May 31, 2011

Solution-Focused Treatment Planning

Guest post by DAVID JOHNS, LMHC

Treatment Planning in agencies and private practice has often been described to me as a dreaded activity that has no immediate or long term relevance to client outcome. It is seen as a waste of time and as a document required only by funding sources who are looking for accountability. Client benefit is not acknowledged nor is obvious to the clinician. I can appreciate that point of view, having been one of many therapists who have been trained to evaluate and treat emotional and psychological problems. Spending half of my career working in agencies, I can relate to having this requirement explained to me as "a necessary evil". Those are exact words that I have heard frequently to refer to this phase of treatment.

It wasn't until I had already been trained in Solution Focused Therapy, having had some solid experience and success with this approach, that the light went off. I realized that this approach, by virtue of the entire focus, IS "treatment planning". It is structurally the same, in that there are "problem statements", "goal statements", "objectives" and "interventions" inherent in all solution focused interactions and collaborations with clients. A treatment plan as well as specific discharge criteria are naturally brought to light to both client and therapist but are not recognized as a formal treatment plan.

I have managed many therapists in agencies who I have observed stressing, agonizing, getting frustrated and trying so hard to write a treatment plan that is "compliant". Many have bought expensive books that purport to make it easier for clinicians to word treatment plans correctly, and to end up with plans that would please me, their supervisor, as well as, and more importantly the funding source. I cannot begin to explain to you the magnitude of the anxiety, effects of lost sleep, long hours spent by therapists attempting to create this document, which is replete with clinical jargon, labels, diagnostic criteria and "canned" statements taken from books and other treatment plans.

Finally, after being tortured again and again by therapist complaints I decided to turn the light on as it had been turned on in me. I put together a training called solution focused treatment planning. The most important observation I made was that something very important was missing. There was no evidence of client participation or guidance in the plans I have. It was evident that the plans I have reviewed were "cookie cutter" statements cut and pasted from books and other plans. To me, that made the whole treatment plan invalid. I realized the training had to be a complete reframe.

Therapists needed to know:
  1. Treatment Planning is the most crucial determinant of a positive outcome.. Positive outcomes are nearly impossible to achieve with a heavy focus on being broken. Therapists must assist clients to formulate outcome images in their minds which come from awareness of past successes, strengths, coping skills already being utilized and diverting clients' attention to possibilities instead of disabilities.
  2. Creating a treatment plan is easy - if the therapist asks the right questions and lets the client lead. The Miracle Question is key in formulating goal and objective statements that can be written on a treatment plan document. Intervention statements are a natural and logical set of things the client can do to achieve objectives.
  3. Success does not depend upon a thorough clinical understanding of the problem. It depends on a client realizing he/she has entered a world of possibilities in which he/she is fully equipped with successes, coping skills, support, & strengths. The energy springs forth with impressive force when the client realizes his/her own empowerment at a time when they previously felt disempowered. The SFT therapist's skillful direction away from problem questioning and toward solution building is like initially pushing a boulder up a hill then at the top, letting it go. Clients no longer see themselves as hopeless as the light is turned on. Distortion, depression, anxiety, confusion cannot exist in the light. Being stuck in problems is a matter of focus. The more one focuses on problems the darker things get. The darker things get the more immobilized one becomes. So turn the light on. Redirect, redirect, redirect until the client's light turns on. You will literally see a shift that is taken over by the client. Solution thinking = more light, more energy.
  4. It is okay to use the Scaling technique to describe discharge criteria. To simply say "when the client is no longer depressed" is inadequate and cannot be observed. Whose criteria are you going to use? Scaling makes sense here because the discussion stems from the client telling the therapist WHAT will have to happen when he/she moves to "a 5, 6, or 7". The number represents concrete, specific behaviors that the CLIENT will notice are happening/doing, not what the clinician observes. The client is the expert and knows when therapy is no longer needed. If the client says he/she is a 9, believe them and find out what they did and how they did it - amplify the progress and ask the client how they plan to keep it going. Congratulate them. Then say goodbye.
Treatment Planning is the most necessary component of Solution Focused Therapy but only when you take it out of the frustrating frame we have traditionally experienced. It takes the client's experience from impossible to possible in a very short time and infuses the client with impressive momentum. Writing the treatment plan is easy - because you are using the client's words, and respecting their subjective views of success. Encouraging clients to do more of what worked in the past or present, or tempting them to do something different will met with little or no resistance. Follow them, celebrate with them, nudge them a little further, scale the progress until the client agrees the discharge criteria has been met.
  • Treatment plans are not permanent documents! They are living documents, which can be changed at any time.
  • Do not make them complicated. One or two solutions at a time will suffice.
  • Avoid jargon except for that little DSM-IV number that is often required. Write the rest as a collaborative solution-building document.
  • Funding sources are often impressed with the brevity and concreteness.

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