Discuss and review Structural Family Therapy. Which population or demographic do you feel this type of treatment would work best and why? Would this type of treatment be beneficial or work with diverse populations? Provide support with case examples (not from the text).
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“Training in family therapy should therefore be a way of
teaching techniques whose essence is to be mastered, then
forgotten…The goal in other words is to transcend
technique.”—Minuchin & Fishman, 1981, p. 1
Theory and Treatment Planning in Family Therapy
Chapter 7:
Structural Family
Therapy
• Associated with Salvador Minuchin
• Several related evidence-based treatments
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• Structural family therapy
Theory and Treatment Planning in Family Therapy
Lay of the Land
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Theory and Treatment Planning in Family Therapy
THE JUICE: SIGNIFICANT
CONTRIBUTIONS TO THE FIELD
• Rules for managing physical/psychological
distance in family members
• Define regulation of closeness, distance, hierarchy,
and family roles
• Are organic, living processes
• Are culturally defined
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Boundaries:
Theory and Treatment Planning in Family Therapy
Juice #1: Boundaries, or Rules for Relating
• Close emotional contact while allowing each person a
sense of identity
• Enmeshment and diffuse boundaries
• Strong sense of mutuality/connection at expense of
individual autonomy
• Disengagement and rigid boundaries
• Lead to relational disengagement; autonomy emphasized
at expense of emotional connection
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• Clear or “normal” boundaries
Theory and Treatment Planning in Family Therapy
Types of Boundaries
• Creating clearer boundaries
• Increasing engagement
• Improving parental hierarchy
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• The therapist prompts family to re-enact a conflict
or other interaction
• Used to assess and alter problematic interactional
sequences: map, track, and modify the family
structure
• Goal: restructure the family
Theory and Treatment Planning in Family Therapy
Juice #2: Enactments
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Theory and Treatment Planning in Family Therapy
RUMOR HAS IT: THE PEOPLE AND
THEIR STORIES
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• Salvador Minuchin
• Harry Aponte
• Marion Lindblad-Goldberg
Theory and Treatment Planning in Family Therapy
Significant Contributors
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Theory and Treatment Planning in Family Therapy
THE BIG PICTURE: OVERVIEW OF
TREATMENT
1. Build an alliance
• Join the family and accommodate to their style
2. Evaluate and assess
• Map family structure, boundaries, hierarchies
3. Address problems identified in assessment
• Intervene to transform structure to diminish symptoms
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Main phases of structural therapy:
Theory and Treatment Planning in Family Therapy
Overview of Treatment
• Always preferred
• Subsystems
• Therapist may meet with specific subsystems or individuals
to achieve structural goals
• Example: couple alone to strengthen boundaries and sever
cross-generational coalitions.
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• Entire family
Theory and Treatment Planning in Family Therapy
Who Attends Therapy?
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Theory and Treatment Planning in Family Therapy
MAKING CONNECTION: THE
THERAPEUTIC RELATIONSHIP
• Therapist “joins” the family system and accommodates to its style
• Therapeutic spontaneity
• Ability to flow naturally and authentically in a variety of contexts and
situations
• Therapist’s use of self
• Use self to relate to family, varying from being highly involved to
professionally detached
• “Make it happen”
• Do whatever it takes to make change happen
• A softer style
• Moved from being active challenger to using humor, acceptance,
support, suggestion, and seduction for same goal
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• Joining and accommodating
Theory and Treatment Planning in Family Therapy
The Therapeutic Relationship
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Theory and Treatment Planning in Family Therapy
THE VIEWING: CASE
CONCEPTUALIZATION AND
ASSESSMENT
• Role of the symptom in the family
• Subsystems
• Cross-generational coalitions
• Boundaries
• Hierarchy
• Complementarity
• Family development
• Strengths
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Elements of assessment:
Theory and Treatment Planning in Family Therapy
Structural Assessment
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Theory and Treatment Planning in Family Therapy
TARGETING CHANGE: GOAL SETTING
• Clear distinction between marital/couple subsystem
and parental subsystem
• Effective parental hierarchy and severing of crossgenerational coalitions
• Family structure that promotes
development/growth of individuals and family
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• Clear boundaries between all subsystems
Theory and Treatment Planning in Family Therapy
Goals for All Families
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Theory and Treatment Planning in Family Therapy
THE DOING: INTERVENTIONS
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• Used for spontaneous enactment of problem or to target
reported problem interactions
• Key intervention used to restructure family interactions in
session
Theory and Treatment Planning in Family Therapy
Enactments
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Phase 1: Observation of spontaneous interaction
• Listen for rules and assumptions that display the family
structure or boundaries
Phase 2: Invitation for enactment: eliciting transactions
• “Can you reenact what happened last night?”
• “Please show me what happens at home when he is
‘defiant’…”
Phase 3: Redirecting problem transactions
• Stopping family members from interrupting/speaking for
one another
• Rearranging chairs physically to increase/decrease
emotional closeness
Theory and Treatment Planning in Family Therapy
Enactment Phases
• Highlights complementary relationships in family
• Piece together members’ description of problem and
reframing to reveal broader systemic dynamic
How to make a systemic reframe
• Assess broader interactional patterns
• Complementary relationships, hierarchy, boundaries, etc.
•
Re-describe the problem
• Use interactional patterns to describe the problem in a larger
context
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Systemic reframing
Theory and Treatment Planning in Family Therapy
Systemic Reframing
• Special form of enactment targeting:
• Over/under-involvement to help families soften rigid boundaries or
strengthen diffuse boundaries
Technique
• Used to direct who participates and how
• Actively setting boundaries
• Therapists interrupt habitual interaction patterns
• Allows members to experience underutilized skills and abilities
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Definition
Theory and Treatment Planning in Family Therapy
Boundary Making
• Challenging unproductive assumptions by questioning
operational assumptions in family system
• Common assumptions:
• “Kids’ needs come first.”
• “If i give here, you should give there.”
• “It’s better for the kids for us to stay in this unhappy
marriage.”
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Family’s worldview
Theory and Treatment Planning in Family Therapy
Challenging the Family’s Worldview
• Different levels and styles of intensity needed depending
on the issue
• Turns up emotional heat using tone of voice, pacing, and
word choice
Crisis induction
• Used with families who chronically avoid a problem
• The therapist can help the family develop new
interactions and patterns
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Intensity
Theory and Treatment Planning in Family Therapy
Intensity and Crisis Inductions
• Only after more direct interventions, such as enactments
and challenging assumptions, have failed
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• Used for extreme difficulties in hierarchy or when (IP) is
being scapegoated
• Use expert position to temporarily “join sides” with
scapegoated individuals or subsystems that need
stronger boundaries
• Done only briefly and with specific realignment goals in
mind
Theory and Treatment Planning in Family Therapy
Unbalancing
• When possible, the therapist works with family
beliefs to expand functioning
• Allows family to maintain core beliefs, but use them in new
ways
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Expanding family worldview
Theory and Treatment Planning in Family Therapy
Expanding Family Truths and Realities
• Example: families usually improve after enactments and
refrain from interrupting in later sessions. Therapists shape
competence by noticing changes in session.
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Compliments
• Used to bolster behaviors that support families in
moving toward goals
Shaping competence
• Noticing small successes along the way to reaching
goals
Theory and Treatment Planning in Family Therapy
Making Compliments and Shaping
Competence
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Theory and Treatment Planning in Family Therapy
WORKING WITH DIVERSE
POPULATIONS
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Hispanics
• brief strategic family therapy (BSFT) and ecosystemic structural
family therapy(ESFT) have been studied and adapted for Hispanic
and African-American families.
African-Americans
• in study of HIV-positive African-American women, ESFT better
than person-centered therapy and community controls for
reducing psychological distress and family-related hassles
Asian-Americans
• hierarchy, advocacy for parental executive system, boundaries, and
subsystems compatible with Asian American culture and values
Theory and Treatment Planning in Family Therapy
Cultural, Ethnic, and Socioeconomic
Diversity
• Family structural considerations are same: clear
boundaries, effective parental hierarchy, separation of the
spousal/parental subsystems
• Common issues when working with
gay/lesbian families:
• Kids defending parents
• Kids not being able to share openly about family
• Parents coming out to children
• Parents feeling need to be “perfect” in society’s eyes
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• Gay/lesbian families similar to those of
heterosexuals
Theory and Treatment Planning in Family Therapy
Sexual Diversity
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Theory and Treatment Planning in Family Therapy
RESEARCH AND THE EVIDENCE BASE
• Integrate structural therapy components to assess and restructure
family
• Include interpersonal boundaries, appropriate family hierarchy,
and enactments
• Includes:
• Brief strategic family therapy
• Ecosystemic structural family therapy
• Multisystemic family therapy
• Multidimensional family therapy
• Functional family therapy
• Emotionally focused therapy
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Empirically supported treatments
Theory and Treatment Planning in Family Therapy
Research and the Evidence Base
• Boundaries
• Hierarchies
• Subsystems
• Goal is to establish an effective family structure
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• Structural therapists map family structure to help
clients resolve individual mental health symptoms
and relational problems. They look at:
Theory and Treatment Planning in Family Therapy
In Conclusion
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• Philadelphia Child and Family Therapy Training
Center: www.philafamily.com
Theory and Treatment Planning in Family Therapy
Online Resource
“If successful therapy is defined as solving the problems of the client, the therapist
must know how to formulate a problem and how to solve it. And if he or she is to
solve a variety of problems, the therapist must not take a rigid and stereotyped
approach to therapy. Any standardized method of therapy, no matter now effective
with certain problems, cannot deal successfully with the wide range that is typically
offered to a therapist. Flexibility and spontaneity are necessary.”
—Haley, 1987, p. 8
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Theory and Treatment Planning in Family Therapy
Chapter 6:
Strategic Therapy:
Systemic Therapies Part
2
• Grounded in general systems and cybernetic theories
• Brief therapy approaches
• Use uniquely crafted behavioral prescriptions
• Differences lie in case conceptualization and approach to
behavioral prescription
• Strategic session characterized by use of
enigmatic, creative directives
• Behavioral prescriptions that interrupt problem interaction
sequence
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• Strategic therapy and MRI similarities:
Theory and Treatment Planning in Family Therapy
In a Nutshell: The Least You Need to Know
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Theory and Treatment Planning in Family Therapy
THE JUICE: SIGNIFICANT
CONTRIBUTIONS TO THE FIELD
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• Directives are directions for the family to complete a
specific task
• Tasks rarely linear solutions to problem; instead
“perturb” system’s interaction patterns to create
new ones
• Directives get people out of ruts with the smallest
change possible
Theory and Treatment Planning in Family Therapy
Directives
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• Jay Haley
• Cloe Madanes
• Eileen Bobrow
• Jim Keim
Theory and Treatment Planning in Family Therapy
Rumor Has It: The People and Their Stories
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Theory and Treatment Planning in Family Therapy
THE BIG PICTURE: OVERVIEW OF
TREATMENT
• Social stage
• Problem stage
• Interaction stage
• Goal-setting stage
• Task-setting stage
Phone contact:
• Initial interview begins w/first contact, typically by
phone.
• Gather information in matter-of-fact way and ask all
members of household to come to the initial
appointment
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Five formal stages:
Theory and Treatment Planning in Family Therapy
Initial Interview
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Theory and Treatment Planning in Family Therapy
MAKING CONNECTIONS: THE
THERAPEUTIC RELATIONSHIP
• Example: if family may benefit from joining together in not liking
therapist, a strategic therapist is willing to serve that role too
• Commonly used positions:
• Social courtesy
• The one down position
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• The therapist’s role/demeanor shifts depending
on client needs
• Strategic position: what response from the
therapist is most likely to promote change?
Theory and Treatment Planning in Family Therapy
Strategic Positioning
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Theory and Treatment Planning in Family Therapy
THE VIEWING: CASE CONCEPTUALIZATION
AND ASSESSMENT
• Involuntary versus voluntary
• Helplessness versus power
• Metaphorical versus literal
• Hierarchy versus equality
• Hostility versus love
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6 ways to think about a problem:
Theory and Treatment Planning in Family Therapy
Strategic Conceptualization
• Symptoms indicate a stage-of-life problem, which therapist can use to
identify where/how to intervene
• Life stages include:
• Birth and infancy
• Early childhood
• School age
• Adolescence
• Leaving home
• Becoming a parent
• Becoming a grandparent
• Old age
• Person may have difficulty transitioning to new
phase
• Family must renegotiate balance of independence/interdependence
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• How it is used:
Theory and Treatment Planning in Family Therapy
Stages of Family Life
• Family hierarchy: who has the influence and in what arenas
• Depends on family/culture
• How it it used
• Observe family interactions; how they respond to demands
• Not identified from single interaction; repeatedly observed
• Patterns of hierarchy can be used to develop interventions
• Parent-child hierarchy: child acts on parent requests or parents
cave in to child
• Effective hierarchy, ineffective hierarchy, excessive hierarchy
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• Definition
Theory and Treatment Planning in Family Therapy
Hierarchy and Power
• Emphasize increasing family’s ability to love and nurture
not dominate and control
• Case conceptualizations focus on family’s unsuccessful
attempts to show love rather than on attempts to control
one another
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Latest developments:
Theory and Treatment Planning in Family Therapy
Strategic Humanism
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Theory and Treatment Planning in Family Therapy
TARGETING CHANGE: GOAL SETTING
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• No predefined set of long-term goals other than
to promote change that alters people’s subjective
experiences (mood, thoughts, and behaviors)
• Ultimate goal is to help clients find ways to love
without dominating, intruding upon, or harming
others
Theory and Treatment Planning in Family Therapy
Strategic Goals
• Correcting the couple or family hierarchy
• Reducing intrusion or increasing engagement
• Reuniting family members
• Changing who is helpful and how
• Repenting for an injustice and forgiving
• Increasing the expression of compassion and unity
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How goals can be achieved:
Theory and Treatment Planning in Family Therapy
Strategic Goals (cont.)
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Theory and Treatment Planning in Family Therapy
THE DOING: INTERVENTIONS
Types of directives:
• Straightforward directives: used when therapist has
power and influence to get people to do what is asked
• Indirect directives: used when therapist has less
authority with client
• Generally take form of paradoxical or metaphorical tasks
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• Behavioral tasks given to clients to alter interaction
patterns
Theory and Treatment Planning in Family Therapy
Directives
• Assess the situation
• Target a small sequence change
• Motivate the family
• Give precise, doable instructions for directive
• Review the task
• Request a task report
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Designing straightforward directives:
Theory and Treatment Planning in Family Therapy
Straightforward Directives
• Also called symptom prescription
• Instructing clients to engage in the problem
behavior in some fashion
• Commonly used:
• With families that avoid change
• With uncontrollable symptoms
• Clients with symptoms claim they cannot control the symptom;
symptom prescription changes the context of problem behavior
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• Paradoxical interventions
Theory and Treatment Planning in Family Therapy
Indirect Directives: Paradoxical Interventions
• Used when it’s not appropriate to explicitly address a problem
• Pretend techniques
• “fake it ’til you make it”
• Ordeal therapy
• Ordeals used when client feels helpless in controlling
symptoms
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• Metaphorical tasks
Theory and Treatment Planning in Family Therapy
Indirect Directives
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Theory and Treatment Planning in Family Therapy
TAPESTRY WEAVING: DIVERSITY
CONSIDERATIONS
• Multisystemic family therapy
• Brief strategic family therapy
• Multidimensional family therapy
• Functional family therapy
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• Used in the development of several evidencebased treatments
Theory and Treatment Planning in Family Therapy
Research and The Evidence Base
• Works with diverse populations because the focus is in developing a
customized approach to effecting systemic changes
• Works with the following cultures:
• Hispanic adolescents and their families
• Sexual identity diversity
• Transgendered youth
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• Readily adaptable
Theory and Treatment Planning in Family Therapy
Ethnic, Racial, and Cultural Diversity
• Six ways to think about a problem
• Looks at stages of family life
• Assess hierarchy and power
• Interventions based off behavioral directives
• Straightforward
• Indirect
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• Similar to MRI and systems theory, but different in
case conceptualization
Theory and Treatment Planning in Family Therapy
In Conclusion
• Brief Strategic Family Therapy Manual:
www.nida.nih.gov/TXManuals/bsft
• Brief Strategic Family Therapy Trainin:gwww.brief-strategicfamily-therapy.com
• Mental Research Institute: www.mri.org
• Multisystemic Therapy: www.mstservices.com
• Strategic Therapy (Jay Haley): www.jay-haley-ontherapy.com/html/strategic_therapy.html
• Strategic Therapy (Cloe Madanes): www.cloemadanes.com
• Strategic Therapy (Eileen Bobrow):
www.briefstrategicfamilytherapy.com
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• Brief Strategic and Systemic World Network: www.bsst.org
Theory and Treatment Planning in Family Therapy
Online Resources
Quick Guide to Goals, Objectives & Interventions
January 2013
Quick Guide
to Developing Goals, Objectives, and Interventions
I. Some considerations when developing goals
Solicit the life-role goal statement at the very beginning of Individualized
Recovery Plan (IRP) Planning. This conversation should be informed by the
assessment process as well as your relationship and previous conversations with
the Personalized Recovery Oriented Services (PROS) participant.
Don’t be concerned about whether or not the goal is “realistic.” Identifying a goal is a
process that you and the person will work on together. Your conversation with the person
can focus on teasing out what the person would like to accomplish in his or her life.
Goal setting is a collaborative process – it offers an important opportunity for you to partner
with people and motivate them in treatment and with their lives.
Encourage the PROS participant to prioritize and identify just a few key goal areas on the
plan. Having too many goals may feel overwhelming to the person and may make the IRP
overly complicated and unwieldy.
Some questions to ask if the person has “no” goals:
o
Steer the conversation to a discussion of the person’s strengths. Use
some of the strengths identified in the assessments as a place to begin.
o
Ask the person to visualize an “ideal day.” What would this look like?
What would the person be doing? Who would he or she be with?
o
Ask the person to imagine that all the challenges of today have
disappeared as if by magic. What would this be like? What would the
person be doing/feeling?
o
If a person focuses his or her goals on symptoms (“I want to feel less
depressed”), the conversation can explore topics such as “If you were
less depressed, what might you be doing? How would you spend your
time? How would life be different for you?”
1
Quick Guide to Goals, Objectives & Interventions
January 2013
Goal Statements: Traditional Treatment Plan vs Person Centered IRP
Kathy’s Goals in a
Traditional Treatment Plan
Kathy’s Goals in a
Person-Centered IRP
Patient will be med-compliant over next 3
months.
I want to have enough energy to focus on my
job. I don’t want to feel dopey all the time.
Patient will refrain from verbal and physical
aggression
I need to get along better with my co-workers.
My boss said I could lose my job if I don’t
figure this out.
Patient will increase insight regarding mental
illness and demonstrate realistic expectations.
I want to finish my General Education
Diploma (GED) but I’m not sure where to
start.
Patient will decrease denial of substance abuse
and achieve and maintain abstinence.
I don’t know how to cope with what I have
been through. I need to figure out other ways
of coping.
2
Quick Guide to Goals, Objectives & Interventions
January 2013
II. Guidelines for Objectives:
Objectives are SMART:
o Simple or straightforward,
o Measurable,
o Achievable,
o Realistic,
o Time framed
Objectives can be also be remembered via RUMBA:
o Realistic,
o Understandable,
o Measurable,
o Behavioral
o Attainable
WHAT?
ACTION
WORD
PERSON’S
NAME
Jane
+
Will
manage
anxiety
+
By using
the
coping
skill of
deep
breathing
HOW
MEASURED?
WHEN?
+
Once a
day in
response
to anxiety
for
6 months
+
As reported
by herself in
Wellness Self
Management
group
OBJECTIVE
=
3
Quick Guide to Goals, Objectives & Interventions
January 2013
III. Tips for Developing Interventions: Using the 5 W’s
•
Who is providing the intervention?
Include the name of the person providing the intervention and his or her
relationship to the person
•
What is the modality that will be used?
Group therapy? Individual therapy?
•
Where will the intervention be provided?
Include the name of the PROS Service and the location where it will be provided
•
When will the intervention be provided?
Include both the frequency and the duration of the intervention, i.e. weekly for
three months
•
Why is the intervention being provided?
What is the purpose for providing the intervention? What mental health barrier is
being addressed?
4
A Counselors Guide to Objective,
Measurable, Obtainable and
Reimbursable Treatment Plans
Gilea & O’Neill (2015)
10/15/2015
Rachel M. O’Neill, Ph.D., LPCC-S
Brandy L. Gilea, Ph.D., LPCC-S, NCC, CDCA
O’Neill & Gilea Mental Health Consultants
mentalhealthconsult@gmail.com
1
Brandy Kelly Gilea earned her Ph.D. in Counselor Education and Supervision from
Kent State University and her Master’s Degree in Mental Health Counseling from
Youngstown State University. She is an Ohio-Licensed Professional Clinical
Counselor with Supervisory Designation, Nationally Certified Counselor, and
Chemical Dependency Counselor Assistant. Dr. Kelly Gilea has several refereed
journal articles and book chapters, as well as a presentation record of nearly 50
international, national, state, and local conferences and workshops. She has over
10 years of experience in Behavioral Health Treatment.
Rachel Hoffman O’Neill earned her Ph.D. in Counselor Education and Supervision
from Kent State University and her Master’s Degree in Mental Health Counseling
from Youngstown State University. She is an Ohio-Licensed Professional Clinical
Counselor with Supervisory Designation. Dr. O’ Neill has authored over 20
scholarly journal articles and book chapters. She has presented over 70 times at
national, state, and local conferences and workshops. She has over 10 years of
experience in Addiction and Mental Health treatment.
Gilea & O’Neill (2015)
About the Presenters
2
• Participants will learn to write objective and measurable goals,
interventions and techniques that are evidence-based.
• Participants will learn to write treatment plans that consider
clients’ strengths and interests, diagnoses and stages of
change.
• Participants will to write treatment plans that consider payer
source and compliance standards.
Gilea & O’Neill (2015)
Objectives
3
Gilea & O’Neill (2015)
1
10/15/2015
• Client-centered
• Objective and measurable (empirically-supported)
• Obtainable (goals and objectives)
• Reimbursable
Gilea & O’Neill (2015)
Good Treatment Planning
4
• Problem selection (e.g., diagnosis, focus of treatment)
• Problem definition (e.g., diagnostic criteria/symptoms, level of
adaptive functioning)
• Goal development (e.g., long-term outcomes of treatment)
• Objectives (e.g., short-term, measureable, behavioral goals
likely to be completed during treatment)
• Intervention (e.g., empirically-supported techniques used by
counselor or social worker)
Adapted from:
Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A
Primer. In. V. E. Kress and M. J. Paylo (Eds.), Treating those with mental health
disorders: A comprehensive approach to case conceptualization and
treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.
Gilea & O’Neill (2015)
Components of a Treatment
Plan
5
Additional Considerations
• Diagnosis and symptoms
• Level of adaptive functioning/severity of impairment (World Health
Organization Disability Assessment Schedule; WHODAS)
• Disability related to the disorder
• Gender and Culture
• Cognitive, emotional, behavioral, and physiological processes that
co-occur with the symptom set
• Stage of change
• Past response to treatment
• Baseline level of functioning (caution setting goals too high)
• Any other important considerations
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Gilea & O’Neill (2015)
• Symptom severity
• Symptom salience (e.g., presence of suicidal ideation)
• Client’s distress
6
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COMPLIANCE CONSIDERATIONS
7
• International and National Accreditation (e.g., Commission on
Accreditation of Rehabilitation Facilities (CARF), The Joint
Commission (JCO), Council on Accreditation (COA)
• State Compliance Standards (e.g., Ohio Department of Mental
Health and Addictions Services (MHAS), Administrative
Code/Law)
• County Behavioral Health Boards
• Agency Policies and Procedures
• Managed Care Systems, Private Insurance, Payer Source
Gilea & O’Neill (2015)
Compliance Considerations
8
• Non-profit organization
• Promote quality services and positive treatment outcomes
• Each accrediting body has standards that must be met to earn
accreditation
• Accredited programs and agencies are evaluated at set
periods (e.g., every three years) to determine ongoing
accreditation
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International and National
Accreditation
9
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• Offer state-level licensing and certification
• Promote quality services and positive treatment outcomes
• Approve/offer funding for services
• NOTE: often govern the content of treatment notes/plans and
frequency of updates (e.g., treatment plans must be updated
annually or every 90 days)
Gilea & O’Neill (2015)
Ohio Department of Mental Health
and Addictions Services (MHAS)
10
• Offer county-level licensing and certification (e.g., grantfunded programs
• Promote quality services and positive treatment outcomes
• Approve/offer funding for services
• Usually comply with state standards
• NOTE: often govern the content of treatment notes/plans and
frequency of updates (e.g., treatment plans must be updated
annually or every 90 days)
Gilea & O’Neill (2015)
County Behavioral Health
Boards
11
• Unique to each institution
• Most agencies have policies specific to documentation
standards
• Policies and procedures should comply with international and
national accreditation, state law and ethical codes, state and
county level regulatory bodies
Gilea & O’Neill (2015)
Agency Policies and
Procedures
12
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• Ensure quality of care
• Ensure consistent/empirically-supported practices are used
• Control cost
• GOAL – finance heath care that is medically necessary and
cost-effective through the use of empirically-supported
techniques and interventions
• Hold providers accountable: may need to justify services
• Determine number of sessions and approved services (e.g.,
counseling, psychiatric case, community psychiatric support
treatment)
Gilea & O’Neill (2015)
Managed Care Systems, Private
Insurance, Payer Source
Gilea & O’Neill (2015)
13
THE GOLDEN THREAD
14
• Treatment planning starts with the diagnosis/symptoms
• Goal, objectives and interventions are directly tied to the
diagnosis (e.g., can not diagnose a client with BiPolar I
disorder and identify goals connected to symptoms of
Schizophrenia)
• Goals, interventions and interventions from treatment plan
should be reflected in progress notes (should not diagnose a
client with BiPolar I, develop goals, objectives and
interventions connected to BiPolar I and then use an
intervention associated with Substance Use in session and
document on the progress note)
• NOTE: Examples of THE GOLDEN THREAD noted throughout
presentation through the use of gold, underlined font
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Gilea & O’Neill (2015)
The Golden Thread
15
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USEFUL TOOLS
16
• What are the main points here?
• What experiences and actions are most important?
• What symptoms are being reported?
• What themes are coming through?
• What is her/his point of view/worldview?
• What is most important to her/him?
• What does her/she want me to understand?
• What decisions are implied in what she/he is saying?
• What is she/her proposing to do?
• What background, circumstances surround this client’s life and affects
the way the client understands and deals with their problems?
• What age related psychosocial/developmental tasks is the
student/client facing?
• How does the client construct meaning (i.e. determining what is
important and right)?
• How does the clients personality style and temperament affect their
approach to the world?
Gilea & O’Neill (2015)
Helpful Questions
17
Prompts
• Assist
• Asses
• Assign
• Compare
• Explain
• Reduce
• Revise
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• Examples:
• Action Verbs!
18
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Support Factor
Catharsis & Trust
Identification with therapist
Positive relationship
Reassurance
Release of tension
Structure
Therapeutic alliance
Therapist/client active participation
Therapist expertness
Therapist warmth, respect, empathy, acceptance,
genuineness
Learning Factor
Advice
Affective experiencing
Assimilation of problematic
experiences
Cognitive learning
Corrective emotional experience
Exploration of internal frame of
reference
Feedback
Insight
Rationale
Action Factor
Behavioral regulation
Cognitive mastery
Encouragement of facing
fears
Taking risks
Mastery efforts
Modeling
Practice
Reality testing
Success experience
Working through
Support factors are correlated with establishing a counselor-client
relationship.
Learning and Action factors are correlated with treatment.
19
Gilea & O’Neill (2015)
Lambert, M. J., & Bergin, A. E. (1994). The effectiveness of
psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of
psychotherapy and behavior change (4th ed., pp. 143-189). New York:
John Wiley & Sons, Inc.
Gilea & O’Neill (2015)
Common Factors Across Therapies That
Are Associated With Positive Outcomes
BUILDING BLOCKS OF TREATMENT
PLANNING
20
• Diagnostic Assessment
• Treatment Plan (Individualized Service Plan)
• Progress Note
• Termination Summary
Gilea & O’Neill (2015)
Building Blocks of Treatment
Planning
21
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DIAGNOSTIC ASSESSMENT
22
• Client diagnosis and associated criteria/symptoms must be
identified to select treatment goals, objectives and
interventions
• Most manage care and private insurance companies consider
treatment necessary and reimbursable when medically
indicated
• The diagnosis, symptoms and severity are evidence of medically
necessary treatment.
• Change in symptoms and alleviation of diagnosis are indicators or
progress and/or termination (e.g., doctor will be reimbursed for
treating cancer if the doctor document symptoms of cancer.
Doctor will not be reimbursed for cancer if documenting
symptoms of heart disease).
Gilea & O’Neill (2015)
Diagnostic Assessment
23
• Frequency: Admission and update every 90 days
• Purpose
• Identify symptoms, diagnosis, strengths, limitation, needs, abilities, treatment
preferences, level of adaptive functioning, psychosocial history, determine
appropriate level of care
• Assessment Considerations:
• Presenting problem, service needs and preferences
• Diagnostic Criteria
• Lethality assessment
• Social history relevant to treatment including: employment and/or school history;
community involvement, interests and supports; history of involvement with the
legal system; role of religious practices in the person’s life; description of current
living arrangements, ethnic and cultural influences; developmental history, and
use of alcohol and/or drugs
• Mental status examination
• Considerations of special needs and additional services
• Health/medical history.
• History or indications of abuse, neglect or violence
• Current or previously used medications, including allergies, effectiveness, side
effects or adverse reactions.
• A summary of assessment information that includes a DSM-V diagnosis
Gilea & O’Neill (2015)
Gilea & O’Neill (2015)
Diagnostic Assessment
24
8
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TREATMENT PLAN
25
Treatment Plan
• Measurable goals that address the client’s strengths, skills
needed and natural supports
• Measurable treatment objectives with a time frame for
achievement that identifies the therapeutic intervention,
frequency, service and the provider responsible for service
delivery
• Goals and objectives that relate to needs, preferences and
obstacles identified in the diagnostic assessment.
• Other agencies involved in treatment, when applicable
• Transition/discharge planning
Gilea & O’Neill (2015)
• Frequency: Second session and update every 90 days
• Typically include:
26
• Specific – concrete, use action verbs
• Measureable – Numeric or descriptive, quantity and quality
• Attainable – appropriately limited in scope, feasible
• Results-oriented – Measures outputs or results, may include
accomplishments
• Timely – Identifies target dates, includes interim steps to monitor
progress
From:
Paylo, M. J., & Kress, V. E. (2015). Developing Comprehensive Treatment Plans. In. V. E. Kress
and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach
to case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.
EXAMPLE: Decrease symptoms of depressed mood (sadness,
loneliness, loss of interest, worthlessness) from an “8 – depressed
mood impacts my life all day/every day” to a “6 – depressed mood
impacts half of my day/ever day” one a scale of 1-10 (10= most severe)
in the next 90 days.
Gilea & O’Neill (2015)
Gilea & O’Neill (2015)
SMART Goals
27
9
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PROGRESS NOTE
28
Progress Note
29
Gilea & O’Neill (2015)
• Date of the service contact
• Time of day of the service contact, start/stop time, including a.m
or p.m.
• Duration of the service contact
• Description of the activities of the service
• Therapeutic interventions
• Behavior and the response to the intervention of the person
served and
• Progress toward treatment goal
• The progress note will be directly tied to the goals and
objectives listed on the client’s current treatment plan (Golden
Thread)
Gilea & O’Neill (2015)
• Frequency: During or following session/meeting with client
• Typically include:
TERMINATION SUMMARY
Gilea & O’Neill (2015)
30
10
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31
Gilea & O’Neill (2015)
• Reason:
• Reached treatment goals
• No longer benefiting from services
• Referred to another agency or level of care
• Client discontinued services or involuntarily terminated
• Typically include:
• Date of admission
• Date of discharge
• Date of last contact
• Diagnostic criteria at admission.
• Diagnostic criteria at discharge
• Level of care and services provided during treatment
• Client’s response to treatment, including progress in meeting treatment
goals and condition at discharge
• Recommendations and/or referrals for additional treatment or other
services, and after care options.
• Reasons for termination
Gilea & O’Neill (2015)
Termination Summary
STAGES OF CHANGE
32
Readiness for Change
• Instead of focusing on what the person
doesn’t want to change – it’s best to focus
on what the person does want to change.
(Miller & Rollnick, 2002)
Gilea & O’Neill (2015)
Gilea & O’Neill (2015)
• The proper question is not, “Why isn’t this
person motivated?” but rather, “For what
is this person motivated?”
33
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Transtheoretical Model
Transtheoretical Theory = How clients change naturally (on
their own) without interference.
Counselors need to know what stage of change the client is in
so that proper interventions can be applied
Gilea & O’Neill (2015)
Stages of Change:
▪ Precontemplation
▪ Contemplation
▪ Preparation
▪ Action
▪ Maintenance
▪ Termination
34
The Stages of Change
No intention of
changing behavior
Has changed
behavior for more
than 6 months
Has changed
behavior for less
than 6 months
Intends to change in
the next 6 months,
but may
procrastinate
Intends to take action
soon, for example next
month
35
Gilea & O’Neill (2015)
Source: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.section.62561
Stages of Change
TREATMENT PLAN LANGUAGE
Gilea & O’Neill (2015)
36
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10/15/2015
• Goal: Consciousness raising/Increasing awareness
• Examples:
• Assist client with increasing awareness of the costs and benefits
of changing unhealthy behaviors that are escalating behavioral
health symptoms
• Assist client with increasing awareness of behavioral health
symptoms
• Assist client with increasing awareness of patterns of behavior
Adapted from:
Gilea & O’Neill (2015)
Precontemplative
Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E. Kress
and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to
case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp. 279-300).
New York, NY: Oxford
37
• Goal:
Client self-evaluation
• Examples:
• Challenge client to evaluate self-perception in relation to
behavioral health symptoms
• Encourage client to identify ways that changing behaviors will
impact current level of functioning
• Assist client with envisioning a future with deceased behavioral
health symptoms
Gilea & O’Neill (2015)
Contemplative
Adapted from:
Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E. Kress
and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to
case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp. 279-300).
New York, NY: Oxford
38
• Goal:
Empowerment
• Examples:
• Assist client with identifying ways he or she can contribute to
changing behaviors that interfere with personal goals
• Encourage client to identify strategies to increase control over
behavioral health symptoms
Adapted from:
Gilea & O’Neill (2015)
Preparation
Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E. Kress
and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to
case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp. 279-300).
New York, NY: Oxford
Gilea & O’Neill (2015)
39
13
10/15/2015
• Goal:
Reinforce progress toward change
• Examples:
• Assist client with identifying internal gratification achieved through
positive changes
• Encourage client to narrate story reflecting changes made and influence
on personal goals
• NOTE: Most treatment planners correlate with the active stage of change
but language can be adapted to all stages of change
Adapted from:
Gilea & O’Neill (2015)
Active
Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E. Kress
and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive approach to
case conceptualization and treatment. (1st ed., pp. 1-24). Upper Sadler River, NJ: Pearson.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross (Ed.),
Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp. 279-300).
New York, NY: Oxford
40
Maintenance
Preventing relapse
• Assist client with reviewing strategies to maintain decrease in
behavioral health symptoms
• Assist client with identifying ways to be proactive in maintaining
progress made toward goals
Adapted from:
Gilea & O’Neill (2015)
• Goal:
• Examples:
Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment Planning: A Primer. In. V. E.
Kress and M. J. Paylo (Eds.), Treating those with mental health disorders: A comprehensive
approach to case conceptualization and treatment. (1 st ed., pp. 1-24). Upper Sadler River,
NJ: Pearson.
Norcross, J. C., Krebs, P. M., & Prochaska, J. O. (2011). Stages of Change. In J. C. Norcross
(Ed.), Psychotherapy relationships that work: Evidence-based responsiveness (2nd ed.,pp.
279-300). New York, NY: Oxford
41
Changing Active Goals:
Precontemplation
• Goal: “Alleviate depressed mood and return to previous level of effective
functioning”
• Objective: “Identify and replace cognitive self-talk that is engaged in to
support” depressed mood
• Intervention: “Assist the client in developing an awareness of his/her
automatic thoughts that reflect a depressogenic schemata”
Jongsma, A. E., & Peterson, L. M. (2006). The complete adult psychotherapy treatment planner.
Hoboken, NJ: John Wiley and Sons, Inc.
• PRECONTEMPLATION
• Goal: Increase awareness of depressed mood and patterns of unhealthy
behaviors
• Objective: Identify examples of negative self-talk from literature and case
examples correlated with depressed mood
• Intervention: Assist the client in developing an awareness of the connection
between thoughts and depressed mood in people diagnosed with depression
Gilea & O’Neill (2015)
Gilea & O’Neill (2015)
• ACTIVE
42
14
10/15/2015
Changing Active Goals:
Contemplation
• Goal: “Alleviate depressed mood and return to previous level of
effective functioning”
• Objective: “Identify and replace cognitive self-talk that is engaged in
to support” depressed mood
• Intervention: “Assist the client in developing an awareness of his/her
automatic thoughts that reflect a depressogenic schemata”
Jongsma, A. E., & Peterson, L. M. (2006). The complete adult psychotherapy treatment
planner. Hoboken, NJ: John Wiley and Sons, Inc.
Gilea & O’Neill (2015)
• ACTIVE
• CONTEMPLATION
• Goal: Identify symptoms of depressed mood
• Objective: Identify impact of cognitive self-talk on depressed mood
• Intervention: “Assist the client in developing an awareness of his/her
automatic thoughts that reflect a depressogenic schemata”
43
Changing Active Goals:
Preparation
• Goal: “Alleviate depressed mood and return to previous level of
effective functioning”
• Objective: “Identify and replace cognitive self-talk that is engaged in
to support” depressed mood
• Intervention: “Assist the client in developing an awareness of his/her
automatic thoughts that reflect a depressogenic schemata”
Jongsma, A. E., & Peterson, L. M. (2006). The complete adult psychotherapy treatment
planner. Hoboken, NJ: John Wiley and Sons, Inc.
• PREPARATION
• Goal: Identify symptoms and behaviors associated with depressed
mood
• Objective: Identify ways cognitive self-talk impacts depressed mood
• Intervention: Assist the client in identifying ways more positive selftalk could impact mood
Gilea & O’Neill (2015)
• ACTIVE
44
Changing Active Goals:
Maintenance
• Goal: “Alleviate depressed mood and return to previous level of
effective functioning”
• Objective: “Identify and replace cognitive self-talk that is engaged in
to support” depressed mood
• Intervention: “Assist the client in developing an awareness of his/her
automatic thoughts that reflect a depressogenic schemata”
Jongsma, A. E., & Peterson, L. M. (2006). The complete adult psychotherapy treatment
planner. Hoboken, NJ: John Wiley and Sons, Inc.
• MAINTENANCE
• Goal: Maintain current level of effective functioning absent of
symptoms of depression that cause clinically significant distress
• Objective: Engage in ongoing positive cognitive self-talk that
supports a healthy level of functioning
• Intervention: Assist the client in reviewing techniques to maintain
positive thinking
Gilea & O’Neill (2015)
Gilea & O’Neill (2015)
• ACTIVE
45
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• American Psychiatric Association (Eds.) (2013). DSM-5. Arlington, VA
: American Psychiatric Publishing .
• Barnhill, J. W. (Ed.). DSM-5 Clinical Cases. Arlington, VA : American
Psychiatric Publishing .
• First, M. B. (2013). DSM-5: Handbook of Differential Diagnosis.
Arlington, VA : American Psychiatric Publishing .
• Jongsma Treatment Planning Series: http://jongsma.com/
• Jongsma, A. E., & Peterson, L. M. (2006). The complete adult
psychotherapy treatment planner. Hoboken, NJ: John Wiley and
Sons, Inc.
• Kress, V. E., & Paylo, M. J. (2015). The Foundations of Treatment
Planning: A Primer. In. V. E. Kress and M. J. Paylo (Eds.), Treating
those with mental health disorders: A comprehensive approach to
case conceptualization and treatment. (1st ed., pp. 1-24). Upper
Sadler River, NJ: Pearson.
Gilea & O’Neill (2015)
Material Adapted from:
46
Q&A
Gilea & O’Neill (2015)
Questions and Answers
47
Gilea & O’Neill (2015)
16
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