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Thursday, September 24, 2009

T3 - Therapy Basics: Treatment Plans

Therapy isn't therapy without a treatment plan. This goes for fictional therapists and their clients, too. Contrary to how it's conveyed in popular shows like Frasier and In Treatment when the audience is privy to the talking but not the behind-the-scenes, therapy isn't just about the talking.

The conversational direction--i.e., the "talking"--should be towards an end that's already been specified between the therapist and the client. That's what a treatment plan is for.

Treatment plans look different depending on which therapist you go to. Here's the elements mine incorporates and the reason behind it.

1) Goals

Developing goals sounds much easier in theory than it actually is in practice. The reason? To make this worthwhile, the goals have to be specific, observable and quantifiable. So a therapist shouldn't just write down, "To decrease depressive symptoms." Yikes! This could be a legal nightmare were my file on that client to be subpoenaed.

So instead, a better way to put this goal would be: "Decrease depressive symptoms (as evidenced by crying, oversleeping and overeating) from 8-9 times a day to 1-2 times a day, as reported by client and her husband."

Now I've managed to convey how many times the symptom is happening and I've made the goal a measurable one by indicating how many times a day we would like the client to not be exhibiting depressive symptoms. It's often unrealistic to go from a certain number to zero, so I strive for reality in my goal-setting with clients.

Typical treatment plans have room for 2-3 goals.

2) Interventions

Then of course the therapist will want to spell out exactly what's in his or her bag of tricks that she will pull out to address the each specific goal. Interventions are as plentiful as goals, but to give you an idea of what I use frequently, say, with children:

art therapy, play therapy, bibliotherapy (reading books with messages/morals), role playing, modeling appropriate behavior, positive reinforcement, relaxation/anger management techniques, assertiveness training (to combat aggressiveness and teach the different), and so on.

3) Duration of Interventions

For sure we have to have a date we're working toward, if for no other reason than to revisit the goals at that time to see if we're on track. This can be 3 or 6 months from when the goals were initially discussed. Treatment plans expire after one year, so for sure a review needs to happen before then.

4) Termination Dates

Treatment plans expire after one year, so for sure a review needs to happen before then. If at the time of any review, it is determined that the goals have been met, then treatment is terminated, and this date is added to the treatment plan as evidence of the acknowledgment of both ther therapist and the client that treatment was satisfactorily concluded.

5) Changes to Treatment Plan

Sometimes changes are made to a specific goal during one of the reviews. In our example above, say the client's depressive symptoms swung mainly toward overeating. We might want to add as an intervention that the therapist referred the client to a nutritionist and exercise consultant (both of which would make the client hopefully feel better about herself and get her on the right track). I would note the date that this addition was made to the treatment plan and have the client initial it, as well.

This can be a hard one for therapists to remember. I know I did when I started out. But now, I just think of the client. Anything pertinent to their treatment should be noted not only for my own safeguard, but for theirs. A change in a goal or an added intervention is definitely pertinent.

6) Signatures

Signatures should be pretty self-explanatory, but sometimes even this can be complicated. Everyone privy to the treatment goals and interventions signs. So if I'm seeing a married woman, who on occasion brings in her husband, he would need to sign, too. If there are family therapy goals, then the family signs. i'f I'm seeing a minor or dependent adult, then the guardian would need to sign, as well. And every time there is a change, EVERYONE signs, which can be a major pain, just so you know. :)

Now we've covered treatment week we'll focus on session notes and you can once again enter the inner sanctum of a therapist's world.

Q4U: What are some topics you'd be interested seeing posted for Thursday Therapeutic Thoughts? I'm nearing the end of my Therapy Basics series and want to post what will help you the most. Thanks!

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Eileen Astels Watson said...

Hi, Jeannie:

I found this fascinating. I always see the therapists with their note pad in hand and pen running across the page and wonder what the heck they are really writing. I'm suspecting that what you talk about next week really leads to this treatment plan write-up. I look forward to reading all about what you therapists make note of. Is it that our eyes shifted to imply we're lying? Chin down, so feels like a loser? Or do you actually quote what the client is saying? Or both?

Rosslyn Elliott said...

Interesting. I saw a therapist while I was in college and there were never any signatures involved. I had NO idea what was going through her head, though I think she did a good job.

If you get a chance, I would like to know about personality disorders. I find them compelling, and especially the way they intersect with diagnoses along the other Axes. For example, I've heard that Narcissistic Personality Disorder is one of the most difficult to treat, and that people won't stay in treatment if they are given this diagnosis by a therapist. Thoughts? To me, it seems that the Axis One diagnoses (like Bipolar Disorder) are the more chemically-based disorders, while the Axis Two diagnoses are the ones that require "attitude adjustment" and the assumption of personal responsibility for one's behavior. But maybe I don't know what I'm talking about! :-)

Jeannie Campbell, LMFT said...

eileen - [insert cackling witch laugh here] - you'll find out next week. :)

rosslyn, PDs are very difficult to treat. and narcissitic PD, by its very nature, is a booger. you can check out the post i did here on axes. thanks for joining up and following!

Natalie said...

This is such an interesting blog! I'm looking forward to next week.

About Me said...

Interesting. I wish I would have read this post back when I was still working on my last novel. One of my main characters was a screwed up therapist.

Btw, I wanted to apologize to you. I just saw the award you gave me back in Aug. I was completely off the radar at the time. Thanks for thinking of me.

Diane said...

Maybe something on setting up healthy boundaries. There's always room for improvement there. :O)

Jessica Nelson said...

Wow, interesting stuff! I've always thought about being a therapist... until I just saw that there's a plan involved! *snort*
Seriously, this is very interesting. I had no clue things had to be so detailed.

Ava Walker Jenkins said...

Just wanted to say thanks for visiting my site and loved the reassuring comments! You have such a unique and truely educational blog that can help so many writers. We really appreciate your generous, giving spirit. Looking forward to more!

Billy Coffey said...

This is fascinating material. Can't wait until those session notes. I've always wondered about those...

Heather Sunseri said...

Great post, Jeannie. Fascinating. I'm looking forward to next week already.

Katie Ganshert said...

Hey girl! Friday night and I'm just getting to your blog. How awful is that?

Something that might be of interest to your suspense writers...psychopaths. Bring us inside a psycho's mind. That could be VERY interesting!

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Both comments and questions are welcome. I hope you enjoyed your time on the couch today.