Treatment Planning What is the purpose of Treatment Planning? • To clarify the treatment focus • The set realistic expectations • To establish a standard for measuring treatment progress • The facilitate communication among professions (both Clinical and Support) • To support treatment authorizations • To document quality assurance efforts How does the Treatment Plan clarify the focus of treatment? • The treatment plan must specify what and how the treatment will be working to accomplish. • Initially, it is a tool to ensure that both the Counselor and Client agree to the goals they are working towards and how they will get there. • Throughout treatment, it serves as a reference that both parties can consult in order to verify that treatment is on tract relative to the established goals and objectives. How does the Treatment Plan set realistic expectations for treatment? • It helps the client understand what they can realistically expect to occur during the course of treatment and at the end of treatment. • It helps clarify the clinician and client’s role in treatment. • It sets the ground rules for therapy. • It helps establish achievable goals before therapy begins to help minimize the changes that the client will be disappointed either during or at the end of the therapeutic experience. How does the Treatment Plan establish a standard for measuring treatment progress? • It is difficult to determine how much progress is being made during treatment unless you first know what the client’s status was at the beginning of treatment and the expected outcome of treatment. • It provides the criteria for terminating an episode of care. Treatment Planning Structure • Problems • Goals • Objectives • Interventions • Services with frequencies Common Elements in Treatment Planning Problem Identification Both the counselor and client must work together to identify and prioritize the most significant problems to work on during treatment. These problems must be defined in a manner that indicates how the problem exhibits itself in the client. Aims and Goals Treatment must always be directed to achieving for the client. An aim can be defined as the single overall desired outcome of a period of therapy. A goal is “a subsidiary objective or end point of therapeutic work that is one of the components needed to realize the aim”. Multiple goals may need to be achieved in order to achieve the aim of treatment. Strategies and Tactics A strategy refers to the general process or approach that the counselor will use to move the client toward an objective – it is the therapeutic modality selected to attain an objective that is necessary to achieve in order to accomplish the goal of treatment. A tactic is a specific task that is undertaken or a technique used within the context of the strategy to help meet the objective. Multiple strategies can be sued to achieve an objective; similarly, multiple tactics can be employed within each strategy. Flexibility Treatment planning should be approached with a flexible approach so that a change in the case formulation based on additional information or a lack of responsiveness to an existing course of treatment prompts the evaluation and possible modification of the treatment plan. Treatment Plan Content Presenting Problem • The treatment plan should contain a statement about the problem for which the client is seeking treatment. • The presenting problem of complaint should always be documented in the client’s own words. • The client’s own problem description frequently can convey more information about themselves, the intensity of the problem, and how these problems affect their life then the clinician’s could ever hope to communicate. • It is important to remember that one of the purposes of the treatment plan is to serve as a vehicle for communicating with others. Thus, when the client’s statement is not sufficiently clear or informative, the counselor can always provide clarification of what the client actually meant to convey or what was implied in their response to the questions regarding the reason for treatment. Goals and Objectives • Goals should indicate the desired positive outcome to the treatment procedure. Goals are achieved through a series of objectives. • Objectives should be stated in behaviorally measurable language. Objectives should be written in such a way that it is clear when the client has achieved it. Each objective should be developed as a step toward attaining the broad treatment goal. • Each objective should be accompanied by a time line for completion. • When all objectives are met for a specific goal, the goal is considered completed. Goals and Objectives Must Be Achievable • Among one of the most important characteristics of the goal or its associated objectives, is whether or not it is achievable. • Given the resources and circumstances, are they something that the client is capable of accomplishing? • If it is an achievable goal or objective, will the client be able to accomplish it within a reasonable time line? • Unachievable goals, objectives, or time lines should always be avoided. These set up the client for failure and the possibility of premature treatment termination. Goals and Objectives Must Be Realistic • Once you have determined that the goals and objectives are achievable in a timely manner, the next question to ask yourself is how realistic that goal, objective or time frame is. The following questions can be used to determine if they are realistic: – Does the client have the motivation to do the work that is required? – Does the client have a support system to assist them? • Regardless of the client’s ability to achieve the goal or objective in the time frame, the reality of the situation must be taken into consideration when determining whether a specific goal, objective, or time frame should become part of the treatment plan. Goals and Objectives Must Be Measurable • Goals and objectives should be stated in measurable terms. • In order to be measurable, goals and objectives should be quantifiable, specific and easily understood by the client and all stakeholders. • Measurability allows for tracking client progress through the treatment process, providing information regarding the effectiveness of the treatment plan. • Additionally, measurability allows the client to see for themselves where they started treatment and what they have accomplished through the treatment process, providing an incentive for continued participation in treatment. Goals and Objectives Should Be Stated in the Positive • Whenever possible, goals should be stated in the positive (e.g., Increase the client’s level of self-esteem). This conveys an effort to move towards improvement in the client’s life rather than a movement away from something that is having a negative effect. • A statement in the positive reinforces the idea that the client is striving to gain something rather than lose something. • It is often difficult to attain a positive goal without eliminating or reducing one or more types of behaviors, emotions, or cognitions, it is appropriate to state objectives in the negative. Goals and Objectives Should Be Prioritized • Just as it is important to prioritize the client’s problems, the goals and objectives should be prioritized. • The priority should be given to the goals and objectives should mirror the priority assigned to the problems. • Regardless of the various priority levels of the goals, the client can work toward achieving one or more goals at a time. • Objectives tied to two or more goals can also be address simultaneously. • Working on goals and objectives simultaneously represents the most efficient use of the client’s and the counselor’s time. Treatment Plan Content Treatment • Following the listing of problems, goals, objectives and time frames is the plan for how the counselor will assist the client in resolving their problems and consequently achieving their goals and objectives. • For clinicians who strictly adhere to a single therapeutic approach (e.g., cognitive-behavioral therapy), the interventions will generally be the same for all clients, regardless of what the problems are. • The selection of the intervention to be used becomes more of a challenge for those counselors who are more eclectic in their treatment orientations. Frequency and Duration of Treatment • Treatment plans should indicate the frequency and duration for which the client will be seen in treatment. • In some instances, statements regarding the frequency and duration may be nothing more than guesses based on the counselor’s experience with similar clients, problems and treatment goals. • Generally, open ended treatment durations should be avoided except in cases for which long- term or continuous treatment is appropriate (e.g., schizophrenics or the chronically mentally ill). • In most cases, the counselor should try to provide a very specific and accurate determination of frequency and duration. Questions to Consider when selecting treatment interventions • Will the planned intervention enable to client to meet all or most of the documented goals and objectives? • Does the treating counselor have the skills necessary for implementing the planned treatment intervention? • Is what the client will be expected to do realistic? • Is what the counselor will be expected to do realistic? • Will the clinician be able to know within a reasonable amount of time if the intervention is working? • Could a different type of intervention yield the same outcome? If so, why was it not selected? Criteria for Discharge • No treatment plan would be complete without an indication of the criteria for successful discharge from treatment. • Both the counselor and client must have an agreed upon point at which treatment or a portion of treatment is considered complete and the services being offered to the client are terminated or transferred to a more appropriate level of care. • The criteria should be objective and measurable and should reflect the stated goals and objectives. • Vague, unspecified, or no criteria can lead to the provision of treatment with no clearly defined end point, a circumstance that can result in unfocused therapeutic efforts that leads one to question the goals of treatment. Treatment Plan Review Date • There should always be a time indicated for treatment plan review. • The treatment plan should be reviewed and updated every 30 days, sooner if there is a significant change in the client’s condition. BHIPS and Treatment Planning Levels of Treatment Planning • Initial Treatment Plan • Adjusted Treatment Plan • Final Treatment Plan Initial Treatment Plan • Must be generated from the assessment • Must contain cognitive-behavioral objectives that reflect the curriculum • Interventions must mirror the recommendations made in the assessment • Must include discharge planning • Must be reviewed at least monthly Adjusted Treatment Plan • Is developed when changes in client treatment including new information and newly identified problems, completion of objectives & strategies and changes in level of care. • Developed from a copy of the original treatment plan. • Interventions must mirror the recommendations made in the assessment • Update and add information including discharge planning Final Treatment Plan • Is the final treatment plan that is generated when the client discharges • Developed from a copy of the original or adjusted treatment plan. • Mark all problems resolved • Update discharge planning to reflect what client will be doing upon discharge to maintain sobriety. Other Treatment Planning Issues When developing a treatment plan there are a multitude of issues that must be taken into consideration in order to create the most appropriate and effective plan. Problem Complexities Whether the client’s presenting problems are high or low with respect to complexity can have an important bearing on the treatment planning process. Ascertaining the level of problem complexity can be facilitated by historical information about other aspects of the client’s life. The historical information can allow for the revelation of “recurrent patterns or themes arising within objectively different but symbolically related relationships”. Clinical Indicators of Problem Complexities: Non-Complex Problems The following may be exhibited or reported during the assessment: • Chronic habits and or transient responses • Behavior repetition is maintained by inadequate knowledge or by ongoing situational rewards • Behaviors have a direct relationship to initiating events • Behaviors are situation specific Clinical Indicators of Problem Complexities: Complex Problems The following may be exhibited or reported during the assessment: • Behaviors are repeated as themes across unrelated or dissimilar situations • Behaviors are ritualized (yet self-defeating) attempts to resolve dynamic or interpersonal conflicts • Current conflicts are expressions of the client’s past rather than present relationships • Repetitive behaviors results in suffering rather than gratification • Symptoms have a symbolic relationship to initiating events • Problems are enduring, repetitive and symbolic manifestations of characterological conflicts Readiness to Change • The importance of the client’s readiness to change in the therapeutic process comes from the work of Prochaska, DiClemente and their colleagues. • They have identified five stages through which individuals go when changing various aspects of their lives. These changes apply not only to change that is sought by behavioral health treatment, but also in non-therapeutic contexts. Pre-contemplative Little or no awareness of problems, little or no serious consideration or intent to change, often presents for treatment at the request of or pressure from another party, change may be exhibited when pressure is applied but the client reverts to previous behavior(s) when pressure is removed. Resistant to recognizing or changing the problem is the hallmark of the pre-contemplative stage. Contemplative Awareness of problem and serious thoughts about working on it, but no commitment to begin to work on it, weighing pros and cons of the problem and its solution. Serious consideration of problem resolution is the hallmark of the contemplation stage. Preparation Intention to take serious, effective action in the near future (e.g., within a month) but has already made small behavioral changes. Decision making is the hallmark of this stage. Action Overt modification of behavior, experiences or environment in an effort to overcome the problem. Modification of problem behavior to an acceptable criterion and serious efforts to change are the hallmarks of this stage. Maintenance Continuation of change to prevent relapse and consolidate the gains made during the action stage. Stabilizing behavior change and avoiding relapse are the hallmarks of this stage. Potential Resistance to Therapeutic Influences • The potential resistance to therapeutic influences may be an indicator of the clients motivation to engage in treatment. • Two different types of resistance exists: – Resistance, which may be considered a state-like quality in which clients fail to comply with external recommendations or directions – Reactance, a more extreme trait-like form of resistance that stems from the clients feelings that their freedom or sense of control is being challenged by outside forces. This is manifested as active opposition. Coping Styles • An important consideration for treatment planning is the identification of the client’s coping style. • Coping style is defined as “an enduring trait that relates to the way one copes with personal or interpersonal threats”. • There are two identified coping styles: internalization and externalization. Coping Style: Internalization This style of coping is suggested in clients who tend to: • Avoid, deny, repress or compartmentalize sources of anxiety; • Be overly introverted, introspective, self-critical, and self-controlled; • Be emotionally constricted. Coping Style: Internalization Clinical Indicators • Undoing • Self-punishment • Intellectualization • Isolation of affect • Emotional over-control or constriction • Low tolerance for feelings or sensations • High resistance for feelings or sensations • Denial • Reversal • Reaction formation • Repression • Minimization • Unrecognized wishes or desires • Introversion • Social withdrawal • Somatization (autonomic nervous system symptoms) Coping Style: Externalization This style of coping is suggested in clients who tend to: • Directly avoid, rationalize, project or act-out onto their environment(s); • Exhibit a degree of insensitivity to their own and others’ feelings; • Be spontaneous, impulsive, extraverted, and sometimes manipulative. Coping Style: Externalization Clinical Indicators • Ambivalence • Acting Out • Blaming others and self • Low tolerance for frustration • Difficulty in differentiating emotions • Avoidance or escape (or both) • Projection • Conversation symptoms • Paranoid reactions • Unsocialized aggression • Manipulation of others • Ego-syntonic behaviors • Extraversion • Somatization (seeking of secondary gain via physical symptoms) Motivation to Change • An important factor to assess for treatment planning is the client’s motivation to change. • How to arrive at a good estimate of the clients level of motivation to change: – Is the client seeking treatment from their own desire for help or from the request/demand of another? – What is the client’s stated willingness to be actively involved in the treatment process? – What is the client’s subjective distress and reactance? – What is the client’s readiness for, or stage of change? Seven factors have been identified that should be considered in the evaluation of motivation to engage in treatment: • A willingness to participate in the diagnostic evaluation. • Honesty in reporting about oneself and one’s difficulties. • Ability to recognize that the symptoms experienced are psychological in nature. • Introspectiveness and curiosity about one’s own behavior and motives. • Openness to new ideas, with a willingness to consider different attitudes. • Realistic expectations for the results of treatment. • Willingness to make a reasonable sacrifice in order to achieve a successful outcome. Cultural Issues A critical component of the assessment is the addressing of cultural needs. Using culturally appropriate interventions can lead to better outcomes for clients. A simple working definition of the concept of culture is that it is a shared set of beliefs, norms, and values in which language is a key factor. Other factors that play an important role include ethnicity, race, sexual orientation, disability, and other self-defined characteristics. Issues of culture, ethnicity, race, and other attributes which individuals use to self-identify impact the quality of interactions with providers and thus the assessment. Cultural tradition, experience and bias, both by the client as well as the counselor, are all part of an unstated but powerful dynamic in the helping relationship that impacts how information is provided and received.
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