Treatment Planning

Treatment Planning

Core & Intermediate Beliefs and Treatment Planning & Treatment Goals A. Antonio Gonzlez-Prendes, Ph.D. School of Social Work SW8340 Core Beliefs F L E Un am he T rl o w ss i d

e f a OT /P HE EO R PL S E le b a St Helplessness Unlovability Worthlessness gu ou s Ge ner al

I am competent I am a fa ilu re co te Def u l init o s ive Ab Core Beliefs bi S re

Whe ey d o th m? o r f me al t en y th r wo t s u r t n u

m a re d a n le u p F Co Peo Pe op Ce ns le ntr ist are al en kin d t Th e world

THE is dan gerou s WORLD/ Life is fair LIFE Core belief (also referred to as schema) Core beliefs form a filter through which one looks at life and gives meaning to lifes events. Generally seen by the individual as absolute truths. Framed in the verb to be. Tint the meaning that we attach to life events; Confirmatory bias: selective processing of information or recall in a manner that conforms with or confirms the content of core beliefs. Influence our automatic thoughts and intermediate beliefs. Core beliefs are stable and consistent across situations (i.e., they are not situation-specific; they do not change from situation-to-situation). Core beliefs (cont.) How do core beliefs form? Begin to develop early in life (i.e. childhood). Out of the interactions of the child with significant objects, entities in his/her environment (e.g. parents, family, teachers, friends, society, etc...)

Out of such interactions the child begins to internalize definitions of self, people/others and the world/life. Ex: I am competent or I am a failure, etc. People are trustworthy or People are untrustworthy. The world/life is unfair or The world/life is fair Once such views are established the persons immediate interpretations of life may become biased as to fit and conform with the content of the core beliefs. Core beliefs (cont.) J. Beck (Ch. 16) identifies 3 categories of negative core beliefs: Helplessness (e.g. I am a loser, I am incompetent). Unlovability (e.g. I am unwanted, I am unlovable). Worthlessness (e.g. I am bad). Working with core beliefs. Longer timeline than when working with automatic thoughts. Identifying core beliefs (from automatic thoughts to core beliefs.) Downward arrow technique is used to identify core beliefs. Educate client about core beliefs How do they develop? Their function? Modifying Core Beliefs (cont.) Cognitive continuum (see J. Beck ch. 15 & 16; Greenberger & Padesky, ch. 9).

To counteract the dichotomous or polarized nature of core beliefs. Is the belief (or trait) 100% true or does it exist along a continuum (i.e. 0 to 100)? Elicit the trait upon which the belief is based (e.g. competency ). Seek evidence for or against the negative core belief. Ask synthesizing questions (e.g. On the one hand...on the other..., so what do you make of that?) Where does the trait (e.g. competency) fall now in the continuum from 0 to 100. Help client explore the validity of the belief across various spheres of his/her functioning (e.g. Social? Family? Work? As a parent/ spouse/partner? Among friends/relationships?) Generate a more realistic, balanced and rational belief. Assess how much strength the client places on the new core belief. p? o l e v e d ey Ou ght

to h t d l o u d o h w S H Ho M av ust et If. o.. . en. .. I should

Need to P e a e op ch le T ot sh he he o u r w ld Intermediate w or ith tre Beliefs ld f a at sh irn ou es s ng ld i th (G

y en n a e ra t lP a If l e i rs p fa wil I say e lh c ti to a te n o th ve le s) m e en t b ri hey

r te is t I If I tim ple e t ase he n t p eo p he l y w e all t ill lik he em e Intermediate Beliefs Intermediate Beliefs Beliefs in the form of assumptions or rules direct ones behavior as well as to gauge and judge the behavior of others.

Intermediate beliefs develop from of ones core beliefs. Ex. (CB) I am unlovable (IB) me. others get close to me. If I please others then they will love I should not let Everyone has rules! Rules help to guide and evaluate our behavior and the behavior of others. Problems arise when rules are dogmatic, rigid, and inflexible. Albert Ellis on rules (shoulds/musts) vs. preferences (wants/desires). Intermediate Beliefs (cont.) Strategies to work with intermediate beliefs (see J. Beck, ch. 15): Bring the intermediate belief to immediate awareness and explain the general function of rules and assumptions. Advantages/Disadvantages (pros/cons) of the rule/assumption. What are the good aspects of such rule? What are the not so good aspects of such rule? So on the one hand the rule helps you to and on the other hand it causes you What do you make of that? Is this something you would like to change? Behavioral experiments. Collaborate with the client to devise an experiment to test out the rule/belief.

The experiment should be commensurate with the clients skills level and have a high probability of success. Cognitive continuum. To address dichotomous thinking (i.e. beliefs that are either...or...) Helps to consider the belief along a continuum (0-100) rather than in the extremes. Compensatory (Behavioral/Coping) Strategies The behavioral manifestation of the conditional beliefs Coping strategies/behaviors influenced by ones intermediate beliefs (i.e., develop out of the rules and conditional assumptions). Purpose: To manage life and cope with challenges. Healthy vs. unhealthy compensatory strategies Unhealthy compensatory strategies aim to compensate for perceived deficiencies and prevent negative core beliefs from coming true: Example: Core beliefs: I am unlikeable Conditional belief/Rule: If I express disagreement with others then they will not like me, I should agree with others at all times. Compensatory strategy: Agreeing with and pleasing others at all times; goes along with what others wish even when it is problematic for him/her. Discussion: Bill tends to isolate and is encouraged to join a social group. As he thinks about it, he tells himself if I do not socialize with others

then I am less likely to be rejected; and does not join. Mary is thinking about applying to business school and as she sits to review the academic curriculum she thinks I am not smart with numbers, I better not apply. Ill look at other programs. Are these examples of: automatic thought, intermediate belief or core belief? Why? Provide the rationale for your opinion. What coping or compensatory strategy might you expect to see out of Bill relative to such belief? Transtheoretical Model: Stages of Change (Prochaska, DiClemente, & Norcross, 1992) (Cormier et al., Ch. 8, pp. 277-282). Assumption: Not everyone has the same level of desire, readiness or motivation to change. Therefore, not everyone changes the same manner. Change does not always happen in a smooth and linear fashion. The change process tends to go back & forth with setbacks & relapses. To help assess clients readiness or motivation to change. Provides alternatives to meet clients where they are (in the change process) and facilitate the process of change. The social worker should tailor his/her role and strategies to meet the client at his/her level of readiness & motivation to change.

Stages & Progression of Change Maintenance Action Preparation Contemplation Pre Contemplation Stage of Change: Precontemplation Contemplation Preparation Characteristic Doesnt acknowledge a problem or the need to change: denial. Minimization, rationalization, etc. Ambivalence.

Recognizes there is a problem, but not sure how change may be helpful/beneficial. Acknowledges problem and prepares to take action to change. Role of the Social Worker Strategies Nurturing parent Motivation enhancer Raise doubt. Empathy. Acknowledge and go with resistance. Ask permission & provide information. Use motivational strategies (MI) Socratic teacher Motivation Enhancer

Tip the balance. Elicit clients pros & cons of the problem. Education (with permission). Reinforce small steps taken towards change. Use MI. Guide, coach, consultant Develop a plan of action. Specificity is the key. Go public with your plan. Therapist Help implement and carry out the plan. Action therapy (CBT) Working on the plan Action Maintenance Maintain desired changes

Coach Relapse prevention. Community sources Discussion After much discussion with her family Mary agrees that her health condition is a problem in need of treatment. She has called her insurance company to get a referral to a medical doctor. In what stage of the transtheoretical model is Mary? What might be an appropriate strategy that you may use with Mary at this point. John was mandated to see you for alcohol abuse treatment after receiving a DUI. In the first meeting he expresses ambivalence as to whether he has a problem with alcohol. In what stage of the transtheoretical model is John? What might be an appropriate strategy that you may use with John at this point. Treatment planning: A dynamic and logical process Biopsychosocial Assessment Clients Goals Case

Conceptualization Treatment Plan Treatment planning: a collaborative approach Factors affecting treatment selection (Cormier et al., pp. 320-348): Client characteristics (e.g. demographics, level of impairment, coping style, social support, etc.). Helper characteristics (e.g. flexibility , clinical expertise, cultural competence). Practice & documentation guidelines (e.g. type of treatment, duration). Treatment plans should be: Client-centered: elicit clients active input to identify: The problem that the client wants to address in treatment. The goal(s) that she or he wants to get out of therapy. Framed in the clients own words. Behaviorally defined. Use evidence-based practice (EBP) Best available research.

Clinical expertise (re: clients characteristics, preferences, and culture). Strengths: Abilities & Resources Treatment plans should aim to build upon the clients strengths: Internal strengths (i.e. abilities) Intelligence, motivation, insight, education, resiliency, resourcefulness, spirituality, creativity, etc. External strengths (i.e. external resources) Family, friends, church, finances, employment, support groups, health insurance, access to needed resources (health care, transportation, etc.). Treatment Planning in a Nutshell: Definition of the Problem Identification of the Goal Formulation of Action Steps: (a)Cognitive Tasks/Objectives (b)Behavioral Tasks/Objectives

Intervention Strategies Monitoring & Evaluation Aftercare Strategies Treatment planning In the treatment planning process the social workers role: Facilitate definition of the problem and identification of goals. General Specific Vague Concrete Help frame goals and objectives in realistic, achievable and measurable terms. Suggestion: When helping clients identify possible treatment goals consider asking: Envision yourself .... months/weeks from now after you have successfully completed treatment, how would you like to be thinking, acting or feeling differently than now as a result of coming here? The Problem

Define the problem presented by the client in behavior-specific and measurable terms. Avoid general and vague descriptions Ex. I feel depressed, I drink too much, Our son acts out Probe for specificity What happens to you when you feel depressed? Want specifically do you do when? Ask for specific examples: Give an example when...happens Ex: The client complains of depression evident by loss of interest in social and recreational activities, decreased level of energy and physical activity, irregular sleep and appetite, feelings of worthlessness, and a pervasive sad mood on most days. Goals & Objectives Developed in full collaboration and agreement with the client. Goal: a more general statement of the anticipated results of treatment. The statement should reflect the increase of a healthy behavior rather than the decrease of an unhealthy one. Objective: a more specific & detailed description of the steps to achieve such goal (i.e. action steps, behavioral steps).

Characteristics of objectives: Behavior-specific. Positive terms (i.e. steps towards the attainment of the goal). Time-limited. Action-oriented (use action verbs to describe what the client will do). Client-initiated (the client will... ) Characteristics of well-constructed goals (Cormier et al., p. 272, Box 8.1) Salutary not remedial Increase something positive rather than decrease something negative. New and different A new behavior or new way of thinking. Process oriented (not static) (1) Endure beyond therapy; (2) Manage (not eliminate) challenges. Realistic & achievable Client-centered & within the clients control and abilities/skills.

Specific & comprehensible Specifically & clearly defined. Compelling & useful to the client Will the client buy into it? Is it emotionally compelling & useful? Interpersonally related Is it visible to others? How might it positively impact others? Involve hard work Change is not easy. Goal Statement A broad & general statement of outcomes: Examples: 1. The client (Mr. Brown) will report improved mood with healthy outlook of self and future (depression). 2. The client (Ms. Perez) will report total abstinence from drugs and alcohol for at least 3 consecutive months (substance abuse).

3. The child (Billy) will demonstrate increased participation in classroom activities (lack of academic involvement). For each goal also indicate the expected date of attainment. Statements of Objectives #1: Example: Depressed Client The client will eat at least 2 meals every day for 3 consecutive months. The client will sleep 6-8 hours per night without interruption for 4 months. The client will exercise 3 days per week for 30 minutes each time. The client will identify at least 5 strengths of his character and discuss in tx the adaptive capabilities of each. The client will engage at least once per tx. session in identifying, evaluating and reframing dysfunctional thinking so as to engender a healthier and more balanced mood. For each objective include the expected date of attainment. Statements of Objectives #2: Example: Substance abuse The client will attend at least 2 AA meetings each week and discuss in weekly therapy at least one benefits derived from participation.

The client will identify 5 triggers of his alcohol use. The client will implement at least one healthy alternative for each trigger. The client will identify and discuss 10 benefits of sobriety. The client will develop 10 self-statements to help dampen thoughts of using alcohol. Statement of objectives #3: Example: Lack of Academic Involvement The child will actively participate in classroom group activities at least once per week for 6 consecutive weeks. The child will volunteer at least once per class to answer questions posed by the teacher. The child will read class material in front of the class at least once per week. The child will ask for permission before getting out of his chair (every time? 50% of the time? At least 4 of 5 times?) Monitoring & evaluating progress Evaluate both: outcome and process. When & how do you measure progress> Weekly? Monthly? Quarterly? By self-report? SUDs? Observations? Standardized instruments?

Use the treatment plan as the blueprint: Refer to the treatment plan regularly to ascertain progress or lack of it. If the client is not progressing accordingly, reassess the treatment plan and explore: Have the problems/goals/objectives been clearly defined? Does the client express ownership for the goals of treatment? Does the client have the necessary information/skills to react to the intervention and meet the goals and objectives? Is the intervention appropriate to the clients level of cognitive development, motivation, and desire to change?

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