self-esteem. Oakland, CA: New

Harbinger.

Zimbardo, P. (1990). Shyness: What it is and what to do about it. Reading, MA:

Addison-Wesley.

Male Sexual Dysfunction

Cervenka, K. (2003). In the mood, again: A couple’s guide to reawakening sexual

desire. Oakland, CA: New Harbinger.

Comfort, A. (2002). The joy of sex: Fully revised & completely updated for the

21st century. New York, NY: Crown.

Herbenick, D. (2012). Sex made easy: Your awkward questions answered—For better,

smarter, amazing sex. Philadelphia, PA: Running Press.

Kaplan, H. S. (1988). The illustrated manual of sex therapy. New York, NY:

Routledge.

McCarthy, B., & McCarthy, E. (2012).

Sexual awareness: Your guide to healthy

couple sexuality.

New York, NY: Taylor & Francis.

Metz, M., & McCarthy, B. (2004). Coping with erectile dysfunction: How to regain

confidence and enjoy great sex. Oakland, CA: New Harbinger.

Metz, M., & McCarthy, B. (2004). Coping with premature ejaculation: How to overcome

PE, please your partner, and have great sex. Oakland, CA: New Harbinger.

Penner, C., & Penner, J. (2003). The gift of sex: A guide to sexual fulfillment.

Nashville, TN: Thomas Nelson.

Schnarch, D., & Maddock, J. (2003). Resurrecting sex: Solving sexual problems and

revolutionizing your relationship. New York, NY: HarperCollins.

Wincze, J. (2009). Enhancing sexuality: A problem-solving approach to treating sexual

dysfunction—Workbook. New York, NY: Oxford University Press.

Zilbergeld, B. (1999). The new male sexuality: The truth about men, sex, and pleasure.

New York, NY: Random House.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

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Medical Issues

Antoni, M. H., Ironson, G., & Schneiderman, N. (2007). Cognitive-behavioral stress

management: Workbook. New York, NY: Oxford University Press.

Apple, R. F., Lock, J., & Peebles, R. (2006). Preparing for weight loss surgery:

Workbook. New York, NY: Oxford University Press.

Carlson, L., & Speca, M. (2011).

Mindfulness-based cancer recovery: A step-by-step

MBSR approach to help you cope with treatment and reclaim your life

. Oakland,

CA: New Harbinger.

Cousins, N. (2005). Anatomy of an illness: As perceived by the patient. New York,

NY: Norton.

Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Penedo, F. J., Antoni, M. H., & Schneiderman, N. (2008). Cognitive-behavioral

stress management for prostate cancer recovery: Workbook. New York, NY:

Oxford University Press.

Friedman, M., & Ulmer, D. (1984). Treating type A behavior—and your heart. New

York, NY: Knopf.

Hopko, D., & Lejuez, C. (2008). A cancer patient’s guide to overcoming depression

and anxiety: Getting through treatment and getting back to your life. Oakland,

CA: New Harbinger.

Kushner, H. (2004). When bad things happen to good people. New York, NY:

Anchor.

Leith, L. (1998). Exercising your way to better mental health. Morgantown, WV:

Fitness Information Technology.

Maximin, A., Stevic-Rust, L., White Kenyon, L. (1998). Heart therapy: Regaining

your cardiac health. Oakland, CA: New Harbinger.

McKay, J., & Schacher, T. (2009). The chemotherapy survival guide: Everything you

need to know to get through treatment. Oakland, CA: New Harbinger.

McPhee, S., Papadakis, M., & Tierney, L. (2008). Current medical diagnosis and

treatment. New York, NY: McGraw-Hill Medical.

Mohr, D. (2010). The stress and mood management program for individuals with

multiple sclerosis: Workbook. New York, NY: Oxford University Press.

Safren, S., Gonzalez, J., & Soroudi, N. (2007). Coping with chronic illness: A

cognitive-behavioral approach for adherence and depression—Workbook. New

York, NY: Oxford University Press.

Smedes, L. (2000). How can it be all right when everything is all wrong? New York,

NY: Doubleday.

Taylor, J. (2006). Solid to the core: Simple exercises to increase core strength and

flexibility. Oakland, CA: New Harbinger.

Westberg, G. (2010). Good grief. Minneapolis, MN: Fortress Press.

BIBLIOTHERAPY SUGGESTIONS

Obsessive-Compulsive Disorder (OCD)

Abramowitz, J. (2009). Getting over OCD: A 10-step workbook for taking back your

life. New York, NY: Guilford Press.

Baer, L. (2000). Getting control: Overcoming your obsessions and compulsions

(rev. ed.). New York, NY: Plume.

Bourne, E. (2011). The anxiety and phobia workbook. Oakland, CA: New Harbinger.

Burns, D. (1999). Ten days to self-esteem. New York, NY: Morrow.

Carmin, C. N. (2009). Obsessive-compulsive disorder demystified: An essential guide

for understanding and living with OCD. Philadelphia, PA: De Capo Press.

Foa, E., & Kozak, M. (2004). Mastery of obsessive-compulsive disorder: Client

workbook. New York, NY: Oxford University Press.

Forsyth, J., & Eifert, G. (2008). The mindfulenss and acceptance workbook for

anxiety. Oakland, CA: New Harbinger.

Hyman, B., & DuFrene, T. (2008). Coping with OCD: Practical strategies for living

well with obsessive-compulsive disorder. Oakland, CA: New Harbinger.

Hyman, B. M., & Pedrick, C. (2010). The OCD workbook: Your guide to breaking

free from obsessive-compulsive disorder. Oakland, CA: New Harbinger.

Landsman, K., Rupertus, K., & Pedrick, C. (2005). Loving someone with OCD: Help

for you and your family. Oakland, CA: New Harbinger.

Munford, P. (2004). Overcoming compulsive checking. Oakland, CA: New Harbinger.

Munford, P. (2005). Overcoming compulsive washing: Free your mind from OCD.

Oakland, CA: New Harbinger.

Neziroglu, F., Bubrick, J., & Yaryura-Tobias, J. A. (2004). Overcoming compulsive

hoarding: Why you save & how you can stop. Oakland, CA: New Harbinger.

Penzel, F. (2000). Obsessive-compulsive disorders: A complete guide to getting well

and staying well. New York: Oxford University Press.

Pudon, C., & Clark, D. (2005). Overcoming obsessive thoughts. Oakland, CA: New

Harbinger.

Schwartz, J. (1996). Brain lock: Free yourself from obsessive-compulsive behavior.

New York, NY: HarperCollins.

Steketee, G. (1999). Overcoming obsessive-compulsive disorder: A behavioral and

cognitive protocol for the treatment of OCD (client manual). Oakland, CA: New

Harbinger.

Steketee, G., & Frost, R. O. (2006). Compulsive hoarding and acquiring: Therapist

guide. New York, NY: Oxford University Press.

Yadin, E., Foa, E. B., & Lichner, T. K. (2012). Treating your OCD with exposure and

response (ritual) prevention: Workbook. New York, NY: Oxford University Press.

Panic/Agoraphobia

Antony, M., & McCabe, R. (2004).

10 simple solutions to panic: How to overcome

panic attacks, calm physical symptoms, and reclaim your life.

Oakland, CA: New

Harbinger.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

490

Barlow, D. H., & Craske, M. G. (2006). Mastery of your anxiety and panic:

Workbook. San Antonio, TX: Graywind/The Psychological Corporation.

Bourne, E. (2011). The anxiety and phobia workbook (4th ed.). Oakland, CA: New

Harbinger.

Burns, D. (2007). When panic attacks: The new drug-free anxiety therapy that can

change your life. New York, NY: Three Rivers Press.

Forsyth, J., & Eifert, G. (2008). The mindfulness and acceptance workbook for

anxiety: A guide to breaking free from anxiety, phobias, and worry using

Acceptance and commitment therapy. Oakland, CA: New Harbinger.

Jeffers, S. (2006). Feel the fear . . . and do it anyway. New York, NY: Ballantine

Books.

Marks, I. (2005). Living with fear: Understanding and coping with anxiety. London,

England: McGraw-Hill.

McKay, M., Davis, M., & Fanning, P. (2011). Thoughts and feelings: Taking control

of your moods and your life. Oakland, CA: New Harbinger.

Swede, S., & Jaffe, S. (2000). The panic attack recovery book. New York, NY: New

American Library.

Tolin, D. (2012). Face your fears: A proven plan to beat anxiety, panic, phobias, and

obsessions. Hoboken, NJ: Wiley.

Wilson, R. (2009). Don’t panic: Taking control of anxiety attacks. New York, NY:

Harper Perennial.

Paranoid Ideation

Burns, D. (1999). The feeling good handbook. New York, NY: Blume.

Cudney, M., & Hardy, R. (1991). Self-defeating behaviors. San Francisco, CA:

HarperCollins.

Kantor, M. (2004). Understanding paranoia. Westport, CT: Greenwood.

Morey, B., & Mueser, K. (2007). The family intervention guide to mental illness:

Recognizing symptoms and getting treatment. Oakland, CA: New Harbinger.

Wood, J. (2010). The cognitive behavioral therapy workbook for personality disorders:

A step-by-step program. Oakland, CA: New Harbinger.

Parenting

Barkley, R., & Benton, C. (1998).

Your defiant child: Eight steps to better behavior.

New York, NY: Guilford Press.

Barkley, R., Robin, A., & Benton, C. (2008). Your defiant teen: 10 steps to resolve

conflict and rebuild your relationship. New York, NY: Guilford Press.

Cline, F., & Fay, J. (2006). Parenting with love and logic. Colorado Springs, CO:

NavPress.

Dobson, J. (2000). Preparing for adolescence: How to survive the coming years of

change. New York, NY: Regal Press.

BIBLIOTHERAPY SUGGESTIONS

Edwards, C. (1999). How to handle a hard-to-handle kid. Minneapolis, MN: Free

Spirit.

Faber, A., & Mazlish, E. (2012). How to talk so kids will listen and listen so kids will

talk. New York, NY: Scribner.

Forehand, R., & Long, N. (2010) Parenting the strong-willed child: The clinically

proven five week program for parents of two- to six-year-olds. New York, NY:

McGraw-Hill.

Forgatch, M., & Patterson, G. (2005). Parents and adolescents living together: Family

problem solving. Champaign, IL: Research Press.

Ginott, H., Ginott, A., & Goddard, H. (2005). Between parent and child. New York,

NY: Three Rivers Press.

Gordon, T. (2000). Parent Effectiveness Training: The proven program for raising

responsible children. New York, NY: Three Rivers Press.

Greene, R. (2010). The explosive child: A new approach for understanding and parenting

easily frustrated, chronically inflexible children. New York, NY: Harper Perennial.

Ilg, F., Ames, L., & Baker, S. (1992). Child behavior: The classic childcare manual from

the Gesell Institute of Human Development. New York, NY: Harper Perennial.

Kazdin, A. (2009). The Kazdin method for parenting the defiant child. New York,

NY: Mariner Books.

Latham, G. I. (1994). The power of positive parenting: A wonderful way to raise

children. Logan, UT: P & T Ink.

Nelson, J., & Lott, L. (2000). Positive parenting for teenagers: Empowering your teen

and yourself through kind and firm parenting. New York, NY: Three Rivers Press.

Patterson, G., & Forgatch, M. (2005). Parents and adolescents living together: The

basics. Champaign, IL: Research Press.

Phelan, T. (1998). Surviving your adolescents: How to manage and let go of your

13–18 year olds. Glen Ellyn, IL: ParentMagic.

Phelan, T. (2010). 1-2-3 magic: Effective discipline for children 2–12. Glen Ellyn, IL:

ParentMagic.

Phelan, T. (2011). 1-2-3 magic workbook: Effective discipline for children 2–12. Glen

Ellyn, IL: ParentMagic.

Sears, W., & Sears, M. (2005). The good behavior book: How to have a better behaved

child from birth to ten. New York: Thorsons.

Turecki, S., & Tonner, L. (2000). The difficult child. New York, NY: Bantam Books.

Wolf, A. (2002). Get out of my life, but first could you drive me and Cheryl to the

mall?: A parent’s guide to the new teenager. New York, NY: Farrar, Straus and

Giroux.

Phase of Life Problems

Abramson, A. (2011). The caregiver’s survival handbook: Caring for your aging

parents without losing yourself. New York, NY: Perigee Books.

Alberti, R., & Emmons, M. (2008). Your perfect right: Assertiveness and equality in

your life and relationships. San Luis Obispo, CA: Impact.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

492

Arp, D., Arp, C., Stanley, S., Markman, H., & Blumberg, S. (2001). Empty nesting:

Reinventing your marriage when the kids leave home. San Francisco, CA: Jossey-

Bass.

Bower, S., & Bower, G. (1991). Asserting yourself: A practical guide for positive

change. Cambridge, MA: Perseus.

Bridges, W. (2004). Transitions: Making sense of life’s changes. Cambridge, MA:

Da Capo Press.

Bridges, W. (2009). Managing transitions: Making the most of change. Cambridge,

MA: Da Capo Press.

Chope, R. (2000). Dancing naked: Breaking through the emotional limits that keep

you from the job you want. Oakland, CA: New Harbinger.

Gottman, J., & Schwartz Gottman, J. (2007). Ten lessons to transform your

marriage: America’s love lab experts share their strategies for strengthening your

relationship. New York, NY: Three Rivers Press.

Gross, J. (2011). A bittersweet season: Caring for our aging parents—and ourselves.

New York, NY: Knopf.

Gyoerkoe, K., & Wiegartz, P. (2009). The pregnancy and postpartum anxiety

workbook: Practical skills to help you overcome anxiety, worry, panic attacks,

obsessions, and compulsions. Oakland, CA: New Harbinger.

Hanna, J., & Y’Barbo, K. (2009). The house is quiet, now what? Uhrichsville, OH:

Barbour Books.

Hollis, J. (2006). Finding meaning in the second half of life. New York, NY: Gotham.

Jones, K. (2007). Everything get ready for baby book. Cincinnati, OH: Adams Media.

Lovely, E. (2011). A parenting conspiracy: The fine print of becoming a parent.

Indianapolis, IN: Dog Ear.

Miles, L., & Miles, R. (2000). The new marriage: Transcending the happily-ever-after

myth. Fort Bragg, CA: Cypress House.

Moore, T. (2005). Dark nights of the soul. New York, NY: Gotham.

Paterson, R. (2000). The assertiveness workbook: How to express your ideas and stand

up for yourself at work and in relationships. Oakland, CA: New Harbinger.

Sanders, D., & Bullen, M. (2001). Staying home: From full-time professional to full-

time parent. London, England: Little Brown.

Simon, S. (1993). In search of values: 31 strategies for finding out what really matters

most to you. New York, NY: Warner Books.

Simon, S., Howe, L., & Kirschenbaum, H. (1995). Values clarification. New York,

NY: Warner Books.

Smith, M. (1985). When I say no, I feel guilty. New York, NY: Bantam Books.

Waxman, B. (2010). How to love your retirement: The guide to the best of your life.

Atlanta, GA: Hundreds of Heads.

Phobia

Antony, M. M., Craske, M. G., & Barlow, D. H. (2006). Mastering your fears and

phobias: Workbook. New York, NY: Oxford University Press.

BIBLIOTHERAPY SUGGESTIONS

Antony, M. M., & McCabe, R. E. (2005). Overcoming animal and insect phobias:

How to conquer fear of dogs, snakes, rodents, bees, spiders, and more. Oakland,

CA: New Harbinger.

Antony, M. M., & Rowa, K. (2007). Overcoming fear of heights: How to conquer

acrophobia and live a life without limits. Oakland, CA: New Harbinger.

Antony, M. M., & Watling, M. (2006). Overcoming medical phobias: How to conquer

fear of blood, needles, doctors, and dentists. Oakland, CA: New Harbinger.

Bourne, E. (2011). The anxiety and phobia workbook. Oakland, CA: New Harbinger.

Brown, D. (2009). Flying without fear: Effective strategies to get you where you need

to go. Oakland, CA: New Harbinger.

Forsyth, J., & Eifert, G. (2008). The mindfulness and acceptance workbook for anxiety:

A guide to breaking free from anxiety, phobias, and worry using Acceptance and

commitment therapy. Oakland, CA: New Harbinger.

Jeffers, S. (2006). Feel the fear . . . and do it anyway. New York, NY: Ballantine

Books.

Marks, I. (2005). Living with fear: Understanding and coping with anxiety. London,

England: McGraw-Hill.

McKay, M., Davis, M., & Fanning, P. (2011). Thoughts and feelings: Taking control

of your moods and your life. Oakland, CA: New Harbinger.

Peurifoy, R. (2005). Anxiety, phobias, and panic: A step-by-step program for

regaining control of your life. New York, NY: Grand Central.

Tolin, D. (2012). Face your fears: A proven plan to beat anxiety, panic, phobias, and

obsessions. Hoboken, NJ: Wiley.

Posttraumatic Stress Disorder (PTSD)

Allen, J. (2004). Coping with trauma: Hope through understanding. Washington, DC:

American Psychiatric Press.

Beckner, V. & Arden, J. (2008). Conquering post-traumatic stress disorder: The

newest techniques for overcoming symptoms, regaining hope, and getting your life

back. Minneapolis, MN: Fair Winds Press.

Bradshaw, J. (2005). Healing the shame that binds you. Deerfield Beach, FL: Health

Communications.

Copeland, M., & Harris, M (2000). Healing the trauma of abuse: A women’s

workbook. Oakland, CA: New Harbinger.

Follette, V., & Pistorello, J. (2007). Finding life beyond trauma: Using acceptance and

commitment therapy to heal from post-traumatic stress and trauma-related

problems. Oakland, CA: New Harbinger.

Frankel, V. (2006). Man’s search for meaning. Boston, MA: Beacon Press.

Jeffers, S. (2006). Feel the fear . . . and do it anyway. New York, NY: Ballantine

Books.

Kennerley, H. (2011). An introduction to coping with childhood trauma. Stuart, FL:

Robinson.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

494

Leith, L. (1998). Exercising your way to better mental health. Morgantown, WV:

Fitness Information Technology.

Matsakis, A. (1996). I can’t get over it: A handbook for trauma survivors (2nd ed.).

Oakland, CA: New Harbinger.

Matsakis, A. (2003). The rape recovery handbook: Step-by-step help for survivors of

sexual assault. Oakland, CA: New Harbinger.

Rothbaum, B. O., & Foa, E. B. (2004). Reclaiming your life after rape: Cognitive-

behavioral therapy for posttraumatic stress disorder—Client workbook. New

York, NY: Graywind.

Rothbaum, B., Foa, E., & Hembree, E. (2007). Reclaiming your life from a traumatic

experience: A prolonged exposure treatment program—Workbook. New York,

NY: Oxford University Press.

Schiraldi, G. (2009). The post-traumatic stress disorder sourcebook: A guide to

healing, recovery, and growth. Lincolnwood, IL: Lowell House.

Smedes, L. (2007). Forgive and forget: Healing the hurts we don’t deserve. San

Francisco, CA: HarperOne.

Smyth, L. (1999). Overcoming posttraumatic stress disorder: Client manual. Oakland,

CA: New Harbinger.

Williams, M., & Poijula, S. (2013). The PTSD workbook: Simple, effective techniques

for overcoming traumatic stress symptoms. Oakland, CA: New Harbinger.

Zayfert, C., & DeViva, J. C. (2011). When someone you love suffers from posttraumatic

stress: What to expect and what you can do. New York, NY: Guilford Press.

Zehr, H. (2001). Transcending: Reflections of crime victims. Intercourse, PA: Good

Books.

Psychoticism

Alberti, R., & Emmons, M. (2008). Your perfect right: Assertiveness and equality in

your life and relationships. San Luis Obispo, CA: Impact.

Bauer, M., Kilbourne, A., Greenwald, D., & Ludman, E. (2009). Overcoming bipolar

disorder: A comprehensive workbook for managing your symptoms and achieving

your life goals. Oakland, CA: New Harbinger.

Compton, M. T., & Broussard, B. (2009) The first episode of psychosis: A guide for

patients and their families. New York, NY: Oxford University Press.

Fast, J., & Preston, J. (2012).

Loving someone with bipolar disorder: Understanding

and helping your partner

. Oakland, CA: New Harbinger.

Fuller Torrey, E. (2006). Surviving schizophrenia: A manual for families, consumers

and providers. New York, NY: Harper Perennial Library.

Garner, A. (1997). Conversationally speaking: Tested new ways to increase your

personal and social effectiveness. Los Angeles, CA: Lowell House.

Miklowitz, D. (2010). The bipolar disorder survival guide: What you and your family

need to know. New York, NY: Guilford Press.

Morey, B., & Mueser, K. (2007). The family intervention guide to mental illness:

Recognizing symptoms and getting treatment. Oakland, CA: New Harbinger.

BIBLIOTHERAPY SUGGESTIONS

Price, P. (2005). The cyclothymia workbook: Learn how to manage your mood swings

and lead a balanced life. Oakland, CA: New Harbinger.

Temes, R. (2002). Getting your life back together when you have schizophrenia.

Oakland, CA: New Harbinger.

White, R., & Preston, J. (2009).

Bipolar 101: A practical guide to identifying triggers,

managing medications, coping with symptoms, and more

. Oakland, CA: New

Harbinger.

Sexual Abuse Victim

Bass, E., & Davis, L. (2008). The courage to heal: A guide for women survivors of

child sexual abuse. San Francisco, CA: Harper Perennial.

Bradshaw, J. (2005). Healing the shame that binds you. Deerfield Beach, FL: Health

Communications, Inc.

Burns, D. (1999). Ten days to self-esteem. New York, NY: Morrow.

Copeland, M. E., & Harris, M. (2000). Healing the trauma of abuse: A women’s

workbook. Oakland, CA: New Harbinger.

Davis, L. (1990). The courage to heal workbook: For men and women survivors of

child sexual abuse. New York, NY: Morrow.

Forward, S., & Buck, C. (1995). Betrayal of innocence: Incest and its devastation.

New York, NY: Penguin.

Fossum, M., & Mason, M. (1989). Facing shame: Families in recovery. New York,

NY: Norton.

Gil, E. (1995). Outgrowing the pain: A book for and about adults abused as children.

New York, NY: Dell.

Kennerley, H. (2011). An introduction to coping with childhood trauma. Stuart, FL:

Robinson.

Matsakis, A. (1996). I can’t get over it: A handbook for trauma survivors. Oakland,

CA: New Harbinger.

Matsakis, A. (2003). The rape recovery handbook: Step-by-step help for survivors of

sexual assault. Oakland, CA: New Harbinger.

Rothbaum, B. O., & Foa, E. B. (2004). Reclaiming your life after rape: Cognitive-

behavioral therapy for posttraumatic stress disorder—Client workbook. New

York, NY: Graywind.

Smedes, L. (2007). Forgive and forget: Healing the hurts we don’t deserve. San

Francisco, CA: HarperOne.

Wallas, L. (1985). Stories for the third ear: Using hypnotic fables in psychotherapy.

New York, NY: Norton.

Zehr, H. (2001). Transcending: Reflections of crime victims. Intercourse, PA: Good

Books.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

496

Sexual Identity Confusion

Beam, J. (2008). In the life: A black gay anthology. Washington, DC: Redbone Press.

Cannon, J. (2008). The Bible, Christianity, & homosexuality. Seattle, WA: Create

Space.

Eichberg, R. (1991). Coming out: An act of love. New York, NY: Penguin.

Katz, J. (1996). The invention of heterosexuality. New York, NY: Plume.

Marcus, E. (2005). Is it a choice? Answers to the most frequently asked questions

about gay and lesbian people. San Francisco, CA: HarperOne.

Signorile, M. (1996). Outing yourself: How to come out as lesbian or gay to your

family, friends, and coworkers. New York, NY: Fireside Books.

Sleep Disturbance

Benson, H. (2000). The relaxation response. New York, NY: Morrow.

Carney, C., & Manber, R. (2009). Quiet your mind and get to sleep: Solutions to

insomnia for those with depression, anxiety or chronic pain. Oakland, CA: New

Harbinger.

Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry:

Workbook. New York, NY: Oxford University Press.

Davis, M., Robbins Eshelman, E., & McKay, M. (1988). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Dotto, L. (1992). Losing sleep: How your sleeping habits affect your life. New York,

NY: Morrow.

Durand, V. M. (2008). When children don’t sleep well: Interventions for pediatric sleep

disorders—Parent workbook. New York, NY: Oxford University Press.

Edinger, J., & Carney, C. (2008). Overcoming insomnia: A cognitive-behavioral

therapy approach—Workbook. New York, NY: Oxford University Press.

Epstein, L., & Mardon, S. (2006). The Harvard Medical School guide to a good

night’s sleep. New York, NY: McGraw-Hill.

Fanning, P., & McKay, M. (2008). Applied relaxation training (Relaxation and stress

reduction audio series). Oakland, CA: New Harbinger.

Hauri, P., & Linde, S. (1996). No more sleepless nights. Hoboken, NJ: Wiley.

Jacobs, G. (2009). Say good night to insomnia. New York, NY: Holt.

Leith, L. (1998). Exercising your way to better mental health. Morgantown, WV:

Fitness Information Technology.

Silberman, S. (2009). The insomnia workbook: A comprehensive guide to getting the

sleep you need. Oakland, CA: New Harbinger.

Wolfson, A. (2001). The woman’s book of sleep: A complete resource guide. Oakland,

CA: New Harbinger.

BIBLIOTHERAPY SUGGESTIONS

Social Anxiety

Alberti, R., & Emmons, M. (2008). Your perfect right: Assertiveness and equality in

your life and relationships. San Luis Obispo, CA: Impact.

Antony, M., & Swinson, R. (2008). The shyness and social anxiety workbook: Proven,

step-by-step techniques for overcoming your fear. Oakland, CA: New Harbinger.

Bradshaw, J. (2005). Healing the shame that binds you. Deerfield Beach, FL: Health

Communications.

Burns, D. (1999). Feeling good: The new mood therapy. New York, NY: Harper.

Burns, D. (1999). The feeling good handbook. New York, NY: Blume.

Burns, D. (1999). Ten days to self-esteem. New York, NY: Morrow.

Butler, G. (2008). Overcoming social anxiety and shyness: A self-help guide using

cognitive behavioral techniques. New York, NY: Basic Books.

Forsyth, J., & Eifert, G. (2008). The mindfulness and acceptance workbook for anxiety:

A guide to breaking free from anxiety, phobias, and worry using acceptance and

commitment therapy. Oakland, CA: New Harbinger.

Fossum, M., & Mason, M. (1989). Facing shame: Families in recovery. New York,

NY: Norton.

Garner, A. (1997). Conversationally speaking: Tested new ways to increase your

personal and social effectiveness. Los Angeles, CA: Lowell House.

Helmstetter, S. (1990). What to say when you talk to yourself. New York, NY:

Pocket.

Henderson, L. (2011). The compassionate-mind guide to building social confidence:

Using compassion-focused therapy to overcome shyness and social anxiety.

Oakland, CA: New Harbinger.

Hilliard, E. (2005). Living fully with shyness and social anxiety: A comprehensive

guide to gaining social confidence. Cambridge, MA: Da Capo Press.

Hope, D. A., Heimberg, R. G., & Turk, C. L. (2010). Managing social anxiety: A

cognitive behavioral therapy approach—Workbook. New York, NY: Oxford

University Press.

Lowndes, L. (2003).

How to talk to anyone: 92 little tricks for big success in

relationships

. New York, NY: McGraw-Hill.

Markway, B., & Markway, G. (2003). Painfully shy: How to overcome social anxiety

and reclaim your life. New York, NY: St. Martin’s Press.

Monarth, H., & Kase, L. (2007).

The confident speaker

. New York, NY: McGraw-

Hill.

Rapee, R. (1999). Overcoming shyness and social phobia: A step-by-step guide.

Northvale, NJ: Aronson.

Steiner, C. (2001). Achieving emotional literacy. London, England: Bloomsbury.

Tolin, D. (2012). Face your fears: A proven plan to beat anxiety, panic, phobias, and

obsessions. Hoboken, NJ: Wiley.

Zimbardo, P. (1990). Shyness: What it is and what to do about it. Reading, MA:

Addison-Wesley.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

498

Somatization

Alberti, R., & Emmons, M. (2008). Your perfect right: Assertiveness and equality in

your life and relationships. San Luis Obispo, CA: Impact.

Asmundson, G. J. G., & Taylor, S. (2005). It’s not all in your head: How worrying

about your health could be making you sick—and what you can do about it.

New York, NY: Guilford Press.

Benson, H. (1980). The mind/body effect. New York, NY: Simon & Schuster.

Claiborn, J., & Pedrick, C. (2002). The BDD workbook: Overcome body dysmorphic

disorder and end body image obsessions. Oakland, CA: New Harbinger.

Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry:

Workbook. New York, NY: Oxford University Press.

Dahl, J., & Lundgren, T. (2006). Living beyond your pain: Using Acceptance and

commitment therapy to ease chronic pain. Oakland, CA: New Harbinger.

Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Duckro, P., Richardson, W., & Marshall, J. (1999). Taking control of your

headaches. New York, NY: Guilford Press.

Fanning, P., & McKay, M. (2008). Applied relaxation training (Relaxation and stress

reduction audio series). Oakland, CA: New Harbinger.

Gardner-Nix, J. (2009). The mindfulness solution to pain. Oakland, CA: New

Harbinger.

Karren, K., Hafen, B., Frandsen, K., & Smith, L. (2009). Mind/body health: The

effects of attitudes, emotions, and relationships. New York, NY: Benjamin

Cummings.

Lewandowski, M. (2006). The chronic pain care workbook: A self-treatment approach

to pain relief using the Behavioral Assessment of Pain Questionnaire. Oakland,

CA: New Harbinger.

Otis, J. (2007). Managing chronic pain: A cognitive-behavioral therapy approach

workbook. New York, NY: Oxford University Press.

Owens, K. M. B., & Antony, M. M. (2011). Overcoming health anxiety: Letting go of

your fear of illness. Oakland, CA: New Harbinger.

Turk, D., & Winter, F. (2005). The pain survival guide: How to reclaim your life.

Washington, DC: APA Press.

Wilhelm, S. (2006). Feeling good about the way you look: A program for overcoming

body image problems. New York, NY: Guilford Press.

Zgourides, G. (2002).

Stop worrying about your health! How to quit obsessing about

symptoms and feel better now.

Oakland, CA: New Harbinger.

Spiritual Confusion

Armstrong, K. (2010). The case for God. New York, NY: Anchor.

Augustine, St. (2002). The confessions of St. Augustine. New York, NY: Dover.

Chopra, D. (2001). How to know God. New York, NY: Three Rivers Press.

BIBLIOTHERAPY SUGGESTIONS

Dyer, W. (2003). There’s a spiritual solution to every problem. New York, NY: Quill.

Helmfelt, R., & Fowler, R. (2010). Serenity: A companion for 12 step recovery.

Nashville, TN: Nelson.

Lewis, C. S. (1995). Surprised by joy. New York, NY: Houghton, Mifflin, Harcourt.

Lewis, C. S. (2001). Mere Christianity. New York, NY: HarperOne.

Lewis, C. S. (2001). The Screwtape letters. New York, NY: HarperOne.

Merton, T. (1999). The seven storey mountain. New York, NY: Mariner Books.

Moore, T. (1994). The care of the soul. New York, NY: Harper Perennial.

Moore, T. (2005). Dark nights of the soul. New York, NY: Gotham.

Norris, K. (1997). The cloister walk. New York, NY: Riverhead Books.

Norris, K. (1999). Amazing grace: A vocabulary of faith. New York, NY: Riverhead.

Peck, M. S. (1998). Further along the road less traveled. New York, NY: Touchstone.

Peck, M. S. (2003). The road less traveled. New York, NY: Touchstone.

Smedes, L. (1994). Shame and grace: Healing the shame we don’t deserve. New York,

NY: HarperOne.

Smedes, L. (2003). My God and I: A spiritual memoir. Grand Rapids, MI: Eerdmans.

Strobel, L. (2000). The case for faith: A journalist investigates the toughest objections

to Christianity. Grand Rapids, MI: Zondervan.

Warren, R. (2011). The purpose-driven life. Grand Rapids, MI: Zondervan.

Substance Use

Alberti, R., & Emmons, M. (2008). Your perfect right: Assertiveness and equality in

your life and relationships. San Luis Obispo, CA: Impact.

Alcoholics Anonymous. (1975). Living sober. New York, NY: A. A. World Service.

Alcoholics Anonymous. (1976). Alcoholics anonymous: The big book. New York,

NY: A. A. World Service.

Carnes, P. (1994). A gentle path through the twelve steps. Minneapolis, MN: Hazelden.

Daley, D., & Marlatt, G. A. (2006). Overcoming your alcohol or drug problem: Effective

recovery strategies—Workbook. New York, NY: Oxford University Press.

Davis Kasl, C. (1992). Many roads, one journey. New York, NY: HarperCollins.

Epstein, E. E., & McCrady, B. S. (2009). A cognitive-behavioral treatment program

for overcoming alcohol problems: Workbook. New York, NY: Oxford University

Press.

Gorski, T. (1992). Staying sober workbook. Independence, MO: Herald House Press.

Gorski, T., & Miller, M. (1986). Staying sober: A guide to relapse prevention.

Independence, MO: Herald House Press.

Johnson, V. (1990). I’ll quit tomorrow. New York, NY: HarperOne.

Meyers, R. J., & Wolfe, B. L. (2003). Get your loved one sober: Alternatives to

nagging, pleading, and threatening. Center City, MN: Hazelden.

Miller, W. R., & Munoz, R. F. (2004). Controlling your drinking: Tools to make

moderation work for you. New York, NY: Guilford Press.

Nuckols, C. (1989).

Cocaine: From dependence to recovery.

Blue Ridge Summit, PA:

TAB Books.

THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

500

Perkinson, R. (2012). The alcoholism & drug abuse client workbook. Thousand Oaks,

CA: Sage.

Sales, P. (1999). Alcohol abuse: Straight talk, straight answers. Honolulu, HI: Ixia.

Solowij, N. (2006). Cannabis and cognitive functioning. New York, NY: Cambridge

University Press.

Tyler, B. (2005).

Enough already!: A guide to recovery from alcohol and drug

addiction

. Parker, CO: Outskirts Press.

Volpicelli, J., & Szalavitz, M. (2000). Recovery options: A complete guide. New York,

NY: Wiley.

Washton, A., & Boundy, D. (1990). Willpower’s not enough: Understanding and

recovering from addictions of every kind. New York, NY: HarperCollins.

Washton, A., & Zweben, J. (2009). Cocaine and methamphetamine addiction:

Treatment, recovery, and relapse prevention. New York, NY: Norton.

Wilson, B. (1999).

As Bill sees it.

New York, NY: A. A. World Service.

For more resources related to motivational interviewing, see the Motivational

Interviewing online at http://www.motivationalinterview.org/

Suicidal Ideation

Butler, P. (2008).

Talking to yourself: How cognitive behavior therapy can change

your life.

Charleston, SC: BookSurge.

Ellis, T. E., & Newman, C. F. (1996). Choosing to live: How to defeat suicide though

cognitive therapy. Oakland, CA: New Harbinger.

Gilson, M., Freeman, A., Yates, M., & Freeman, S. (2009). Overcoming depression:

A cognitive therapy approach—Workbook. New York, NY: Oxford University

Press.

Helmstetter, S. (1990). What to say when you talk to yourself. New York, NY:

Pocket Books.

Knaus, B. A cognitive behavioral workbook for depression: A step-by-step program.

Oakland, CA: New Harbinger.

Leith, L. (1998). Exercising your way to better mental health. Morgantown, WV:

Fitness Information Technology.

McKay, M., Davis, M., & Fanning, P. (2011). Thoughts and feelings: Taking control

of your moods and your life. Oakland, CA: New Harbinger.

Miklowitz, D. (2010) Bipolar disorder survival guide: What you and your family need

to know. New York, NY: Guilford Press.

Pettit, J., & Joiner, T. (2005). The interpersonal solution to depression: A workbook

for changing how you feel by changing how you relate. Oakland, CA: New

Harbinger.

Seligman, M. (2006). Learned optimism: How to change your mind and your life. New

York, NY: Vintage.

Seligman, M. (2011). Flourish: A visionary new understanding of happiness and well-

being. New York, NY: Free Press.

BIBLIOTHERAPY SUGGESTIONS

Type A Behavior

Antony, M., & Swinson, R. (2009). When perfect isn’t good enough: Strategies for

coping with perfectionism. Oakland, CA: New Harbinger.

Bailey, K., & Leland, K. (2006). Watercooler wisdom: How smart people prosper in

the face of conflict, pressure, and change. Oakland, CA: New Harbinger.

Benson, H. (2000). The relaxation response. New York, NY: Morrow.

Charlesworth, E., & Nathan, R. (2004). Stress management: A comprehensive guide

to wellness. New York, NY: Ballantine Books.

Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Fanning, P., & McKay, M. (2008). Applied relaxation training (Relaxation and stress

reduction audio series). Oakland, CA: New Harbinger.

Friedman, M., & Ulmer, D. (1985). Treating type A behavior—and your heart. New

York, NY: Knopf.

Hayes, S. (2005). Get out of your mind and into your life: The new acceptance and

commitment therapy. Oakland, CA: New Harbinger.

Kidman, A. (2011). Staying sane in the fast lane. Epping, AU: Delphian Books.

McKay, M., & Fanning, P. (2006). The daily relaxer: Relax your body, calm your

mind, and refresh your spirit. Oakland, CA: New Harbinger.

Peck, M. S. (1998). Further along the road less traveled. New York, NY: Touchstone.

Peck, M. S. (2003). The road less traveled. New York, NY: Touchstone.

Pirsig, R. (2008). Zen and the art of motorcycle maintenance: An inquiry into values.

New York, NY: Morrow.

Unipolar Depression

Addis, M. E., & Martell, C. R. (2004). Overcoming depression one step at a time: The

new behavioral activation approach to getting your life back. Oakland, CA: New

Harbinger.

Alberti, R., & Emmons, M. (2008).

Your perfect right: Assertiveness and equality in

your life and relationships.

San Luis Obispo, CA: Impact.

Bieling, P. J., Antony, M. M., & Beck, A. T. (2003). Ending the depression cycle: A

step-by-step guide for preventing relapse. Oakland, CA: New Harbinger.

Burns, D. (1999). Feeling good: The new mood therapy. New York, NY: Harper.

Burns, D. (1999). The feeling good handbook. New York, NY: Blume.

Burns, D. (1999). Ten days to self-esteem. New York, NY: Morrow.

Butler, P. (2008). Talking to yourself: How cognitive behavior therapy can change

your life. Charleston, SC: BookSurge.

Gilson, M., Freeman, A., Yates, M., & Freeman, S. (2009). Overcoming depression:

A cognitive therapy approach—Workbook. New York, NY: Oxford University

Press.

Greenberger, D., & Padesky, C. (1995). Mind over mood: Change how you feel by

changing the way you think. New York, NY: Guilford Press.

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502

Hayes, S. C. (2005). Get out of your mind and into your life: The new acceptance and

commitment therapy. Oakland, CA: New Harbinger.

Helmstetter, S. (1990). What to say when you talk to yourself. New York, NY:

Pocket Books.

Knaus, B. (2006). A cognitive behavioral workbook for depression: A step-by-step

program. Oakland, CA: New Harbinger.

Leith, L. (1998). Exercising your way to better mental health. Morgantown, WV:

Fitness Information Technology.

Lewinsohn, P. (1992). Control your depression. New York, NY: Fireside.

Marra, T. (2004). Depressed and anxious: The dialectical behavior therapy workbook

for overcoming depression and anxiety. Oakland, CA: New Harbinger.

Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001)

Depression in context:

Strategies for guided action

. New York, NY: Norton.

McCullough, J. P., Jr. (2003). Patient’s manual for CBASP. New York: Guilford

Press.

McKay, M., Davis, M., & Fanning, P. (2011). Thoughts and feelings: Taking control

of your moods and your life. Oakland, CA: New Harbinger.

Nezu, A. M. Nezu, C. M., & D’Zurilla, T. J. (2007). Solving life’s problems: A 5-step

guide to enhanced well-being. New York, NY: Springer.

Pettit, J. W., & Joiner, T. E. (2005). The interpersonal solution to depression: A

workbook for changing how you feel by changing how you relate. Oakland, CA:

New Harbinger.

Seligman, M. (2006). Learned optimism: How to change your mind and your life. New

York, NY: Vintage.

Seligman, M. (2011). Flourish: A visionary new understanding of happiness and

well-being. New York, NY: Free Press.

Strauss, C. (2004) Talking to depression: Simple ways to connect when someone in

your life is depressed. New York, NY: New American Library.

Strosahl, K., & Robinson, P. (2008). The mindfulness and acceptance workbook for

depression: Using acceptance and commitment therapy to move through depression

and create a life worth living. Oakland, CA: New Harbinger.

Weissman, M. M. (2005). Mastering depression through interpersonal psychotherapy:

Patient workbook. New York, NY: Oxford University Press.

Yapko, M. (1998). Breaking the patterns of depression. New York, NY: Three Rivers

Press.

Zonnebelt-Smeenge, S., & DeVries, R. (1998). Getting to the other side of grief:

Overcoming the loss of a spouse. Grand Rapids, MI: Baker Books.

Zonnebelt-Smeenge, S., & DeVries, R. (2006). Traveling through grief: Learning to

live again after the death of a loved one. Grand Rapids, MI: Baker Books.

Vocational Stress

Bailey, K., & Leland, K. (2006). Watercooler wisdom: How smart people prosper in

the face of conflict, pressure, and change. Oakland, CA: New Harbinger.

BIBLIOTHERAPY SUGGESTIONS

503

Benson, H. (2000). The relaxation response. New York, NY: Morrow.

Bolles, R. (2011). What color is your parachute?: A practical manual for job-hunters

and career-changers. Berkeley, CA: Ten-Speed Press.

Brantley, J., & Millstine, W. (2007). Five good minutes at work: 100 mindful practices to

help you relieve stress and bring your best to work. Oakland, CA: New Harbinger.

Charland, W. (1993). Career shifting: Starting over in a changing economy.

Holbrook, MA: Bob Adams.

Charlesworth, E., & Nathan, R. (2004). Stress management: A comprehensive guide

to wellness. New York, NY: Ballantine Books.

Craske, M. G., & Barlow, D. H. (2006). Mastery of your anxiety and worry:

Workbook. New York, NY: Oxford University Press.

Davis, M., Robbins Eshelman, E., & McKay, M. (2008). The relaxation and stress

reduction workbook. Oakland, CA: New Harbinger.

Fanning, P., & McKay, M. (2008). Applied relaxation training (Relaxation and stress

reduction audio series). Oakland, CA: New Harbinger.

Friedman, M., & Ulmer, D. (1985). Treating type A behavior—and your heart. New

York, NY: Knopf.

Gill, L. (1999). How to work with just about anyone: A 3-step solution for getting

difficult people to change. New York, NY: Fireside.

Johnson, S. (1998). Who moved my cheese?: An amazing way to deal with change in

your work and in your life. New York, NY: Putnam Publishing Group.

Krebs Hirsh, S., & Kise, J. (1996). Work it out: Clues for solving people problems at

work. Palo Alto, CA: Davies-Black.

Lloyd, K. (1999). Jerks at work: How to deal with people problems and problem

people. Franklin Lakes, NJ: Career Press.

McKay, M., & Fanning, P. (2006). The daily relaxer: Relax your body, calm your

mind, and refresh your spirit. Oakland, CA: New Harbinger.

McKay, M., Fanning, P., Honeychurch, C., & Sutker, C. (2005). The self-esteem

companion: Simple exercises to help you challenge your inner critic & celebrate

your personal strengths. Oakland, CA: New Harbinger.

Kase, L. (2006). Anxious 9 to 5: How to beat worry, stop second-guessing yourself,

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Stranks, J. (2005).

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504

Appendix B

REFERENCES TO EMPIRICAL SUPPORT

AND CLINICAL RESOURCES FOR

EVIDENCE-BASED CHAPTERS

Sources Informing Evidence-Based Treatment Planning

and Practice

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American Psychiatric Association. American Psychiatric Association practice

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evidence-based practice in behavioral healthcare: Applications and new directions.

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Chambless, D. L., Sanderson, W. C., Shoham, V., Johnson, S. B., Pope, K. S., Crits-

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Anger Control Problems

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Attention Deficit Disorder—Adult

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Therapies

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adulthood. Journal of Clinical Psychiatry, 67(8), 46–50.

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Bipolar Disorder—Depression

Selected Studies and Reviews of Empirical Support for Cognitive-Behavioral

Therapies

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P. (2003). A randomized controlled study of cognitive therapy of relapse

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Miklowitz, D. J., & Craighead, W. E. (2007). Psychological treatments for bipolar

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Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Kogan, J. N.,

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National Institute for Health and Clinical Excellence. (2006, July). Bipolar disorder:

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Reiser, R. P., & Thompson, L. W. (2005). Bipolar disorder. Cambridge, MA:

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commitment therapy in treating depression. Oakland, CA: New Harbinger.

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Selected Studies and Reviews of Empirical Support for Family-Focused

Therapy

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Miklowitz, D. J., & Craighead, W. E. (2007). Psychological treatments for bipolar

disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that

work (3rd ed., pp. 309–322). New York, NY: Oxford University Press.

Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. L.

(2003). A randomized study of family-focused psychoeducation and

pharmacotherapy in the outpatient management of bipolar disorder. Archives of

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Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Kogan, J. N.,

Sachs, G. S., & Wisniewski, S. R. (2007). Intensive psychosocial intervention

enhances functioning in patients with bipolar depression: Results from a 9-month

randomized controlled trial. American Journal of Psychiatry, 164, 1340–1347.

National Institute for Health and Clinical Excellence. (2006, July). Bipolar disorder:

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CG38

Reiser, R. P., & Thompson, L. W. (2005). Bipolar disorder. Cambridge, MA:

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treatment approach. New York, NY: Guilford Press.

Selected Studies and Reviews of Empirical Support for Interpersonal and

Social Rhythm Therapy

Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini,

A. M., & Monk, T. H. (2005). Two-year outcomes for interpersonal and social

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[Online]. Accessed April 2012 at http://www.div12.org/PsychologicalTreatments/

disorders/bipolar_main.php

Miklowitz, D. J. (2008). Adjunctive psychotherapy for bipolar disorder: State of the

evidence. American Journal of Psychiatry, 165, 1408–1419.

Miklowitz, D. J., & Craighead, W. E. (2007). Psychological treatments for bipolar

disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that

work (3rd ed., pp. 309–322). New York, NY: Oxford University Press.

Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Kogan, J. N.,

Sachs, G. S., & Wisniewski, S. R. (2007). Intensive psychosocial intervention

enhances functioning in patients with bipolar depression: Results from a 9-month

randomized controlled trial. American Journal of Psychiatry, 164, 1340–1347.

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Reiser, R. P., & Thompson, L. W. (2005). Bipolar disorder. Cambridge, MA:

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Bipolar Disorder—Mania

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Colom, F., Vieta, E., Martinez-Aran, A., Reinares, M., Goikolea, J. M., Benabarre,

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Miklowitz, D. J. (2008). Adjunctive psychotherapy for bipolar disorder: State of the

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Miklowitz, D. J., & Craighead, W. E. (2007). Psychological treatments for bipolar

disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that

work (pp. 309–322). New York, NY: Oxford University Press.

Morriss, R., Faizal, M. A., Jones, A. P., Williamson, P. R., Bolton, C. A., &

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Selected Studies and Reviews of Empirical Support for Systematic Care

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Johnson, S. L., & Fulford, D. (n.d.). Bipolar disorder. American Psychological

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Miklowitz, D. J. (2008). Adjunctive psychotherapy for bipolar disorder: State of the

evidence. American Journal of Psychiatry, 165, 1408–1419.

Miklowitz, D. J., & Craighead, W. E. (2007). Psychological treatments for bipolar

disorder. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that

work (pp. 309–322). New York: Oxford University Press.

National Institute for Health and Clinical Excellence (2006, July). Bipolar disorder:

Clinical guideline CG38 [Online]. Available from http://guidance.nice.org.uk/

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Reiser, R. P., & Thompson, L. W. (2005). Bipolar disorder. Cambridge, MA:

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Simon, G. E., Ludman, E. J., Bauer, M. S., Unutzer, J., & Operskalski, B. (2006).

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Simon, G. E., Ludman, E. J., Unutzer, J., Bauer, M. S., Operskalski, B., & Rutter,

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Johnson, S. L., & Fulford, D. (n.d.). Bipolar disorder. American Psychological

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Lam, D. H., Hayward, P., Watkins, E. R., Wright, K., & Sham, P. (2005). Relapse

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Lam, D. H., McCrone, P., Wright, K., & Kerr. N. (2005). Cost-effectiveness of

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Cognitive Deficits

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Empirical Support

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Couples Therapy

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Medical Issues

Selected Studies and Reviews of Empirical Support for Cognitive-Behavioral

Stress Management

Antoni, M. H., Lechner, S., Diaz, A., Vargas, S., Holley, H., Phillips, K., &

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