TREATMENT PLANNING ESSENTIALS: SKILL BUILDING FOR CLINICIANS Week 5: Being SMART about our Treatment Plans & Progress Notes 1

Welcome Back!  Review of last class  Connection before Content: Cultural Competence Reflection  What are we talking about today?  Interventions  Progress notes

Cultural Competency 1.05 Cultural Competence and Social Diversity Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability. 3

Personal Reflection (10 MINS)  Do you have specific knowledge about your own racial and cultural heritage and how it personally and professionally affects your definitions and biases of normality/abnormality and the process of counseling?  Do you familiarize yourself with relevant research and the latest findings regarding mental health and mental disorders of various ethnic and racial groups?  Do you value bilingualism and do not view another language as an impediment to counseling (monolingualism may be the culprit)?  Are you aware of your discomfort when you encounter differences in race, color, religion, sexual orientation, language, and ethnicity?  Are you aware of your stereotypes as they arise and have developed personal strategies for reducing the harm they cause?

A FEW MORE THINGS ABOUT TREATMENT PLANS 5

Identifying the Problem The presenting problem or complaint should always be stated in client’s own words: “My wife asked me to come here. Life has become a struggle. I just can’t get going and I don’t want to even try. Nothing seems worthwhile anymore.” Versus “the patient is suffering from depression.” 6

Questions to Consider When Prioritizing Problems What problems does the patient identify as being the most troublesome or the primary reason for seeking treatment? Which of the identified problems are having the greatest impact on the patient’s life? Which of the problems must be dealt with first in order to resolve the central problem identified in the case formulation? Which problems can provide the patient with an opportunity to easily and quickly experience a sense of success and mastery early in the therapeutic process? If the patient only had one treatment session available and could work on only one problem during that session, which problem would you (the clinician) choose? Which one would the patient choose? Maruish, M.E. (2002)

Maslow’s Hierarchy

Treatment Plan Development ◦ A goal is a statement of the desired outcome Client has a history of experiencing symptoms of depression such as persistently low or sad mood, trouble sleeping, difficulty concentrating, loss of interest and motivation and social withdrawal. “I would like to improve my mood, sleep better, do better at my job, do things I used to do and spend more time with my friends. ◦ An objective is a statement of observable, measurable steps to be taken to meet a desired goal (e.g., the warm, chewy cookies) ◦ Client will engage with a friend in a social activity 1x weekly and record this encounter in her behavioral activation log. ◦ An intervention is a method, approach, action and/or strategy that will be used to support the client’s attainment of the objectives. (e.g., the ingredients)

Classroom Examples Poor Objective Statement: Client will learn about anger management and will be able to identify feelings. Improved Objective Statement : Client will learn to identify 3 new feelings and 3 triggers for anger specifically

Interventions Interventions are captured on the treatment plan in 2 ways: 1.What do I need to do to achieve this? 2.Who’s responsible? Examples: Clinician will assist client in identifying triggers to low or sad mood through review of weekly journal while using CBT to examine negative thought processes Clinician and client will role play scenarios about engaging with friends to join in activities to help reduce social withdrawal.

Classroom Examples Poor Intervention Statement: Good choices/bad choices, solution focused therapy, Reality therapy Technique Improved Intervention Statement: Clinician will teach Mrs. Test two breathing techniques and develop a guided imagery narrative to be used in conjunction with meditation. Poor intervention Statement : Psychosocial skills training and counseling) Improved Intervention Statement : * PSC staff will work with ct. and the family to identify a list of expectations for behavior in the home and community. ◦ PSC staff will teach ct. self-calming strategies such as deep breathing and progressive muscle relaxation.

Some Questions When Selecting Interventions ◦ Will the planned intervention enable the consumer to meet all or most of his/her objectives? ◦ Does the treating clinician have the skills necessary for implementing the planned intervention? ◦ Is what the client will be expected to do realistic? ◦ Is what the clinician will be expected to do realistic? ◦ Will the clinician be able to know within a reasonable amount of time if the intervention is working? ◦ Could a different type of intervention yield the same outcomes? If so, why was it not selected? Maruish, M.E. (2002)

EBPs In general, those treatments qualify as an EBP that produce positive outcomes in two or more studies and preferably conducted by more than one research group. The outcomes typically measured in studies include some combination of the following: Symptom Reduction and Improved Functioning Improved school attendance and performance Improved family and peer relationships Decreased involvement with law enforcement and the juvenile justice system Decreased rates of substance use and abuse Reduction in self-harm and suicide related behaviors. Decreased hospital admissions, institutional care, and other types of out-of- home placement.

Caution about EBPs  Not widely available  Lack of training  Interventions not recognized as EBPs can be just as effective  Not all EBPs have been studied in racially and ethnically diverse populations  Ensure that the EBP has been studied on the population that you are treating

Treatment Plan Review ◦ Treatment plans should be reviewed with the consumer at least monthly ◦ Each objective should be reviewed, and progress toward the goal identified. ◦ Justification for either continuation or discontinuation of objective ◦ Goals and objectives must be modified if necessary.

PROGRESS NOTES

What in the World is SGIRPP ◦ A template for writing progress notes that allows the counselor to focus on the client’s goals and progress while writing a note that is “audit safe” ◦ S = Symptoms – Presenting symptoms that day ◦ G = Goal – the goal(s) that we worked toward during the session ◦ I = Intervention – the clinical intervention we provided during the session (this should be the most detailed, comprehensive part of the note) ◦ R = Response – the client’s response to our clinical intervention ◦ P = Progress – the progress the client has made toward his/her goal(s) ◦ P = Plan – The next steps we will take to help the client achieve his/her goals 18 Proprietary and Confidential May 2015

“S” is for Symptoms… ◦ Each note should “stand alone” and document Medical Necessity ◦ Include demographic information ◦ Brief history statement ◦ How is the client presenting today? ◦ Dangers of cutting and pasting the “S” 19 Proprietary and Confidential June 2015

“G” is for Goal… ◦ …. Or Objective(s) ◦ What are we working on today? ◦ How is this relevant to the Objectives ◦ Did we stay on track? ◦ Always have a copy of the Treatment Plan when writing notes ◦ How can an EHR help? 20 Proprietary and Confidential June 2015

“I” is for Intervention… ◦ …. And IMPORTANT ◦ Most important component of the note ◦ Most comprehensive part of the note ◦ What did we do? ◦ How does this help the client meet the objectives? ◦ How can an EHR help? 21 Proprietary and Confidential June 2015

“R” is for Response… ◦ Look to the client… ◦ How did the client react? ◦ Did the response initiate another skilled clinical intervention? ◦ Remember that the client will be reading these notes… 22 Proprietary and Confidential June 2015

“P” is for Progress… ◦ How are things going? ◦ In each note, we are accountable ◦ Headway toward the objectives? ◦ Why or why not? (Critical to discuss the “why not” in clinical supervision) ◦ Is it time to make a change? ◦ What will we work on next? ◦ Golden Thread 23 Proprietary and Confidential June 2015

“P” is for Plan… ◦ One sentence is fine, but include detail ◦ Remember the Golden Thread ◦ What was acceptable before is not acceptable now: ◦ “Will provide CBT next week.” ◦ How can this be improved? 24 Proprietary and Confidential June 2015

Progress Note (room for improvement!) 25

Progress Note (SGIRPP) 26

Progress Note (room for improvement!) 27

Progress Note (SGIRPP) 28

References ◦ Maruish, M.E. (2002). Essentials of Treatment Planning. NY: John Wiley & Sons INC