Developing A Treatment Plan

The process of developing a treatment plan involves a logical series of steps that build on each other much like constructing a house. The foundation of any effective treatment plan is the data gathered in a comprehensive evaluation. As part of the process prior to developing the treatment plan, the family counselor must sensitively listen to and understand what the parents struggle with in terms of family dynamics, cognitive abilities, current stressors, social network, physical health and physical challenges, coping skills, self-esteem, extended family support, and so on. It is imperative that assessment data be drawn from a variety of sources that could include family background and social history, physical and mental health evaluations, clinical interviews, psychological testing, psychiatric evaluation/consultation, and assessment of the child's school history and records. The integration of the data by the mental health care provider or team is critical for understanding the parent/child relationship and discipline needs. We have identified five specific steps for developing an effective treatment plan based on assessment data.

Step One: Problem Selection

Although the parents may discuss a variety of issues during the assessment, the family counselor must ferret out the most significant problems on which to focus the treatment process. Usually a primary problem will surface, although secondary problems may also be evident. Some other problems may have to be set aside as not urgent enough to require treatment at this time. An effective treatment plan can deal only with a few selected problems or treatment will lose its direction. A variety of problems are presented as chapter titles representing specific social/ emotional issues within the Parenting Skills Treatment Planner. The mental health professional may select those that most accurately represent the parents and child's current needs.

As the problems to be selected become clear to the family counselor or team, it is important to consider opinions from the parents, and the child's perspective in determining the prioritization of social/emotional concerns. The identified child's motivation to participate with the parents and cooperate with the treatment process depends, to some extent, on the degree to which treatment addresses his or her greatest needs, particularly in circumstances with adolescent children who may have strong feelings as to what should be emphasized.

Step Two: Problem Definition

Each parent presents with unique nuances as to how a problem behaviorally reveals itself in his or her life. Therefore, each problem that is selected for treatment focus requires a specific definition about how it is evidenced in the particular family. The symptom pattern is associated with diagnostic criteria similar to those found in the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV). The Planner offers behaviorally specific definition statements to choose from or to serve as a model for your own personally crafted statements. You will find several behavior symptoms or syndromes listed that may characterize one of the 31 presenting problems identified in the Planner. Turn to the chapter that identifies the presenting problem being experienced by parents or their child. Select from the listed behavioral definitions the statements that best describe the observable behavior directly interfering with the parent/ child relationship.

Step Three: Goal Development

The next step in treatment plan development is that of setting broad goals for the resolution of the target educational problem. These statements need not be crafted in measurable terms but can be global, long-term goals that indicate a desired positive outcome to the treatment procedures. The Planner suggests several possible goal statements for each problem, but one statement is all that is required in a treatment plan.

Step Four: Objective Construction

In contrast to long-term goals, short-term objectives must be stated in behaviorally observable language. It must be clear when the parents and the identified child have achieved the objectives; therefore, vague, subjective objectives are not acceptable. Various alternatives are presented to allow construction of a variety of treatment plan possibilities for the same presenting problem. The family specialist must exercise professional judgment as to which objectives are most appropriate for a given family.

Each objective should be developed as a step toward attaining the broad instructional goal. In essence, objectives can be thought of as a series of steps that, when completed, will result in the achievement of the long-term goal. There should be at least two objectives for each problem, but the mental health professional may construct as many as are necessary for goal achievement. Target attainment dates may be listed for each objective. New objectives should be added to the plan as the family's treatment progresses. When all the necessary objectives have been achieved, the parents should have resolved the target problem successfully.

Step Five: Intervention Creation

Interventions are the therapeutic actions of the counselor designed to help the parents and the child to complete the objectives. There should be at least one intervention for every objective. If the parents do not accomplish the objective after the initial intervention has been implemented, new interventions should be added to the plan.

Interventions should be selected on the basis of the family's needs and the mental health specialist's full instructional and/or therapeutic repertoire. The Parenting Skills Treatment Planner contains interventions from a broad range of approaches including cognitive, behavioral, academic, dynamic, medical, and family-based. Other interventions may be written by the provider to reflect his or her own training and experience. The addition of new problems, definitions, goals, objectives, and interventions to those found in the Planner is encouraged to add to the database for future reference and use.

Some suggested interventions listed in the Planner refer to specific books, journals, or Internet sites where specific methodologies can be located for the counselor to look for a more lengthy explanation or discussion of the intervention. Appendix A offers a list of bibliotherapy references that may be helpful to families, referenced by the problem focused on within each chapter.

Step Six: Diagnosis Determination

The determination of an appropriate diagnosis is based on an evaluation of the client's complete clinical presentation. The clinician must compare the behavioral, cognitive, emotional, and interpersonal symptoms that the client presents to the criteria for diagnosis of a mental illness condition as described in DSM-IV-TR. The issue of differential diagnosis is admittedly a difficult one that has rather low inter-rater reliability. Psychologists have also been trained to think more in terms of maladaptive behavior than in disease labels. In spite of these factors, diagnosis is a reality that exists in the world of mental health care and it is a necessity for third-party reimbursement. However, recently, managed care agencies are more interested in behavioral indices that are exhibited by the client than in the actual diagnosis. It is the clinician's thorough knowledge of DSM-IV-TR criteria and a complete understanding of the client assessment data that contribute to the most reliable, valid diagnosis. An accurate assessment of behavioral indicators will also contribute to more effective treatment planning. If the parents are being seen in a family therapy mode, along with a child or children, there may be separate diagnoses given for different members of the family. Appendix B contains all of the suggested diagnoses cited in this book, sorted by presenting problems and chapter titles.

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