One therapist commented, saying that using a treatment plan during therapy was “rigid” and “unsophisticated” and that she liked to “go with the flow”. She …
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Adam
3:28 pm on
April 13th, 2010Hi Richard, I have been sold to your point of view. This is due, in no short measure, to your own example which is one of conscientious and unselfish honest and commitment to the welfare of the patient, and her or his rights.
In particular the right to accountability – the patient has a right to be able to hold the therapist accountable for what she or he claims to be doing. As you youself say, it is only what we would demand of a plumber or a lawyer, so why should a therapist offer any less. Even if a treatment plan isn’t necessary for improved treatment – I still think that it might not be in all instances to be honest – it should still be a requirement for this reason alone.
And if a therapist is honest and sincere then what have they got to lose. And if not…. then surely they need to made to ‘shape up or shift out’ – not sure if you have that expression in the States.
So you’ve won the argument as far as I’m concered, and therapists who want to be creative should be encouraged to learn to combine their creativity with a reasonable request for some sort of treatment plan and time-scale.
Unless of course the patient themselves doesn’t want this and prefers to engage in open-ended therapy, in which case I guess that you have to respect their right of choice in this matter.
I am sure that there is lots that I have missed out, but this one point is the one that strikes me most strongly at present.
Hi Adam,
That is quite a terrific comment you wrote!
Can I win you over even more?
Even brief therapy should have a (brief) treatment plan. You don’t have to spend a tremendous amount of time on developing it, but sometimes the mere fact of analyzing the problem and putting it to paper can help both the therapist and the patient figure things out–sometimes, in rare instances, propel the solution forward very, very quickly, especially if the problem isn’t so serious.
So I guess I am that 100 percent kind of guy on this, although yes, there are exceptions to every rule.
One more thing: I would be hard-pressed to imagine a patient absolutely refusing to have a treatment plan. After all, so much is how a therapist presents things. If a therapist presents it as a useful tool, than the patient will most likely want that useful tool, especially if the use of it will help him save time and money.
Are there patients who want to be in therapy with no end in sight? Sure! But again, it is the therapist’s job to get the patient functioning independently (as much as possible, if not totally). It is my belief that it is not usually in the patient’s best interest for him to be in therapy endlessly, barring some types of mental illness.
Again, thank you for your kind comments and thank you for reading and writing.
(We call it shape up or ship out, on this side of the pond).
TPG
11:52 pm on
April 13th, 2010This has been a great series.
The only question I have left is whether that treatment plan should be part of the discoverable record of the psychotherapy, or should be treated as process notes. I’m leaning toward the former, but I can certainly see how some therapists might not want their patients to read theirs…particularly if they are skimpy.
As for open-ended therapy, at the very least it must progress toward the highest possible functioning for the patient. Now, that sounds like it would require a plan, too.
Thanks, TPG.
As treatment progresses discoverables come up which should be integrated into treatment plan. In general, I believe the patient has a right to see his records (progress notes and treatment plans). I believe the patient should actively participate in creating the treatment plan (so he would naturally know what is in it).
I know that not everyone agrees with this approach, but my experience shows that this openness creates a more effective therapeutic relationship.
Also, a progress note could yield information that is important to include in the treatment plan.
There are certainly some instances where it is best to keep some clinical observations and/or goals unrevealed for a period of time–this obviously requires professional judgment.
I am not 100 percent sure what open-ended therapy means–but if that means endless therapy, then I am against that on principle, in most cases.
Again, there is room for other opinions here–mine are based on my clinical experience.
Thank you so much for your kind comments.
Annapurna
10:55 am on
April 14th, 2010The comments regarding a treatment plan as a means of measuring the therapists skills, as well as the willingness of the client to embrace new insights and behaviors, seems essential to any successful outcome, in this or any other contract.
I am wondering how the author would address my situation, where open ended therapy seems called for. I have several complicated medical challenges, leading toward a likely earlier end to my life. I look fine, yet am challenged in ways my peers are unable and unwilling to accept or tolerate.Generally requiring me to adopt lifestyle and psychological skills normally found in the elderly.
I find my therapy to be a lifeline in the ever-changing circumstances and challenges arising on this journey. What kind of treatment plan should I adopt for this scenario?
I find that I build on skill sets for a time very successfully. Then inevitably experience an event so triggering that the idea of waiting for an appointment to open up, would add greatly to my distress. I continue ongoing therapy to avoid “hanging off the edge of a cliff” when things get too intense. I often wonder if my situation really does justify open ended therapy.
I suspect there are many who can relate to this kind of scenario. Does having a mindful and compassionate witness, justify open ended therapy?
I would appreciate any thoughts which might help me focus on the best possible contract in my particular situation.
Best Wishes Annapurna
Adam
4:14 pm on
April 14th, 2010Hi Richard,
I wrote a really long answer, too long it seems – it didn’t save and has now been lost in cyberspace!
I really don’t have the energy to try again so I will cut to the chase:
If people want to pay to go to see someone to discuss the meaning of their dreams and daily life events over a long period of time, without a treatment plan, or any clear and obvious therapeutic goals in sight, then I see no harm in this necessarily as long as they know what they are entering into.
For the remaining 99.99% of patients who just want to get better as soon as possible I defer to your opinion on this matter.
Miastella
8:33 pm on
April 14th, 2010As a therapist I see treatment plans as a guideline and not a contract since reality happens. Each persons life changes moment to moment. However, the basics of the goals and struggles remain the same.When a client comes in to me each week, I know him or her and what they are really struggling with. When I have to put that struggle into simple words for bean counters, it looses the soul of the experience. So, I guess I see the “plan” as another insurance paperwork demand. The real healing comes from the therapist-client relationship. This is an art, a skill and a careful balance. It’s not a business plan.Well, it didn’t used to be.
SS
8:40 am on
April 15th, 2010Thank you for this series of posts. It has been very valuable and informative for me. Wish I’d had this information before my devastating experience with ineffective and useless therapy. If I ever do bother with therapy again, now I will know it’s not insane to expect for the therapist to take an active role and actually try to help rather than just taking a paycheck and saying that sounds tough every week.
Annapurna,
Thank you so much for sharing your story and questions. Your comments were very moving.
Yes, your situation does seem to be benefiting from ongoing therapy. Certainly, as new challenges with your health and situation arise, you and your therapist can address them together.
There are some situations that can benefit from ongoing, open-ended therapy, and it sounds like you know yourself quite well and what works for you. Kudos to you for that.
Perhaps you might consider talking with your therapist about strengthening and/or expanding your interpersonal network of family and/or friends. Also, you might consider connecting with a fellowship of people who are facing the same or similar difficulties you are facing. Whether you connect in person or in cyberspace, relationships are important. That might be something that could be part of your treatment plan–though I don’t know all the details of your life, so forgive me if I am overstepping. There really are people out there who do understand and can be supportive and you deserve to have them in your life.
Also, though this subject is controversial, and you may already be discussing this with your therapist, finding meaning in suffering can be a psycho-spiritual challenge. I want to interject here that relieving suffering should be an important role of any healer, though exploring the meaning might be helpful to this end.
Viktor Frankl wrote eloquently about this in his bestselling book, Man’s Search for Meaning. It is a brief autobiography of his experience as a prisoner in a concentration camp as well as an introduction to his philosophy of “logotherapy.” Many hail it as the standard-bearer, and we agree it is one of the finest, most moving non-religious books on suffering ever written. His essential conclusion is: suffering can be borne if there is real meaning in it (that is a personal meaning for the person who suffers).
Of course, not everyone is so inclined to explore spirituality in life or in therapy, but if you are, might I suggest you talk about this with your therapist, your spiritual advisor, your community members, and your friends and family that you feel are supportive? Or, you can simply explore the bookshelves at your local bookstore.
May you go from strength to strength,
Richard
SS,
Thank you for your comments. I am sorry that you had that experience. It is very sad to hear this from people, but know that most therapists do put their patients first, and go into the field because they care about others. The therapist is absolutely supposed to put their needs aside and focus on what the patient needs, period.
There are some therapists who may not care as much as they should, and there are therapists who overidentify with the therapy experience and expect to get some emotional/psychic reward from them in addition to the natural reward that is inherent in the helping process.
Fortunately, there are professional standards and it is possible (with some education) for patients to access good care and advocate for themselves. The National Alliance of Mental Illness is one organization that comes immediately to mind that is concerned with patient rights.
Hope you have success, in and/or out of therapy,
Richard
I believe the therapist must elicit realistic and appropriate goal(s), support the client’s goals and not interject any agenda of the therapist’s, and check in frequently about progress towards the client’s goal(s). So those behaviors do overlap with what you are calling a treatment plan. I find that using the CDOI approach developed and advocated by Duncan & Miller to be more encompassing and effective in keeping therapy on target and privileging the client’s voice and theory of change.
Most of the treatment plans I have seen…well, I’m not so sure. [Also, maverick therapists should beware: many states have laws requiring them in the client file] Not too many of them conform to your rules, or seem to be much more involved than a paper stored in the client file and not much referred to. Do you have several good examples of treatment plan documents you could point us to?
I’d also like to see some cites for “… a treatment plan … helps … improve successful outcomes.” so I can review them for reliability, validity, and whether the study was a “fair race”.
Annapurna
12:25 pm on
April 20th, 2010Thank you for your thoughtful suggestions Richard. I agree that Frankl’s work defines the process of finding meaning in suffering. One of the challenges in dealing with chronic terminal illness was to discover that there are few therapists truly equipped to understand the process. My wish is that there would be more training and exploration of the psycho-spiritual landmarks along the path of conscious dying. Despite many philosophical viewpoints which seem useful, there is so often a disconnect when it comes to practicalities.
Indeed we do all deserve to be supported in the process.Unfortunately, the longer I am in this process, the clearer it has become just how rare this support truly is. A few years ago I tried to connect with Elizabeth Kubler Ross, who reportedly had a loosely formed support group. Her own challenges prevented this. Other than certain Buddhist teachers, there is very little teaching available on how to be supportive in a practical sense when faced with crippling long term disabilities, with a terminal outcome.
The most well intentioned folks simply cannot go where they have not explored the terrain in themselves. I do not have hope that this blind spot in our collective psyche will change in my lifetime. It seems within mankind’s search for meaning, the fear of death and dying, becomes both motivation and resistance toward the value of looking it straight on. Perhaps this will become a part of a “Green” psycho-spiritual ecology, as the planet seems to be going through an identical process. A universal process which no one escapes, with little openness to the ramifications on the individual psyche
I have been devoted to being practical in this process for years now. It seems meant to be lonely, no one goes with another on this path in life. I had spent years at a stroke center, recovering at 48 from a moderate stroke. Despite the much older population, there was no more wisdom in general, or willingness to fully confront and embrace the process of dying consciously than anywhere else. I have found it to be a unsubstantiated belief that others support each other, not necessarily a reality.
Of course I would not have known any of this myself if I had continued to lived along side my peer group. It is simply not taught as life lessons. Considering the inevitability of old age, loss of function, it is a shame each person has to discover how to cope on their own. Perhaps someday there will be a more realistic teaching platform of how to help ourselves and others with less fear and less than helpful rationalization, which becomes painfully isolating. I hope so for my sake and everyone else who walks alone on this path. Thank you again for your kind remarks. Best Wishes Annapurna
Rick Stich
7:21 pm on
April 23rd, 2010Mr. Zwolinski,
You cite no empirical research that supports the notion that a treatment plan as a stand alone document improves clinical outcomes. You merely state that you interviewed researchers. You set up directionless therapy as a straw man. My understanding is that good therapists work collabaratively with their clients to set specific goals, these are carefully documented in progress notes, and are modified as new problems and goals emerge during the course of therapy. It is the governmental and accrediting agencies that require these separate treatment plan documents. Again, there is no research to support the effiecacy of this practice.
Richard Zwolinski, LMHC, CASAC
2:49 pm on
April 27th, 2010Hi Rick,
Thanks for your comments! It is obvious that you care deeply about this issue. I would like to share some thoughts with you.
As I say in my book, Therapy Revolution, therapists should collaborate with their patients to create treatment plans(whenever possible), and these plans should document specific goals and objectives, and these should be able to be modified as new problems and goals emerge during therapy. I urge you to read the chapter on treatment plans in my book or read what I’ve written here, in the treatment plan series. Additionally, a book on treatment planning by Mark Maruish may be helpful.
Have their been scientific studies that compare side-by-side mental health treatment with the use of treatment plans, and mental health treatment without? Not that I know of, but since the National Alliance of Mental Illness, Mental Health America, SAMHSA, NIMH, the vast majority of University counseling educational programs, all psychiatric hospitals, the NYU Child Study Center and all other university-based treatment programs, virtually every state agency, and yes, even those pesky insurance agencies all recommend or require the use of mental health treatment plans it would be very difficult to set up a study where therapy was conducted without using a plan. Furthermore, it wouldn’t necessarily be the humane thing to do. Virtually every professional organization (including the American Mental Health Counselors Association) regularly publishes articles in their journals and other publications about the use of treatment plans, not because of any hidden agenda or nefarious purpose, but simply because treatment plans work.
Many if not most psychotherapists in private practice, even those who don’t accept insurance, create treatment plans with and for their patients/clients, at least the ones that I refer to, do. I have referred many patients who have been in therapy for five or more years without a diagnostic reason for that long a course of treatment (sometimes there is a reason for ongoing or longer term therapy) and without a treatment plan to therapist who do use plans which create a tighter focus. I have never once in follow up had any of these patients tell me anything other then that this time around they were benefitting from therapy. Anecdotal? Sure, but I’m in excellent company, including my colleagues in general, and see above list.
In the past psychotherapy model was quite different, but except for psychoanalytic styles of therapy, which are a whole other subject, psychotherapy has evolved to recognize the need for patients to be actively involved in understanding their problems and crafting their treatment goals. Having a document where patients and therapists can be clear about the reason for therapy and what therapy is supposed to accomplish is the right thing to do in the vast majority of cases. (And yes, there are probably exceptions to the rule).
Ellie
10:16 pm on
May 7th, 2010My therapist has asked me for goals, things to put in a treatment plan.
This creates great anxiety in me! If we have goals, then we might reach them and then I’d be DONE! ack!
I’ve been able to articulate a general goal for an improved relationship with my FOO. However, we rarely work on that in therapy, maybe 25% of the time.
Are there tools (worksheets, checklists, storyboards, etc) that can be used with clients in the process of building a treatment plan? And anything that can help with getting a resistant client to participate?
Most ironic is that I’ve always got a detailed project plan and schedule in my professional work. One of the ways I resist a plan in therapy is that I don’t want it to feel like my job.
Richard Zwolinski, LMHC, CASAC
2:07 pm on
May 9th, 2010Hi Ellie,
There are many kinds of tools that can be used–ask your therapist what tools he/she is familiar with.
Also, might I suggest that perhaps you revisit the treatment plan? If you are overwhelmed, that may be a sign the goals are simply too big. They may need to be broken down into smaller components and you may need to address only one of them at a time, and not even write down the other goals yet. Your therapist should be able to help you break down larger goals until they reach a comfortable size for you. Let me know if this works out!
Best,
Richard
Jeff Williams
10:12 am on
January 8th, 2012I have worked and have always worked in community mental health as a counselor. I have been finding lately that more and more the treatment plans are written more for third parties such as accrediting agencies, insurance companies and other regulatory bodies that have a stake in ensuring appropriate treatment takes place. I understand the necessity of having these agencies although it feels as though we are moving away from person centered treatment planning and going towards third party treatment plans.
Richard Zwolinski, LMHC, CASAC
12:57 pm on
January 8th, 2012@ Jeff
Thanks for your comment. You are absolutely right-treatment plans can become mere tools for billing purposes in the hands of a therapist that isn’t invested in his patient’s well being.
However, I would rather have insurance companies insisting on treatment plans for reimbursement, than not, in many cases. Treatment plans, and there are a variety to suit most kinds of therapist outlooks, help the therapist and the patient focus on therapy goals and keep on track. You can adhere to a treatment plan without rigidity, too. They are constantly updateable and should flex with the changes that occur as therapy progresses. Like a map, there might be more than one road to follow to get somewhere.
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