Trauma Common DAPS
D: Client was referred by primary therapist for additional trauma specific treatment.
Clt reported symptoms of hyperarousal such as
Clt identified overbounded boundary style.
Clt identified underbounded boundary style.
Clt exhibited dysregulated hypoarousal AEB report of fuzzy vision, feeling disconnected, numbing sensation, and difficulty thinking clearly.
Clt exhibited dysregulated hypoarousal AEB report of tunnel vision, feeling disconnected, numb, and far away.
Clt exhibited dysregulated hyperarousal AEB report of racing heart, the sensation of heat, intense muscle tension, and dilated pupils.
Clt exhibited dysregulated hypoarousal AEB report of feeling "outside of" their body.
Clt has difficulty sensing somatic experience AEB delayed responses and reporting "I don't know".
Clt exhibits cognitive distortion as a result of dysregulated arousal.
Clt has inadequate relational resources to manage traumatic symptoms.
Clt has inadequate somatic resources to manage traumatic symptoms.
Clt has inadequate internal resources to manage traumatic symptoms.
Clt has inadequate psychological resources to manage traumatic symptoms.
Level of Care
Clt is at risk of relapse AEB inability to regulate physiological arousal in response to daily stressors as a result of trauma.
Clt is at risk for relapse AEB inability to regulate physiological arousal as a result of past trauma without therapist intervention.
Clt has difficulty reporting experience mindfully AEB answering questions in the past and future tense.
Clt is making progress toward the goal of identifying dysregulated physiological arousal; however, clt requires more time in treatment to meet the goal of regulating physiological arousal.
Clt is making progress toward the goal of regulating physiological arousal; however, clt requires more time in treatment to develop the ability to recount traumatic memories without dissociated arousal.
Clt requires more time in treatment to meet the goal of regulating physiological arousal as a result of trauma in order to maintain sobriety.
Clt requires more time in treatment to meet the goal of identifying dysregulated physiological arousal as a result of trauma in order to maintain sobriety.
Clt requires more time in treatment to meet the goal of recounting traumatic memory without dissociated arousal in order to develop emotional regulation, delayed gratification, frustration tolerance, and impulse control to deal with daily stressors.
Clt requires more time in treatment to meet the goal of regulating dysregulated physiological arousal as a result of past trauma, in order to develop emotional regulation, delayed gratification, frustration tolerance, and impulse control to deal with daily stressors.
Clt requires more time in treatment to meet the goal of identifying dysregulated physiological arousal as a result of past trauma, in order to develop emotional regulation, delayed gratification, frustration tolerance, and impulse control to deal with daily stressors..
Therapist will assist client in developing 5 somatic and 5 relational resources for regulating physiological arousal.
This therapist will provide individual trauma therapy 1x/week and group therapy on Trauma Symptom Reduction and Stabilization 2x/week. Clt will continue to work with primary therapist toward other treatment goals.
This therapist will provide individual trauma therapy 2x/week and group therapy on Trauma Symptom Reduction and Stabilization 2x/week. Clt will continue to work with primary therapist toward other treatment goals.
Group met to provide trauma psychoeducation.
Group met to develop resources for identifying and regulating physiological arousal as a result of past trauma.
Clt was engaged in group AEB leaning forward in chair, asking clarifying questions, and volunteering to do dyadic work with this therapist in front of the group.
Clt was engaged in group AEB engaging other members, asking clarifying questions, and sharing with the group that...
Therapist will provide group therapy focused on Symptom Reduction and Stabilization 1x/week.
Therapist will provide group therapy on Trauma Symptom Reduction and Stabilization 2x/week.
Therapist will provide group therapy on Trauma Symptom Reduction and Stabilization 3x/week.
Common DAP Phrases
Clt is making progress toward the goal of maintaining sobriety; however, clt requires more time in treatment to develop emotional regulation, delayed gratification, frustration tolerance, and impulse control to deal with daily stressors.
Clt requires more time in treatment in order to stabilize...
Clt is making progress toward goal of ; however, clt requires more time in treatment to meet treatment goal of .
Clt is motivated by .
Clt continues to struggle with.. AEB...
Clt is at risk for ... AEB...
Clt's recent relapse has led to (insert life threatening experiences/behaviors).
Clt is currently being medicated/being treated for .
Clt reports Post Acute Withdrawal Symptoms such as .
Clt reports struggling with activities of daily living such as .
Clt reports changes in sleep such as difficulty falling asleep, difficulty staying asleep, and nightmares.
Clt reports changes in appetite and loss of weight.
Clt reported (severe, moderate, mild) cravings.
Clt reported an increase in cravings since last session.
Clt was engaged in group AEB participating in group exercise, sharing experience with the group, and asking clarifying questions.
Justifying Level of Care
Changes, difficulty staying asleep, difficulty falling asleep, nightmares,
Changes, weight loss/gain
Activities of Daily Living
Bathing, dressing, grooming, oral care, toileting, transferring, walking, climbing stairs, eating, shopping, cooking, managing medications, using the phone, housework, doing laundry, driving, managing finances
Post Acute Withdrawal Symptoms
Emotional outbursts or lack of emotion; Anxiety; Difficulty dealing with stress; Low energy; Having a hard time sleeping, strange dreams, and changes in sleep patters; Memory problems/hard to learn new things; Trouble thinking clearly, making decisions, and solving problems; Problems with balance and delayed reflexes; Feeling dizzy; Increased accident proneness
Mental Status Exam
Mental Status Exam
Rapid/pressured (hyper verbal) OR soft and hesitant;slurred;tangential
Poor to Moderate;depends on how long client has been in treatment
Impaired; minimizes; rationalization; intellectualizes; lacks insight
pre occupied;difficulty concentrating;disorganized;illogical;obsessive;flashbacks;intrusive thoughts
Recent memory impaired; remote memory impaired; easily distracted
Depressed and anxious; mood liability (mood swings); helpless; hopeless; impulsive; irritable; restless; agitated; apathetic
Congruent to mood; flat affect; blunted; tearful; constricted, blunted, Flat; Constricted; Inappropriate; Labile; Full range
Per patient report; if any suicidal thoughts (passive or with plan or intent) contract for safety
stay away from things like "disorientation", "confusion" "vomitting" unless client is entering detox.
depends on how long in treatment; will be evaluated for anti-craving meds if cravings do not decrease
Poor: 2-3 hrs/night; Moderate: 5-6 hrs/night; Diffoculty staying asleep; difficulty falling asleep; drug dreams; nightmares
Any weight fluctuation
Activities of Daily Living
Unkempt, slightly disheveled; odorous; disheveled poor hygiene
Guarded, defensive, combative, introverted, social withdrawal, med seeking, justifying, elevated mood, preoccupied, passive, indifferent, solemn, suspicious, belligerent, abrupt, sluggish, timid, meek, people-pleaser, unyielding, stubborn, pompous, manipulative, and defensive
Integrated Diagnostic Summary/Clinical Impression
high risk behaviors
SLAP Suicide Assessment
How specific is the plan? The more specific the details, the higher degree the present risk.
How lethal is the proposed method? How quickly would the person die if the plan was enacted? The greater the lethality, the greater the risk.
How available is the proposed method? If the tool to be used is readily available, the greater the suicide risk.
What is the proximity of helping resources? Generally, the greater the distance the person is from helping resources, if the plan were implemented, the greater the degree of risk.
Assessments with Scoring Cutoffs
DAST (Drug Abuse Screening Test)
Intermediate (likely meets DSM-V criteria)
AUDIT (Alcohol Use Disorder Identification Test)
Moderately Severe Depression
Beck Anxiety Inventory
Score above 35
BPS (Bio-Psycho-Social w/ Integrated Diagnostic Summary)
ASAM PPC-2R (Patient Placement Criteria for the treatment of Substance Related Disorders)
Patient Placement Criteria for the treatment of Substance Related Disorders
Case Presentation Outline
1. Demographics & Diagnosis & Precipitating event
Age, gender, ICD-10 Diagnosis name and code, ethnicity/cultural relevance/spiritual, living situation/sober living/residential/homeless and Education. Precipitating event for client seeking treatment (what made them pick up phone and come to treatment). Note agencies, organizations, or groups involved including court cases, probation, CPS, referring source...
2. Client Background/Relevant History
Previously in treatment? Age of First time to therapy or rehab. Any psychiatric hospitalizations, relevant previous treatment episodes, number of times in rehab, suicide attempts/ideations ever in life. Share any historical information which might clarify client’s current situation, or the situation may have arisen suddenly without obvious historical causes. Significant adverse or traumatic events, school performance, family structure, alcoholism or addiction in family.
3. Key findings/observations/Ct desires
Give details of the current situation relevant to understanding why this situation is a case. For example, give observable signs/symptoms of illness, environmental factors that may impinge on client, and potential resources within the situation/client. Ct desires/perception of problems, Client quotes are helpful here.
Describe your understanding of why things are as they are. This should reflect one or more theoretical perspectives in some way. Note any countertransference issues.
5. Interventions and Plans
Treatment plan in Kipu may be referenced. Describe what you have done and what you plan to do about the situation. May wish to state where you on in progress on goals.
6. Reason for Presentation: What would you like help with?
Explain why you selected this case when you could have presented several other cases. Does it present a unique challenge or an unusual problem? Does it illustrate the effectiveness of an intervention? Would you like help with the case, or are you presenting it so others can learn from your experience? What do you want from us, instruct your audience.
Physical health, financial assets, health insurance, Safe and recovery-conducive shelter, clothing, food, access to transportation
Identified values, personal knowledge, educational/vocational skills, problem solving capabilities, self-awareness, self-esteem, self-efficacy, hopefulness/optimism, right perception, sense of meaning and purpose, interpersonal skills
Partner, friendships, family of origin, family of choice, work, school, church, community organizations
"family" involvement in therapy and/or recovery efforts, friends/family in recovery, sober outlets for fellowship and leisurely activities
Active efforts to reduce addiction/recovery related stigma
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Local recovery role models
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Availability of continuum of treatment resources
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Community recovery support institutions
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Sources of sustained recovery support and early re-intervention
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Culturally prescribed pathways of recovery that resonate with particular individuals and families