Category Archives: Case Formulation and Treatment Planning

Deciding Who is the Client

FullSizeRender (49)I was contacted recently by the mother of a 10-year-old girl who has been showing symptoms of anxiety. The mom said her father died two months ago and the whole family has been affected by his death. She asked if I can see her 10-year-old daughter weekly and also see the family (including mom, dad, and older brother) every few weeks to help them through their period of grieving. I’m not sure how to respond to her request.

This situation illustrates one of the first questions we face in beginning with a new case: “who is my client?” or “what is the unit of treatment?”. You need to define the unit of treatment in order to decide who will participate in therapy sessions and how you define your therapeutic relationship with one or more members of the family. Chapter 9 of my book is devoted to the topic of treatment planning, which includes decisions about the therapeutic frame and structure, the client’s goals for change, and the therapeutic interventions that will facilitate that change.

When a child is involved in the initial request for therapy, your client may be the individual child with the parents participating in collateral sessions or may be the family. Your decision about the unit of treatment will affect how you structure the sessions, in terms of who participates and how frequently, but more importantly it will affect your treatment goals and interventions. Let’s look at how you might make this decision, assuming that you have experience in conducting both individual child and family therapy.

The first step is to recognize that you can take time to reach a decision about how to approach this case. You can respond to mom’s request by telling her that you would be open to seeing both her daughter alone and the family together, but that you would need to learn more about them in order to recommend the best way to work with them. All cases begin with an initial assessment, but the complexity of this situation make it preferable to explicitly begin with several sessions of assessment. This would give you a chance to meet with the family in different combinations, gaining information and making observations about them individually, as a unit, and in different subgroups. I would recommend one or two individual sessions with the daughter, one or two sessions with the parents individually and/or together, one family session, and possibly an individual session with the older brother. At that point, you would be able to determine the best way to proceed.

As I mentioned above, answering the question “who is my client?” primarily refers to how you define your relationship with the family. If you decide that the 10-year-old daughter is your client, your treatment goals and interventions will be focused on her symptoms and you will hold sessions with her parents and possibly the whole family in order to facilitate her progress. If you decide that the family is your client, you will develop treatment goals for the family as a whole and any individual sessions with the daughter or other family members would be in the service of helping the family grieve and reach some resolution of their loss. Your interventions would be oriented toward strengthening and improving the communication patterns and relational dynamics within the family rather than being targeted toward the symptoms or behaviors of any individual in the family.

Answering the question “who is my client” is an important step at the beginning of treatment. It deserves time and attention in order to make sure you will be successful in addressing the presenting symptoms and issues. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Value of Case Formulation

I recently started at a new practicum placement, and the agency assessment form includes a case formulation.  I haven’t done this before, so I’m not sure how to write it and how I can use it in my work with clients.  

A case formulation, also called a clinical or case conceptualization, is a theoretically based explanation for the client’s presenting problems and symptoms.  You use the concepts from your chosen theoretical perspective to describe why this client has developed the particular issues that are the focus of treatment.  The formulation follows your diagnosis and assessment and guides development of your treatment plan.  Chapter 8 of my book is devoted to the topic of case formulation, including an illustration of a case formulation written from three different theoretical perspectives for the same case.

The case formulation model I present in my book includes the following five aspects of the case:

  • Symptoms and presenting problems—Begin with a brief summary of the reason for treatment, both from the client’s initial presentation as well as additional issues that may be emerged from the assessment.
  • Developmental history and recent events relevant to the symptoms—Summarize the life events that are relevant to the client’s symptoms.  These would include traumatic events, losses, and significant psychosocial stressors that occurred in the past as well as recent precipitants that have contributed to the client’s current presentation.
  • Factors that contribute to the symptoms—This is the core of your case formulation, making clinical inferences about the links between your client’s life events and symptoms.  It is best to use one theoretical orientation as the basis of your formulation, in order to have a cohesive guide for your treatment.  Sample statements are “client developed a core belief of that she is unworthy of love and attention” or “the early disruption in client’s family life led him to develop an avoidant attachment to his mother.”
  • Cultural issues—Describe how cultural identities and other cultural factors impact the client’s symptoms and will be relevant in the treatment.
  • Strengths and resources—Review the internal and external factors that will assist in lessening the client’s symptoms and will enhance the client’s progress in therapy.

Regarding the question of how you can use a case formulation in your work, it can enhance your work in several ways.  When you hold and communicate an accurate understanding of the client’s difficulties, you are able to convey a deeper level of empathy than is possible based only on the client’s presenting symptoms themselves.  Your case formulation also guides your choice of treatment goals and interventions, allowing you to target more specifically the underlying source of the client’s problems.  Last, you are able to organize new clinical material more readily when you have a case formulation that structures your knowledge of the client’s present and past experiences.

I hope this model for case formulation enables you to develop clinically useful descriptions of the links between your clients’ symptoms and history.  If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Theoretically Based Concepts in Documentation

person-apple-laptop-notebookI’m using a psychodynamic theoretical orientation in my work with clients, and I don’t know how much explanation of these concepts to put in my client’s progress notes and assessment. If anyone else looked at my notes, they might not understand why I chose particular interventions without the theoretical background. However, I learned from my supervisor that documentation should be behavioral rather than psychodynamic.

This is an important issue to consider in creating a client record, since your record may be viewed by other professionals or by your client. The primary interest for others viewing the client’s record is less about the reason for your interventions and more about what you did and how your client responded. When a client or another professional requests a record, it is most often for the purpose of insuring continuity of care or to learn about your client’s presenting problem and progress. You can maximize the value of the record for those purposes when you use language that is easily understood by people who are unfamiliar with psychodynamic or other theories of psychopathology and psychotherapy. It is likely to be distracting rather than helpful to try to explain the theoretical basis for your interventions.

One way to create a record that others can understand and use is to translate theoretically based concepts into terms that are more descriptive and objective. An example is to describe the client as “protecting herself from painful experiences” rather than “using the defense of projection” or to describe your intervention as “assisting the client to develop insight in order to modify his habitual patterns” rather than “interpreting unconscious motivations for self-sabotage.” This approach may be contradictory to assignments in your academic courses, where you are being evaluated on your understanding of and ability to apply theoretical concepts. That is an important skill, and it is a crucial element to an effective treatment plan. However, clinical documentation serves a different purpose and is written for a different audience than academic papers or a clinically oriented theoretical formulation of a case.

Another way to focus your attention in writing clinical documents is to keep the client’s goals uppermost in your mind. This means being aware of the context of your interventions as working to help the client make the changes they want to make. This might lead you to say “declined client’s request to extend the length of the session and supported her ability to self-regulate intense emotions” rather than “set limit on client’s attempt to test boundaries when in a dysregulated state.” Your documentation will convey a more collaborative tone when you focus on the desired outcome of your interventions, which is preferable when the record is viewed by others including the client.

I hope you can use some of these suggestions in writing clinical documentation that is understandable to professionals who have a different theoretical perspective and to nonprofessionals. Please email me with comments, questions, or suggestions for future blog topics.

Sharing Client Information in a Team

Teachers TalkingI am a counselor at a high school, and the teachers often ask me about my clients’ progress. I know they have good intentions, but I’m uncomfortable answering their questions. How much should I share and how do I explain the reason I can’t answer some of their questions?

This is an example of working in a team with other professionals who have different expectations and requirements regarding confidentiality and privacy of information. Your client work is probably covered by the Health Insurance Portability and Accountability Act (HIPAA), which carries more limitations on sharing information than the regulations applicable to educational information. It is likely that the teachers know you can’t share fully with them, but your role in the school supports the students’ academic success so it is important to find ways to communicate productively with teachers. This requires that you create a collaborative working relationship with the teachers and other staff in the high school. I will recommend several steps you can take to establish yourself as part of a professional team.

One step is to have a short response regarding confidentiality requirements that you can use when a teacher asks you for specific information. An example is “you probably know I can’t share any details about the counseling, but I’d like to work together within the constraints I have to follow.” This establishes the limits of confidentiality while also communicating your desire to collaborate. Remember that teachers are often working in difficult circumstances and may be looking for support. When you can express your understanding of their concern for the students and the challenges they face in the classroom, the teachers will see you as an ally even if you can’t answer their questions. Follow your statement about confidentiality with an acknowledgement of their concern and desire for the student to get the help he/she needs.

Often, the next step will be to open a conversation with the teacher about how the student is doing in class. You might say “has anything happened lately that I should know about?” or “I’m interested in your perspective on how things are going.” The teacher’s question to you about the student’s progress may represent a desire to tell you something about the student’s life or a recent incident in the classroom. This information can be valuable background in your understanding of the student. Your client may present very differently in your counseling sessions than in the classroom or with teachers and peers. HIPAA limits the information you can share about treatment, but it doesn’t limit what you can hear from others.

You may also want to schedule a more formal conversation with one or more of your student’s teachers to ask specific questions that will aid in your assessment and treatment planning. It is wise to prepare a list of questions in advance so you can be focused in your discussion with the teacher and insure that you get the information you need. As treatment progresses, check in with the teachers periodically to get updates on the student’s progress in the classroom both academically and behaviorally. This information will enhance your review of treatment goals and help you to shape the direction of treatment.

Last, there may be times when you feel it would be helpful for you to share your impressions of the student with one or more teachers. You might have suggestions that the teacher could implement in the classroom or you might be able to provide an explanation for some of the student’s behavior that is otherwise confusing or creates conflict. If this is the case, you will need to have written permission from the parents and/or your client. Generally, parental consent is required for sharing treatment information for children under 18, but some states allow a minor to consent to treatment which would require that you get the student’s permission to share information. Even if it isn’t required by law, it is clinically sound to talk with the student about what you plan to share with the teachers and the reasons you think it would be helpful.

I hope you find these suggestions helpful in working as part of a team. Please email me with comments, questions, or suggestions for future blog topics.

Cultural Values in Treatment Goals

counselingI just completed my first session with a 21-year-old Latina who is a first generation American. She seems to rely too heavily on the opinions of her parents and other older members of her family in making decisions about her career and dating life. She said she wants to feel less anxious, and I think that will only happen if she becomes more independent of her family. How shall I talk with her about this?

Before talking with your client about her goals, I would suggest doing some exploration of your views and how they differ from your client’s. This situation highlights the impact of cultural values on treatment goals, and it is important that we examine our values and assumptions before recommending a treatment approach.

The first step in this situation is to recognize that you have developed an agenda that is different from your client’s. Any time this happens, you need to pause, examine the discrepancy, and work to understand your client’s perspective on what is best for her. In this case, you seem to have made some assumptions about your client’s relationship with her elders that will interfere with the therapeutic alliance. Her alliance with your depends on experiencing your respect and support for her in working toward her priorities. Over the course of time, your client may come to desire greater independence from her elders, but your task at the beginning of treatment is to join with her in working toward reducing her anxiety. Otherwise, she may feel undermined in defining what she needs.

The second issue to recognize is the extent to which values and beliefs about developmental goals and relationships are embedded in a cultural context. Your view that independence from parents and other family members is a desirable goal for young adults is no doubt consistent with the values of your cultural community, but your client comes from a cultural community that values interdependence and respect for elders. Talking with your supervisor and other colleagues about these cultural differences will help you to identify the strengths and benefits of your client’s values rather than assuming that she should come to share yours.

Another more complex issue to consider is the extent to which your response to your client may reflect her own conflict about her family relationships. It is helpful to reflect on your countertransference feelings and to talk about them in supervision. If you usually find it easy to join with your client’s agenda, it is possible that your strong opinion about this client’s need for independence represents your resonance with a part of herself that she is reluctant to articulate. If this seems plausible, you can support your client to recognize and sort through the complicated nature of her feelings toward her parents and other family members. This will work in her best interest if you can express an attitude of curiosity rather than judgment and if you help her identify and honor the mixture of different feelings she holds.

I hope you find this helpful in working with clients whose initial treatment goals are different from yours. Please email me with comments, questions, or suggestions for future blog topics.

Using Therapist Emotions to Understand the Client

new2I have been seeing a 35-year-old woman for about six months at my practicum site. I left the last session feeling at a loss about how to help her. She was sexually abused as a child, and I’m afraid I don’t have enough experience to be an effective therapist for her. How can I decide whether to refer her to a more experienced clinician or get more training myself?

It sounds like you had a strong emotional response to the recent session with this client that brought up questions for you about your effectiveness. Before making a decision to do something different in the treatment, I would suggest reflecting on your emotions as a way to understand the client in a deeper way. Your feelings of inadequacy and self-doubt may reveal something important about the client’s experience in relationships and her view of herself.

The first step I recommend is to take some time to identify your emotional response to the client more completely. In addition to your own reflection, you may find it helpful to talk about this with your supervisor, therapist, and colleagues. When we feel uncomfortable emotions during and after a session, it is tempting to ignore or avoid them and to take action to reduce our discomfort. Instead, take time to go more deeply into your emotions by identifying the thoughts, images, and physical sensations that accompany the emotion. If you have a mindfulness practice, use that practice to engage with your emotional experience without judgment.

After you have a more complete understanding of your emotional response in this recent session, review what you know about your client’s history, developmental trauma and losses including the sexual abuse, and her current relationship patterns. All of these experiences may be relevant to the emotion that has been stimulated in you. Think about the connections you can make between your emotions and the client’s experience. It is likely that your emotions mirror a painful experience from her past and present relationships. Ask yourself when your client has felt inadequate and ineffective with others. She may or may not have been able to talk directly about these feelings, so you may need to make inferences about feelings she has kept outside of her awareness and aren’t accessible verbally. Supervision is helpful in identifying links between your emotions and the client’s.

Last, identify ways you can respond therapeutically to your client in the face of your feelings of inadequacy. It will help to think about capacities she needs to develop or how she could manage her feelings of inadequacy with greater strength and confidence. An example might be for you to say “it may feel daunting to face the impact of your past but I think our work together can result in you developing different ways of handling the triggers when they arise” or “I wonder if you sometimes feel like giving up and it’s hard to believe things can get better.” If your client is directly questioning your capacity to help her, you can acknowledge her worry along with your commitment with a statement like “you may worry whether your difficulties are more than I can handle and I think that’s an important issue for us to talk about together.”

As you respond therapeutically to the client using your understanding of your emotions as a connection to her experience, you will notice changes in her way of relating to you and changes in your emotional response to her. She may begin talking more directly about her feelings of inadequacy, she may deepen her engagement with the therapy and the pain of her abuse, or you may notice that you’re feeling more sadness about the impact of her trauma rather than worry about helping her. All of these changes are indications that you have used your emotions to further the therapeutic process. If your questions about the effectiveness of the therapy continue, talk further with your supervisor about whether a different therapeutic approach or a referral to additional services would be indicated.

I hope you find this helpful in using your emotional responses to understand your clients. Please email me with comments, questions, or suggestions for future blog topics.

Client Reactions to Therapist Absence

portrait-female-therapist-office-her-patient-44629457I took some time off for the holidays, and my clients seem to be reacting to this. A few have cancelled sessions, a few have arrived late when they’re usually on time, and one said he thinks it’s time to stop therapy even though there is clearly more to do. How can I bring up the possibility that they’re upset about my being away without making the therapy all about me?

I agree with your assessment that your clients are having reactions to your absence and that it’s desirable to encourage them to talk about their feelings instead of demonstrating them in action. I’ll share some ideas about ways you can initiate this discussion and some of the reasons that clients may be reluctant to acknowledge and talk about their feelings.

Before talking with your clients about their reactions to your absence, notice and work to understand your countertransference feelings about this. You may feel annoyed, afraid, or guilty, reflected in thoughts like “don’t they appreciate how hard I work?” or “what if I lose clients every time I’m gone?” or “I guess I shouldn’t take so much time off next year.” These countertransference feelings can interfere with your ability to talk with the clients about their feelings, so wait to do so until you have understood and gotten support to process your annoyance, fear, guilt, or other feelings.

Your clients will probably have difficulty acknowledging to themselves and to you that they were affected by your absence. Our society generally values independence and autonomy over connection and interdependency, and it is unusual and unfamiliar for a professional to acknowledge the impact of a break in the relationship. Other health care and social service providers generally don’t acknowledge that the client may be affected by the provider’s absence or lack of availability. In addition, some of your clients probably coped with difficulties in their families of origin by denying their need for reliability and consistency and by shutting off their awareness of feelings of dependency and accompanying anger when their relational needs weren’t met.

Despite your clients’ reluctance and lack of practice, there are ways you can introduce the topic that will make it easier for them to engage in exploring their reactions to your time away. First, notice for yourself how the client’s behavior is different and mention this with an attitude of curiosity. For example, you might say “I notice that you were late for both of our sessions since I returned from my holiday break. That’s unusual for you, and I wonder if it might be related to the fact I was gone for a couple weeks.” This opening statement doesn’t make any judgment or assumption but simply tracks the change in behavior following your absence.

Second, it may help to make a statement that normalizes the fact that clients are affected by a break in the flow of therapy and that these emotions can be at odds with their rational or intellectual understanding of the reasons for the break. A sample statement would be “Many clients find they have feelings about missing a week or two of therapy, even though they understand the reason for my being away. Could that be the case for you?” With a client who is especially reluctant to look at her feelings about the therapy relationship, you might also talk about why this could be important to look at in light of her presenting issue or the focus of treatment. An example is “It may seem odd for me to ask about your feelings related to my being away for two weeks, but we’ve been talking about how you feel when your husband is on a business trip. It might help us understand that better if we also look at your feelings when I’m away.” This gives the client an explanation for why you think it is important to explore this and how it could help her in the area of concern to her. In some cases, it can be helpful to make a statement about the early experiences and coping strategies that interfere with acknowledging the impact of your absence by saying something like “We’ve been discussing how hard it was for you to come home to an empty house when both of your parents were working, and some of those feelings may have returned when I was away. You’ve worked hard to not let yourself know how painful that was, and it may be hard to recognize how you felt while I was gone.”

Last, let the client know that you’ll continue to notice and bring up the question of her feelings when you are away in the future. Sometimes the repetition over time helps the client to develop more awareness of the underlying emotions that aren’t accessible in your initial discussion.

I hope you are able to use these suggestions when working with client reactions to your absences. Please email me with comments, questions, or suggestions for future blog topics.

Client Attendance

young woman in therapyI’ve been seeing a client for three months, but she has only come to 7 sessions.  Sometimes she calls to cancel, but often she just doesn’t show up. I don’t know whether I should stop seeing her or if there is another way to help her understand the importance of coming in regularly.

This is a common dilemma, especially for clinicians in training or agency settings. It is difficult to make therapeutic progress when clients miss one or more sessions each month, and it is often challenging to engage the client in examining the reasons for irregular attendance. I will describe two approaches to this issue, and you may find either or both of these approaches helpful with this client and similar situations.

The first approach involves having a standard policy regarding attendance, setting a limit on the number of missed appointments or late cancellations. Your agency may have such a policy or you may develop one if you are working in a private practice setting. This policy should be part of your informed consent process, and I recommend that you remind the client about this each time she misses an appointment without notice or with late notice. A common standard is to allow three missed appointments or late cancellations (usually less than 24 hours’ notice) in a four month period before ending treatment. You may decide to make exceptions for illness or unavoidable emergencies, but be sure to discuss this with the client and let her know the reason for making an exception. The purpose of this type of policy is to insure that there is discussion about the issue of attendance and that the client is able to make progress on the issues she wants to address.

The second approach, which can be used instead of or in addition to an attendance policy, is to handle the client’s sporadic attendance as a clinical issue. The basis for this approach is an assumption that the client is repeating a traumatic or maladaptive interpersonal relationship and that you can provide the client with a different experience that will have a therapeutic outcome. I will outline a three step process for making such a clinical decision.

The first step in understanding the meaning of the client’s missed sessions is to reflect on her developmental history, especially regarding attachment and loss, and her descriptions of current relationships with intimate partners. Identify one or two themes that are present in these early and recent relationships. One common theme is an unpredictable attachment figure which leaves the client with feelings of longing and inadequacy. Another is an intrusive or abusive attachment figure leading the client to sacrifice safety to meet her need for connection. Think about the implications of these interpersonal experiences for the client’s view of herself and expectations of others.

The second step is to examine your countertransference and identify the interpersonal experience that the client is repeating with you. Be honest and thorough in reflecting on all of the thoughts, emotions, and images that are present when you wait for your client or when you pick up a message cancelling a few hours before the appointment. Notice any attributions you make about the reasons for the client missing the appointment and about the value of the therapy or your value as the therapist. Think about parallels between your thoughts and emotions and the client’s interpersonal themes. The client may be placing you in the position of the attachment figure or in the more vulnerable position she was in as a child.

Once you have identified the relevant experience and the roles being enacted by you and the client, you are ready to decide on a response that will allow the client to experience this interaction differently. This third and final step usually begins with shifting your countertransference state so that you are in touch with your therapeutic intentions and skills. You can then talk with the client in a different way than is possible when you are in the grip of the client’s enactment. In the best of circumstances, your response allows the client to become more engaged in the therapy whether or not she gains insight into the nature of the repetition. At other times, the client continues her side of the repetition, and you will need to decide whether to introduce limits as discussed above. Even in these situations, however, there is an opportunity for your learning and you can end the therapy, if necessary, knowing that you provided every opportunity for a therapeutic outcome.

I hope you are able to use these suggestions when working with clients whose attendance is irregular. Please email me with comments, questions, or suggestions for future blog topics.

What to do with Things that Can’t be Changed

therapyI’m working with a 20-year-old woman who has a bad relationship with her parents. I’ve been encouraging her to use better communication techniques with them but their conversations always end with the parents yelling and my client feeling blamed. She’s asked them to go to family therapy with her but they refuse. How can I help her when her parents won’t change?

As therapists, we focus on the potential for growth and change, and we maintain hope for our clients when they are discouraged. This is an important and effective trait in many clinical situations; however, it is equally important to recognize and help clients deal with circumstances that can’t be changed.

The first step I would recommend for you is to examine your countertransference. Sometimes we develop unrealistic goals with and for our clients because of personal issues and feelings. In this case, I would ask yourself if your relationship with your own parents is related in some way to your feelings about your client’s situation. You may be trying to achieve something that wasn’t possible in your own life or to replicate an aspect of your life that worked well for you. Either way, work to separate your parental relationship from your client’s relationship with her parents.

Another countertransference issue that may be present is related to feeling competent and effective. Therapists in training are often more comfortable when giving advice, teaching a skill, or proving an active intervention. Reflect on how you feel when your client follows your suggestions and reports they don’t work. If it is hard for you to sit with your client’s painful feelings, your definition of therapeutic success may be too restrictive. Talk with your supervisor about what it’s like for you to be less active in session and explore the usefulness of being emotionally attuned and present.

If you are able to sit with your own feelings of discomfort you will be better able to help your client with one of her therapeutic tasks: accepting what cannot be changed. It sounds like you and she have become invested in her parents changing their behavior toward her and that change isn’t possible right now. It will feel painful to both of you to face this, but it seems to be the current reality of her life. Acknowledging this and allowing her to express her anger, fear, helplessness, and loss will be an important therapeutic intervention. It may take time and will be painful but it is in the service of her developmental growth. Accepting the state of her parental relationship will facilitate her ability to focus on other aspects of her life. She is entering adulthood and facing decisions about work, friendships and intimate relationships. If she has put these on hold to resolve things with her parents, it may be time for her to shift her attention and energy.

Paradoxically, you may find that your client reports some improvement in her relationship with her parents as she moves toward acceptance. Sometimes relational conflict is exacerbated by an implicit desire for change that is experienced as an unwanted demand. Your client may have been communicating a more complex message than what you and she worked on with better communication skills. Her acceptance conveys a different message and may lead to a decrease in conflict.

Your question also raises an important issue related to treatment goals. Clients often enter treatment with a goal for change in something that is outside their control. You may have inadvertently agreed to a goal for individual therapy that can’t be achieved in that modality, so consider reviewing your treatment goals with your client. It sounds like a goal related to understanding her feelings about her parents and a goal related to de-escalation and detachment would be more appropriate than a goal about better communication between your client and her parents.

I hope you find this helpful in facing aspects of your clients’ lives that cannot be changed. Please email me with comments, questions or suggestions for future blog topics.

Tips for Developing Treatment Plans

I am working with adolescents who have a variety of presenting problems including grief and loss, depression, anxiety, and PTSD.  How can I develop an effective treatment plan for each of these presenting problems?

It has become standard practice in most behavioral health settings to develop a treatment plan with the client in the early sessions, to guide the direction of your work together.  Treatment plans have two parts: 1) the goal, objective or target for change in the client’s symptoms or behavior and 2) the interventions and therapeutic modality you will use, informed by a theoretical orientation.  I will discuss tips for each part of the treatment plan below.

The first part of the treatment plan, the target for change, is often written in behavioral terms in order to be clear about how you and the client will know that treatment is successful.  Clients sometimes begin treatment with a clear idea of what they want to change and other times are confused or vague.  Their initial discussion with you may focus on the desire for a change in others or a situation rather than something that is within their control.  If this is the case, you’ll need to take some time to talk about what is possible for you and the client to achieve.  With adolescents, you generally need to consider the priorities of parents and sometimes teachers and other school personnel in developing treatment goals.  Some negotiation may be necessary in developing treatment goals that are acceptable to all parties.

Once you and the client have agreed on the focus of change, identify goals that are achievable within the period of time you have to work together.  You will specify more modest goals if you have a limit of 12 sessions than if you are able to work for a school year of 8-9 months.  Your goals should also take into account the current baseline, length and severity of the problem, and complexity in terms of multiple diagnoses or family dynamics.  Your client and parents may be unrealistic about the degree of change that is possible or may transfer their feelings of pressure to you.  Sometimes you can compromise with writing shorter term goals that can be updated when they are reached.  For example, if a 17-year-old girl rates her depression at 8 on a 1-10 scale you might have a target of reducing to a 6 within 6 weeks, then a further reduction to a 5 within another 6 weeks if the initial target is reached.

The second part of the treatment plan, your interventions, comes from your case formulation of the reasons for the client’s presenting problems.  The case formulation is grounded in a theoretical orientation and provides an explanation for how and why the presenting problem developed and is held in place.  For example, you might develop a cognitive-behavioral formulation of your client’s depression with inferences about her automatic thoughts, leading to interventions targeting these thoughts.  You could also develop a family systems formulation with inferences about the client having an overly parentified position in the family, leading to interventions with the family system.  A psychodynamic formulation might view the client’s depression as a response to the anticipated loss of her needs for dependency as she and her parents plan for her to leave for college, leading to interventions interpreting her conflict about individuation.

Some clinicians believe that behavioral treatment goals require behavioral interventions, but this is not the case.  All approaches to psychotherapy exist for the purpose of facilitating change in the client including symptoms, emotions and behavior, and treatment goals can target any of these areas of change.  Your choice of interventions should be based on your preferred theoretical orientation and your client’s preferences and expectations, some of which are influenced by cultural identifications.  The choice of treatment modality, individual or family, is influenced by your theoretical orientation as well as the practices and policies of the setting in which you are working.

I hope you can use these tips for developing clear, effective treatment plans with your clients.  Please email me with comments, questions or suggestions for future blog topics.