INTRODUCTION

ABOUT PRACTICEPLANNERS®TREATMENT PLANNERS

Pressure from third-party payors, accrediting agencies, and other outside parties has increased the need for clinicians to quickly produce effective, high-quality treatment plans. Treatment Planners provide all the elements necessary to quickly and easily develop formal treatments plans that satisfy the needs of most third-party payors and state and federal review agencies.

Each Treatment Planner:

As with the rest of the books in the PracticePlanners® series, our aim is to clarify, simplify, and accelerate the treatment planning process, so you spend less time on paperwork, and more time with your clients.

HOW TO USE THIS TREATMENT PLANNER

Use this Treatment Planner to write treatment plans according to the following progression of six steps:

1. Problem Selection. Although the client may discuss a variety of issues during the assessment, the clinician must determine the most significant problems on which to focus the treatment process. Usually a primary problem will surface, and secondary problems may also be evident. Some other problems may have to be set aside as not urgent enough to require treatment at this time. An effective treatment plan can only deal with a few selected problems or treatment will lose its direction. Choose the problem within this Planner which most accurately represents your client’s presenting issues.
2. Problem Definition. Each client presents with unique nuances as to how a problem behaviorally reveals itself in his or her life. Therefore, each problem that is selected for treatment focus requires a specific definition about how it is evidenced in the particular client. The symptom pattern should be associated with diagnostic criteria and codes such as those found in the DSM-IV or the International Classification of Diseases. This Planner offers such behaviorally specific definition statements to choose from or to serve as a model for your own personally crafted statements.
3. Goal Development. The next step in developing your treatment plan is to set broad goals for the resolution of the target problem. These statements need not be crafted in measurable terms but can be global, long-term goals that indicate a desired positive outcome to the treatment procedures. This Planner provides several possible goal statements for each problem, but one statement is all that is required in a treatment plan.
4. Objective Construction. In contrast to long-term goals, objectives must be stated in behaviorally measurable language so that it is clear to review agencies, health maintenance organizations, and managed care organizations when the client has achieved the established objectives. The objectives presented in this Planner are designed to meet this demand for accountability. Numerous alternatives are presented to allow construction of a variety of treatment plan possibilities for the same presenting problem.
5. Intervention Creation. Interventions are the actions of the clinician designed to help the client complete the objectives. There should be at least one intervention for every objective. If the client does not accomplish the objective after the initial intervention, new interventions should be added to the plan. Interventions should be selected on the basis of the client’s needs and the treatment provider’s full therapeutic repertoire. This Planner contains interventions from a broad range of therapeutic approaches, and we encourage the provider to write other interventions reflecting his or her own training and experience.
Some suggested interventions listed in the Planner refer to specific books that can be assigned to the client for adjunctive bibliotherapy. Appendix A contains a full bibliographic reference list of these materials, including these two popular choices: Read Two Books and Let’s Talk Next Week: Using Bibliotherapy in Clinical Practice (2000) by Maidman and DiMenna and Rent Two Films and Let’s Talk in the Morning: Using Popular Movies in Psychotherapy, Second Edition (2001) by Hesley and Hesley (both books are published by Wiley). For further information about self-help books, mental health professionals may wish to consult The Authoritative Guide to Self-Help Resources in Mental Health, Revised Edition (2003) by Norcross et al (available from The Guilford Press, New York).
6. Diagnosis Determination. The determination of an appropriate diagnosis is based on an evaluation of the client’s complete clinical presentation. The clinician must compare the behavioral, cognitive, emotional, and interpersonal symptoms that the client presents with the criteria for diagnosis of a mental illness condition as described in DSM-IV. Despite arguments made against diagnosing clients in this manner, diagnosis is a reality that exists in the world of mental health care, and it is a necessity for third-party reimbursement. It is the clinician’s thorough knowledge of DSM-IV criteria and a complete understanding of the client assessment data that contribute to the most reliable, valid diagnosis.

Congratulations! After completing these six steps, you should have a comprehensive and individualized treatment plan ready for immediate implementation and presentation to the client. A sample treatment plan for borderline personality is provided at the end of this introduction.

INCORPORATING EVIDENCE-BASED TREATMENT INTO THE TREATMENT PLANNER

Evidence-based treatment (that is, treatment which is scientifically shown in research trials to be efficacious) is rapidly becoming of critical importance to the mental health community as insurance companies are beginning to offer preferential pay to organizations using it. In fact, the APA Division 12 (Society of Clinical Psychology) lists of empirically supported treatments have been referenced by a number of local, state and federal funding agencies, which are beginning to restrict reimbursement to these treatments, as are some managed-care and insurance companies.

In this fourth edition of The Complete Adult Psychotherapy Treatment Planner we have made an effort to empirically inform some chapters by highlighting Short-term Objectives (STOs) and Therapeutic Interventions (TIs) that are consistent with therapies that have demonstrated efficacy through empirical study. Watch for this icon as an indication that an Objective/Intervention is consistent with those found in evidence-based treatments.

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References to their empirical support have been included in the reference section as Appendix B. Reviews of efforts to identify evidence-based therapies (EBT), including the effort’s benefits and limitations can be found in Bruce and Sanderson (2005), Chambless and colleagues (1996, 1998), and Chambless and Ollendick (2001). References have also been included to therapist- and client-oriented treatment manuals and books that describe the step-by-step use of noted EBTs or treatments consistent with their objectives and interventions. Of course, recognizing that there are STOs and TIs that practicing clinicians have found useful but that have not yet received empirical scrutiny, we have included those that reflect common practice among experienced clinicians. The goal is to provide a range of treatment plan options, some studied empirically, others reflecting common clinical practice, so the user can construct what they believe to be the best plan for their particular client.

In many instances, EBTs are short-term, problem-oriented treatments that focus on improving current problems/symptoms related to a client’s current distress and disability. Accordingly, STOs and TIs of that type have been placed earlier in the sequence of STO and TI options. In addition, some STOs and TIs reflect core components of the EBT approach that are always delivered (e.g., exposure to feared objects and situations for a phobic disorder; behavioral activation for depression). Others reflect adjuncts to treatment that are commonly used to address problems that may not always be a feature of the clinical picture (e.g., assertive communication skills training for the social anxious or depressed client whose difficulty with assertion appears contributory to the primary anxiety or depressive disorder). Most of the STOs and TIs associated with the EBTs are described at a level of detail that permits flexibility and adaptability in their specific application. As with previous editions of this Treatment Planner, each chapter also includes the option to add STOs and TIs that are not listed.

Criteria for Inclusion of Evidence-Based Therapies

Not every treatment that has undergone empirical study for a mental health problem is included in this edition. In general, we have included EBTs the empirical support for which has either been well established or demonstrated at more than a preliminary level as defined by those authors who have undertaken the task of identifying EBTs, such as Chambless and colleagues (1996, 1998) and Nathan and Gorman (1998, 2002). At minimum, this requires demonstration of efficacy through a clinical trial or large clinical replication series that have features reflective of good experimental design (e.g., random assignment, blind assignments, reliable and valid measurement, clear inclusion and exclusion criteria, state-of-the-art diagnostic methods, and adequate sample size). Well established EBTs typically have more than one of these types of studies demonstrating their efficacy as well as other desirable features, such as demonstration of efficacy by independent research groups and specification of client characteristics for which the treatment was effective. Because treatment literatures for various problems develop at different paces, treatment STOs and TIs that have been included may have the most empirical support for their problem area, but less than that found in more heavily studied areas. For example, Dialectical Behavior Therapy (DBT) has the highest level of empirical support of tested psychotherapies for Borderline Personality Disorder (BPD), but that level of evidence is lower than that supporting, for example, exposure-based therapy for phobic fear and avoidance. The latter has simply been studied more extensively, so there are more controlled trials, independent replications, and the like. Nonetheless, within the psychotherapy outcome literature for BPD, DBT clearly has the highest level of evidence supporting its efficacy and usefulness. Accordingly, STOs and TIs consistent with DBT have been included in this edition. Lastly, just as some of the STOs and TIs included in this edition reflect common clinical practices of experienced clinicians, those associated with EBTs reflect what is commonly practiced by clinicians that use EBTs.

Summary of Required and Preferred EBT Inclusion Criteria

Required

Preferred

There does remain considerable debate regarding evidence-based treatment amongst mental health professionals who are not always in agreement regarding the best treatments or how to weigh the factors that contribute to good outcomes. Some practitioners are skeptical about the wisdom of changing their practice on the basis of research evidence, and their reluctance is fuelled by the methodological problems of psychotherapy research. Our goal in this book is to provide a range of treatment plan options, some studied empirically, others reflecting common clinical practice, so the user can construct what they believe to be the best plan for their particular client. As indicated earlier, recognizing that there are interventions which practicing clinicians have found useful but that have not yet received empirical scrutiny, we have included those that reflect common practice among experienced clinicians.

A FINAL NOTE ON TAILORING THE TREATMENT PLAN TO THE CLIENT

One important aspect of effective treatment planning is that each plan should be tailored to the individual client’s problems and needs. Treatment plans should not be mass-produced, even if clients have similar problems. The individual’s strengths and weaknesses, unique stressors, social network, family circumstances, and symptom patterns must be considered in developing a treatment strategy. Drawing upon our own years of clinical experience, we have put together a variety of treatment choices. These statements can be combined in thousands of permutations to develop detailed treatment plans. Relying on their own good judgment, clinicians can easily select the statements that are appropriate for the individuals whom they are treating. In addition, we encourage readers to add their own definitions, goals, objectives, and interventions to the existing samples. As with all of the books in the Treatment Planners series, it is our hope that this book will help promote effective, creative treatment planning—a process that will ultimately benefit the client, clinician, and mental health community.

SAMPLE TREATMENT PLAN

BORDERLINE PERSONALITY

Definitions: A minor stress leads to extreme emotional reactivity (anger, anxiety, or depression) that usually lasts from a few hours to a few days.
Exhibits a pattern of intense, chaotic interpersonal relationships.
Engages in recurrent suicidal gestures, threats, or self-mutilating behavior.
Reports chronic feelings of emptiness and boredom.
Exhibits frequent eruptions of intense, inappropriate anger.
Easily feels unfairly treated and believes that others can’t be trusted.
Analyzes most issues in simple terms (e.g., right/wrong, black/white, trustworthy/deceitful) without regard for extenuating circumstances or complex situations.
Goals: Develop and demonstrate coping skills to deal with mood swings.
Replace dichotomous thinking with the ability to tolerate ambiguity and complexity in people and issues.
Learn and practice interpersonal relationship skills.
Terminate self-damaging behaviors (such as substance abuse, reckless driving, sexual acting out, binge eating, or suicidal behaviors).
OBJECTIVES INTERVENTIONS
1. Discuss openly the history of difficulties that have led to seeking treatment. 1. Assess the client’s experiences of distress and disability, identifying behaviors (e.g., parasuicidal acts, angry outbursts, overattachment), affect (e.g., mood swings, emotional overreactions, painful emptiness), and cognitions (e.g., biases such as dichotomous thinking, overgeneralization, catastrophizing) that will become the targets of therapy.
2. Explore the client’s history of abuse and/or abandonment, particularly in childhood years.
2. Verbalize an accurate and reasonable understanding of the process of therapy and what the therapeutic goals are. 1. Orient the client to dialectical behavior therapy (DBT), highlighting its multiple facets (e.g., support, collaboration, challenge, problem-solving, skill-building) and discuss dialectical/biosocial view of borderline personality, emphasizing constitutional and social influences on its features (see Cognitive-Behavioral Treatment of Borderline Personality by Linehan).
3. Verbalize any history of self-mutilative and suicidal urges and behavior. 1. Probe the nature and history of the client’s self-mutilating behavior.
2. Assess the client’s suicidal gestures as to triggers, frequency, seriousness, secondary gain, and onset.
3. Arrange for hospitalization, as necessary, when the client is judged to be harmful to self.
4. Reduce actions that interfere with participating in therapy. 1. Continuously monitor, confront, and problem-solve client actions that threaten to interfere with the continuation of therapy, such as missing appointments, noncompliance, and/or abruptly leaving therapy.
5. Reduce the frequency of maladaptive behaviors, thoughts, and feelings that interfere with attaining a reasonable quality of life. 1. Use validation, dialectical strategies (e.g., metaphor, devil’s advocate), and problem-solving strategies (e.g., behavioral and solution analysis, cognitive restructuring, skills training, exposure) to help the client manage, reduce, or stabilize maladaptive behaviors (e.g., angry outbursts, binge drinking, abusive relationships, high-risk sex, uncontrolled spending), thoughts (e.g., all-or-nothing thinking, catastrophizing, personalizing), and feelings (e.g., rage, hopelessness, abandonment; see Cognitive-Behavioral Treatment of Borderline Personality by Linehan).
6. Participate in a group (preferably) or individual personal skills development course. 1. Conduct group or individual skills training tailored to the client’s identified problem behavioral patterns (e.g., assertiveness for abusive relationships, cognitive strategies for identifying and controlling financial, sexual, and other impulsivity).
7. Identify, challenge, and replace biased, fearful self-talk with reality-based, positive self-talk. 1. Explore the client’s schema and self-talk that mediate their trauma-related and other fears; identify and challenge biases; assist him/her in generating thoughts that correct for negative biases and build confidence.
2. Assign the client a homework exercise in which he/she identifies fearful self-talk and creates reality-based alternatives; review and reinforce success, providing corrective feedback for failure (see “Journal and Replace Self-Defeating Thoughts” in Adult Psychotherapy Homework Planner, 2nd ed. by Jongsma, or “Daily Record of Dysfunctional Thoughts” in Cognitive Therapy of Depression by Beck, Rush, Shaw, and Emery).
3. Reinforce the client’s positive, reality-based cognitive messages, which enhance self-confidence and increase adaptive action.
Diagnosis:     301.83     Borderline Personality Disorder