Treatment Planning

William P. Wattles, Ph.D.

Francis Marion University 1

What percent score between a T score of 40 and 60?

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Referral Question

• A brief description of the client • general reason for conducting the evaluation 3

Referral Question

• Orients the reader to the initial focus of the report and what follows. • Clinician must clarify the referral question.

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Referral Question

• “Referred for a psychological” – lacks focus and precision – leads to “shotgun” reports • A wide variety of often-fragmented descriptions in the hope that something useful can be found. 5

Referral Question

• Example • “Mr. Smith is a 35-year-old, white, married male with a high school education who presents with complaints about depression and anxiety.” 6

Emphasis began in the 80’s

• Prior to this ongoing unlimited treatment was commonplace. 7

Treatment Planning

• A program outlining in advance the specific steps by which the therapist will help the patient recover. 8

Treatment Planning

• A process involving sequential decisions with weighting of information regarding patient characteristics including diagnoses, problem areas, treatment context, relation variables, treatment strategies and techniques. 9

JCAHO

• The Joint Commission for the Accreditation of Healthcare Organizations • Accreditation guidelines require development and documentation of individual treatment plans. 10

Managed Care

• Clinicians must move rapidly from assessment to formulation and implementation of the treatment plan.

– Specific problems – Specific interventions – Individualized – Measurable 11

Purposes of Treatment Planning

• To clarify treatment focus • Set realistic expectations • Establish standard for measuring progress • Facilitate communication among professionals • Support treatment authorization • Document quality assurance • Facilitate communication with external reviewers 12

Advantages of Treatment planning

• Provides a roadmap to guide treatment • Forces critical thinking in formulating interventions • Helps meet HMO requirements for accountability • Assists in coordinating care • Provides protection from some kinds of litigation.

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Assumptions about Treatment Planning

• The patient is experiencing behavioral health problems • Not all patients are suited for psychotherapy • The patient is motivated to work on problems • Treatment goals are tired to identified problemes 14

Assumptions about Treatment Planning (cont)

• Treatment goals have criteria that are – Achievable – Collectively developed – Prioritized • Progress toward treatment goals can be tracked • Deviations from expectations may require modifications in treatment plan 15

Basic Assessment goals

• For what problems is the patient seeking help?

• How have these problems affected the patient’s life?

• What is maintaining these problems?

• What does the patient hope to gain from treatment. 16

Assessment details

• Is treatment required?

• If so what are the relative merits of medical, psychological and social interventions?

• If psychological intervention is required: – Which approach is best – What depth of therapy is needed?

– Who should therapy involve?

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Initial Interview

• Why did the patient come here?

• Why did the patient come now?

• What does the patient want?

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Semistructured Interview

• • • • • • •

Presenting Problem or chief complaint History of the problem Family and social history Educational history Employment history Mental health and substance abuse history Medical history

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Semistructured Interview

• –

Important patient characteristics Functional impairment

– –

Subjective distress Problem complexity

– –

Readiness to change Potential to resist therapeutic influence

– –

Social support Coping styles

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Semistructured Interview

• • • • • •

Patient strengths Mental status Risk or harm to self or others Diagnosis and related considerations

– –

Treatment goals: Patient-identified goals Third-party goals Motivation to change

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Specificity and Sensitivity

• Specificity- the ability to rule out those without the condition • Sensitivity the ability to provide a definitive diagnosis 22

Assessment

• Ultimate goal to solve problems and aid in decision making – Information – recommendations • Specifics of: – Problem – Client resources – Personal characteristics – environment 23

Therapeutic Relationship

• A major predictor of success • Assessment – Optimal treatment – Prediction about intervention efforts • Example, – Empathy not good for suspicious, low motivation patients 24

Non-specific features

• Things not specific to a particular therapeutic orientation that facilitate treatment • Genuineness, • Unconditional positive regard • Accurate empathy • Positive relationship • Respect 25

Differential therapeutics

• Refining techniques for specific diagnoses • Changing research for different problems • Accurate diagnosis essential 26

Client characteristics

• Research demonstrates patient-treatment matching can explain 64% of outcome variance 27

Systematic Steps in Treatment Planning

• Functional Impairment • Social Support • Problem complexity • Coping Style • Resistance • Subjective distress • Problem Solving Phase 28

Functional Impairment

• Restrictiveness • Intensity • Medical vs. Psychological • Prognosis • Urgency 29

High Level of Functional Impairment

• Longer duration – Serious diagnosis – Poor premorbid – Internal cause – 25-50 – Expectation of time – Low social support • Shorter duration – Acute disorder – Causal stress – Good premorbid functioning – Expectation of change – Symptom orientation – Directive intervention – Child or elderly – Good social support 30

Social Support

• Respected and trusted • Extent and quality of confidents • Sense of abandonment • Feeling a part of • Number of friends with common interests 31

Problem Complexity

• High – Behaviors repeated across unrelated situations – Behaviors reflect underlying problems – Interactions in past – Suffering rather gratification.

– Problems symbolic • Low – Situation specific – Transient – Reflect lack of knowledge or skills – Related to current events – Stemming from bad habits.

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Treatment

• High complexity – Two-chair work – Dream work – Family therapy – Cathartic discharge – Interpreting transference/resistance – Free association • Low – Behavioral contracting – Social skills training – Graded exposure – Reinforcement of targets – Challenge cognitions – Relaxation – Biofeedback – Paradoxical methods 33

Coping Style

• External-internal continuum • Scales 4, 6 and 9 external • Scale 2, 7, 0 internal 34

External coping style

• Projection • Blaming others • Paranoia • Low frustration tolerance • Extroversion • Aggression • Manipulation • Distraction via stimulation • Somatization for secondary gains 35

Internal coping style

• More subjective distress • Introversion • Intellectualization • Overcontrolled • Denial • Repression • Reaction formation • Minimization • Social withdrawal • Autonomic somatization 36

Resistance

• High – Need for autonomy – Opposition – Dominance – Anxious oppositional style – Interpersonal conflict – Poor response – Incomplete work • Low – Seeks direction – Submissive – Open – Accepts interpretations – Follows through 37

Resistance and Treatment

• High – Nondirective, supportive, self directed interventions – Self-monitoring – Therapist reflection – Support and reassure – paradoxical • Low resistance – Directive, structured approach – Behavioral – Thought stopping – Advice – Stimulus control 38

Subjective distress

• Moderate distress best prognosis 39

Indicators of High Distress

• High emotional arousal • High symptomatic distress • Motor agitation • Poor concentration • Unsteady faltering voice • Excited affect • Intense feelings • Autonomic symptoms • hyperventilation 40

Problem Solving Phase

• Stages of change theory – Precontemplation – Contemplation – Preparation – Action – maintenance 41

Stages of Change

• Precontemplation – Has no intention to take action within the next 6 months • Contemplation – Intends to take action within the next 6 months. • Preparation – Intends to take action within the next 30 days and has taken some behavioral steps in this direction. • Action – Has changed overt behavior for less than 6 months • Maintenance – Has changed overt behavior for more than 6 months.

• Termination – Overt behavior will never return, and there is complete confidence that you can cope without tear of relapse.

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9 Major Processes of Change

• • • • • • • • •

1. Consciousness-raising 2. Social liberation 3. Emotional arousal 4. Self-reevaluation 5. Commitment 6. Countering 7. Environment conferral 8. Rewards 9. Helping relationships

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Processes of Change

• Consciousness Raising – Involves providing information regarding the nature and risk of unsafe behaviors and the value and drawbacks of the safer behavioral alternatives. • Dramatic Relief – Fosters the identification, experiencing, and expression of emotions related to the risk the safer alternatives in order to work toward adaptive • Environmental Control – Allows the individual to reflect on the consequences of his or her behavior for other people. It can include reconsideration of perceptions of social norms and the opinions of people important to him or her. • Self-Reevaluation – Entails the reappraisal of one's problem and the kind of person one is able to be given the problem. 44

Processes of Change

• Commitment – Encourages the person to consider their confidence in their ability to change and their commitment to doing so. • Social Liberation – Seeking to help others with similar situations. • Helping Relationships – Assists the person In a variety of ways, Including providing emotional support, modeling a set of moral beliefs, and serving as a sounding board. • Reward – Developing internal and external rewards and making them readily but contingently available to improve the probability of the new behavior occurring or continuing. • Countering – Weighing the "pros" and "cons" of the behavior change. The challenge is to tip the balance in favor of making positive changes 45

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Precontemplation Stage

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• During the precontemplation stage, patients do not even consider changing. Smokers who are "in denial" may not see that the advice applies to them personally. Patients with high cholesterol levels may feel "immune" to the health problems that strike others. Obese patients may have tried unsuccessfully so many times to lose weight that they have simply given up. 47

Contemplation Stage

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• During the contemplation stage, patients are ambivalent about changing. Giving up an enjoyed behavior causes them to feel a sense of loss despite the perceived gain. During this stage, patients assess barriers (e.g., time, expense, hassle, fear, "I know I need to, doc, but ...") as well as the benefits of change. 48

Preparation Stage

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• During the preparation stage, patients prepare to make a specific change. They may experiment with small changes as their determination to change increases. For example, sampling low-fat foods may be an experimentation with or a move toward greater dietary modification. Switching to a different brand of cigarettes or decreasing their drinking signals that they have decided a change is needed. 49

Action Stage

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• The action stage is the one that most physicians are eager to see their patients reach. Many failed New Year's resolutions provide evidence that if the prior stages have been glossed over, action itself is often not enough. Any action taken by patients should be praised because it demonstrates the desire for lifestyle change 50

Maintenance and Relapse Prevention

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• Maintenance and relapse prevention involve incorporating the new behavior "over the long haul." Discouragement over occasional "slips" may halt the change process and result in the patient giving up. However, most patients find themselves "recycling" through the stages of change several times before the change becomes truly established 51

Helping patients set realistic treatment goals.

• What is your biggest problem?

• Is there a problem that needs to be addressed immediately?

• What do you consider your primary goal for therapy?

• How will you know when you have achieved this goal?

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Helping patients set realistic treatment goals. (cont)

• What problems might keep you from achieving this goal?

• If you achieve this goal, how will things be different?

• What aspects of you will help achieve this goal?

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Steps to developing a case formulation

1. Develop a problem list 2. Determine the nature of each problem.

3. Identify patterns among the problems.

4. Develop a hypothesis to explain the problems 5. Validate and refine the hypothesis 6. Test the hypothesis during treatment.

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The End

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