Treatment Planning in Psychotherapy: Taking the Guesswork Out of Clinical Care
251
Treatment Planning in Psychotherapy: Taking the Guesswork Out of Clinical Care
251eBook
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Product Details
| ISBN-13: | 9781462505791 |
|---|---|
| Publisher: | Guilford Publications, Inc. |
| Publication date: | 01/19/2012 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 251 |
| File size: | 3 MB |
About the Author
Jerusha Detweiler-Bedell, PhD, is Assistant Professor of Psychology at Lewis and Clark College in Portland, Oregon.
Bethany A. Teachman, PhD, is Assistant Professor of Psychology at the University of Virginia.
Todd O'Hearn, PhD, was previously Director of the Yale Psychological Services Clinic and served on the teaching faculty in Yale's Department of Psychology. Currently he is developing a private practice in the Santa Barbara area.
Read an Excerpt
Treatment Planning in Psychotherapy
Taking the Guesswork Out of Clinical CareBy Sheila R. Woody Jerusha Detweiler-Bedell Bethany A. Teachman Todd O'Hearn
The Guilford Press
Copyright © 2004 The Guilford PressAll right reserved.
ISBN: 1-59385-102-2
Chapter One
TREATMENT PLANNING USING A PHASE APPROACHTreatment planning involves mapping not only the direction taken to meet the needs of the clients but also the tools used along the way. Planning also involves formulating expectations about how much change is anticipated and how quickly it should occur. A number of clinicians have emphasized the importance of treatment planning (e.g., Galasso, 1987; Makover, 1992, 1996), and these days many managed care organizations require it. As Heinssen, Levendusky, and Hunter (1995) described, "Focused, well-articulated treatment plans [improve] communication with managed care agencies because each client's presenting problems, treatment goals, and interventions are specified in understandable terms" (p. 530). Contemporary mental health care providers are usually bound by significant time constraints, so they must focus treatment strategies to accomplish as much as possible in just a few sessions. Given these constraints, treatment planning is a necessary element of accountable practice. Creating a Treatment Plan can help to organize a client's problems into a set of measurable goals andintervention strategies that maximize the efficiency of practice.
Nonetheless, treatment planning may be difficult for some practitioners to embrace, perhaps because it appears to be incompatible with the artistry and spontaneity that attract many individuals to the practice of psychotherapy. Makover (1996), who noted that an "anti-planning bias" has permeated the culture of psychotherapy over the years, argued for setting aside this bias, in part because it is based on three questionable assumptions: (1) human behavior is mysterious and unpredictable; (2) humans are too complex to be subject to rational planning; and (3) the relationship in psychotherapy is more important than the therapeutic activity. Makover suggests instead (and we agree) that psychotherapy is understandable, teachable, and amenable to a planning process. Although human behavior is complex and often unpredictable, contemporary practice of clinical psychology, clinical social work, and psychiatry involves identifiable therapeutic strategies that can be specified or sketched out in advance. Apositive therapeutic alliance appears to be necessary for good therapy outcomes, but it is not the only critical element (Bergin & Garfield, 1994).
FROM PROBLEM IDENTIFICATION TO PROBLEM SOLVING
Once the Problem List is created (as detailed in Chapter 2), the therapist moves from problem identification to problem solving, an iterative process in the PACC model. After cataloguing the client's problems, the therapist specifies aims that represent short-term goals related to the most pressing problems and are targets of the initial stage of intervention. The therapist then outlines treatment strategies to achieve these aims, measures how effectively the client is progressing toward them, and regularly reviews progress to determine whether the treatment should change, remain the same, or end. In short, treatment planning is a systematic way to move through the Problem List.
TREATMENT PLANNING AS THE THERAPIST'S MAP
Of course, it is impossible to address all of the client's problems at once. In our own practices, we weigh the options, often in collaboration with the client, to come up with a tentative "map" of the treatment process-essentially a brief plan of priorities and interventions. The challenge for the therapist is to synthesize the data that have been gathered from the initial interview and to formulate a case conceptualization that targets the treatment to the particular problems and strengths of the client. As we have discussed in Chapters 1 and 2, the therapist need not be constrained by a single therapeutic orientation, but can instead use an integrative approach that flexibly adapts the initial Treatment Plan based on the client's response to the intervention. By combining an evidence-based approach to selection of treatment strategies with ongoing measurement of progress, the therapist can avoid falling into the trap of offering all clients the same treatment, regardless of the nature of their difficulties (see Lewis & Usdin, 1982).
The case formulation bridges the Problem List and the Treatment Plan, acting as "the clinician's compass" (Sperry et al., 1992) to guide treatment. As discussed in Chapter 2, effective case formulation includes descriptive components ("What is happening to the client?"), explanatory components ("Why did it happen?"), and treatment-prognostic components ("What can be done, and how effective is it likely to be?"; Sperry et al., 1992). Whereas the formulation is the therapist's compass, the Treatment Plan is the map, detailing where the therapy is headed and likely paths to reach the destination. The therapist uses the case formulation's descriptive, explanatory, and treatment-prognostic components to help integrate the biological, psychological, and social underpinnings of the client's difficulties. This groundwork informs the order in which problems are best addressed, the expectations for change, and the treatments that are most likely to be helpful (Lewis & Usdin, 1982).
For example, a client who is dissatisfied with her marriage may seek treatment for a number of reasons. Understanding why she is dissatisfied is not only the explanatory component of the case formulation, but it also influences the therapist's selection of interventions and his or her expectations for treatment. If the client's marital dissatisfaction is grounded in her belief that she is unlovable, the therapist is likely to choose initial interventions to address such beliefs. On the other hand, if the dissatisfaction appears to be due to the client's lack of identity outside of marriage, the therapist is likely to choose different interventions. If the dissatisfaction comes from the client's inability to be assertive and to communicate effectively with her spouse, the interventions will be different still. The degree to which the client is coming to treatment to "fix" the marriage versus "escape" it is also a part of the formulation that helps to dictate expectations for change. If the client comes from a background in which divorce is common or accepted, the expectations may be slightly different than if she believes that divorce is unacceptable. There is no right or wrong answer to how the formulation should guide treatment planning, and different clinicians have their own preferences as to where to begin an intervention. Nonetheless, the formulation helps therapists to prioritize goals and create plans for change.
Realistic Goal Setting
Task performance is greatly enhanced by setting goals related to the task. This is one of the most robust and replicable findings in psychology (Locke, Shaw, Saari, & Latham, 1981). A client who works toward a goal is more likely to make productive use of the therapy sessions and of the time between sessions. Furthermore, goal setting enhances the tendency of the client to persist in the face of inevitable obstacles, and focusing on the goals encourages the client and therapist to develop creative strategies to attain the goal.
An important factor influencing the type of goals set is the client's efficacy expectations. As Bandura (1977) described, an outcome expectation is a person's belief that certain behaviors will lead to certain outcomes (e.g., "Exercise will improve my mood and make me feel good about myself"). An efficacy expectation is the person's belief that he or she will successfully carry out the behavior (e.g., "I can meet my goal of exercising three times a week"). Often, the client may expect good outcomes but have low confidence in his or her ability to carry out the planned changes. For example, "I know spending time with my friends will make me feel better, but I simply can't bring myself to pick up that phone and dial." Efficacy expectations are critical because the strength of clients' convictions in their own effectiveness is likely to affect whether they will even try new strategies for coping with their problems (Bandura, 1977). As a consequence, even therapists who use a very collaborative style may need to take the lead in setting goals if a client is demoralized because of low efficacy expectations.
Goal Acceptance and Commitment
Motivation to establish goals in psychotherapy comes from within the client as well as from external sources (e.g., family, therapists, agencies). Nevertheless, even the most agreeable and motivated clients may have difficulty maintaining commitment to established goals. (Indeed, this is often part of the problem that brings clients to treatment.) As therapists, how can we help boost clients' motivation and commitment to achieving therapy-related goals? Setting concrete goals that are challenging yet realistic is one way to help make this happen (Locke et al., 1981). Encouraging clients to make a public commitment to the goal also increases goal commitment (Hollenbeck, Williams, & Klein, 1989). The simple act of discussing treatment aims with a therapist (or with other members of a treatment group) can function as a public commitment, or clients can go further and discuss goals with trusted friends or family members. We recommend looking into motivational interviewing (Miller & Rollnick, 1991) for specific strategies to evaluate and enhance commitment to change for those clients who need a motivational boost.
TREATMENT PHASES
The PACC approach views treatment as a series of phases rather than as a single overall target or intervention. In general, it is only possible to work on a limited number of problems at once. Some clients with relatively straightforward and circumscribed problems may need only one phase of therapy, but more complicated clients will progress through several phases. Within each phase, the therapist (usually in collaboration with the client) defines aims that are to be the focus of that particular section of therapy, develops a measurement plan for those aims, and specifies the intervention strategies to be used within the phase. See Figure 3.1 for a blank copy of the form we use for this aspect of treatment planning.
The client should be included in the decision-making process to determine where to focus treatment initially. Consider the case of Peter, a 15-year-old high school sophomore, who had been experiencing panic attacks for the past year. Peter had been taking antianxiety medication prescribed by his primary care physician who was a family friend. In March of his sophomore year, Peter's panic attacks became so severe that he was spending every day in the nurse's office rather than attending his classes. His guidance counselors became increasingly concerned, and Peter began to feel isolated and hopeless about his condition. In April, he took an overdose of Tylenol and was hospitalized. Although his parents were reluctant to acknowledge that Peter had emotional problems, they nevertheless enrolled him in a short-term residential treatment program for adolescents. During this therapy, Peter revealed that he not only experienced panic attacks but also had a fear of vomiting that prohibited him from eating regular, balanced meals. In the 2 months leading up to his hospitalization, Peter had lost over 20% of his body weight, putting him at risk for multiple health problems.
Peter's problems crossed multiple domains of concern, including his depression and suicide attempt, panic attacks, agoraphobia, fear of vomiting, severe weight loss, and his parents' tendency to minimize his problems (which could undermine treatment progress). Not all of Peter's problems could be addressed at once. Instead, using a phase model, the treatment team at the residential program worked with Peter and his family to create a plan of action. Obviously, the high-risk problems, including Peter's suicidality, had to be addressed before his other problems could be tackled in subsequent phases of treatment. Conceptualizing treatment in terms of phases requires a degree of patience and an open acknowledgment to the client (and in Peter's case, to his parents) that not everything will get better at once.
The assumption that therapy can only target a limited number of problems at one time means that the "current" aims of treatment will shift over time. In Peter's case, the initial treatment aims were to minimize suicide risk and improve his depressed mood. Once Peter's mood was stabilized, the treatment aims changed. Although there were a number of possible problem areas to target (e.g., family relationships, panic attacks, weight loss through food avoidance), the therapist and Peter chose to focus on his panic attacks and avoidance of school. This issue was a priority for Peter because summer school had begun and, having been a high-achieving student, Peter wanted to begin making up the work he had missed due to his illness. Simultaneously, Peter's therapist arranged for a consultation with a nutritionist to partially address his weight loss. In this way, Peter worked on multiple problems concurrently without detracting from the focus on his panic. See Figure 3.2 to see how Peter's therapist completed the Aims portion of the Treatment Plan for the first two phases of therapy.
The number of phases clients will need depends on several factors, including the number and severity of their problems. Some clients come to therapy to work on a discrete problem, such as a specific phobia. Others come to treatment with multiple, complicated problems, such as a first psychotic break within the context of ongoing substance abuse, job loss, and an unsupportive home environment. Still other clients come to treatment in the midst of a depressive episode, and the true extent of their problems may not be apparent until some of the depressive symptoms subside. In contemporary models of treatment delivery, it is likely that one clinician will not be responsible for delivering all phases of care to a client. In Peter's case, for example, his primary clinician was a psychologist, but he also had sessions with a nutritionist as well as some family sessions with a social worker.
EFFECTIVENESS OF PHASE MODELS OF PSYCHOTHERAPY
Rogers (1958) was among the first clinicians to describe distinct phases of psychotherapy, noting an early phase in which clients struggle to identify problems, and a later phase in which clients feel a heightened sense of self-awareness and confidence. Although the specific objectives of each phase of treatment may depend upon the clinician's background and training, the notion that psychotherapy proceeds in stages is a common heuristic tool that transcends theoretical orientation (Beitman, Goldfried, & Norcross, 1989).
Continues...
Excerpted from Treatment Planning in Psychotherapy by Sheila R. Woody Jerusha Detweiler-Bedell Bethany A. Teachman Todd O'Hearn Copyright © 2004 by The Guilford Press. Excerpted by permission.
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Table of Contents
1. The PACC Approach to Treatment Planning PACC: Going beyond Randomized Clinical Trials PACC: Enhancing Accountability Guiding Principles of Our ApproachOverview of the Model
What Are the Benefits of the PACC Approach?
What the PACC Approach Is Not
Time and Cost
2. Developing a Problem List
Why Formalize the Problem List?
Domains of Functioning: A Biopsychosocial Perspective
An Outline for Biopsychosocial Assessment
Case Formulation and the Problem List
Prioritizing Problems
Reexamining the Problem List
Shortcuts for the Busy Clinician
3. Treatment Planning Using a Phase Approach From Problem Identification to Problem Solving Treatment Planning as the Therapist's Map
Treatment Phases
Effectiveness of Phase Models of Psychotherapy
Phases in the PACC Approach
Outlining Expectations for Progress within Phases
Treatment Aims
Treatment Strategies
Choosing Aims and Strategies: Case Example
Challenges in Implementing the Treatment Plan
Shortcuts for the Busy Clinician
4. Ongoing Measurement
Benefits of Ongoing Measurement
Obstacles to Routine Measurement
Completing the Measures Section of the Treatment Phase Form
Establishing a Measurement Plan
Case Study: Group Treatment for Social Phobia
Shortcuts for the Busy Clinician
5. Illustrating Progress through Graphing
Why Graph?: Rationale for Visual Inspection of the Data
Creating Graphs
Graphing Progress with Microsoft Excel
Reviewing Progress and Moving across Phases
Case Example
Research Implications
Shortcuts for the Busy Clinician
6. Review of Progress
Strategies for Implementing a Progress Review
Cultural Considerations in Conducting the Progress Review
Conducting Progress Reviews with Clients with Personality Disorders
Readiness to Change and the Progress Review
Reasons to Move to a New Treatment Phase
Seeking Consultation to Improve Treatment Delivery
When a Lapse Has Occurred
Case Example
Troubleshooting: Anticipating Barriers to Conducting Progress Reviews
Conclusion
Shortcuts for the Busy Clinician
7. Iterative Treatment Planning and Its Applications
The Decision Tree
Case Study: Using the Decision Tree
Ethical Implications of Using PACC
Applications of PACC
Final Comments
Appendix: Measures for Tracking Clients' Progress
Overview
Description of the Measures
Brief Psychiatric Rating Scale
Bulimia Test-Revised
Center for Epidemiological Studies-Depression Scale (CES-D)
Daily Spiritual Experiences Scale
Kansas Marital Satisfaction Scale
Psychotic Symptoms Rating Scales
Rosenberg Self-Esteem Scale
Yale-Brown Obsessive Compulsive Scale (Y-BOCS)
Sources for Other Measures
Interviews
Mental health professionals from a range of backgrounds, including clinical psychologists, clinical social workers, psychiatrists, and couple and family therapists; graduate students and trainees in these areas. Serves as a text in graduate-level courses in psychotherapy and evidence-based clinical practice, particularly within clinical psychology and social work.