"Unexpressed emotions will never die. They are buried alive and will come forth later in uglier ways"
Who is Freud
This must be documented anytime suicide risk is assessed.
What is risk level, severity/frequency, safety plan, protective factors, supports in place
Client reports persistent sadness, low energy, insomnia, feelings of worthlessness, and loss of interest for 3+ weeks.
What is Major Depressive Disorder
A client says, “I don’t have a drinking problem. I just drink because everyone else stresses me out.”
What is denial
Client says “If I don’t get this job, my whole life is ruined.”
What is Catastrophizing
"I am not what happened to me, I am what I choose to become."
Who is Carl Jung
This type of note focuses on medical necessity and insurance justification.
What is a simple progress note
Depressed mood most days for at least 2 years, never symptom-free longer than 2 months.
What is Persistent Depressive Disorder (Dysthymia)
A child who is jealous of a new sibling becomes excessively helpful and overly loving toward the baby.
What is reaction formation
Client says “My boss frowned during the meeting. I’m definitely getting fired.”
What is fortune telling (jumping to conclusions)
"The curious paradox is that when I accept myself just as I am, then I can change"
Who is Carl Rogers
Clinical Accuracy: Instead of writing “Client was angry/manipulative/withdrawn/etc,” documentation should focus on this.
What is "appeared" or "client was observed to be" (based in observation)
Attention difficulties, forgetfulness, losing things, poor sustained focus since childhood, impairing work functioning in adulthood.
What is ADHD, Predominantly Inattentive Presentation
A client who feels shame about financial struggles constantly criticizes others for being irresponsible.
What is projection
Client says “I feel anxious, so something bad must be about to happen.”
What is Emotional Reasoning
"The real question is not whether machines think but whether men do"
Who is B.F. Skinner
This phrase protects you legally when documenting clinical impressions.
What is "Client reports" or "Clinician observed"
Intense fear of abandonment, unstable relationships, identity disturbance, impulsivity, and chronic emptiness.
What is Borderline Personality Disorder
A client is fully aware they are upset but says, “I’ll deal with this after my exam next week.”
What is suppression (conscious postponing)
Client says “If I’m not perfect, I’m a failure.”
“Intelligence is what you use when you don't know what to do.”
Who is Jean Piaget
The golden rule of documentation: If it isn’t documented, legally it ______.
Exposure to actual or threatened death/serious injury followed by symptoms lasting 3 days to 1 month.
What is Acute Stress Disorder
A client engages in impulsive self-harm after feeling abandoned instead of verbalizing distress.
What is acting out
Client says "“I got promoted, but that was just luck. Anyone could’ve done it.”
What is Discounting the positive