At the risk of oversimplifying, many incarcerated patients come to us with some manifestation of the following (or a combination of these):
- Problematic emotional experiences
- Problematic thought patterns
- Problematic behaviors
- Problematic relationships
It is important to work with the patient to understand which of these issues is experienced by the patient as most distressing and in need of change. I think back to a patient I once saw who was diagnosed with schizophrenia. She had significant trouble with tangential and disorganized thinking but what she wanted more than anything was having cigarettes at the end of the month. (This was back when inmates could still smoke in the prison.) She often smoked all her cigarettes prior to the end of the month and then had to borrow cigarettes “2-for-1” for the remainder of the month, putting her at a deficit at the start of the next month…you see the cycle. She did not have any interest in meeting with me to improve her thinking. She wanted her cigarettes.
As mental health professionals, it is necessary and essential to remember that we provide a professional service to our patients. They come to us for assistance that cannot be offered by a lay person. We are not just sounding boards or supports for them, we are licensed, credentialed trained professionals who provide a professional service. So, job #1 in treatment with a patient is to understand the source of their distress or dysfunction: Emotional? Cognitive? Behavioral? Interpersonal? Some combination of these?
For the patient above, the problem was two-fold – cognitive and behavioral. She needed to pay better attention to her resources and modify her behavior. Enter, treatment planning.
Step one is to define the problem and the goal simultaneously. For most of us, when we are experiencing distress or a challenge or a problem, it is usually defined not only by what is, but also by what is not. In other words, I don’t want to be overwhelmed by anxiety, and I want to be calm. I don’t want to ruminate in the middle of the night, and I want to get some sleep. The same is true for our patients. Where they are is, at least partially, defined by where they are not. As you begin to outline the cause of the patient’s distress, or the “problem,” you are also working to simultaneously define the “goal,” or the place the patient wants to be.
We can get to goals in several ways, but I often find that asking questions of the patient is the most helpful:
- How will you know when you are “better” or in a place you want to be with this issue?
- What does “better” feel like, look like, act like?
- Get specific, get examples, get evidence.
One important factor to keep in mind during treatment planning with your patient is what my colleague and friend, Dr. John S. Wilson, calls the “dead man test.” Goals are not goals if a dead man could reach them. In other words, the absence of something is not a goal. It is not a goal to “not feel depressed” to “stop engaging in violence” to “no longer experience hallucinations.” Those are not goals to strive toward, those are empty experiences. A goal is to get to something, to experience, to do, to feel, to think.
For this patient – her goal was to have at least two cigarettes in her pack on the last day of the month.
Next, we need to figure out the best path to get there. This is where your professional training comes into play. There are a few questions to consider here:
- What are the obstacles for this patient?
- What treatments have you been trained to use?
- Which treatment fits best with your patient’s needs and preferences?
For this patient, her obstacles were related to behavior (not running out of cigarettes) and cognition (focusing on and tracking her supply). I had training in cognitive-behavioral treatment. Perfect match. We collaborated on a plan where she would smoke half of a cigarette at a time, instead of the whole thing. Then, she would count her cigarettes at the end of each day and track how many days were left in the month so she could plan accordingly. For her, she had a treatment plan she was motivated to follow. For me, I was able to work with the patient on targeting the behavioral and cognitive symptoms related to her schizophrenia. She also cut down on her smoking. Win-win-win.
Our patients with mental health needs come to us for treatment. Active, engaged, formal treatment with a purpose. We need to collaborate with them to identify the problem as they see it, develop a goal they want to achieve and provide formal treatment to support them getting there.
Or at least that’s how I see it based on my training, research and experience. I could be wrong. If you think I’ve got it wrong, please let me know why in the Comments.
Do you have any recommendations regarding treatment planning? Please feel free to share.