01 - 9. Treatment Planning

9. Treatment Planning

I t’s helpful to view therapy as a journey, and the conceptualization as the road map. You discuss the client’s aspirations and goals, the destination. There are a number of ways to reach that destination: for example, by main highways or back roads. Sometimes detours change the original plan. As you become more experienced and better at conceptualization, you fill in the relevant details in the map, and your efficiency and effectiveness will improve. At the beginning, however, it’s reasonable to assume that you may not accomplish therapy in the most effective or efficient way. An accurate cognitive conceptualization helps you determine what the main highways are and how best to travel. In this chapter, you’ll learn how to create a treatment plan for a client with depression. (You’ll need to consult specialized texts for clients who have a different disorder or a comorbid condition.) Here are the questions that are answered in this chapter: What are (and how do you accomplish) broad therapeutic objectives? How do you plan treatment across sessions? How do you create a treatment plan? How do you plan treatment to accomplish a specific goal? How do you plan individual sessions? How do you decide whether to focus on a particular goal or issue? How do you help clients who have difficulty identifying a problem? TREATMENT PLANNING

ACCOMPLISHING THERAPEUTIC OBJECTIVES Effective treatment planning requires a sound diagnosis, a solid formulation of the case, and consideration of clients’ characteristics and their aspirations, values, sense of purpose, and goals. Treatment is tailored to the individual; you develop an overall strategy as well as a specific plan for each session. You also consider your conceptualization of the client; the stage of treatment; the client’s values, state of mind, and level of motivation; and the nature and strength of the therapeutic alliance. At the broadest level, your objectives are to facilitate a remission of clients’ disorders; significantly improve their mood, functioning, and resilience; and prevent relapse. You arrange meaningful experiences for clients (in and out of sessions) that increase optimism, hope, and motivation along with their sense of control, worth, empowerment, purpose, connectedness, and well-being. You help them increase flexibility in how they think and act. My objectives with Abe, given his values and aspirations, are to help him see himself as a good family man and worker, someone who has grit and is resourceful, who can solve problems and overcome challenges, who helps other people, and who is confident that he has what it takes to lead a productive and satisfying life. To achieve your therapeutic objectives, you will • build a sound therapeutic alliance with clients; • make the structure and the process of therapy explicit; • monitor progress weekly and modify the treatment plan as needed; • teach clients the cognitive model and share your conceptualization with them; • alleviate their distress through a variety of interventions, including cognitive restructuring, problem solving, and skills training; • increase positive affect by creating opportunities for meaningful, pleasurable, mastery-­enhancing, and/or social experiences; • develop and strengthen clients’ adaptive (positive) beliefs about themselves, others, the world, and their future by helping them draw conclusions about their positive experiences, and identify and weaken their negative beliefs and draw more adaptive conclusions about their negative experiences; and • teach clients how to use CBT and other techniques, generalize the use of the techniques, and motivate them to use the techniques in the future.

Treatment Planning

PLANNING TREATMENT ACROSS SESSIONS Therapy can be viewed in three phases. In the beginning phase of treatment, you • build a strong therapeutic alliance; • identify and specify clients’ aspirations, values, and their goals for therapy; • identify steps to achieve each goal or solve each problem; • resolve obstacles (automatic thoughts and problems) that interfere with taking steps toward goal attainment; • socialize clients to the process of therapy (e.g., to collaboratively set agendas with you, provide feedback, and do Action Plans); • educate clients about the cognitive model, their disorder, and various helpful coping strategies; • emphasize clients’ strengths, resources, and positive beliefs; • teach clients to identify, evaluate, and respond to their automatic thoughts; • help clients draw positive conclusions about their experiences, including what these experiences mean about them; • teach clients needed skills; and • help clients schedule activities (especially if they’re depressed and avoidant). It’s especially important to facilitate a decrease in clients’ symptoms and an improvement in their functioning early in treatment. Doing so is linked to decreased early termination and to better treatment outcomes (King & Boswell, 2019). It’s also important to increase positive emotion throughout treatment (Dunn, 2012). In the middle phase of therapy, you continue not only to work toward these objectives but also to emphasize strengthening clients’ adaptive, more positive beliefs, and you more directly identify, evaluate, and modify clients’ dysfunctional beliefs, using use both “intellectual” and “emotional” techniques. In the final phase of therapy, you add an emphasis on preparing for termination, continuing to work toward goals, increasing a sense of well-being, improving resilience, and preventing relapse. By this point, clients have become much more active in therapy, taking the lead in setting the agenda, identifying Cognitive Behavior Therapy: Basics and Beyond

solutions to obstacles, responding to unhelpful thinking, taking therapy notes, and creating Action Plans. CREATING A TREATMENT PLAN You develop a treatment plan based on • your diagnostic evaluation and the cognitive formulation of the disorder(s); • the principles of treatment and general treatment strategies for that disorder; • your conceptualization of the client; • the client’s aspirations, strengths, values, and sense of purpose; and • the obstacles they face in taking steps to reach their goals. You adapt your treatment plan to the individual, considering his or her characteristics and preferences, culture and age, religious or spiritual orientation, ethnicity, socioeconomic status, disability, gender, and sexual orientation. Having formulated a general treatment plan, you adhere to it to a greater or lesser degree, revising it as necessary. Analyzing obstacles to taking steps to reach their goals compels you to conceptualize clients’ difficulties in detail and to formulate a treatment plan tailored to overcome them. Doing so also helps you focus each session, understand the flow of therapy from one session to the next, and become more aware of progress. You’ll find the initial treatment plan I devised for Abe in Figure 9.1. PLANNING TREATMENT TO ACCOMPLISH A SPECIFIC GOAL It’s helpful to identify the steps needed to help clients reach a goal or solve a specific problem. Figure 9.2 provides an example. You’ll see it outlines the necessary steps and specifies obstacles for each step (practical problems, interfering cognitions, and/or skill deficits) and a plan to overcome them.

Treatment Planning

OVERALL TREATMENT PLAN • Reduce depression, hopelessness, and anxiety; increase optimism and hopefulness • Improve functioning, social interactions, and self-care • Increase positive affect • Improve self-image and confidence • Prevent relapse VALUES, ASPIRATIONS, AND GOALS • Values: Family, being a good person, responsible, useful • Aspirations: To “get my old self back”; to be in control, productive, helpful to others, mentally healthy, a “good father and grandfather” • Goals: Get a job, spend more time with children and grandchildren, reconnect with friends, get apartment in order, get along better with ex-wife (if possible), take better care of self (exercise, sleep, eating) POTENTIAL OBSTACLES • Pessimism, hopelessness, anxiety about future • Low motivation, lack of energy, desire to avoid, inactivity • Negative self-image, self-criticism, rumination • Conflict with ex-wife POTENTIAL INTERVENTIONS • Provide psychoeducation about depression, anxiety, the cognitive model, and information processing, moving from the depressive to the adaptive mode, the importance of activity scheduling, the structure of sessions • Increase positive emotions by creating positive experiences; schedule activities (self-care, interpersonal, home management, job seeking; mixture of mastery, pleasure, and interpersonal activities) • Increase attention to and draw positive conclusions about these experiences • Reconnect with family and friends • Decrease time in bed and on the couch; decrease passive activities such as watching television, surfing the web • Break down large tasks into smaller components • Give self credit • Examine advantages and disadvantages when making a decision (e.g., how to approach ex-wife, what kind of job to look for) • Evaluate and respond to dysfunctional thoughts and beliefs, using guided discovery, Socratic questioning, and behavioral experiments • Teach mindfulness skills to decrease rumination • Do problem solving (especially of obstacles that could arise in coming week) • Teach communication skills (e.g., role-play interactions with ex-wife and job interviewer) FIGURE 9.1.  Abe’s initial treatment plan. Cognitive Behavior Therapy: Basics and Beyond

FIGURE 9.2.  Sample plan for a specific goal. Goal: Getting a job Identify steps and potential obstacles; create plan to address obstacles. Step 1: Update résumé. Potential Obstacles • Automatic thoughts: “I won’t do this right”; “I won’t get hired anyway” • Skill deficit: how to describe previous work experience Plan to Overcome Obstacles • Socratic questioning to evaluate automatic thoughts; summarize for therapy notes • Look online for sample résumés • Ask son for help; evaluate automatic thoughts that could pose obstacles (e.g., “I shouldn’t ask for help”); summarize for therapy notes • Give self credit for taking these steps • Set specific Action Plan to look online and ask son; assess likelihood of completion; if indicated, look for additional obstacles or change Action Plan Step 2: Identify potential jobs and apply for them. Potential Obstacles • Automatic thoughts: “If I look online, I won’t be able to find any in my area”; “If I network, people will find out I’m unemployed and they’ll think less of me” • Problem/skill deficit: doesn’t know where to look online Plan to Overcome Obstacles • Socratic questioning to evaluate automatic thoughts; summarize for therapy notes • Ask son for help in finding job opportunities online Step 3: Go on interviews. Potential Obstacles • Automatic thoughts: “I’ll make a bad impression”; “I’ll mess it up” Plan to Overcome Obstacles • Role-play • Work on making good eye contact; firm handshake, smiling, acting as if he’s confident

Treatment Planning

PLANNING INDIVIDUAL SESSIONS When planning a session, remember that the way people get better is by making small changes in their thinking and behavior every day. Before and during a session, ask yourself questions to formulate an overall plan for the session and to guide you as you conduct the therapy session. At the most general level, ask yourself: “What am I trying to accomplish, and how can I do so most efficiently?” Experienced therapists automatically reflect on many specific issues. If you’re a novice therapist, the following list may look daunting. But it’s useful to read it now and review it periodically, especially just before sessions. It will help you make better decisions about how to proceed within the session. Consciously contemplating the questions during a session would undoubtedly interfere with the therapeutic process.   1. As you review your notes from the previous session before the session, ask yourself: “What, if anything, do I need to do today to strengthen our alliance?” “What is the cognitive formulation [most important cognitions, coping strategies, and maintaining factors] for the client’s disorder? What is my conceptualization of the client?” “Do I need to vary treatment to accommodate the client’s individual characteristics?” “What has happened in the past few therapy sessions? What progress have we made toward the client’s goals and helping the client achieve a better level of functioning and sense of wellbeing? What obstacles have been interfering?” “How can I build on the client’s strengths, assets, and resources, and how can I help the client experience positive affect in the session?” “At which stage of therapy are we [beginning, middle, or final], and how many sessions do we have left [if there is a limit]?” “At which cognitive level have we primarily been working: automatic thoughts, intermediate beliefs, core beliefs, or a mixture? What behavioral changes have we been working toward? Which skills do I need to reinforce or introduce?” “What was the client’s Action Plan? What, if anything, did I agree to do [e.g., call client’s health care provider or find relevant bibliotherapy]?” Cognitive Behavior Therapy: Basics and Beyond

2. As you begin the therapy session and check on the client’s mood, ask yourself: “How has the client been feeling since our last session compared to earlier in treatment? Which moods predominate?” “Do objective scores match the client’s subjective description? If not, why not?” “Is there anything about the client’s mood we should put on the agenda to discuss more fully?”   3. As the client provides a brief review of the week, ask yourself: “How did this week go compared to previous weeks? When was the client at his best in general?” “What signs of progress are there? What positive experiences did the client have? What conclusions did the client draw about these experiences and about herself?” “Did anything happen this week [positive or negative] that we should put on the agenda to discuss more fully?”   4. As you check on the client’s use of alcohol, drugs, and medication (if applicable), ask yourself: “Is there a problem in any of these areas? If so, should we put it on the agenda to discuss more fully? And/or does the client have a goal in any of these areas?”   5. As you and the client set the agenda, ask yourself: “Which goal(s) does the client want to work toward this week? Or what problem(s) does the client want my help in solving?”   6. As you and the client prioritize agenda items, ask yourself: “Which agenda item is most important to discuss first?” “How much time will each agenda item take? How many items can we discuss?” “Are there any goals or issues the client could resolve alone or with someone else, or bring up at another session?”   7. As you and the client review the Action Plan, ask yourself: “When was the client at his best in relation to his goal(s) in the past week?” “How much of the Action Plan did the client do? What obstacles or challenges, if any, got in the way?” “Was the Action Plan useful? If not, why not?” “What did the client learn from the Action Plan? What did the client conclude about her experiences and about herself?” “How much does the client agree with the therapy notes from last week [and previous weeks, if still relevant]?”

Treatment Planning

“Which Action Plan items [if any] would be beneficial for the client to continue in the coming week?” “How, if at all, should we modify the Action Plan we create today to make it more effective?”   8. As you and the client discuss the first agenda item, ask yourself questions in four areas: Defining the Issue or Goal “What is the specific issue or goal the client wants to work on?” “How does this issue or goal fit into my overall conceptualization of the client?” Devising a Strategy “What has the client already done to try to resolve the issue or reach the goal?” “What would I do if I were in the client’s position and had this issue or goal?” “Do we need to do problem solving? What cognitions might interfere with problem solving, carrying out a solution, or making progress toward the goal?” Choosing Techniques “What specifically am I trying to accomplish as we discuss this agenda item?” “Which techniques have worked well for this client [or for similar clients] in the past? Which techniques have not worked well?” “Which technique should I try first?” “How will I evaluate its effectiveness?” “Will I employ the technique or employ it and teach it to the client?” Monitoring the Process “To what degree are we working together as a team?” “Is the client having interfering automatic thoughts about himself, this intervention, our therapy, me, the future?” “Is the client’s mood improving? How well is this technique working? Should I try something else?” “Will we finish discussion of this agenda item in time? If not, should I suggest continuing this item and curtailing or eliminating discussion of another item?” “What Action Plan might be beneficial?” “What should we record for the client to review at home?”   9. Following discussion of the first agenda item, ask yourself: “How is the client feeling now?” “Do I need to do anything to reestablish rapport?” Cognitive Behavior Therapy: Basics and Beyond

“How much time is left in the session? Do we have time for another agenda item? What should we do next?” 10. Before closing the session, ask yourself: “Did we make progress? Is the client feeling better?” “Is the client committed and highly likely to do the Action Plan we agreed on?” “In addition to asking for feedback, do I need to probe for any negative reactions [that the client hasn’t expressed]? If there is negative feedback, how should I address it?” 11. After the session, you ask yourself: “How should I refine my conceptualization?” “Do I need to improve our relationship?” “How would I score myself on each item of the Cognitive Therapy Rating Scale [beckinstitute.org/CBTresources]? If I could do the session over again, what would I do differently?” “What do I want to remember to address in the next session? Future sessions?” [You can write these things down on your previous or next Session Note or put a sticky note in the client’s chart.] DECIDING WHETHER TO FOCUS ON AN ISSUE OR GOAL A critical decision in every therapy session is deciding how to spend the time. Although you collaborate in making this decision with clients, ask yourself: “Which issue(s) or goals can we work on that will help the client feel better by the end of the session and have a better week?” You gently guide clients away from discussion of issues that • they can resolve themselves, • are isolated incidents unlikely to recur, • are not particularly distressing or associated with dysfunctional behavior, and/or • they are unlikely to make much progress toward while more pressing issues need to be addressed.

Treatment Planning

You also avoid problems or goals that clients don’t want to work on, unless you conceptualize that it’s very important to do so at that session. Even then, you initially try to conceptualize why the client doesn’t want to discuss them. Responding to what they see as the disadvantages may increase their willingness. Even if they’re not willing to discuss them in full, they may be willing to spend just a few minutes on them. Ultimately, though, you need to respect their decision. Judith: Maria, do you think we should talk about the upcoming holiday with your family. Maria: No, not really. Judith: I’m concerned that you could have a repeat of what happened last month. Would it be okay if we just looked at the disadvantages of discussing it? And then maybe we can look at the potential advantages. Having identified and specified an issue or goal, you need to decide (collaboratively with the client) how much time and effort to spend on it. You should gather more data (if needed), review your options, reflect on practical considerations, and use the stage of therapy as a guide. When clients first bring up an issue, either while setting the agenda or later in the session, you assess the nature of the problem and turn it into a goal. For example, Abe has put a new problem on the agenda: His cousin’s business is failing, and Abe feels badly for her. I ask Abe what his goal is in relation to this problem so we can assess how useful it will be to devote a significant portion of therapy time to it. Judith: Okay, you said you wanted to bring up something about your cousin? Abe: Yeah. Her business has been pretty rocky for a while, but now it looks as if it may go bankrupt. I’m really sad for her. Judith: What would be your goal in talking about this? Do you want to help her in some way? Abe: No, I don’t think there’s anything I can do. Judith: How sad do you feel? Do you think you’re feeling “normal” sadness over this? Or do you think this is affecting you too strongly? Abe: I think I’m having a normal reaction. Judith: [having assessed no further work on this problem is warranted] Anything else on this? Abe: No, I don’t think so. Judith: Okay. I’m sorry this happened to your cousin. (pause) Should we turn to the next item on our agenda? Cognitive Behavior Therapy: Basics and Beyond

Abe doesn’t seem to be having distorted thoughts about this issue, he’s not catastrophizing; the issue seems to be time limited, and most importantly, he’s having a normal emotional reaction to it. So we collaboratively decide to start talking about another agenda item, Abe’s goal to look for a new apartment, which does warrant intervention. Judith: You wanted to talk about maybe getting a new apartment? Abe: Yes. But just thinking about it makes me really nervous. I don’t know where to start. Unlike the issue with his cousin, it was clear that investigating the possibility of moving was a reasonable goal and that we had enough time in the session to discuss what could get in the way and still have time for other important issues or goals. I help Abe figure out what an initial step could be. We look for obstacles that could get in the way, and I do some combination of helping Abe respond to cognitions that could derail him, solving problems, and teaching necessary skills. HELPING CLIENTS IDENTIFY A PROBLEMATIC SITUATION Sometimes clients recognize they are distressed but can’t identify a particular situation or issue that is associated with their distress (or which part of a situation is the most upsetting). When this happens, you can help them pinpoint the most problematic situation by proposing several potentially upsetting problems, asking them to hypothetically fix one problem, and determining how much relief the client feels. Once a specific situation has been identified, the automatic thoughts are more easily uncovered. Judith: [summarizing] So, it sounds as if you’ve been very upset for the past few days and you’re not sure why, and you’re having trouble identifying your thoughts—­you just feel upset most of the time. Is that right? Maria: Yes. I just don’t know why I feel so bad. Judith: What kinds of things have you been thinking about? Maria: Well, I’m still fighting with my mom. And my sister is mad at me too. I still can’t find a job, my apartment is a mess, and, I don’t know, everything. Judith: Anything else? Maria: I haven’t been feeling too well. I’m afraid I might be getting sick. Judith: Which of these situations bother you the most? Your mom, your sister, not having a job, your apartment, or feeling sick?

Treatment Planning

Maria: Oh, I don’t know. They’re all pretty bad. Judith: Let’s say hypothetically we could completely eliminate the feeling sick problem. Let’s say you now feel physically fine, how upset are you now? Maria: About the same. Judith: Okay. Say, hypothetically, your mom and your sister call and apologize and say they want to have a better relationship with you. How do you feel now? Maria: Somewhat better. Judith: Okay. Let’s say you find out you got the job you interviewed for after all. Now how do you feel? Maria: Much better. That would be a great relief. Judith: So it sounds as if it’s the job that’s the most distressing situation. Maria: Yeah. I think so. Judith: In a moment, we’ll talk more about getting a job, but first I’d like to go over how we figured it out, so you can do it yourself in the future. Maria: Well, you had me list all the things I was worried about and pretend to solve them one by one. Judith: And then you were able to see which one would give you the most relief if it had been resolved. Maria: Yeah. The same process can be used to help the client determine which part of a seemingly overwhelming problem is most distressing. CLINICAL TIPS Sometimes you can’t easily assess how difficult a goal will be to reach or how likely it is that a particular discussion will trigger a painful core belief. In these cases, you may initially focus on a goal but collaboratively decide to switch to another goal when you realize your interventions aren’t successful and/or the client is experiencing greater (unintended) distress, as you’ll see in the following interchange I had in an early therapy session with Maria. Judith: Okay, next on the agenda. You said you’d like to meet more people. (We discuss this goal more specifically.) Now, how could you meet new people this week? Maria: (in a meek voice) I could talk to people in my building, I guess. Cognitive Behavior Therapy: Basics and Beyond

Judith: (noticing that Maria suddenly looks downcast) What’s going through your mind right now? Maria: It’s hopeless. I’ll never be able to do it. I’ve tried this before. (Appears angry.) All my other therapists have tried this too. But I’m telling you, I just can’t do it! It won’t work! I hypothesize from Maria’s sudden negative affect shift that a core belief has been activated. I recognize that continuing in the same vein at this time will likely be counterproductive. Instead of refocusing on the goal, I decide to repair the therapeutic alliance by positively reinforcing her feedback (“It’s good you told me that”). Then I give her a choice about whether to return to this agenda item (“Would you like to talk some more about meeting new people, or should we come back to it another time [at another session] and move on to the issue that you’re having with your mom?”). SUMMARY The overarching goals of treatment are to facilitate remission of clients’ disorders; to increase their sense of purpose, meaning, connectedness, and well-being and to build resiliency and prevent relapse. To achieve these objectives, you need to have a solid understanding of clients’ current symptoms and functioning; aspirations, goals, and values; and presenting problems, precipitating events, history, and diagnosis. The treatment plan should be based on your ongoing conceptualization, and you should share your treatment plan with clients and elicit feedback. It’s important to plan treatment both for individual sessions and across the course of treatment. REFLECTION QUES TIONS What is an example of a problem or goal that would be helpful to work on in a therapy session with a client? Why would it be helpful? What is an example of a problem or goal that wouldn’t be helpful to work on? Why wouldn’t it be helpful? PRACTICE EXERCISE Let’s say your goal is to become more proficient in CBT in the next year. Create a plan to reach this goal. Use Figure 9.2 as a guide.

Treatment Planning