Treatment plans can be understood as a regulatory requirement, one of the many chores of contemporary health care, or they can be understood as recipes for changing a patient’s life. After all, the goal of any medical intervention is to help a person achieve a therapeutic change she cannot make on her own, so a treatment plan simply names what she needs to change, who will help her, and how she will make the change. Any reasonable treatment plan will include a problem list, a list of measurable goals, and a recipe for how to achieve them.
The reality, of course, is that managing a treatment plan is both a recipe and a chore. After all, treatment plans are often mental health care regulatory requirements demanded by governmental agencies and third-party payers. Regulators and payers often require the completion of mental health treatment plans in a proprietary format. We encourage you to identify treatment plans specific to your clinical setting, because only those treatment plans will fulfill the chore aspect of a treatment plan. In this chapter, we discuss three general principles universal to the recipe aspect of treatment plans: problem lists, patient and caregiver goals, and best practices. They are the what, the who, and the how of treatment plans.
When you evaluate a young person in mental distress, your goal should be to create a therapeutic alliance, but the tangible result of an evaluation is a diagnosis. This diagnosis is the foundation of a treatment plan.
In earlier versions of DSM, diagnoses were described in a multiaxial, or five-axis, system. Practitioners divided a diagnosis 250into five components: mental disorders, personality disorders, general medical conditions, psychosocial problems, and global functioning. At its best, the multiaxial system encouraged practitioners to understand a person’s distress from several different perspectives: a biological account of mental illness, a psychological account of personality, a mechanistic account of physical illness, a subjective list of psychosocial factors, and a standardized assessment of functioning. At its worst, the multiaxial system reinforced divisions between mind and body; allowed personality disorders to be used as pejorative slurs; included inconsistent accounts of psychosocial functioning; and jumbled together categories, lists, and assessments. It turned out to be a messy recipe.
The authors of DSM-5 (American Psychiatric Association 2013) reorganized the multiaxial system into a problem list. For physicians, the problem list is familiar, because it is already in use throughout medicine. Nonphysicians may benefit from a brief introduction to the problem list. Simply put, a problem list is a comprehensive, hierarchical catalog of the problems addressed during a current encounter.
To be helpful, the items on the list should be standardized because standardization enables communication. There are many ways to account for mental distress and mental illness. Individual practitioners may focus on dysfunctional neural circuits, adverse childhood experiences, or maladaptive personality traits. When these practitioners wish to speak with each other, they need a standard list. The standard list we favor is DSM-5 because it is the consensus diagnostic system of contemporary psychiatry, our way for mental health practitioners to work together while we await a diagnostic system with greater validity.
One reminder that we are awaiting a diagnostic system with improved validity is that the diagnoses generated by a DSM-5 interview are called disorders rather than diseases or illnesses. Physicians usually think in terms of diseases, which can be described as pathological abnormalities in the structure and function of body organs and systems. Patients usually present with illnesses, their experience of pathological abnormalities or of being sick. From a distance, diseases and illnesses may seem like the same experience viewed from the different perspectives of patient and physician. However, diseases and illnesses are often divergent experiences, not just different perspectives, as anthropologists have repeatedly documented (Estroff and Henderson 2005).
251Disorders are a kind of middle path between disease and illness because the term acknowledges the complex interplay of biological, social, cultural, and psychological factors in mental distress. Broadly speaking, a disorder simply indicates a disturbance in physical or psychological functioning. Use of the disorder label to describe mental distress draws attention to how mental distress impairs a person’s functioning, suggests the complex interplay of events that result in mental distress, and implicitly acknowledges the limits of our knowledge about the causes of mental distress (Kendler 2012). The field does not yet know enough to be more precise. The ongoing use of disorder in our diagnostic systems is an opportunity for humility and a spur to further study but primarily is a way to communicate together.
In order for DSM-5 to work as a common language, practitioners need to select a specific diagnosis. Standardization does not work without specificity. Imagine a recipe that asks you to add “a serving of fat.” Someone following the recipe would be confused. Did the author of the recipe mean a spoonful of bacon drippings, 2 tablespoons of salted butter, or a half-cup of coconut oil? Each is possible, but each results in a different dish. More to the point, it makes the recipe more of a personal inspiration than a communal instruction. Similarly, practitioners should recognize that characterizing a young person as having “an unspecified mental disorder” inadequately communicates the precise nature of a patient’s illness to other practitioners.
We encourage practitioners to select the most specific diagnosis for which a patient qualifies. If you believe a child is depressed, determine not only whether the depression constitutes a major depressive episode but also whether it is a single or recurrent episode, with or without psychotic features, and whether it is mild, moderate, or severe. This level of specificity enables communication with other practitioners and informs their treatment. We recognize the different ways to treat depression in a child if it is a mild first episode rather than a severe recurrent episode with psychotic features, but we barely know how to proceed with a child who has a non-specific disorder. Identifying a specific disorder improves communication with other practitioners, while communicating to your patients (and their caregivers) your diagnostic ability and your understanding of the patient’s illness. Diagnosis is, itself, a response to a patient’s suffering, because giving a specific name to the seemingly unnamable is itself 252salutary. (It also improves your ability to communicate with regulators and third-party payers, many of whom reimburse better for more specific diagnoses.)
Still, at times, a specific diagnosis is inappropriate. When you are uncertain of the diagnosis or need additional information, a provisional diagnosis is always preferable to a specific but inaccurate diagnosis. Just remember to eventually arrive at the most specific diagnosis possible. It is discouraging to review medical records in which a young person’s diagnosis remains poorly characterized for years.
Even if your diagnoses lack specificity, you can make them comprehensive. They should include all problems that are currently diminishing a young person’s ability to function. Thus, the list should include mental disorders, general medical conditions, and psychosocial problems. We, as you know by now, use DSM-5 to describe mental disorders, including the adverse effects from psychiatric treatment that are described in Section II of DSM-5. To describe general medical conditions, we include the medical conditions that are currently affecting a young person’s function. You do not need to list well-healed injuries. To describe psychosocial problems that influence a young person’s health, we favor using the standardized list of ICD-10 (World Health Organization 1992) Z codes. Several of the most relevant Z codes are found in Chapter 11, “Rating Scales and Alternative Diagnostic Systems,” of this book, but the complete list of Z codes, numbered Z00–Z99, is found in the ICD chapter “Factors Influencing Health Status and Contact With Health Services,” which can be found online at http://apps.who.int/classifications/icd10/browse/2010/en#/XXI.
Finally, the problems should be ordered hierarchically. Problems that are the focus of your treatment should lead the list. For example, an adolescent may have cystic fibrosis, but if you are treating her for an episode of major depressive disorder following an intentional overdose, then her first two problems are her major depressive disorder and her suicide attempt. If you evaluate her again 2 months later and she has recovered from her depression and has recovered from her overdose, then her depressive episode and suicide attempt would be lower on her problem list. A well-ordered problem list communicates to everyone who reviews your record the focus of your treatment.
You develop the goals of your treatment in conversation with your patient and her caregivers. Sometimes practitioners ask about goals toward the end of a clinical conversation. We prefer to ask about goals from the beginning and then throughout a conversation. Asking about goals is another way to establish a therapeutic alliance, the mutual commitment you and a patient make to improve her well-being. You and the patient establish the alliance when a patient identifies treatment goals and you ally yourself with her in pursuit of those goals. By doing this early in your encounter, you invariably increase the amount and reliability of information a patient offers. More profoundly, you help motivate a patient’s desire to change. We ask, often very directly, “What is your treatment goal?” or with younger children, “If you had three magic wishes, what would you change about your life?” Then, as the encounter progresses, we frequently check about additional goals, saying something like, “I hear that you are concerned; should we address that as a treatment goal?” or for smaller children, “Is that the kind of thing you would use a magic wish on?” By continuing to ask about treatment goals, a practitioner clarifies the focus of treatment and further builds the alliance with a patient.
By the end of a conversation in which you have frequently asked about treatment goals, it is usually straightforward to summarize the most pressing treatment goals. We often do so by saying, “It sounds like we have identified the most important treatment goals, but I want to be certain. Have we identified the right goals?” or with a younger child, “I think I know what you would use your three wishes on, but I want to check with you and be sure.” These kinds of conversations ensure that your treatment goals will reflect a patient’s desire, which usually increases her interest in pursuing the treatment goals. When possible and appropriate, phrase the treatment goals with the patient’s own words.
Part of the challenge of working with children and adolescents with mental distress is bringing patients and caregivers together in pursuit of common goals. With patients, we prefer to identify goals early in an encounter. With caregivers, we like to understand the relationship between a caregiver and a patient before asking about treatment goals. Different 254caregivers will be invested in a patient in different ways. Is the caregiver a biological parent, stepparent, foster parent, grandparent, older sibling, guardian, probation officer, or teacher? These relationships affect the treatment goals a caregiver identifies and her ability to affect those goals. If, say, an adolescent presents for treatment with her probation officer, the treatment goals will likely include legal requirements, which are quite different from the patient’s goals. You need to know how and why a caregiver is involved in a young person’s life before soliciting a caregiver’s treatment goals.
Once the patient, caregiver, and practitioner agree on treatment goals, it helps to consider the settings in which the goals will be pursued. If the problems you mutually identify occur mostly at home, then the goals should focus on the home. If the problems occur mostly at school, then your goals need to engage the school’s teachers and staff. If you are seeing the patient in a primary care clinic, the treatment goal may include learning coping skills, developing new habits, or establishing care with a mental health practitioner. If you are seeing the patient in a hospital, the treatment goals usually address acute concerns, such as decreasing suicidality or improving mood.
Any good treatment goal can be achieved. It does no one a service to set unachievable goals. Unachievable goals are a species of magic thinking, the wish that simply thinking about something will make it happen. We may earnestly desire to play center for an NBA team, but no amount of training will ever help two middle-aged psychiatrists achieve that goal. Similarly, it is foolish to set a goal that is truly impossible for a young person—whether because of age, developmental status, or physical or psychological characteristics—to achieve. It also does no one a service to set unexceptional goals. Unexceptional goals are a kind of everyday cruelty, the setting of the low bar in order to claim an unearned victory. We may not play basketball like NBA centers, but we can (at least for now!) tie our own shoes, so setting a treatment goal of shoelace tying would be insulting. The best goals are just a little bit out of reach of what seems possible; in our hypothetical case, our goal should be to improve our passing and shooting in games of pickup basketball. Pursuing similarly appropriate goals improves the lives of patients, caregivers, and practitioners because these goals expand our imagination for what is possible.
255Writing about how setting the right goal can expand our imagination of the possible can seem too aspirational, so we remind you that goals must simultaneously be measurable. A treatment goal cannot be to “be more healthy,” “be less ill,” or “have better behavior.” Parents often say they want their children to be “good,” which is a similarly unmeasurable goal. In our own example, a difficult-to-measure goal would be that we each “become a better basketball player,” whereas a measurable goal would be to “increase our assist-to-turnover ratio from 1.5 to at least 4.5.” The treatment goals you set with patients also should be measurable, so that you know when the patient is, or is not, achieving the goals you have agreed on.
One way to identify achievable and measurable goals is to personalize treatment goals to what is possible to achieve as reported in the medical literature. Several practice guidelines and treatment plans are available (e.g., Nurcombe 2014). In our work with young people, we prefer the practice parameters created and maintained by the American Academy of Child and Adolescent Psychiatry (AACAP). The parameters cover most of the major categories of mental illness that children and adolescents experience. The parameters were written by experts in the field and include information about etiology, diagnosis, treatment, and prognosis. All include specific recommendations that can be widely adopted. The practice parameters can be found online at www.jaacap.com/content/pracparam.
As of this writing, 52 practice parameters are included in the AACAP library. We could never hope to summarize all 52 here. Even if we could, they are dynamic documents, and some of them will likely have been updated by the time you read this text. Instead, we dispersed some of the knowledge in the current practice parameters throughout this book, especially in the next three chapters. The American Psychiatric Association also has developed a set of clinical practice guidelines, but these are targeted to treatment in adult patients. Those guidelines of care may be found at http://psychiatryonline.org/guidelines. Table 13–1 provides some general advice for developing an initial treatment plan.
256TABLE 13–1. Sequential ways to develop an initial treatment plan
1. |
Identify your patient’s initial treatment goal. |
2. |
Develop a therapeutic alliance with your patient. |
3. |
Clarify the relationship between the caregiver and your patient. |
4. |
Reach the most specific DSM-5 diagnosis for your patient. |
5. |
Write a hierarchical list of current problems |
6. |
Rewrite the problem list into treatment goals. |
7. |
Identify measurable and achievable goals from the available evidence base. |
8. |
Customize the treatment for your patient’s cultural background and available resources. |
9. |
Assign responsibility for each goal to a member of your patient’s treatment team. |
10. |
Monitor the progress toward each goal. |
11. |
Revise the goals as your patient’s situation changes. |