Welcome to What’s Better This Week? Episode 7: Making Treatment Plans Solutions Focused
When we last left off, we had collected some superfluous data and some pee, and now, here in our fourth appointment, we need to make a treatment plan that we’re going to refer back to regularly for a host of reasons. First, and foremost, at least in New York State, where we are mandated to by the Office of Mental Health: patients’ discharge planning is actually begun at their admission, or at least we have to check a box that says “discharge planning has begun.” Why? Because someone on the state or funding level has said that it is vitally critical that we make it apparent that we’re not trying to create patients for life, and that we are actively working on moving our patients along. For someone who is a Solutions Focused Brief Therapist, this is a no-brainer: the Brief, in SFBT means that we never keep a patient a micro-second longer than they want, to be in treatment. We don’t want patient’s for life, it means we’re n to doing our jobs. It is antithetical to our treatment model. However, part of proving that we’re being honest with the finances of insurance companies (who again, dominate this industry far more than they should) is that we indicate that we have already begun discharge planning by our fourth apartment (right after admitting our patient) and we continue this through the collaborative creation of a treatment plan.
Additionally, the Treatment Plan ensures (or, in theory it works to try to ensure) for therapists and counselors who are not Solution Focused, that they are working with a goals/objective modality of therapy, rather than just talk therapy: those paying for therapy want to make sure that something more than a therapeutic relationship is happening…they want to make sure that patients are getting somewhere and that somewhere is “cured” and out the door. It is the Medical, not the Sociological model. Goal/Objective therapy removes “talk therapy” largely as an option, because a patient must consistently be doing something, to consistently be moving toward their goals…for my astute listeners, you will note that this is actually placing (or can have the trap of placing) many patients into some kind of pass/fail model of therapy, where they're “not making progress” quickly enough…and it’s largely nonsense; it also serves two interests: first the funders/insurance companies, and second, those clinicians who don’t take a step or two step down approach, but rather wish to seem superior to their patients who don’t “make enough” progress in their own eyes.
So what do we do about this nonsense? And how on EARTH do we ethically and honestly connect Solution Focused Brief Therapy work into this insurance based, financially based, diagnostically riddled model? Actually, quite easily - but we have to be careful about it.
First, our treatment plans follow a Problem -> Goal -> Objective -> Intervention model. This means that we have to share what our patient’s problem is, what their goal is, how they’re going to get to their goal, and what specific intervention is going to get them there. We call it a “PGOI” for short. Ergh.
When working with patients, I will often explain - much like when I explain that all a diagnosis is, is a title heading that works to explain a combination of symptoms that go together, a treatment plan works like a journal, to log what we’ve been working on, and to make sure that I understand them correctly. I also - much like we have discussed to date - will then have to balance out the patient’s wants, needs, desires, and goals - my own, as an SFBT therapist - and the state’s, as our licensor, and of course the insurance company (as funder, and of course sometimes that’s the state).
So first is working with the patient to explain to them all of the reasons that we have to co-create this document together, and then explain how on earth we can make it useful (“it’s like a journal, you can use it to hold us accountable, you probably wouldn’t want to go into a teacher’s classroom if she didn’t have a lesson plan, or go to a Doctor’s office where they gave everyone the same shot…”). Then we work on the treatment plan itself.
So, let’s say a patient came in, and we had to diagnose them (because again, we’re making SFBT fit in a clinical, insurance based, environment) with depression; first we would discuss the “problem.” However, we’re going to discuss it in a solution’s focused way. So rather than say “John Doe is having depression!” or “John Doe is suffering from depression!” or “John doe is depressed!” (right, all normally “good” problem statements”) we’ll phrase it as “John desires to reduce the impact of symptoms of depression on his daily life.” I am not saying that John *IS* depressed or *IS* depression. I’m not saying he has anything. We’re merely, factually, stating that through SFBT language John has identified as wanting to have these barriers reduced. Then we’re going to come up with a goal.
Of course the Goals are more, or less, pre-selected for us. So we’re probably going to select that John Doe wants to reduce the intensity and frequency of his symptoms. All good and well. So how are we going to get there? Well, John now has to pick an objective, and 99.99% of the time, that Objective will be “Learn & Practice New Coping Skills.” So what on EARTH does that look like in the Solutions Focused world?
Normally the pre-fill starts with “John Doe will learn x number of new coping skills in order to reduce mental health symptoms.” Okay…great. So John Doe is going to learn his “lucky number” of coping skills to reduce mental health symptoms. BUT Solutions Focused work is a process and it’s a way of thinking (and for many it becomes a way of life). This isn’t DBT where there’s manualized therapy and you can give a worksheet, go over it, and check it off that the patient is “making progress” or “not.” How do you document a journey? How do you do so ethically? How do you bring Insurance Companies on board and do so ethically?
First, in the objective, we add that “John doe will learn 5 new coping skills, through a solution focused lens, in order to reduce mental health symptoms.” (document, document, document)”. In our intervention, we obviously note down “individual therapy” and how many times a week.
Okay, so we add in anything else that we may be working on in a similar fashion, we add in “Physical Health” because New York State says that we have to (never mind that it should be a patient’s choice, no matter how important it is!), along with Tobacco if the patient is a smoker (again, who’s the patient/client here?); and then we get to the thorny part: how do we make this, this treatment plan, this document, that we have to link everything to, make sense? How do we make an SFBT session where a patient comes in and talks about something seemingly unrelated make sense when it “has to” be related to a patient’s depression, right?
A patient can only work on what's in their treatment plan, every session has to link to the treatment plan, there can be no deviation from the treatment plan, or we have to add it to the treatment plan, because otherwise we're not being ethical, we have to document and it has to link to the treatment plan, every single session must somehow be linked to the treatment plan, so the answer is openly, honestly, and sincerely: through good SFBT practice. I’ll talk more about how we document and connect it in our notes in our next episode (when we get into documentation) but for now, how do we have our conversation? We start with “What’s better this week?” we then follow that up with “What is your best hope’s for this session?” and usually scaling questions, we move into what I refer to as “discernment” where we use change talk, and come up with an experiment…and then follow that up with (somewhere in there) a question about “and, if this experiment works, do you think this will help you to reduce symptoms of your depression?” and all of a sudden…SFBT becomes clinical; because the patient, themselves, will give you - IN THEIR OWN WORDS, how the experiment that they came up with, fits into their treatment plan, even if it seemingly had NOTHING TO DO with depression at all…maybe they were worried about what they were going to have for dinner…the point is that not that you were able to connect everything together, but that the patient, the client was, and you were able to document it, all by asking the very simple question of “how does it fit?".
Which is why it's very important that you look at the treatment plan before each session, so you know how you can guide the patient to connect it, what you're working on, in the solution focused process, to what you are allowed to work on and bill through, and that is how you make solution focused function in this clinical environment legally and ethically.
And since this seems a good a place as any to end off as any, we’ll do so and close here. Next week, we’ll discuss documentation, and then after, we’ll move into more of a “everything Solution Focused” format.
Thank you for listening. Please tune in again next Sunday, as we continue forward together down our solutions focused path. Comments, constructive criticism, feedback, and questions can be sent to firstname.lastname@example.org. Yes we’re on Social Media @WBTWCast on all of the platforms you’d think to look at. I’m @TheMattSchwartz, and it’s time for some self-care with my cat, Akiva, who is patiently waiting for cuddles while I record this.
The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you next Sunday with more; until then, make good choices.