Treatment planning for any mental disorder or psychological issue or problem is an extremely important component to the healing process. In my own experience, this is perhaps the one professional skill or practice that separates the beginners from the novices and the novices from the experts. Having a well-thought-out plan is an invaluable tool. This is perhaps even more important when dealing with the all too typical complexity and chaos of PTSD.
Before we get into some of the specific treatment planning issues for PTSD, let's take a quick look at treatment planning from a more general perspective.
Before treatment begins and a clinician begins to penetrate the trauma membrane, he or she should consider in detail the current life circumstances and supports in which a potential patient or client finds
Professional Alert him- or herself. At the most basic of levels, con sider where you are in a physical sense. Can This material is intended prima- PTSD treatment be undertaken where you and rily for" students and lay people, the client find yourselves? For instance, if your but a little brush up never hurt job is to provide short-term-coping-based stabi-anyone' lization treatment to jail inmates, can you really engage in the complexity of PTSD treatment in that setting? Is there enough time? Is there enough outside or third-party support available? I am not suggesting that if the answer to these questions is no that you do not address PTSD at all, but, rather, that the answers to these questions be important factors in considering what to treat, how to treat, when to treat, and whether to treat at all.
Also consider whether the person coming to you wants treatment for PTSD or trauma. This may sound like a strange point, but if someone comes to you for test-taking anxiety and you start digging into their past for trauma and how it is currently affecting them, you may be guilty of psychological voyeurism. What are the patient's expectations? Does he or she expect you to heal or cure him or her? Are you simply going to ameliorate the patient's symptoms? Addressing these issues from the very beginning will facilitate communication and empathy and serve as a good foundation to work from when the inevitable ruptures in the working alliance between patient and clinician develop. Be cautious of going where you are not invited. Also, a patient's personality, current level of functioning, and both internal and external supports and coping resources should be important features of your treatment plan. Is the prospective patient motivated to enter into treatment, to face their trauma, or to make the necessary alterations in his or her life that might be required? Practical issues, such as language compatibility; communication barriers, such as hearing impairment or blindness; and, certainly, cognitive and intellectual deficits should be considered. Remember that issues such as the length of treatment; termination issues, including follow up if necessary; frequency of contacts; general format; patient and clinician's responsibilities; and, of course, cost should be discussed. Finally, it is always helpful to talk about the potential risks of going into treatment, such as discomfort, rage, and disruptions in relationships. Ultimately, the things I am mentioning are part of the informed consent process that empowers the patient to enter treatment with knowledge and willful participation.
In any type of treatment or treatment setting, the most pressing issues should always be addressed first, with life-threatening issues being at the top of the list, such as suicidal or homicidal threat or grave disability. Restoration of basic functioning must begin before more complex treatment can proceed.
The initial contact with a patient should address such issues as the patient's expectations of treatment. Does he or she believe you are going to remove his or her problems, for instance? It is always helpful to explain what treatment is about and what it involves. Some helpful points to discuss with patients are as follows:
1. Treatment involves focusing on mental processes in which he or she will engage in discussions about thoughts, feelings or emotions, relationships, and behaviors.
2. Self-disclosure and openness are required and expected, albeit at his or her pace.
If nobody in school has told you that you do not have to treat everyone that comes to you, then you can hear it from me first—you don't!
3. Emotional expression and release are often involved.
4. Oftentimes (but not always) there is an exploration of one's childhood.
5. Insight is encouraged.
6. Interpretation of current problems in light of past issues and development may occur.
7. A working relationship with the clinician or therapist is expected to form.
8. There are boundaries that exist within and define the limits to this working relationship. It is a professional relationship.
9. A range of treatment options are available and may be utilized, and he or she might be expected to take medication as a necessary component of treatment and be willing to take difficult steps during a crisis, such as being admitted to a hospital in the instances of suicidal ideation, homicidal ideation, or grave disability.
10. The patient has the right to terminate therapy at any time, except in circumstances of court-ordered treatment or within other legal constraints.
Now let's turn to some PTSD-specific treatment planning issues. As a clinician or a treatment team is formulating a treatment plan, they should consider the following issues: duration and repetition of the particular trauma, type of pathology, chronicity, concomitant diagnoses and comorbid conditions, and attempt to match the treatment approach with the PTSD core phenomenology (Wilson et al. 2001).
Wilson et al. (2001) suggest that a patient's treatment be approached through one of the core symptom cluster or clusters that presents as primary and most pressing. If a patient is most concerned with and is having significant relationship issues, then this might be the initial focus. If a patient presents with hyper-arousal and physiological reactivity, psychopharmacological intervention may be the initial inroad. These authors also suggest that the source of referral is a critical issue in treatment planning, citing that referrals by family members may point toward the necessity to involve the family in treatment at a very central level, for example.
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