Title: Treatment Planning
1Treatment Planning
- William P. Wattles, Ph.D.
- Francis Marion University
2What percent score between a T score of 40 and 60?
3Referral Question
- A brief description of the client
- general reason for conducting the evaluation
4Referral Question
- Orients the reader to the initial focus of the
report and what follows. - Clinician must clarify the referral question.
5Referral 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.
6Referral 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.
7Emphasis began in the 80s
- Prior to this ongoing unlimited treatment was
commonplace.
8Treatment Planning
- A program outlining in advance the specific steps
by which the therapist will help the patient
recover.
9Treatment 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.
10JCAHO
- The Joint Commission for the Accreditation of
Healthcare Organizations - Accreditation guidelines require development and
documentation of individual treatment plans.
11Managed Care
- Clinicians must move rapidly from assessment to
formulation and implementation of the treatment
plan. - Specific problems
- Specific interventions
- Individualized
- Measurable
12Purposes 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
13Advantages 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.
14Assumptions 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
15Assumptions 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
16Basic 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.
17Assessment 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?
18Initial Interview
- Why did the patient come here?
- Why did the patient come now?
- What does the patient want?
19Semistructured 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
20Semistructured Interview
- Important patient characteristics
- Functional impairment
- Subjective distress
- Problem complexity
- Readiness to change
- Potential to resist therapeutic influence
- Social support
- Coping styles
21Semistructured 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
22Specificity and Sensitivity
- Specificity- the ability to rule out those
without the condition
- Sensitivity the ability to provide a definitive
diagnosis
23Assessment
- Ultimate goal to solve problems and aid in
decision making - Information
- recommendations
- Specifics of
- Problem
- Client resources
- Personal characteristics
- environment
24Therapeutic Relationship
- A major predictor of success
- Assessment
- Optimal treatment
- Prediction about intervention efforts
- Example,
- Empathy not good for suspicious, low-motivation
patients
25Non-specific features
- Things not specific to a particular therapeutic
orientation that facilitate treatment
- Genuineness,
- Unconditional positive regard
- Accurate empathy
- Positive relationship
- Respect
26Differential therapeutics
- Refining techniques for specific diagnoses
- Changing research for different problems
- Accurate diagnosis essential
27Client characteristics
- Research demonstrates patient-treatment matching
can explain 64 of outcome variance
28Systematic Steps in Treatment Planning
- Functional Impairment
- Social Support
- Problem complexity
- Coping Style
- Resistance
- Subjective distress
- Problem Solving Phase
29Functional Impairment
- Restrictiveness
- Intensity
- Medical vs. Psychological
- Prognosis
- Urgency
30High 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
31Social Support
- Respected and trusted
- Extent and quality of confidents
- Sense of abandonment
- Feeling a part of
- Number of friends with common interests
32Problem 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.
33Treatment
- 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
34Coping Style
- External-internal continuum
- Scales 4, 6 and 9 external
- Scale 2, 7, 0 internal
35External coping style
- Projection
- Blaming others
- Paranoia
- Low frustration tolerance
- Extroversion
- Aggression
- Manipulation
- Distraction via stimulation
- Somatization for secondary gains
36Internal coping style
- More subjective distress
- Introversion
- Intellectualization
- Overcontrolled
- Denial
- Repression
- Reaction formation
- Minimization
- Social withdrawal
- Autonomic somatization
37Resistance
- High
- Need for autonomy
- Opposition
- Dominance
- Anxious oppositional style
- Interpersonal conflict
- Poor response
- Incomplete work
- Low
- Seeks direction
- Submissive
- Open
- Accepts interpretations
- Follows through
38Resistance 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
39Subjective distress
- Moderate distress best prognosis
40Indicators of High Distress
- High emotional arousal
- High symptomatic distress
- Motor agitation
- Poor concentration
- Unsteady faltering voice
- Excited affect
- Intense feelings
- Autonomic symptoms
- hyperventilation
41Problem Solving Phase
- Stages of change theory
- Precontemplation
- Contemplation
- Preparation
- Action
- maintenance
42Stages 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.
439 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
44Processes 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.
45Processes 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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47Precontemplation 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.
48Contemplation 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.
49Preparation 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.
50Action 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
51Maintenance 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
52Helping 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?
53Helping 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?
54Steps 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.
55The End