Writing mental health progress notes for your clients can be time-consuming, primarily because they require you to use clinical language. This jargon serves a purpose: it allows you to clearly and precisely communicate important information about your client and your treatment. But you probably don’t use clinical terms in your daily conversations, so it’s easy to get a bit rusty.
Because you use the same interventions for multiple clients, you can speed up the progress note-writing process by keeping a list of commonly-used intervention words handy. When you’re casting about for the right word, simply refer to your list! While the words you choose will depend on your clients and the treatments you use, we’re sharing an extensive list of common interventions as well as intervention words to use in your progress notes so you’re never at a loss for the perfect one.
Anger Management — At their core, anger management techniques help clients to recognize that anger is a normal emotion that we all feel. Therapists use this intervention to help clients more easily recognize when they’re becoming angry and develop strategies for expressing this powerful emotion in an appropriate way that will benefit them rather than create additional problems.
Behavior Reinforcement — A behavior that’s followed up with a reinforcement will either increase or decrease the possibility of that behavior being repeated in the future. A positive reinforcer will encourage the likelihood of the behavior’s repetition, while a negative reinforcer is likely to decrease the chances of that behavior being repeated.
Cognitive Restructuring — One of the core components of Cognitive Behavioral Therapy or CBT, cognitive restructuring operates on the assumption that it’s not what happens to us that makes us unhappy, anxious, or depressed — rather, it’s how we think about what happens to us. Cognitive restructuring techniques focus on increasing awareness, challenging the accuracy of troublesome thoughts, and developing a more mindful awareness with the goal of lessening the frequency and intensity of difficult emotions.
Collaborative Problem-Solving — Originally designed for use with children and adolescents exhibiting challenging behavior, CPS has been applied successfully in a range of applications that involve conflict. This technique involves three steps: gathering information about the challenging situation from the opposing perspective, sharing your own vantage point, and then working together to create a realistic plan to resolve the difficulty through mutually agreeable compromise.
Communication Training — The goal of communication training is to provide individuals with tools to be more effective communicators in a variety of work and interpersonal contexts. These may include stressing positives over negatives and using validation to increase the comfort level of the listener. Active listening and rephrasing or questioning the speaker to ensure understanding are also communication training skills.
Developing Coping Strategies — Positive coping skills help clients to work through difficult circumstances in a healthy way. Therapists assist clients in identifying coping skills that best fit their lifestyle and individual needs. Common coping skills include meditation, mindfulness, physical activity, spending time in nature. This process often involves gradually replacing unhealthy coping skills with healthy ones.
EMDR — Eye Movement Desensitization and Reprocessing, or EMDR, is a technique used to assist clients in processing traumatic life events. This type of therapy involves the therapist directing the client’s lateral eye movements or providing other external stimulus while the client revisits the traumatic experiences gradually over time, in small increments.
Exploration of Feelings — Therapists can direct a client’s examination of how feelings impact behaviors and the body’s physiological responses.
Goal/Progress Review — Therapists and clients can collaborate on goal-setting for desired therapy outcomes and periodically review progress towards goals.
Identifying Triggers — An emotional trigger is any experience that makes us feel uneasy. These triggers may invoke feelings of anger, shame, or envy. Therapists work with clients to identify situations that cause a significant reaction. Triggers often point to underlying issues that may be addressed in therapy. Strategies to cope in a triggering situation can also be developed.
Imagery/Relaxation Training — Guided imagery is a stress-reduction technique that involves visualizing oneself in a non-stressful, relaxed setting. When a client imagines being in a favorite place, they engage their senses in noting specific sensory details of the experience, such as what they’re seeing, the temperature of the air, and the scents they’re likely to encounter. Other commonly-used relaxation techniques include progressive muscle relaxation, breathing exercises, or mindfulness practices. These methods work by engaging the parasympathetic nervous system to create a calmer, more relaxed state.
Labeling Feelings — Clients can benefit by purposefully naming difficult feelings in order to decrease the emotional and physiological response.
Mindfulness — Mindfulness is the practice of being fully engaged in the present moment, aware of where they are, what they’re experiencing, and the physical space they’re inhabiting. Specific examples of mindfulness techniques include meditation, breathing exercises, and gratitude or self-compassion practices.
Problem-Solving Skills Training — Problem-solving skills training is a cognitive-behavior intervention that provides a framework for addressing difficult life challenges. It’s a four-step process that involves examining the current approach used when problem solving, carefully defining the problem being addressed, brainstorming and evaluating possible solutions, and implementation and follow through.
Stress Management — Stress management encompasses a diverse array of techniques and programs designed to help people deal with life stressors in a more effective, proactive way. By examining specific sources of stress and taking action to reduce their effects, stress management practices can significantly improve quality of life. Meditation, yoga, physical exercise, setting healthy boundaries, and affirmations are examples of a few of the more widely practiced stress management approaches.
Descriptive Intervention Words for Progress Notes
This list isn’t comprehensive, but it’s robust enough to provide you with ideas and serve as a handy reference.
- Assisted client in
- Focused on
- Gave homework
- Inquired about
- Reflected back
- Responded to
- Role played
- Set boundaries
Writing progress notes doesn’t need to be a time-consuming process. By keeping a list of commonly-used intervention words available to reference, you can speed up the process. Additionally, using a practice management software with progress note functionality also makes the process more streamlined. You can use templates and reference a library with information on requirements, treatments, and specialties.