Treatment Planning

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Treatment Planning

• William P. Wattles, Ph.D.
• Francis Marion University

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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

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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.

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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.

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Emphasis began in the 80s

• Prior to this ongoing unlimited treatment was
  commonplace.

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Treatment Planning

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

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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.

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JCAHO

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

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Managed Care

• Clinicians must move rapidly from assessment to
  formulation and implementation of the treatment
  plan.
• Specific problems
• Specific interventions
• Individualized
• Measurable

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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

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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

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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

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Basic Assessment goals

• For what problems is the patient seeking help?
• How have these problems affected the patients
  life?
• What is maintaining these problems?
• What does the patient hope to gain from
  treatment.

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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

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Assessment

• Ultimate goal to solve problems and aid in
  decision making
• Information
• recommendations

• Specifics of
• Problem
• Client resources
• Personal characteristics
• environment

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Therapeutic Relationship

• A major predictor of success
• Assessment
• Optimal treatment
• Prediction about intervention efforts

• Example,
• Empathy not good for suspicious, low-motivation
  patients

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Non-specific features

• Things not specific to a particular therapeutic
  orientation that facilitate treatment

• Genuineness,
• Unconditional positive regard
• Accurate empathy
• Positive relationship
• Respect

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Differential therapeutics

• Refining techniques for specific diagnoses
• Changing research for different problems

• Accurate diagnosis essential

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Client characteristics

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

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Systematic Steps in Treatment Planning

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

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Functional Impairment

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

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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

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Social Support

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

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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

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Coping Style

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

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External coping style

• Projection
• Blaming others
• Paranoia
• Low frustration tolerance
• Extroversion
• Aggression
• Manipulation

• Distraction via stimulation
• Somatization for secondary gains

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Internal coping style

• More subjective distress
• Introversion
• Intellectualization
• Overcontrolled
• Denial
• Repression
• Reaction formation
• Minimization

• Social withdrawal
• Autonomic somatization

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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

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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

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Subjective distress

• Moderate distress best prognosis

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Indicators of High Distress

• High emotional arousal
• High symptomatic distress
• Motor agitation
• Poor concentration
• Unsteady faltering voice

• Excited affect
• Intense feelings
• Autonomic symptoms
• hyperventilation

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Problem Solving Phase

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

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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.

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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

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Precontemplation Stage.

• 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.

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Contemplation Stage.

• 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.

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Preparation Stage.

• 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.

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Action Stage.

• 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

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Maintenance and Relapse Prevention.

• 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

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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

• Develop a problem list
• Determine the nature of each problem.
• Identify patterns among the problems.
• Develop a hypothesis to explain the problems
• Validate and refine the hypothesis
• Test the hypothesis during treatment.

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The End