Treatment Planning

Abigail T. Fausto
 Treatment Planning

• integral part of the psychiatric interview

and should be explicitly discussed with the
patient in detail
• first part: determine whether a treatment
relationship is to be established
• may not be voluntary
• there should be a discussion of the options
available
 Treatment Planning

• The structure of that treatment should be

discussed.
– Will the main focus be on medication
management, psychotherapy, or both?
– What will the frequency of visits be?
– How will the clinician be paid for service
– what are the expectations for the patient to be
considered engaged in treatment?
 Treatment Planning

• Medication recommendations
• The prescriber must obtain informed
consent from the patient for any
medications (or other treatments) initiated.
 Treatment Planning

• Other clinical treatment recommendations:

– referral for psychotherapy, group therapy,
chemical dependency evaluation or treatment,
or medical assessment.
– psychosocial interventions: case
management, group home or assisted living,
social clubs, support groups
 Treatment Planning

• Collaboration with primary care doctors,

specialists, or other clinicians should
always be a goal
• family involvement in a patient's care can
often be a useful and integral part of
treatment
• A thorough discussion of safety planning
and contact information should occur
during the psychiatric interview
 Techniques

1. Facilitating Intervention
2. Expanding Intervention
3. Obstructive Intervention
 Facilitating Interventon

a) Reinforcement
b) Reflection
c) Summarizing
d) Education
e) Reassurance
f) Encouragement
g) Acknowledgement of Emotion
h) Humor
i) Silence
j) Nonverbal Communication
 Reinforcement

• simple but very important in the patient

sharing material about himself or herself
and other important individuals and events
in the patient's life.
• "I see," "Go on," "Yes,“ "Tell me more'"
"Hmm" or "Uh-huh" all convey the
interviewer's interest in the patient
continuing.
 Reflection

• using the patient's words to indicate that

you have heard what the patient is saying
and conveys an interest in hearing more.
• This response is not a question.
• It should be said as a statement of fact.
• Sometimes it is helpful to paraphrase the
patient's statement so it doesn't sound like
it is coming from an automaton.
 Summarizing

• This provides the opportunity for the

patient to clarify or modify the
psychiatrist’s understanding and possibly
add new material.
 Education

• Educate the patient about the interview

process
 Reassurance

• It is often appropriate and helpful to

provide reassurance to the patient.
• It is generally inappropriate for
psychiatrists to reassure patients when the
psychiatrist does not know what the
outcome will be.
 Encouragement

• It is difficult for many patients to come for

a psychiatric evaluation. Often they are
uncertain as to what will happen, and
receiving encouragement can facilitate
their engagement.
 Acknowledgement of Emotion

• This frequently leads to the patient sharing

more feelings and being relieved that he or
she can do so.
• If the display of the emotion is clear (e.g.,
patient openly crying), then it is not helpful
to comment directly on the expression of
the emotion. It is better to comment on the
associated feelings.
 Humor

• At times the patient may make a

humorous comment or tell a brief joke. It
can be very helpful if the psychiatrist
smiles, laughs, or even, when appropriate,
add another punch line.
• This sharing of humor can decrease
tension and anxiety and reinforce the
interviewer's genuineness.
 Silence

• Careful use of silence can facilitate the

progression of the interview. The patient
may need time to think about what has
been said or to experience a feeling that
has arisen in the interview. The
psychiatrist whose own anxiety results in
any silence quickly being terminated can
retard the development of insight or the
expression of feeling by the patient.
 Nonverbal Communication

• the most common facilitating interventions

are nonverbal
 Expanding Communications

a) Clarifying
b) Association
c) Leading
d) Probing
e) Transitions
f) Redirecting
 Clarifying

• At times carefully clarifying what the

patient has said can lead to unrecognized
issues or psychopathology.
 Associations

• As the patient describes his or her

symptoms, there are other areas that are
related to a symptom that should be
explored.
• For example, the symptom of nausea
leads to questions about appetite, bowel
habits, weight loss, and eating habits.
 Leading

• Often, continuing the story can be

facilitated by asking a "what," "when,"
"where," or "who" question. Sometimes
the psychiatrist may suggest or ask about
something that has not been introduced by
the patient but that the psychiatrist
surmises may be relevant.
 Probing

• The interview may point toward an area of

conflict, but the patient may minimize or
deny any difficulties. Gently encouraging
the patient to talk more about this issue
may be quite productive.
 Transitions

• Sometimes transitions occur very

smoothly. The patient is talking about her
primary education major in college and the
psychiatrist asks, "Did that lead to your
work after college?" On other occasions,
the transition means moving to a different
area of the interview and a bridge
statement is useful.
 Redirecting

• difficult technique for unseasoned

interviewers is redirecting the focus of the
patient. If the interviewer is concentrating
on reinforcing the patient's telling of his or
her story, it can be especially difficult to
move the interview in a different direction.
However, this is often crucial to a
successful interview because of the time
constraints and the necessity to obtain a
broad overview of the patient's life as well
 Obstructive Interventions

1. Close – Ended Questions

2. Compound Questions
3. Why Questions
4. Judgmental Questions or Statements
5. Minimizing Patient’s Concerns
6. Premature Advice
7. Premature Interpretation
8. Transitions
9. Nonverbal Communications
 Closed – Ended Questions
• A series of closed-ended questions early
in the interview can retard the natural flow
of the patient's story and reinforces the
patient giving one word or brief answers
with little or no elaboration
 Compound Questions
• Some questions are difficult for patients to
respond to because more than one
answer is being sought.
 Why Questions
• Especially early in the psychiatric
interview, "why" questions are often
nonproductive. Very often the answer to
that question is one of the reasons that the
patient has sought help.
 Judgmental Questions or Statements

• Judgmental interventions are generally

nonproductive for the issue at hand and
also inhibit the patient from sharing even
more private or sensitive material.
 Minimizing Patient’s Concerns
• In an attempt to reassure patients,
psychiatrists sometimes make the error of
minimizing a concern. This can be
counterproductive in that rather than being
reassured, the patient may feel that the
psychiatrist does not understand what he
or she is trying to express
 Premature Advice
• Advice given too early is often bad advice
because the interviewer does not yet know
all of the variables. Also it can preempt the
patient from arriving at a plan for himself
or herself.
 Premature Interpretation
• Even if it is accurate, a premature
interpretation can be counterproductive as
the patient may respond defensively and
feel misunderstood.
 Transitions
• Some transitions are too abrupt and may
interrupt important issues that the patient
is discussing.
 Nonverbal Communication
• Just as reinforcing nonverbal
communications can be powerful
facilitators of a good interview, these
obstructive actions can quickly shatter an
interview and undermine the patient-doctor
relationship.
 Closing of Interview
• The last 5 to 1 0 minutes of the interview
are very important and are often not given
sufficient attention by inexperienced
interviewers. It is important to alert the
patient to the remaining time : " We have
to stop in about 1 0 minutes. " Not
infrequently, a patient will have kept an
important issue or question until the end of
the interview and having at least a brief
time to identify the issue is helpful. If there
 Motivational Interviewing
• Motivational interviewing is a technique
used to motivate the patient to change his
or her maladaptive behavior. The therapist
relies on empathy to convey
understanding, provides support by noting
the patient's strengths, and explores the
ambivalence and conflicting thoughts or
feelings the patient may have about
change. Guidance is provided in the
interview by imparting information about