Topic from the field:  A problem with treatment plans. Part 2 – Some considerations toward improved treatment planning

Disclaimer:  nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care. 

In Part 1 of this topic from the field I addressed the problem of treatment plans that seem to reflect the counselor more than the patient.  In doing so, I described some ways to assess treatment plans for that kind of deficiency.

I’ll now turn to the second part of this topic:  some considerations toward improving the development of treatment plans.  I’ll cover 5 sub-topics in order:

1. Person-driven vs. Clinically-derived
2. Structural completeness
3. The Strengths Model
4. CRA and the Session Rating Scale
5. The separation of target and method

Treatment plan:  Person-driven or Clinically-derived? 

Is the development of the treatment plan driven by the patient (formed and directed at the patient’s discretion), or clinically derived (sourced in the counselor’s expertise)? 

In clinical SUD work it is common to hold these considerations as opposites and thus consider building the whole treatment plan or its elements accordingly – using one of those two methods or the other. 

But it can also be helpful to think of those two approaches as ingredients to make a mixture – a third or novel kind of product – that is sourced in both.

Toward that end, consider changing “or” to “and”, and the separate value of each of the two elements.  Thus, we would have “person-driven and clinically derived”.  Or perhaps, “person-centered and clinically derived”. 

In any current clinical instance what should be person-driven? What should be clinically derived? And what should reflect elements of both? 

• To what extent should the current topic, goal, patient objective, clinician activity, etc. be driven by the person served? 
• To what extent should it reflect technical clinical know-how? 
• What proportions of those influences are best in this instance?  And how can that admixture lead to an innovated element – that if at all possible – is written in the patient’s voice within the treatment plan? 

In this regard I asked a trainer in the late 1990’s what we should do as we reflect upon (these then new) person-centered methods with someone who is in imminent need of medically managed alcohol withdrawal and also actively psychotic in the context of a long-standing thought disorder.  I asked if and how we should remain person-centered or person-driven in that instance?  The trainer said in the face of such a picture we should function parentally, from a clinically-derived position of expertise, protect their life with proper medically managed alcohol withdrawal protocols, and also treat their psychosis. The trainer stressed the point that neither “person driven” nor “clinically derived” are either always right or always wrong, in every instance, by definition.  That helped me gain flexibility while retaining common sense.

Structural completeness.  Another source of tension that can help us lean into individualization of treatment plans is the inclusion of all 3 of the following considerations related to structural completeness. 

1. Top-down, bottom-up.
   • What methods can make use of higher pre-frontal brain regions and drive effects downward into deeper parts of the body and mind? (e.g. readings, paper and pencil homework exercises, imagery, etc.). These are top-down.
   • What methods can make use of bodily processes that promote helpful impacts in higher areas, such as the mind? (e.g. walking, diaphragmatic breathing, exercise, etc.).  These are bottom-up. 
2. Left to right, right to left.
   • What methods make use of logic, structure, ordered sequence, and attention to process adherence?  These are so-called “left hemisphere” activities.
   • What methods make use of intuition, creativity, set the occasion for insight to happen, are in the big picture, holistic by nature, and experiential?  These are so-called “right hemisphere” activities.
   • Can we use the open door of the patient’s natural preference between these two (as a method), in order to begin to impact the other (as a target)? 
3. Outside-in, inside-out.
   • What methods originate outside of the patient, are taken in, and are helpful?  (e.g. a medication reminder system, coping skills handout, warning signs checklist, etc.).  Things the clinician does are commonly called “activities”.
   • What methods originate inside of the patient, work their way outward, and are helpful?  (e.g. progressive muscle relaxation, creativity work, etc.).  Things the patient does are commonly called “objectives”.

By the way, something I really like about a therapeutic community of peers and about mutual aid fellowships is that they tend to provide most or all of these 3 elements in the long run.

All too often, however, without forcing themself to think these opportunities through in a procedurally check-listed way, the counselor will regress to their strengths and preferences.  And as a result, the treatment plan they write will reflect those limitations accordingly, and only touch those domains. 

The Strengths model. Better treatment planning starts with a structured process for data collection and then one for case conceptualization.  One helpful source of a starting place that can sit inside and also encompass almost any routine assessment tool or process is The Strengths Model. 

Here are two particular elements of that model that can help inject a source of variability that the counselor would need to grapple with, toward improved individualization of the treatment plan that is eventually developed.   

1. The assessment of strengths (ROPES):  resources, options, possibilities, exceptions, solutions. 
2. Strengths-based assessment.  As you assess the problem, using your normal methods, also do so from a strengths-perspective. 
   • When does the problem not happen?  Look for sources of positive variability outside of or around the problem itself.  Chase down the sources of that helpful variability and build upon it.
   • The axiom for the clinician I seem to recall came from David Loveland during the BHRM project:  “You can’t build on a deficit.”  The notion here is to gather awareness of the assets and efficacies that are in place, so they can be built upon at that very location – as opposed to trying to build something on top of a void.   

The message here is as follows.  While considering the choosing and blending of person-centered and clinically-derived approaches, and the structural completeness of the problem and the plan, framing the work from a strengths perspective can be very helpful and promote ample individualization.  This is even true when working within an entire theoretical or programmatic model (such as the Community Reinforcement Approach – CRA) and the provision of individual counseling.

CRA + Session Rating Scale 

Across decades, and across meta-analytic studies of methods of addiction treatment, CRA is among those models of care that consistently rise to the top in efficacy and power for change.  Likewise, use of the Session Rating Scale sets the occasion for improvement of empathy/rapport from the practical perspective of the person served.  In combination, these program-level and session-level mechanisms provide potent source material, helpful tension for change, and consistent pressure for innovation in our clinical methods.   

An exposition of these is beyond the focus of this work.  However, here is an outline of some elements of these that apply toward undermining the counselor’s tendency to remain in charge and to do so automatically, entrenched in their circular clinical operations.

• Happiness scale.  Work on the items that are scored as being in the middle. 

1. Do not initially work on the items rated 0-3 (initially these are too painful, present lots of inertia, and meaningful improvement is hard). 
2. Do not initially work on the items rated 7-10 (improving these from their already-good or very good status is just too hard at the beginning of the work).
3. Pick items perhaps rated approximately 4-6 to start on initially.  These are relatively easier to obtain initial movement and gain rapid reinforcement. 

• Goals of counseling. 

1. Pick the person’s goals for each problem area from the Happiness Scale that will be initially addressed.
2. Word the goals in the person’s own language and voice.
3. When defining the goals and related objectives, work within the framework of the person’s interests.

• Session rating scale.

1. Use the session rating scale each session while moving forward; use it to continuously improve the work by co-creating adjustments to the plan.
2. Privilege the patient as teacher.

This person-centered approach retains involvement of the clinician as an expert, yet is not purely “person-driven” while excluding the clinician’s expert input.  Regardless, the patient can essentially:

• Write the treatment plan;
• In their voice;
• Using their goals;
• Reflecting their interests. 

But is that enough to help ensure person-centered thoroughness and effectiveness?

The counselor’s case conceptualization can be a key entrance point toward the clinical supervisor determining the origin of the treatment plan.  And to have a beginning place toward improving the treatment plan’s value, and adjusting it, as we begin to see its results. 

Toward meeting the aim of a person-centered and effective treatment plan, the counselor and clinical supervisor alike might wonder if the treatment plan is the best blend of effective and efficient, and contains what is necessary and sufficient. 

To help the clinician gain a fresher starting point and improve the individualization of the plan, they can be encouraged to strain forward and remove their common clinical assumptions by separating methods from targets.

Separation of Target and Method.

While functioning on autopilot, clinicians often think of a clinical target (e.g. a behavior to start or stop) and aim right at it with their clinical method (e.g. a behavioral assignment, or a worksheet).  When given the chance to slow down, they might give better consideration and bring about targets in the context of goals that are achieved developmentally. And thus, they might instead target an upstream location that will bring the proper downstream change. 

Another consideration in separating target from method is to choose methods from among differing clinical disciplines (e.g. what discipline is best suited to bringing about this hoped-for change?).  For instance, perhaps depressive symptoms for this person in this context are better addressed by spiritual care or a family therapist. 

Meanwhile, some targets or methods might be more observable or less observable.  Recognizing this adds appropriate and relevant difficulty.

Here are simple slogans for these two considerations.  We can use these slogans to help us remember to separate target and method – toward keeping things nimble and fresh.

1. “We don’t think our way to right behavior, we behave our way to right thinking”.
2. That’s the target, but what discipline or tool should we use?

In closing

When I was asked to blog on this topic, I was happy to do so, given how much and how long I’ve struggled with the topic of treatment planning, and the clinical supervision of treatment planning. 

Another critical aspect of this topic, however, did not occur to me until I was nearly finished writing my posts.  It’s the emerging use by some of ChatGPT and other super-new AI to generate treatment plans, followed by the clinician making a few final tweaks for relevance and quality control, before they are finalized and presented to the patient.  It concerns me that this practice would set aside the aspirational role of the clinician as “master soup-maker”. 

Toward preserving that role, below I’ve listed the few resources that are most relevant to this work.  But I’ve also included a much longer list of further readings to help expand horizons.

As I’ve hinted all along in this work, we can also improve our treatment planning by involving ourselves in lifelong clinical supervision of counseling, and of clinical supervision.  And I think we should.  Afterall, we should improve ourselves as addiction counselors, and as clinical supervisors, rather than rely on AI to improve our patients. 

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Resources

Bernard, J. B. & Goodyear, R. K.  (1998).  Fundamentals of Clinical Supervision, Second Edition.  Allyn & Bacon. 

Coon, B.  February 1, 2020.  Peer Support, or Harm Reduction, or Recovery Coaching?  Recovery Review.

Coon, B.  December 26, 2020.  “Recovery”:  let’s do the math.  Recovery Review.

Community Reinforcement Approach.

Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Reynolds, L. R., Brown, J. & Johnson, L. D.  (2003).  The Session Rating Scale:  Preliminary Psychometric Properties of a “Working” Alliance Measure.  Journal of Brief Therapy.  3(1): 3-12.

Graybeal, C. (2001). Strengths-Based Social Work Assessment: Transforming the Dominant Paradigm. Families in Society.  82(3): 233-242.

Rapp, C., & Goscha, R. J.  (2011).  The Strengths Model:  A Recovery-Oriented Approach to Mental Health Treatment, 3^rd Edition.  Oxford Press.

Solms, M. (2021). The Hidden Spring: A Journey to the Source of Consciousness. W. W. Norton.

Weiss, R., Tilin, F. & Morgan, M.  (2018).  The Interprofessional Health Care Team:  Leadership and Development, Second Edition.  Jones & Bartlett, Burlington, MA.  

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Further Readings

Allsopp, K., Read, J., Corcoran, R. & Kinderman, P. (2019).  Heterogeneity in Psychiatric Diagnostic Classification.  Psychiatry Research.  279:15-22.  

Amit, E., Hoeflin, C., Hamzah, N. & Fedorenko, E.  (2017).  An Asymmetrical Relationship Between Verbal and Visual Thinking: Converging evidence from behavior and fMRI.  Neuroimage.  152: 619-627.  

Blood, A. J. & Zatorre, R. J.  (2001).  Intensely Pleasurable Responses to Music Correlate with Activity in Brain Regions Implicated in Reward and Emotion.  Proceedings of the Natural Academy of Sciences.  98(20): 11818-11823.

Carroll, D. (2012). The 9 And 12 Workbook. William Donald Carroll, Jr.

Coon, B.  Gathering Ideas From Outside the Field:  Lessons from Jackson Pollock.  November 29, 2021.  Recovery Review.   

Coon, B.  “One-Kind-Fits-All” Denial, All the Time.  August 22, 2020.  Recovery Review.

Coon, B.  Older Model 2.0, Newer Model 3.0.  July 11, 2020.  Recovery Review.

Coon, B.  Reflections on “The Universal Mind of Bill Evans”.  December 28, 2019.  Recovery Review.

Enos, G. A. November 21, 2016. A Young-Adult Treatment Approach With Visual Appeal. Addiction Professional.

Ferreri, L., Mas-Herrero, E., Zatorre, R. J., Ripollés, P., Gomez-Andres, A., Alicart, H., Olivé, G., Marco-Pallarés, J., Antonijoan, R. M., Valle, M., Riba, J. & Rodriguez-Fornells, A.  (2019).  Dopamine Modulates the Reward Experiences Elicited by Music.  Proceedings of the Natural Academy of Sciences.  116(9): 3793-3798.  

Galanter, M.  (2014).  Alcoholics Anonymous and Twelve-Step Recovery:  A model based on social and cognitive neuroscience.  The American Journal on Addictions. 23: 300-307.

Goupil, L. & Aucouturier, J-J.  (2019).  Musical Pleasure and Musical Emotions.  Proceedings of the Natural Academy of Sciences.  116(9): 3364-3366.  

Haley, J. (1987).  Problem-Solving Therapy, Second Edition.  Jossey-Bass:  San Francisco.

Hang Hai, A., Franklin, C., Park, S., DiNitto, D. M. & Norielle, Aurelio, N.  (2019). The efficacy of Spiritual/Religious Interventions for Substance Use Problems:  A systematic review and meta-analysis of randomized controlled trials.  Drug and Alcohol Dependence. 202: 134-148.

Malchiodi, C. A. (Ed.).  (2012).  Handbook of Art Therapy, Second Edition.  The Guilford Press: NY.

Harrison, L. & Loui, P.  (2014).  Thrills, Chills, Frissons, and Skin Orgasms: Toward an Integrative Model of Transcendent Psychophysiology Experiences in Music.  Frontiers in Psychology: Theoretical and Philosophical Psychology.  5(790).  

Hedaya, R.J.  (1996).  Understanding Biological Psychiatry.  Norton & Company: New York.  

Horton Jr., A.M. (1990).  Neuropsychology Across the Life-Span:  Assessment and Treatment. Springer: New York.  

Hoss, R. J.  (2005).  What Are Dreams About?  In: Dream Language: Self-Understanding through Imagery and Color.  Innersource:  Ashland, OR. 

Janowsky, D. S., Hong, L., Morter, S. & Howe, L.  (1999).  Underlying Personality Differences Between Alcohol/Substance-Use Disorder Patients With and Without An Affective Disorder.  Alcohol and Alcoholism. 34(3): 370-377.

Kaplan, G.B. & Hammer, R.P., Eds. (2002).  Brain Circuitry and Signaling In Psychiatry:  Basic Science and Clinical Implications.  American Psychiatric Publishing:  Washington, DC.

Kramer, R.  (1995).  The Birth of Client-Centered Therapy:  Carl Rogers, Otto Rank, and “The Beyond”.  Journal of Humanistic Psychology.  35(4): 54-110.

Malchiodi, C. A.  (2012).  Art Therapy and the Brain.  In (Malchiodi, C. A. Ed.):  Handbook of Art Therapy, Second Edition.  Guilford Press:  NY.  

Mallik, A., Chandra, M. L. & Levitin, D. J.  (2017).  Anhedonia to Music and Mu-Opioids:  Evidence from the administration of naltrexone.  Scientific Reports.  7:41952. 

Mavridis I. N. (2015). Music and the nucleus accumbens. Surgical and Radiologic Anatomy: SRA.  37(2): 121–125. 

Melemis, S.M.  (2015).  Relapse Prevention and the Five Rules of Recovery.  Yale Journal of Biology and Medicine.  88(3): 325-332.

Miller, W. R.  (2000).  Rediscovering Fire:  Small interventions, large effects.  Psychology of Addictive Behaviors.  14(1):  6-18.

Mori, K. & Iwanaga, M.  (2017).  Two Types of Peak Emotional Responses to Music:  The psychophysiology of Chills and Tears.  Scientific Reports.  

Nielsen JA, Zielinski BA, Ferguson MA, Lainhart JE, Anderson JS (2013). An Evaluation of the Left-Brain vs. Right-Brain Hypothesis with Resting State Functional Connectivity Magnetic Resonance Imaging. PLOS ONE 8(8): e71275.  

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Rank, O.  (1936, 1978).  Will Therapy.  WW Norton & Company, Inc.

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Roth, S.  (1987, 1990, 2000).  Psychotherapy:  The Art of Wooing Nature.  Jason Aronson, Inc:  NY.

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Salimpoor, V. N., Benovoy, M., Larcher, K., Dagher, A. & Zatorre, R. J.  (2011).  Anatomically Distinct Dopamine Release During Anticipation and Experience of Peak Emotion to Music.  Nature Neuroscience.  14(2): 257-264.  

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