Thursday, March 1, 2007

Developing Treatment Plans: The Basics

[Episode 11] In this podcast I cover the basics of problem definition, developing goals and measureable objectives as well as identifying interventions and strategies. The key to good treatment planning is making sure that there is a clear and logical relationship between your assessment, problem formulation, goals, objectives and interventions.
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Transcript



Today’s podcast is on how to identify problems, develop goals, objectives and interventions. In Social Work, we often refer to the document that contains the problem statement, goals, objectives and interventions as the treatment plan or service plan. At its best, the treatment plan is a road map that outlines how the client and social worker will travel from point A to point F. Point A can be thought as the issues concerns or problems that were identified through the assessment and diagnosis. Point F is what the client’s life will look like when those issues have been successfully addressed. Now I intentionally used point F as the end point because it’s unrealistic to assume that the problems that the clients come in with can be resolved in a linear fashion. So, rather than thinking, “Oh the client and I will develop a treatment plan, and follow it and then we will be done”. It’s more realistic to think, we are going to develop the best plan we can and when life derails are plan, we’re going to revisit and revise. When you find yourselves travel through points B,C,D, and E don’t get discouraged. Just remember they are all parts of the journey.

Today we’re going to talk about how to frame the vast amounts of information that the client presents, into a workable problem. We’ll discuss the difference between goals and objectives and how to develop useful and achievable goals and objectives. We’ll talk about what types of interventions and strategies that are typically used to achieve the goals that you and your client set. Then we’ll end with a comparison of a poorly conceived and appropriately conceived treatment plan. Some of the resources I consulted as I was making up this podcast were: Donald Wiger’s Clinical Documentation Primer and Sourcebook, both available through Wiley Press; Dr Lambert Maguire’s Clinical Social Work available from Brooks Cole and Hepworth Rooney and Larsen’s Direct Social Work Practice from Wadsworth Thompson.

Imagine that you are a social worker in an outpatient community mental health agency. You’re newest client is a woman, we’ll call her Tammy. She’s in her mid-50’s and she presents with depressed mood. She’s soft spoken, she has an engaging smile, and reports enjoying daytime soaps and movies starring Will Smith. Her housing is safe and is accessible. She reports having faith in something but she is not sure exactly what the something is. During your assessment, you learn that she has been sober for 6 years, but reported a 15 year addiction to crystal meth. She reports a history of sexual abuse, both as a child and as an adult, including multiple rapes during the time she prostituted herself for drugs. She also reports a history of physical abuse towards others including her 3 children, each of whom spent time in foster care. She reports having no social supports and no living relatives and including her children with whom she is in contact. Her physical health is poor, as she is suffering the effects of post-polio syndrome resulting in the loss of her use of her legs and the progressive loss of the use of her arms. As you listen to Tammy’s story, you might find yourself feeling overwhelmed and think to yourself, "how could I possibly help her?" If you are feeling overwhelmed then it is possible that you are tapping into the experience that Tammy herself is having. Most of our clients come in with a lifetime of problem, as well as a lifetime of solutions, and it’s our job to help our clients focus on what is most important to address in this moment. Milton Erickson, the famous hypnotherapist, was one asked how he was so successful at treating patients that others had no success helping. He answered, when people come into my office they often come in with problems they can’t solve. What I do is I make sure they leave with problems that they can solve. So, the first step in any helping process is to identify what the solvable problem is. Regardless of your theoretical perspective, there are a few questions that you need answered in order to help your client. The first is to find out why your client is seeking help and why is she seeking help now. What problem or problems would she like to resolve. You would also like to have some idea of what you’ll do in therapy and what your client will do outside of therapy to address these problems. Next, you’ll want to figure out how you and your client will know if the treatment is working. And finally, what will let you know that therapy is no longer necessary? How will you know when to terminate or to transition into another treatment? If you can answer all of these questions, then you’ve gone a long way in developing a sound treatment plan.

Problem definition: defining a problem can be challenging, but the good news is that once you define the problem, then you’ve suggested a solution. For example, if one of Tammy’s problems is feeling worthless, specifically she is not important to anyone, then the solution is to help her see that she is important to someone. Feeling worthless is one of the symptoms of major depressive disorder. In many agencies and for nearly all 3rd party reimbursement and by 3rd party reimbursement, I mean insurance, whether that is private or federal. DSM diagnoses provide the bases for problem definition; however, the diagnosis itself is simply a category a short hand way describing a cluster of symptoms, a level of impairment, and distress or disability caused by a symptom. And as a category, the diagnosis is insufficient as a description of a problem. If you want to learn more about DSM diagnosis, or the biopsychosocial assessment, you can listen to the related podcast that can be found on the socialworkpodcast.com website.

So in Tammy’s case, the problem isn’t major depressive disorder, that’s just too vague. A more specific description of the problem is that she believes her life is worthless. This is obviously not the only problem in Tammy’s life, but it is the one we can work on. Once we have identified the problem, we can come up with the goals and objectives that will help us to achieve our solutions.

Goals and Objectives: Donald Wiger writes that "goals are long-term, general and often the opposite of the problem." In Tammy’s case, if the problem is that she feels worthless, then the goal is to help her feel important to something or to someone. Can you see how by flipping around the problem, we take a seemingly overwhelming situation and make it a little more manageable? And manageable doesn’t mean easy or quick, but it does mean that the problem is a little closer to being solved. If you’re in an agency that bases treatment and reimbursement on the DSM, then you want to make sure you list goals and objectives for each symptom of the diagnosis. If you find yourself getting stuck figuring out what the goal should be, just remember, that the most basic goal should be for your client is to be able to function at whatever level they were functioning at before the current problem started. Wiger refers to that as pre-morbid functioning.

The specific steps we take to achieve the goal are called objectives. Objectives are short-term and specify who does the action, for how long, and how often to achieve the desired outcome. Hepworth, Rooney and Larsen suggest a simple formula for remembering the components needed for clear objective. Their formula is to specify "who will do what by when." The who is the individual responsible for accomplishing a task. And that might be the client or the therapist. It could be somebody in the client’s social network, or another a professional possibly a referral. The what refers to the tasks that the individual needs to complete in order to achieve the goal. And the when sets a time limit. And the time limit can be really useful because it adds a sense of urgency as well as an endpoint. For example, during your assessment with Tammy, you found out that the last time she felt important to someone or something was before she lost the use of her legs. She reported that she would go out with her friends and meet them for dinner twice a week. Since she has been in a wheel chair, she doesn’t drive because she can’t afford a modified car and because her friends didn’t really follow-up with her once she lost her ability to meet them for dinner, she believes she’s lost those friendships and that her friends no longer accept her in her disabled state. So, at the moment Tammy feels worthless and she doesn’t feel important to anybody and she’s not going out she’s not meeting her friends. So, an objective might be to meet friends for dinner which is zero times a week now, and the objective would be to meet friends two times a week, sometime in the next 3 months. Notice how the objective has a baseline (zero times a week) as well as a target (two times a week) and a timeframe that it will happen in the next 3 months. It also has a who, Tammy; a what, meeting friends for dinner and a when, within the next 3 months. Because the goals and objectives derive from the assessment, you don’t have to make up these numbers out of thin air. You just have to find out what Tammy’s life was like before this problem started and then work backwards. If she is able to increase her social outing to 2 times a week, you’ve help her return to what Wiger calls her pre-morbid functioning or her level of functioning before this problem started. If you’re thinking to yourself, well ok but there are steps in order for her to meet her friends 2 times a week, then you’re starting to get the hang of this. The more realistic and precise you can be in your objectives and in the objectives to meet the objectives, then the more successful you and your client will be in solving whatever problem it is that they came in to resolve. You will feel a sense of professional pride and probably most importantly your client’s life will be more fulfilling.

Interventions and strategies: Wiger writes that strategies are the means by which you will achieve your treatment goals. Lambert Maguire notes that each objective can have more than one intervention. Interventions are typically specific to whatever theoretical approach you take. For example, if you take a cognitive-behavioral approach, you’re more likely to use interventions such as identifying distortive thoughts. If, however ,you use a solution focused approach, you might use things like the miracle question and finding exceptions. Wiger has listed the following typical strategies: type of therapy, that can include individual, group, family, play etc., models of intervention such as CBT or pharmaco therapy, techniques ,such as systematic desensitization, social skills training, etc., and home work assignments. For Tammy, our intervention might include individual therapy, using interpersonal psychotherapy, to address role transition, from being able-bodied to a person with a disability. Another intervention might be to refer Tammy to post-polio syndrome support group where she can develop relationships with people in her same situations. Techniques may include grieving the loss of the old role and accepting her new role. And homework assignments can include journaling, investigating transportation options, etc. An intervention specific to the goals and objectives that we discussed earlier could be that I will do some role-playing with Tammy to help her practice talking to her former friends or friends that she considers former friends, and find out exactly what she would say and how she would say it so we can work through some of her anxiety or sense of hopelessness about re-connecting with these old friends.

To sum up, the most important thing to remember when setting goals, objectives, and interventions is that they derive from the assessment and they result in the client returning to their pre-morbid functioning or even better. Your goals have to relate to the problem otherwise your interventions won’t result in a solution. If your goals are vague and your objectives aren’t measurable, then it’s going to be very difficult for you to answer the questions that we talked about in the beginning, such as how will I know if my interventions are working? And how will I know when treatment is no longer necessary? Imagine Tammy coming in and the problem would be identified as she’s depressed, the goal would be to feel happier and the objectives are measurable. They can be things such as improved mood, which is fine, but we have no idea what improves mood looks like. And the interventions can be anything I’m used to doing, such as having her keep a journal, having her talk to people. And the interventions might be fine, but they wouldn’t be specifically related to what we were doing in the therapy session to solve her problems. And in the worst case scenario, she would leave and she would feel like therapy is a waste of my time: “Not only am I alone, but the one thing I went to solve my problems couldn’t even help me. That’s how hopeless my situation is.”

So, when you come up with specific goals and objectives, and your interventions address the problems that your client came in with, there’s this sense of success, both for you and your clients. And your clients overall objective to lead a happier more fulfilling life is most likely will come true.

References

Hepworth, D. H., Rooney, R., & Larsen, J. A. (1996). Direct social Work practice: Theory and skills (5th ed). Belmont, CA: Wadsworth/Thomson.

Maguire, L. (2001). Clinical social work: Beyond generalist practice with individuals, groups and families. Belmont, CA: Wadsworth/Thomson.

Wiger, D. E. (1999). The Clinical Documentation Sourcebook (2nd ed.). Hoboken, NJ: John Wiley & Sons.

Wiger, D. E. (2005). The Psychotherapy Documentation Primer (2nd ed.). Ed. Hoboken, NJ: John Wiley & Sons.


APA (6th ed) citation for this podcast:

Singer, J. B. (Host). (2007, March 1). Developing Treatment Plans: The Basics [Episode 10]. Social Work Podcast. Podcast retrieved Month Day, Year, from http://socialworkpodcast.com/2007/03/developing-treatment-plans-basics.html

5 comments:

wschwartzmd said...

My name is Wendla Schwartz and I am CEO of PsychNotesEMR. We are trying to make our electronic medical records application more LCSW and MFT friendly (both from a clinical and cost standpoint) and I am wondering if anyone on this site would be willing to check it out and give us feedback.
www.PsychNotesEMR.com
I can be emailed directly at wschwartzmd@psychnotesemr.com
Thanks. I apologize if this is the wrong format. I could not figure out how to leave a general post.
ws

Anu said...

This podcast was very helpful, especially the list of questions that need to be answered to develop a treatment plan. Thanks so much :)

Malisa Price said...

This has been the most helpful information, especially for us new therapists!

Thank you!!

Tahl Leibovitz said...

That was very helpful. Thank you. I printed out the example.

Tahl Leibovitz MA, LMSW

Elisabeth said...

Thank you Prof. for these practical and informative podcasts!