Treatment Planning

I have spent the last week with a JCAHO reviewer who was conducting Klingberg’s Tri-Annual Review. After reading many treatment plans in many of our programs, I have decided to discuss them here.

We all know we have to do treatment planning. Why is this an important part of every program requirement? Treatment planning is designed to make us think about what we are doing in treatment and to proceed in a planful way. It forces us to consider what we are trying to achieve with this client, and how we will know if we are making progress. What will success look like? The planning process leads us to consider what change is necessary for the client to leave this particular level of care. Not be perfect, not have solved all his problems or worked on all his issues, but just to be able to step down to the next lower level. And when done right, the process includes the client and his family. How do they define success? What change are they looking for?

Treatment planning is the expression of a theory. The first part of the theory is: what has happened to this person, and how does that relate to his present problem behaviors? The second part is: what will help heal this person? As you write your treatment plan, you are expressing your theory of how events affect people, and what creates change. Your theory determines what you focus on, how you explain what is wrong, and what you propose to do about it.

For example, consider Jason. Jason was abused in his biological family and was removed from them at age four. He has been is five foster homes. He was removed from the second one because he was found outside at midnight and it was discovered that he was being neglected. In the fourth he was molested by an older foster brother. He presents with extreme angry outbursts whenever he cannot get what he wants right away. He often destroys property and has at times hit people. Afterwards, Jason avoids talking about these incidents and often blames the other person.

Suppose your theory leads you to focus on the fact that Jason has never received reliable rules and structure. He is used to taking care of himself. You learn that in his last foster home the parents often gave in to him to avoid his outbursts. You realize that Jason has never been able to accept adult authority. Therefore, you think that what will be helpful to him is a clear set of rules and guidelines. He needs to learn that you must follow rules and respect authority, or he will never get anywhere in this world. He needs to take responsibility for his actions. Therefore, the plan you create for Jason focuses on establishing strict rules and not backing down due to his tantrums. A behavior system that punishes and rewards will help. After any incident, Jason will be restricted until he acknowledges what he did and apologizes. He will be enrolled in an anger management group. In therapy, you will discuss any recent episodes and encourage him to acknowledge his part in them. Your measure of success will be that Jason can accept no for an answer without acting out.

On the other hand, if you held different theories you might look at Jason’s behavior through a different lense. You would focus on how the repeated trauma in Jason’s life had affected his sense of relationships, his biology, and his feelings management skills. You would assume he did not trust adults because the adults in his life had not been trustworthy. You would assume that he blames himself for everything that has happened to him and thus harbors deep feelings of shame. You relate this to his present response to not getting what he wants through understanding that a no to Jason feels like he will never get what he wants and no one loves him and this is because he is a worthless child. So, your treatment plans would focus on building trusting relationships with adults, learning how to calm his racing mind, and developing self worth through exploring his strengths. You discover that he likes to draw so one part of your treatment plan is art lessons. Your treatment plan also includes individual time with adults to build trusting relationships. In therapy you plan some psychoeducation on trauma, which you expect will lessen Jason’s self-blame. You will work with him to develop some things he can do to calm himself down when something goes wrong. You still measure success by the elimination of outbursts that hurt others, but your theory of what causes these outbursts and what will reduce them is different.

The treatment plan evolves from the formulation. The sequence should be:

Child’s history and experiences
Materials from other treaters and adults
History from family

Combine with

Program assessments
The child’s ideas
The family’s ideas

To create

The formulation, which connects the child’s past with his present behavior through a theoretical model of how inherited tendencies combine with experience to shape the person.

By considering the formulation, the therapist can see what the goals are: what changes will have to happen for the child to move to a lower level of care? What skills need to be learned? How will success look?

This understanding is broken into:

A description of the problem
It’s opposite, the goal
Specific measurable objectives which detail the steps that will lead towards achieving that goal
The interventions which will accomplish those objectives
The person responsible for each intervention

The objectives are another expression of the theory. If (as with Jason) we are working on decreasing shame and increasing self worth, we must consider what do we actually think decreases shame? Objectives could include helping younger kids in an elementary classroom, a leadership role on the unit, taking art classes and holding a show of his work, etc. These would express a conviction that positive accomplishments decrease shame.

It is tempting in our hectic lives to complete treatment plans without any thought, and use the same plan for many kids. Yet if we actually allocate time to think about them and discuss them with our Treatment Team, they can become an excellent tool for sharpening our thinking and our work.

I developed a library of treatment planning goals and objective that come from trauma informed practice. Feel free to email me at patw@klingberg.com if you are interested.