Therapeutic interventions to use in your documentation

Choosing the right intervention to address a patient’s condition, symptoms, and temperament is a crucial part of a therapist’s job. After you’ve picked the right intervention, it’s equally important to accurately and precisely describe it in your progress notes. Common tools include:

Trigger identification

A trigger, sometimes also called a stressor, is something that brings on or worsens mental health symptoms. People, places, objects, behaviors, and many other things can be triggers. Specific sights or sounds may trigger the symptoms of post-traumatic stress disorder, for example, while sleep disruption or substance use may trigger the symptoms of bipolar disorder. Helping a patient identify their triggers in therapy often makes it easier for them to avoid, manage, or cope with stressors that worsen their condition, ideally reducing symptoms and preventing relapses.

Cognitive behavioral therapy

Cognitive behavioral therapy, or CBT, is among the most common styles of talk therapy used in the U.S. It involves helping a patient learn to recognize and change problematic patterns of thought and behavior that contribute to mental health issues. CBT patients may also complete exercises meant to help them develop coping skills for use outside the therapy room. Studies show that CBT is effective in treating a wide range of mental health concerns, including depression, anxiety disorders, substance use disorders, eating disorders, relationship problems, and even some severe mental illnesses. 

Mindfulness

Mindfulness helps individuals cultivate better awareness of their feelings and daily experiences, without judging those feelings and experiences. Practices such as meditation, yoga, tai chi, and breathing exercises can all help foster mindfulness. In therapy sessions, mindfulness practices may be useful tools for reducing stress, agitation, emotional reactivity, or rumination; improving working memory; and enhancing self-insights and introspection. Mindfulness may benefit patients with depression, anxiety disorders, bipolar disorder, low mood, and a range of other mental health concerns, research suggests. 

Communication training

Fulfilling relationships and strong social support are key components of mental well-being. Patients who are struggling in their interpersonal relationships may benefit from communication training, which aims to identify and replace problematic communication styles with more productive habits, such as active listening and positive non-verbal communication. Although communication training can be used in individual therapy appointments, sessions that involve more than one person — such as couples counseling or family therapy sessions — often lend themselves especially well to communication training techniques.

Problem-solving skills training

No matter how much progress is achieved in the therapy room, patients must also learn to cope with difficult situations, interactions, thoughts, and emotions in their everyday lives. That’s where problem-solving skills training comes in. It aims to help clients find realistic and achievable ways of coping with both minor and major stressors they may encounter in daily life. This intervention may be helpful for patients living with depression, anxiety, chronic stress or the symptoms of other chronic diseases, post-traumatic stress disorder, substance misuse, and a range of other mental health concerns.