Let’s start with the wrong way. The following is an efficient way of making your treatment plan weak, generic, and not optimized to help the patient. Drum roll, please ….
The wrong way is to start with the solution and then attach the problems that that solution can help with. The right way is the opposite, to start with a specific problem and find the interventions to resolve that problem (and I’ll talk about that next.) Here, first, is an example of the wrong way and the reasons it doesn’t work well.
At last week’s, Beat The Boards! Psychiatry Oral Board Prep course, one candidate interviewed a 58 year old male-to-female transgender individual who was in treatment for Bipolar Disorder. During the interview the doctor asked the patient about being transgender. The patient said that she was relieved that after so many years she finally made the gender switch, that she had come out to friends, and that in general, that part of her life “was going well.”
During the treatment plan the doctor stated that she (the psychiatrist) believed the patient would benefit from “supportive therapy.” My immediate question was, “What for? What will be your focus of treatment?” The candidate looked taken-aback, as if I asked an unexpected question. She paused and said that the focus will be on the patient’s “gender issues.” I said, “OK, what in particular will you be helping the patient with regarding her gender issues?” The candidate said, “To support her, to give her some therapist validation.”
OK, so now I ask you, do you think that was that a good or a bad response? Would the patient benefit from “some therapist validation?”
My answer is “That depends, but I doubt it. ” Remember that this patient seemed to be quite accepting of her female gender, thought her gender switch was long overdue, and in general thought that that part of her life was “going well.”
Now, for another transgender individual, therapist validation may indeed be crucially needed. I can imagine a person in the throes of gender confusion, someone still closeted and ashamed, and someone unsure of what to do next. That person may indeed need to ventilate, to receive validation, to be given opportunity to abreact and come to terms, and to be guided in setting goals and planning for the future.
But that would have been a different patient. So the two lessons here are.
One: An intervention is not in itself good or bad. It is whether and to what the degree it is helpful to the individual sitting in front of you.
And two: You are likely to run into problems when you start with the solution, that is, the treatment intervention, and only then try finding reasons to justify it.
What’s the more effective approach to designing a treatment plan? One that is, by the way, easier to figure out? It is, of course, to start with the problem, and then find the solutions that will resolve that problem.
To make this approach work really well requires two simple steps. First, define your problem specifically. Here’s an example. Rather than including on your problem list “Borderline Personality Disorder” include something more specific, such as “Frequent parasuicidal behaviors” or “Poor communication and negotiation skills” or “Impaired emotional regulation and self-soothing skills.” Notice the fact that when you define your problem as specifically as you can, the solutions present themselves to you without much mental effort. Which brings me to the next point.
And second, present laser-focused solutions to your specifically defined problem. Then just work down your list of problems. For example, the patient with frequent parasuicidal behaviors might benefit from CBT inteventions focused on correcting the cognitive distortions related to the feelings of overwhelm, helplessness, and hopelessness that then trigger parasuicidal behaviors. This problem of parasuicidal behaviors may also benefit from a “chain analysis” of the parasuicidal behaviors, to identify the antecedents and consequences that make those behaviors likely. (These are super useful concepts from learning theory and techniques of CBT that I can expound upon in a later post.) And, lastly, this problem of parasuicidal behaviors may benefit from communication and negotation skill training.
OK? Bottom Line: Start with Specifically Defined Problems and offer Laser-Focused Solutions (i.e., Treatment Interventions). Great. Let me know your thoughts, examples from your own practice, etc. Would love to hear from you.
Today’s Quote
“The first thing to do about an obstacle is simply to stand up to it and not complain about it or whine under it but forthrightly attack it. Stand up to your obstacles and do something about them. You will find that they haven’t half the strength you think they have. Just stand up to it, that’s all, and don’t give way under it, and it will finally break. You will break it. Something has to break and it won’t be you, it will be the obstacle.” – Andrew Carnegie
Thanks and take care.
Jack Krasuski, MD
877-225-8384
