Treatment Planning and Goal Setting | NCMHCE Test Prep

Welcome to the brief course on treatment planning brought to you by allce.com treatment plans serve as roadmaps and help clients learn to set goals. They provide an objective reference for progress and are necessary for ethical and reimbursable practice. The process and format of a treatment plan can vary a little bit, but basically you first want to assess the biopsychosocial needs of the person. Strengths, needs and abilities. Identify areas in which the client is motivated to work and then write a goal statement which answers the question how will I know when I or the client has accomplished this? And it also states what new behaviors and feelings will be present. Not just John will stop drinking. Okay, what's he going to do instead? And is John motivated to stop drinking? Maybe not. He may be motivated to get his wife off of his back or his boss off of his back, of which something he's going to have to do is stopping drinking. But his motivation is a different goal. Ultimately, the outcome is the same. He's got to stop drinking. When we write treatment plans, we want to write them in the format of KSAs, or knowledge, skills and abilities. First, we help people learn about something. Someone comes to you and they're suffering from major depressive disorder. First thing they need to do is learn about depression, what causes it, what are the treatments, and what might be causing it in their particular situation. Then they need to develop the skills and this is based on their strengths, needs, abilities and preferences. Help them learn coping skills, positive self talk, identifying when they're starting to have a depressive episode so they can catch it early. Whatever other skills they may need in order to achieve whatever goal they're trying to achieve. And they practice these and rehearse these in group or in individual session. And then abilities. Abilities are merely skills that have been successfully used in the natural environment. When we have our aftercare groups, people come back to the group and say, I used this skill in this situation and it worked great, or it didn't work so well. And then the group works to help them figure out what they could have done slightly differently in order to handle the situation. Knowledge, skills and abilities let's talk about it in terms of something concrete like operating a computer. Knowledge. First you have to know what a computer is. You don't need to know all the specifics about RAM and all that other stuff, but you need to know that you need a monitor and you need some sort of a processor and you need a keyboard and a mouse or a mouse pad. That's your knowledge how the computer works. Not so important, but you need to know how it stores information in files and folders. Then skills is when you practice working on the computer. Can you open Microsoft Office? Can you create a Word document? Can you save it and then find it again? Then abilities is when you don't have to think so hard about the skills and you just go to work and you have the ability to operate all of the programs in Microsoft Office. KsAs are objectives or sub goals. For example, before you read, you need to know your letters and sounds, how to sound out words, and demonstrate the ability by reading. KSAs are accompanied by interventions which are assigned to the therapist or client. Some things the therapist is going to do, such as I will provide you a worksheet on cognitive behavioral therapy and irrational thoughts. The client will complete the worksheet on cognitive behavioral therapy, bring it back, and discuss it with the therapist the next day or the next session. All of these interventions need to be assigned to people and have time limited achievable dates. What did you learn in grad school? Well, we learn hopefully where the problems come from. Symptoms of Problems what are the symptoms of depression? Changes in eating, changes in sleeping, feeling hopeless more often than not, for more days than not out of the week, the list goes on. Hopelessness, helplessness, etc. We learn the impacts of problems. When people are depressed, they generally have difficulty getting out of bed. They have difficulty getting out of bed, they lose their job, they start having marital problems, et cetera. And we learn how to tailor methods to the individual. So Jim Bob, who is an introvert, really does not like going to these huge 12 step meetings where there's like 60 people in a room. He needs to go to a home group. John, who's a visual learner, does a whole lot better reading about something or doing an anger management workshop than he does sitting in your office and just talking about it with you. These are all things we learn. These are all things we need to teach the clients. We didn't learn magic, we just learned about people. People know a lot about themselves, but there are a lot of things about temperament and learning that they can't articulate or they don't know they know yet. And once they know they know then they can apply it. This demystifies the counseling process. People think that we work some magic and make them feel better. No, we just help them make better choices and use more effectively the tools that they already have. Characteristics of Good Goals and one of the first things we're going to teach people in counseling is how to set goals because we're going to write the treatment plan together. Good goals need to be observable. You've got to be able to see something change and it can be observable. Like on a likert scale from 1 to 5, 1 being really crappy to 5 being really great. Sally is going to feel like she is at a three or a four more days than not over the next two week period. Measurable again, that Likert scale comes in there. Or if somebody is trying to lose weight, that's obviously measurable. If somebody has anger management problems, maybe the number of outbursts that they have goes down and time limited, especially early on in counseling. People are there. They really need results to help them stay motivated. They need to feel like something's changing. So make your goals time limited so they can achieve them and feel a sense of accomplishment. A week, two weeks, a month. And they need to be achievable. If somebody thinks that they have had an addiction for the past 17 years and in 28 days they're going to be fixed, that's just not going to happen. So we need to help them understand that the goals they set need to be achievable. And while long term sobriety is possible, it's not just 28 days and out. It's going to be a long process. Once you've set the goals, then you have to help the client get and stay motivated to achieve those goals. Emotional motivation, what makes them happy or excited about achieving this goal. Cognitive motivation, what interests them, what intrigues them, what challenges them. Physical motivation, how's it going to help them feel better? Now physical motivation is a tricky one because a lot of people say, well, I'm depressed. Well, yeah, that's mainly. Or when we think of it, we talk about the emotional symptoms. But physically a lot of people somaticize their depression. So physically they'll feel better because they're going to sleep more restfully, they're not going to be tired all the time. They may not ache as much, they may not get sick as much. There are a lot of physical reactions to depression and lack thereof. Socially, how is it going to impact your relationships? If you're not depressed and ho hum all the time, how are your kids going to react? How are your spouse going to react? How are your friends going to react? And environmentally, if you're not depressed and tired and in pain all the time, you know what? You're probably going to want to take better care of your environment. Guess what? It won't be a big deal to empty the dishwasher. Or sweep the floor. That'll be something you look forward to doing because you'll enjoy and have the energy to be in a pleasant environment. The key is to setting again, setting small goals that produce success and reward, not huge ones. If Sally comes to you and she's sleeping every day until 4 o', clock, she gets up, eats one meal and goes back to bed and sleeps for the rest of the time. The first small goal should be between now and next week when you meet. I want you to get up at 8am or 9am if she likes to sleep late, get dressed and walk outside and walk around the block once. Then if you just can't stand it anymore, you can go back to bed. That's a small goal, but it's achievable. Just about anything, anybody can walk around the block once, but getting outside helps reset the circadian rhythms, tells the body it's time to be awake. Whereas staying in bed and hiding under the covers, your body's like, is it night? Is it day? Do I eat? Am I tired? That's a small goal. And she can come back and say, yes, I did that. Next, when we're talking about motivation, we want to look at decisional balance exercises. We forget this. Counselors and clients alike, we forget this. Not only are there positives to change, we wouldn't do it if there weren't positives to change. But there are also drawbacks to it. I know. Say it isn't so. Yep, there are drawbacks to change or we would have done it already. There's also positives to staying the same. Yep, that's another one that people don't want to hear. What are the benefits to staying depressed? Well, people take care of you. People don't bother you. You can blame just about any failure on your depression and lack of energy. Yeah, there's a lot of benefits to being depressed, but there's also a lot of positives to not being depressed. So helping people do this decisional balance exercise so they can figure out where their motivation lies, you can identify all of the drawbacks to change and address those. For example, not being depressed anymore. A drawback is I've got to take responsibility for what I do. Well, yeah, that's true, and it sucks sometimes. But on the positive side, you also get to take all the credit for the positive things that you do. Drawbacks to not being depressed anymore is that I actually have to get up and go to work every day. Well, yeah, you do positive, you get a paycheck. Another positive, if you don't like this job. Once you've really established yourself as being a consistent employee, guess what? You can probably change jobs. Helping your clients work through all of their obstacles, to change in all of these quadrants. So change is a positive, Is going to be important. It's time for you to be a cheerleader. And you replace chocolate with what? No, we don't replace chocolate with celery. You go on a diet and you crave chocolate, and you chomp on a piece of celery. It's very unsatisfying. The same is true for a lot of our old behaviors. We did them because they had a benefit. So you don't take away that behavior and replace it with something not nearly as satisfying. This is something that we talk about in substance abuse treatment a lot. You take away somebody's crack cocaine and you tell them that they can replace that with reading a book. You know what? No. Unless it's some really. I can't even think of a book. Except for maybe for some people, their spiritual text, whether it be the Koran or the Bible or whatever. There are not many books that can give you the same sort of oomph that cocaine does. So let's not set people up to think this is all there is to sobriety. This really sucks. The old behavior served a purpose. The new behavior must accomplish the same goal in a healthier way. So we'll take the person who was depressed. The old behavior of staying in bed served a purpose. They hurt all over. They were tired all the time. They kept thinking, if I sleep long enough, maybe I'll wake up and I'll have the energy to do something. Well, anybody who's been on bed rest knows that that's not the case. So we need to educate them. That whole knowledge component again, staying in bed and messing up your circadian rhythms is not going to help you find the energy. So what can you replace that sleeping with? Because you know what? Sleeping is pretty darn easy. Well, what's enjoyable that you might actually be willing to do? Walk around the block, get up and take your dog out for a walk, Walk down to the park and sit and watch the kids for a little while. What is it that's not too draining that you can do when you wake up that might help you feel a little bit better? In substance abuse, a lot of people use in order to escape from negative feeling states, either emotions or physical pain, whatever, so they start hurting again in whatever way. And obviously we're not going to say, well, go out and get a hit. Not going to happen. So if they can't do that, if they can't get that numbing, if they can't get that escape from their drug, how are they going to get it? Can they go to a meeting where people totally understand and they feel like they fit in? Can they go out on a really, really long run? I had one client, he was detoxing from methadone, and when he start to have a bad day, he'd start craving the methadone and he would go out and run as hard as he could until he got that endorphin rush, which gave him a similar feeling to what the, the methadone had, what the opiates had. So it was similar. He found something that worked for him. Some of my other clients, not that we support this, have sex. They have sex a lot, and usually not in the best places, but when you look at what's the motivation behind their behavior? Well, we took away their drug, and they can't listen to rock and roll all the time. So what is it? Sex, drugs and rock and roll. They've only got sex left. They need to have something that helps them feel good. We need to assess how the old behavior impacted the person emotionally, mentally, physically, socially, spiritually and environmentally. Because we've got to find a replacement that meets the majority of those needs. If it made them feel emotionally and physically better and it made the confusion and the fog go away, well, okay, what can we do that also does those things that are not harmful and try to add three new behaviors for every one you are trying to eliminate. So if you take someone, we'll go back to the person who's depressed and they sleep all the time. Okay, we need to identify three things that they're going to do Instead of turning off their clock and rolling over and going back to sleep again, Walk around the block, walk their dog, cook breakfast, whatever it is that they may actually get up and semi look forward to doing? A little note about discriminative stimuli. These are sights, sounds, smells, times of day, activities, people associated with the old behavior. It will trigger cravings and urges. When you walk into the mall and you smell the pretzels or the cinnabons, guess what? That's a discriminative stimuli. It says, ooh, I want a cinnabon. When you wake up in the morning and the alarm goes off and you look around your room and it's the same thing that you went to sleep in last night and you want to pull the covers over your head and try to run away from it all, that's a discriminative stimuli. These are all things that trigger emotions or reactions. They need to be eliminated, counter conditioned or changed to elicit a different behavior. So eliminated. If you can avoid if you're in recovery and you can avoid going down that same route where your dealer lives, that's a good thing. If you tend to be a binge eater and you can eliminate those foods that you tend to binge on like pizza, chocolate and candy from your house, so you only have them when you go out or something like that, that's helpful. You can counter condition these stimuli so instead of causing pleasure, they cause discomfort. For example, when you drive down the route to where your dealer used to live, snap a rubber band on your arm. There are certain medications people can take so it makes them pretty darn sick and ill if they drink. Or you can change the behaviors to elicit a different behavior. If you used to come in and this is one of my bad habits, I come in, I put my bag down and I head straight for the refrigerator, what is the stimuli? Coming home, what is the behavior? I go straight for the refrigerator and I have a snack. Now dinner could be 20 minutes away, but it's just what I do. So we want to change it to elicit a different behavior. You come in, put down your bag and you do something different. It says, hey, why don't you take the dogs out? That's a different behavior. So then it sets up a different chain of events for the person who is depressed and hits the snooze button or the alarm button instead of the alarm saying it's daylight, roll back over and go back to bed. Maybe the alarm can say it's nine in the morning and your fitness buddy is waiting for you at the gy. Fundamental Goals we want to help people develop and enhance their coping skills. For example, they need to identify five to 10 ways that they deal with stress. Measurable objective they need to learn about three different coping methods including radical acceptance options, REBT and reality therapy or choice theory by reading handouts, visual learners, participating in coping skills group and discussing with primary therapists, auditory and kinesthetic learners. And they need to evaluate the effectiveness of their existing coping skills to eliminate those that don't work. If your existing coping skill when you get stressed out is to go home and drink a rum and Coke and when you sober up, not only are you still kind of depressed, but the problem is still there, then we probably need to get rid of that one. The skills Add at least one new coping skill to your list and practice using those skills in group and and in sessions and scenarios as you discuss current issues and stressors. So as a therapist we can say, okay, John, you had a really bad day this week and I hear you handled it by doing X. How else might you have handled it? Or I hear you handled it by doing X and that didn't work so well. So what could you have done differently. And abilities. Have consumers keep a log of each week of stressors, how they coped, how effective it was, and anything they might need to do differently and discuss in group. Another fundamental goal for many people is developing self esteem. Learn what it is. Self esteem is this like garbage concept that nobody. Well, that's not true. Many people just kind of use, you need to improve your self esteem. Well, nobody knows what it means. What does self esteem mean to you? What does self esteem mean to your client? The true definition of self esteem is the difference how you feel about the difference between your real self and your ideal self. So we have people learn what self esteem is, how it's created in children and maintained in adults by attending an educational group. Just a little brief educational group that helps people understand. Have people list the traits they envision in their ideal self and list the traits in their real self and discuss in group or in individual the differences and their goals for change of those things in their ideal self that they don't currently possess. Which ones are worth working toward and which ones just need to be crossed off the list? Skills. Use cognitive behavioral approaches to identify those ideal traits that will help them achieve their overall goals. Happiness. Oh, that's wonderful. Happiness. That is so stinking abstract though. Happiness is going to be different for every single person in your room. So they need to define what happiness is to them. Use behavior modification and goal setting to develop three goals to help you achieve your overall place. Your overall ideal. So if their overall ideal is being happy, which is one of those vague things that's not really identifiable, what are three things that they can start doing that will help them feel happier? And you know, a lot of times you can look in the different areas of the person, social relationships, physical health and emotional reactions, and then abilities. Report back to the group each week about their progress in achieving their goals and the impact on their self esteem. How does it feel now that you've taken control of your own happiness? Social support is one of those other fundamental goals. We can't do it alone. We're not made that way. People are not made to be hermits that live all by themselves for their entire lives. We're meant to have social supports, but in order to do that we need to have healthy social supports. And in substance abuse treatment we throw in sober, healthy, sober social supports. The first thing most of the consumers that I've worked with need to learn about is what a healthy relationship looks like. They need to learn effective communication skills. Not always blaming, it's not always about them. There's no I in we fair fighting how to get things out without sounding accusatory. They need to identify the traits in a friend that they think are important. Again, we don't always think the same things are important in friends. And then they can identify places or ways that they might meet such people. The skills include practicing effective communication skills in group. That's one of the best uses of group counseling is to help people enhance and develop their communication skills because the group will call them out on it if they are not sharing enough or if they're being snitty or what have you and create a plan to nurture current healthy relationships and create at least one new relationship per week, per month, whatever. But nurturing the old relationships means you can't just make a friend and say, okay, you're a friend, I made you, I'll call you in six months. How can they nurture it? Go out to dinner, go to the library, go to the gym together, call on the phone. What and abilities means implementing your plan to develop sober social supports and discuss its effectiveness. How effective have you been at finding and connecting with healthy people? Discuss how your relationships and communication skills have improved and modify your plan as needed. Basic Needs Amazing how many people forget to assess their basic needs or who don't have the skills to attend to their basic needs like financial management, stable housing. They need to learn about safety by doing a safety assessment. Learn about wellness by attending a wellness group and completing weekly worksheets. What are they doing to take care of themselves? Sometimes people need to learn about nutrition. They need to learn about how to have good sleep. And that doesn't mean taking something that knocks you on your butt every night like Seroquel. What can they do to help improve the quality of their sleep? And they need to learn about the mind body connection. How when the mind is all in turmoil, a lot of times it comes out through the body too, with an upset stomach, constipation, diarrhea, backache. And the solution to that is not just chugging Pepto Bismol. The solution to that is identifying what's causing the upset. The skills include developing a realistic Plan for improving their health and wellness, that bottom level of the Maslow hierarchy and improve any areas of their environment that are unsafe. That can be walking to their house. Maybe they feel unsafe in their house, maybe they feel unsafe at work or whatever. If there's any place where they don't feel safe, what can they do to improve that? The abilities are translating all this information into practice and modifying their plan as needed to maintain motivation and ensure success. Depression Fundamental goals what is it? What causes it? What triggers it for you? What are your exacerbating factors? What makes it worse? And what are your mitigating factors? What makes it better? I can be having a really bad day and I go out and I take a walk and I see a squirrel on the sidewalk eating a peanut. It just makes my day. I don't know why it's a rodent, but he has a cute little hand. What is it that helps mitigate your depression? Of the triggers that make your depression worse, identify which ones you can control and which ones you cannot. Of the mitigating factors, the things that help you feel better, identify the ones you can control and increase those. Don't wait till you're depressed before you go out on a walk to see a little squirrel. Bring peanuts with you to work so you can actually have them come to you. Whatever it takes to make your day and identify exceptions. If you're having a hard time figuring out what makes you less depressed, say the last time that I was happy, this was what was different. Skills Develop a plan for increasing the exceptions and the things that make you feel less depressed. Use behavioral and cognitive behavioral strategies to address those things you can't control. There are some things that are out of your control. If you live in the Northwest, there are certain times of year where it rains all the time. You have no control over that. It can lead to seasonal affective disorder or depression. So what can you do to help yourself? You can't control the weather, but you can use light therapy to help reset your circadian rhythms. You can make sure that you stay on the same schedule so your body knows when it's time to sleep. You can set other schedule reminders, like children. Think about when we're teaching them how to learn how to go to sleep. You know, when they're 6 months, 12 months, 18 months, there's a routine. And as soon as they get into this routine, their body says, oh, it's time to start winding down. Eat dinner, take a bath, read a book, go to bed. We all have those routines around our house. It's eat dinner, watch tv, and have snuggle time, take a bath, go to bed. Just the act of having the schedule cues your brain in, even if the sun's not there. Now, don't get me wrong, there are some people who really need the light therapy, and that's important to remember. It's important to remember that there are certain times of year because of the sunlight or because of hormone changes or whatever that you may have to work with your doctor to adjust your medication. Those are things to be aware of. It doesn't mean you're weak. It doesn't mean you're not trying. It may just mean that you need some help leveling the playing field. The abilities are discussing how effective your plan is, things that need to be altered in your plan to help you feel less depressed, and discuss the different strategies you use to address those things you cannot control and how effective they are. Why is this important? Because so many of us get hung up on trying to control those things that we can't control. We fix all the stuff we can control, and then we just focus on those things that we can't control and we drive ourselves nuts. So it's important to make sure you stay focused on how you deal with the things you cannot control. Anxiety. First thing is learning about those six basic pesky old fears. Fear triggers the fight, anger, or flee anxiety response. We fear the unknown. We fear loss of control. We fear rejection and isolation. We fear failure, and we fear death. When you look at things that trigger anxiety, depression, and anger in most people, they're related to those six basic fears. Once we help people identify those fears and realize how the situation triggered this fear, triggered this reaction, then they can deal with it more. They go for a job interview. They don't get the job interview. They feel depressed. Why? Rejection, failure. Okay, so now we have to challenge them to look at the rejection and failure. Were they rejecting you as a person or you were a bad fit to the job? Was it a personal rejection or is it their loss? How can we turn this around to help it feel less like something that's anxiety provoking or fearful, and more like it's something that could be a positive outcome. They need to learn about the fight or flight reaction and that anxiety and anger are very natural emotions. We have to have them. They kick us in the butt and tell us to do something. Fight or flee. Get up off the couch. The key is what you do with it. If the anxiety paralyzes you or the anger makes you act out, or you just nurture that grudge until you're just the most miserable person walking around grumbling at everybody. You know, those aren't real positive things to do with those two emotions. But if you take that anxiety and say, oh, I need to do something, it's positive. You're going to feel angry, you're going to feel anxious, and you're going to feel depressed sometimes. But it's what you do with it, whether you nurture it and blow it out of proportion or use it as a launch pad for change. Skills include developing a list of positive self statements to use when you're anxious. Identify ways to eliminate unnecessary stressors. For example, it's little, but if I want to work out, it's much better if I pack my bag the night before than if I wait until that morning and I'm rushing around. There's no need for me to exert all that extra energy rushing around like a mad woman. I reserve that energy for something that requires it later than the day. Discuss ways to use the anxiety to your advantage. How can you use a little bit of a feeling of trepidation to grow to feel more confident, to nudge you in the direction of taking a step outside your comfort zone? And then practice, discuss and modify these things as needed. Case conceptualization and Treatment Planning Exercises for Integrating Theory with Clinical practice. You click on this link, it will take you to books.google.com where you can scan chapters two through five. If you like the text, you can buy the text. If not, or what you need for the purposes of this class, you can get offline. In summary, treatment planning serves to help clients learn to problem solve. Develops a roadmap for treatment for them. It helps them communicate with team members and team members communicate with each other. And it protects everybody from liability. If a lawyer comes back later and says, why did you do that? You can point to the clinical rationale, not just you know, I pulled it out of my butt in one session and figured what the heck, not the best choice. So you always want to document what you're doing, where you're going, and your rationale. Treatment planning needs to focus on KSAs knowledge, skills and abilities. Teach it, educate it, practice it, learn the skills, rehearse and apply. Practice the abilities. Treatment is most effective when the client only focuses on a couple of goals at once. Rome wasn't built in a day. They're not going to turn their whole world around in 12 weeks. And we all know that if you focus on too many things, you're going to do all of them poorly, whereas if you focus on one, two or three things, you can probably do them all quite well and ensure that the client receives frequent rewards.