1 Treatment Planning William P. Wattles, Ph.D. Francis Marion University.

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Treatment PlanningTreatment Planning

William P. Wattles, Ph.D.

Francis Marion University

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

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Referral QuestionReferral Question

• A brief description of the client

• general reason for conducting the evaluation

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• Orients the reader to the initial focus of the report and what follows.

• Clinician must clarify the referral question.

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• “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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• 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 80’sEmphasis began in the 80’s

• Prior to this ongoing unlimited treatment was commonplace.

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

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• 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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JCAHOJCAHO

• The Joint Commission for the Accreditation of Healthcare Organizations

• Accreditation guidelines require development and documentation of individual treatment plans.

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Managed CareManaged 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 PlanningPurposes 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 planningAdvantages 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 Assumptions about Treatment PlanningPlanning

• 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 Assumptions about Treatment Planning (cont)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 goalsBasic 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.

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Assessment detailsAssessment 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 InterviewInitial Interview

• Why did the patient come here?

• Why did the patient come now?

• What does the patient want?

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Semistructured InterviewSemistructured 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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• 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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• 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 SensitivitySpecificity and Sensitivity

• Specificity- the ability to rule out those without the condition

• Sensitivity the ability to provide a definitive diagnosis

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AssessmentAssessment

• 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 RelationshipTherapeutic 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 featuresNon-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 therapeuticsDifferential therapeutics

• Refining techniques for specific diagnoses

• Changing research for different problems

• Accurate diagnosis essential

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Client characteristicsClient characteristics

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

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Systematic Steps in Treatment Systematic Steps in Treatment PlanningPlanning

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

Phase

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Functional ImpairmentFunctional Impairment

• Restrictiveness• Intensity• Medical vs.

Psychological• Prognosis• Urgency

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High Level of Functional High Level of Functional ImpairmentImpairment

• 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 SupportSocial 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 ComplexityProblem 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 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 StyleCoping Style

• External-internal continuum

• Scales 4, 6 and 9 external

• Scale 2, 7, 0 internal

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External coping styleExternal 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 styleInternal coping style

• More subjective distress

• Introversion

• Intellectualization

• Overcontrolled

• Denial

• Repression

• Reaction formation

• Minimization

• Social withdrawal• Autonomic

somatization

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ResistanceResistance

• 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 TreatmentResistance 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 distressSubjective distress

• Moderate distress best prognosis

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Indicators of High DistressIndicators 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 PhaseProblem Solving Phase

• Stages of change theory– Precontemplation

– Contemplation

– Preparation

– Action

– maintenance

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Stages of ChangeStages 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 Change9 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 ChangeProcesses 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 ChangeProcesses 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 StagePrecontemplation 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 StageContemplation 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 StagePreparation 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 StageAction 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 Maintenance and Relapse PreventionPrevention..

• 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 Helping patients set realistic treatment goals.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 Helping patients set realistic treatment goals. (cont)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 Steps to developing a case formulationformulation

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 EndThe End

1 Treatment Planning William P. Wattles, Ph.D. Francis Marion University.

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Transcript of 1 Treatment Planning William P. Wattles, Ph.D. Francis Marion University.