"Smart" Treatment Plans

With the push to make mental healthcare more like medical healthcare, there is more pressure from payors and regulatory agencies to deliver measurable results using "evidence-based" treatments. Regardless of the many therapeutic processes and outcomes that defy measurement, we're expected to base our model of effectiveness on concrete, behavioral outcomes. Similarly, the Council on Social Work Education is requiring schools to evaluate students' performance using concrete, behavioral measures. I'm assuming there is a similar trend in other disciplines as well.

Setting aside whether this trend seems useful or appropriate, it does seem useful to know how to format documentation to fit what are these regulatory, accrediting, and/or funding agencies looking for - whether or not that actually carries over into how we work with clients (documentation certainly need not...interfere...with treatment!). Fortunately for us, there is a convenient acronym for how treatment goals should be worded: SMART.

S - Specific

Objectives should be specific. Instead of an overarching, general area of change (e.g., decrease depression), identify specifically what the client will do - what behavior s/he will exhibit (e.g., spontaneously smile in session). Remember that you're not trying to describe what treatment will involve, but rather how the person will behave differently if treatment is effective.

M - Measurable

There should also be some way to "objectively" measure whether the specified behavior is occurring (which is why they want us to focus on behavior rather than the harder-to-quantify outcomes and processes of therapy). Use of numbers is preferred, so think about something that can be counted (e.g., s/he will spontaneously smile in session 3 times), tested (e.g., s/he will score 10 points lower on the Beck Depression Inventory), or subjectively rated (his/her self-rating of mood will increase from 3 to 5 or more on a 1-10 scale).

A - Attainable

It's not very useful to set goals that can't be reached. They are discouraging, and also don't provide any information about whether expected changes are occurring. It also doesn't make sense to set goals that are too easily reached. They don't provide information about whether meaningful change is occurring. (They also make more work for us, since new objectives have to be created once the existing ones have been met). Instead, aim for the "sweet spot" in the middle - meaningful but achievable change.

R - Relevant

While some people use Realistic for the R, that overlaps quite a bit with Attainable. Instead, R generally stands for Relevant. In other words, the objectives should have something to do with the presenting problem, and/or something that the client identifies as personally important. To continue with the depression example, there are a wide range of behaviors that could be considered relevant, based on the diagnostic criteria: sleep, eating, social interactions, self-rated energy, motivation, or enjoyment, thoughts of death, etc, etc. However, if a client does not have a particular symptom (e.g., sleep disturbance), it would not be relevant to target that symptom in the objectives. It also would not be relevant to target unrelated behavior. And of course, it makes the most sense to start with what the client identifies as most important - whatever is motivating him/her to seek treatment in the first place.

T - Time-limited

Finally, there should be a specified time-frame in which the behavior change is expected and will be assessed. (Going back to attainability, the objective should be something that is reasonably reachable within the specified time-frame. Different settings and levels of care have different time-frame requirements - e.g., outpatient treatment goals are often reevaluated quarterly, while inpatient or partial hospital treatment goals are reevaluated weekly, or even more frequently. Going back to earlier examples, I might specify that the client will spontaneously smile in session 3 times by the end of the quarter, or that the client will rate mood at or above 6 on a 1 - 10 scale by the end of the week. (Note that not meeting the goal within the time-frame does not indicate failure; the time-frame is just an opportunity to reevaluate the goals, and whether they are attainable and relevant to current functioning and treatment).

Have you used this SMART model? What do you think about structuring treatment plans this way?

The Chicken and Egg of Comorbidity

Which came first, the chicken or the egg? This perennial, unanswerable question seems to have a parallel in therapy: what do you treat first? When a client comes in with multiple issues (as so many of them do), where do we start?

A professor in graduate school would quip: "Partialize and Prioritize." In other words, try to break problems down into manageable sections, and take them one at a time. But which one first? I've heard different schools of thought: either start with a relatively easy, achievable goal to increase self-efficacy and help people feel like therapy is helping (particularly if you don't yet have a rapport with them), or start with the most urgent concern. However, there are certainly other factors that influence this decision - for example, an insurance company that recently told my colleague they'd pay for a client to receive treatment for one problem, but not for another.

DBT actually offers a sequence of "primary behavioral targets," starting with risk issues (suicide, self-harm), then "therapy-interfering behaviors," then behaviors that interfere with quality of life (dysfunctional behaviors of all kinds, including substance abuse, impulsivity, and poor judgment), then increasing coping/life skills, then decreasing other symptoms.

I tend to agree that you have to start with imminent risk, and anything that is impeding or preventing treatment. I tend to include substance use in the latter category if people can't address emotional issues because they are under the influence and pretty much numb. However, with multiple problems, all of which are somewhat risky, I try to figure out whether one problems seems to be driving others, and start there.

However, like the metaphorical chicken and egg, it's rarely easy or clear to determine causality. Sometimes one problem emerged first (depression, and then an eating disorder, for example), but people often aren't aware of a sequence. Starting with whatever feels more important to the client is a good alternative (or even primary) strategy. Then, if another problem begins to prevent further progress on the top-priority issue, it becomes clear how they're related, and how to begin untangling them. For example, a client entering treatment for an eating disorder, who is totally unmotivated to change their behavior (and unresponsive to motivational interviewing) because depression has sapped all motivation about anything. Unless we treat the depression, we're unlikely to get far with anything else.

How do you "partialize and prioritize"? How do you make decisions about what to focus on when clients present with comorbid problems?