Tuesday, July 12, 2011

Solution-Focused Treatment Planning

Guest post on Doing What Works by DAVID JOHNS, LMHC

Treatment Planning in agencies and private practice has often been described to me as a dreaded activity that has no immediate or long term relevance to client outcome. It is seen as a waste of time and as a document required only by funding sources who are looking for accountability. Client benefit is not acknowledged nor is obvious to the clinician. I can appreciate that point of view, having been one of many therapists who have been trained to evaluate and treat emotional and psychological problems. Spending half of my career working in agencies, I can relate to having this requirement explained to me as "a necessary evil". Those are exact words that I have heard frequently to refer to this phase of treatment.

It wasn't until I had already been trained in Solution Focused Therapy, having had some solid experience and success with this approach, that the light went off. I realized that this approach, by virtue of the entire focus, IS "treatment planning". It is structurally the same, in that there are "problem statements", "goal statements", "objectives" and "interventions" inherent in all solution focused interactions and collaborations with clients. A treatment plan as well as specific discharge criteria are naturally brought to light to both client and therapist but are not recognized as a formal treatment plan.

I have managed many therapists in agencies who I have observed stressing, agonizing, getting frustrated and trying so hard to write a treatment plan that is "compliant". Many have bought expensive books that purport to make it easier for clinicians to word treatment plans correctly, and to end up with plans that would please me, their supervisor, as well as, and more importantly the funding source. I cannot begin to explain to you the magnitude of the anxiety, effects of lost sleep, long hours spent by therapists attempting to create this document, which is replete with clinical jargon, labels, diagnostic criteria and "canned" statements taken from books and other treatment plans.

Finally, after being tortured again and again by therapist complaints I decided to turn the light on as it had been turned on in me. I put together a training called solution focused treatment planning. The most important observation I made was that something very important was missing. There was no evidence of client participation or guidance in the plans I have. It was evident that the plans I have reviewed were "cookie cutter" statements cut and pasted from books and other plans. To me, that made the whole treatment plan invalid. I realized the training had to be a complete reframe.

Therapists needed to know:
  1. Treatment Planning is the most crucial determinant of a positive outcome.. Positive outcomes are nearly impossible to achieve with a heavy focus on being broken. Therapists must assist clients to formulate outcome images in their minds which come from awareness of past successes, strengths, coping skills already being utilized and diverting clients' attention to possibilities instead of disabilities.
  2. Creating a treatment plan is easy - if the therapist asks the right questions and lets the client lead. The Miracle Question is key in formulating goal and objective statements that can be written on a treatment plan document. Intervention statements are a natural and logical set of things the client can do to achieve objectives.
  3. Success does not depend upon a thorough clinical understanding of the problem. It depends on a client realizing he/she has entered a world of possibilities in which he/she is fully equipped with successes, coping skills, support, & strengths. The energy springs forth with impressive force when the client realizes his/her own empowerment at a time when they previously felt disempowered. The SFT therapist's skillful direction away from problem questioning and toward solution building is like initially pushing a boulder up a hill then at the top, letting it go. Clients no longer see themselves as hopeless as the light is turned on. Distortion, depression, anxiety, confusion cannot exist in the light. Being stuck in problems is a matter of focus. The more one focuses on problems the darker things get. The darker things get the more immobilized one becomes. So turn the light on. Redirect, redirect, redirect until the client's light turns on. You will literally see a shift that is taken over by the client. Solution thinking = more light, more energy.
  4. It is okay to use the Scaling technique to describe discharge criteria. To simply say "when the client is no longer depressed" is inadequate and cannot be observed. Whose criteria are you going to use? Scaling makes sense here because the discussion stems from the client telling the therapist WHAT will have to happen when he/she moves to "a 5, 6, or 7". The number represents concrete, specific behaviors that the CLIENT will notice are happening/doing, not what the clinician observes. The client is the expert and knows when therapy is no longer needed. If the client says he/she is a 9, believe them and find out what they did and how they did it - amplify the progress and ask the client how they plan to keep it going. Congratulate them. Then say goodbye.
Treatment Planning is the most necessary component of Solution Focused Therapy but only when you take it out of the frustrating frame we have traditionally experienced. It takes the client's experience from impossible to possible in a very short time and infuses the client with impressive momentum. Writing the treatment plan is easy - because you are using the client's words, and respecting their subjective views of success. Encouraging clients to do more of what worked in the past or present, or tempting them to do something different will met with little or no resistance. Follow them, celebrate with them, nudge them a little further, scale the progress until the client agrees the discharge criteria has been met.
  • Treatment plans are not permanent documents! They are living documents, which can be changed at any time.
  • Do not make them complicated. One or two solutions at a time will suffice.
  • Avoid jargon except for that little DSM-IV number that is often required. Write the rest as a collaborative solution-building document.
  • Funding sources are often impressed with the brevity and concreteness.

Friday, July 1, 2011

From the Flagler Live

Prescription Pill-Popping By Far a Leading Killer as Florida’s Drug Deaths Spike 20%

Jul 1st, 2010 | By admin | Category: Drugging


Oxycodone, the addictive prescription pain-killer also known by its Purdue Pharma brand name OxyContin, directly caused more deaths in Florida in 2009 than cocaine, heroin and morphine combined. Prescription drugs as a whole are killing far more Floridians than illegal drugs, with some 8,600 deaths last year involving at least one prescription drug, according to an annual report released today by the Florida Medical Examiners Commission.

That’s 5 percent of all deaths in Florida in 2009, when 171,300 people died in the state.

The number of people killed by prescription drugs is a significant 20 percent increase over last year’s 6,200 deaths attributed to overdoses. Much of the increase is due to a spike in oxycodone addiction. The increase in prescription-drug addiction continues a trend that began in Florida 10 years ago, when prescription drugs overtook illegal drugs as leading causes of drug-related deaths.

Alcohol is also included in the examiners’ analysis, and it leads the way of all drug-related deaths, with 4,046.

The annual report is a stark look at the effects of legalized drug addiction and over-prescription of drugs, both of which affect a far larger segment of the population than recreational or illegal narcotics.

For the first time in 2009, the commission tracked deaths by region. In Flagler County’s district, which includes St. Johns and Putnam counties, 22 deaths were attributed to oxycodone (the fourth lowest number in the state’s 23 districts), with 13 of those deaths directly attributed to the drug, and nine cited as being present among other drugs that contributed to death.

Hydrocodone claimed 16 lives in the district. Cocaine contributed to 19 deaths in the Flagler district, though only four cases were directly attributed to the drug. In 15 cases, cocaine was present in the body in conjunction with other drugs that proved lethal. Overall in Florida, cocaine-related deaths (including the majority of cases where cocaine wasn’t directly the factor but was present in the body at the time of death), have fallen from a peak of 2,179 in 2007 to 1,462 in 2009. (Again, cocaine was the direct result of death in 529 cases out of those).

Ken Kramer, a researcher with the Citizens Commission on Human Rights of Florida, says the numbers underestimate the extent of the problem, because medical examiners do not track deaths attributed to antipsychotic drugs or to antidepressants, both of which carry black-box or black-label warnings. The warnings on antidepressants, required by the Food and Drug Administration, state that the drugs increase the risk of suicidal thinking and behavior in children, adolescents and young adults up to age 24. (Antidepressants include Paxil, Prozac, Zoloft, Effexor, Lexapro and Celexa.)

Anti-psychotic drugs carry a variety of black label warnings of increased mortality in elderly patients (including a death rate almost twice as high for people taking Risperdal, for example). Those drugs, prescribed and often overprescribed in nursing homes and assisted living facilities, include Abilify, Clozaril, Geodon, Risperdal, Seroquel and Zyprexa.

“Certainly, the actual number of prescription drug deaths is higher than the annual report states,” Kramer said. “It is unknown just how much higher because the Medical Examiners Commission does not track these classes of drugs.”

Two years ago Kramer got his concern heard by the commission following an email exchange with a commissioner in which he argued that antidepressants and anti-psychotic drugs’ contributions to mortality should be part of the annual report. He was rebuffed. One examiner vsaid he had not seen “more than the occasional death caused by these types of drugs,” according to the minutes of the Aug. 13, 2008 meeting of the commission.

Other findings in the 2009 report, which can be read in its entirety here:

  • Prescription drugs tracked in the report account for 79 percent of all drug occurrences in deaths when alcohol is excluded.
  • Deaths directly attributed to Oxycodone increased by 25.9 percent over 2008.
  • Cocaine occurrences decreased by 18.4 percent over 2004.
  • 5,275 individuals, or 7.1 percent more than in 2008, died with one or more prescription drugs in their system. The drugs in those cases were identified as both the cause of death and present in the deceased person.
  • Overall, 171,300 deaths occurred in Florida in 2009.

The report specifies that the “state’s medical examiners were asked to distinguish between the drugs being the ’cause’ of death or merely ‘present’ in the body at the time of death. A drug is only indicated as the cause of death when, after examining all evidence and the autopsy and toxicology results, the medical examiner determines the drug played a causal role in the death.”