Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists, interested bystanders are also welcome. A place to talk; no one has to listen.
Sunday, December 01, 2013
A local hospital was recently reviewed by one of those hospital accreditation agencies. It did well-- passed with bells and whistles -- but for a few citations for psychiatry.
Individual Treatment Plans (ITP)s:
"Surveyors cited us for not having measurable goals in the ITPs. So, changes were made to [the electronic records system] to clarify the requirement for objective and measurable patient goals as well as the patient’s progress toward those goals."
Okay, so help me with this. Two decades of trying to come up with acceptable, measurable goals and I'm left with the idea that therapy has a limited number of goals and they aren't that measurable:
~Patient wants to feel better / Less psychic pain.
~To work and to love.
~No psychosis (and we measure that how?)
~To remain out of the hospital. (While measurable, I'm not sure that is acceptable to the bean counters).
~To remain out of jail/prison.
~Patient will resist urges to drink alcohol/shoot heroin/snort cocaine.
~Fewer self-injurious behaviors.
~Living up to potential.
~Acceptance of self as is, including the reality that patient may never be as beautiful/rich/smart or accomplished as he once believed he should be.
Patient will have a Beck Depression Inventory score of less than 10 at every visit?
Patient will report spending less than 1 hour a day on compulsive checking?
Patient will lacerate himself fewer than 4 times per week and all lacerations will be less than 2 cm long and none will penetrate arteries?
Patient will report having suicidal thoughts less than 23% of waking hours?
I remain clueless. And of course, the treatment plan is about naming the goals, there are no citations for achieving them or not, or even for having them make sense in the context of the patient's life.
Paperwork chaos is not new. I remember being an intern and being paged in the middle of the night to put a cause of death on a death certificate. It was 3AM and I wrote down "pneumonia," because the patient had died of pneumonia. I was paged again soon after. "Pneumonia" is not an acceptable cause of death. But that was what the patient died from. I needed to know what organism caused the pneumonia, and that could only be known if a culture was done and that would take days to know. The requirements said that a cause of death needed to be given now. "Sepsis," I said (overwhelming infection). Nope, I would still need to know the infectious agent, something I still didn't have access to at 3AM with a newly admitted patient. I tried again: cardiopulmonary arrest. That worked, sort of. What was the cardiopulmonary arrest due to, I was asked? Pneumonia, I said. That's still not acceptable, unless I knew the organism. I finally asked what is an acceptable cause of death. I was given a few options, none of which pertained to the patient, but I picked one because there was nothing else to do.
Okay, so what are acceptable, measurable goals in psychiatry? And does measuring something make it more meaningful?
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The lack of measurable goals is perhaps an unintentional argument against forced treatment. If there are no measurable goals, then how is a patient supposed to meet some goal that no one can measure, in order to be released? She "seems" better, she "seems" calmer, she painted a picture during recreational therapy, etc. Yikes. Where's the patients' protection in that scenario?
P-K: The area cited was the outpatient clinic of the hospital, and in Maryland there is no forced outpatient treatment: all of these patients are voluntary and they can refuse to come at any time.
In this case, it's about having some standards of care to be attained (relevant or not to patient treatment; much of it is about cutting and pasting pre-formed statements into the an electronic record). I believe it started with insurance/managed care companies who may have used 'unacceptable' goals as a reason to deny payment.
This seems to be an issue across the board in medicine. My insurance once pulled my physical therapy approval because they believed my goal to be un-measurable.
It seems that setting goals, (i.e., the example of cutting < 4 times per week at < 2cm), can sometimes backfire. Maybe the person is adhering to that goal, yet developing another self-destructive behavior to compensate. As important as it is to have goals in therapy to make meaningful progress, attempting to set a strictly measurable goal can be akin to putting a square peg in a round hole. If the goal is to control anxiety, it clearly does not happen overnight. Breaking it up into smaller goals, like utilizing relaxation techniques, can be helpful. However, for patients who on medication, attempting to optimize the dose is a big part of the puzzle. The goal for optimization of medication is...to reduce symptoms of anxiety. It seems that is not truly a measurable goal either, without utilizing a test/inventory to document such symptoms.
Love the 23%. Made me laugh out loud.
The real question for me is, "How do I stop people who have no clue about my profession from running my profession?"
Perhaps a more attainable goal is, "How do I make people who have no clue about my profession realize they have no clue about my profession."
Gee, and you wonder why a sizeable population of physicians are not going to participate in Obamacare.
Bureaucracy, what a concept. Just remember, I have been warning for the last 2 plus years now, any interested to consider my unpleasant prediction, psychiatry will be made irrelevant by 2016. At least those who tried to work in the Obamacare system.
Just think how all those patients will be treated with the experts of mental health relegated to basically non clinical care roles.
Yes, those who care and are concerned, you can shudder.
the SMART framework isn't my favorite way of conceptualizing goals, but it is some semantics. I like that you may be implying SMMART goals, being measurable and meaningful.
I like to separate indicators from outcomes. Indicators are things that are measurable that taken together can be used to reasonably, meaningfully, and with nuance assess to what extent an outcome (the benefit of treatment) is occurring.
Measuring doesn't just mean
You mock, and I get it, because as a special educator for the severely disabled I am also required to use SMART goals where they don't always fit, but....patients would also like quantifiable goals. It's too bad no one's found a way to write any yet, but I too would like a quantifiable measure of progress and progression, not just unending therapy and medication at the therapist's discretion.
I think Cassandra and L both make good arguments. I can see both perspectives. I tend to think like L in that I want a quantifiable goal, but I can also see the point that issues take time and what if the patient's situation doesn't fit neatly?
But, I do want quantifiable goals, because if they're not set how do we know when we're there? I like the idea of a plan with an endpoint.
Hopefully, the agenda (goals and all), belong to the patient:
I don't think this is something the therapist can set.
As a patient, I would want some goals set. I would want to hear that the therapist has a plan. I know some people meander through therapy, but those therapists tend to turn me off. I had one therapist, somehow, end up talking about his favorite author for most of our session...? I still have no clue how that happened, and I never went back to see him after that. I tend to like a goal oriented therapist. The ones who don't have any kind of goal or plan to help me have tended to randomly turn the focus of the sessions onto themselves. Either they talk way too much about how they feel about me, without any kind of plan of action spurring from that, or they will start making small talk and make that the basis of the session. I have actually learned, with some therapists, I need to make sure they are not getting sidetracked and diverging onto chitchat topics (like their fav author). Again, those tend to be the ones I do not care to see again.
As a patient I don't think I've ever explicitly had quantifiable long-term goals. My long term objectives were always along the lines of "feel better, be less anxious, have fewer suicidal thoughts, be successful at school/work, have more meaningful relationships, etc." I have however had short term goals that are meant to address some aspect of these. Sometimes, these probably could be strung together into some form of - not really long term, but maybe middle term? - goals, but a lot of times they were things that came up on a week-to-week schedule and were phrased as such, "over the next week, why don't you try to..." Oftentimes, they were something that my therapist at least seemed to hit upon on the fly or at most develop over 2-3 weeks. Over time, I could subjectively say whether or not I was meeting long term goals, but could you develop a treatment plan or whatever based on it - I doubt it. Although I did have one therapist who had to create these sorts of long term goals (she worked at a community clinic that offered reduced priced services, and recognized that this was something she had to do for funding and such). At one point my stated "long term goal" was to something on the order of "work towards identifying, articulating, and following through on short term objectives" or some such nonsense, and whoever needed the goals must have bought it, because I never heard anything more about it.
r: exactly, it's a community mental health center/ institution thing. They only pull a few charts for audits, they don't go over every one with a fine tooth comb. Private insurance companies no longer ask for treatment plan goals, very few ask for treatment plans at all.
Others: I have the sense that people here think the therapist should set the patient's goals. The patient comes to treatment: shouldn't they define what they want to get out of it? Perhaps I misunderstood?
I think one of the things I like about that particular therapist was she was good at explaining to me that "hey, this is something I need to do for other reasons/other people. Can we come up with something to put that will make them happy. We'll keep working on what you want to work on, but we may have to divert 5 minutes ever few weeks to some stupid exercise in order to make that work"
What I meant was that I have certain goals (less anxiety, etc), but I would want to hear the therapist also set a goal, complete with plan of action, for helping me reach my broader goal.
What I mean is that I would want the therapist to recognize his/her own limits and abilities and have an idea of how much work he or she can do and how much success can be expected.
Fictional Patient goal: reduce nightly insomnia
Fictional Therapist goal: Have patient sleeping 7-8 hours at least half the week by one month.
I don't think the therapist should set the goals, but they should have some sort of plan on how to help the patient meet the goals. For example, my first therapist was nice but completely ineffective. I'm easily distracted, and I need structure. I needed someone who would keep me on topic and help me focus. I wasted inordinate amounts of time talking about nonsense and accomplishing nothing. Look, a squirrel!
The second therapist was much more structured, and a lot more was accomplished. I think when you have never been in therapy before it's easy to get stuck with a nice, but ineffective therapist, because you don't really don't know what effective therapy looks like.
So, I guess what I'm trying to say is, yes the patient should set the goals, but the therapist should not just let the patient wander all over the place, getting nowhere. We need a roadmap.
Yes, I agree with the Ancient One.
I agree with Dinah's post that the real goals of psychiatric treatment are often not quantifiable, and that attempting to quantify them trivializes our work. Absurd examples are easy to find.
The question of who sets treatment goals often appears as an oversimplified power struggle: "Doctor knows best!" vs "Empower the patient!" Goals are really co-constructed. The patient has goals that led him/her to treatment. If these aren't addressed the person will feel unheard and unhelped. Meanwhile, the psychiatrist's goals should take the patient's into account, and in addition incorporate considerations of:
- what can change and what cannot
- what the patient would want if he/she were conscious of currently unconscious material
- what may help the patient that the patient hasn't yet considered
The psychiatrist's goals are a starting point, and will be tempered by the patient's assent and willingness to pursue them. The goals of neither party alone can define the relationship.
DInah, it's a mix. If I come to therapy, my goal is that I want to feel better, have depression symptoms remit, etc. HOW to do that - that is the therapist's area of expertise. Goals should be developed together, but I do hold the therapist responsible for them. When someone in my field comes to me with something they want to achieve, it's up to me, in collusion with them, to find the way how to get there. But it's my responsibility as the expert. This is directly translatable to psychiatry, (and how psychiatrists are loathe to take responsibility and let therapy go on indefinitely and unfocused but that's another tale.....)
There is the assumption here that the therapist knows what the patient's goals should be: what if the patient comes in saying their goal is to have a better relationship with their mother and the therapist decides it would be in the patient's best interest to be estranged from their mother? Or divorce their cheating husband? Or be heterosexual rather than homosexual? While it seems fine to point out other issues a patient might want to address (hey, I know you're here because you want to get along better with your boss, but maybe the fact that you're 3 hours late to work because you're obsessively checking the doors before you leave the house, and perhaps we should address this as well?), I stand by my belief that the patient comes to see a therapist with an agenda and that agenda needs respect.
Treatment plan/course of action belonging to the therapist, well sure, to a degree. I think you should take meds and you don't want meds. Should I kick the patient out? I try to work with people on their terms.
But there is the assumption here that therapists as the professional know precisely how to use therapy to fix problems with a precise roadmap, and this simply isn't true. I don't know how conduct therapy so that a patient will get X numbers of hours of sleep within X period of time.
Many people come to therapy to address a problem. Many problems are addressed fairly quickly and the patient keeps coming. On the one hand, you could blame the therapist for holding the patient captive, but shouldn't the patient say "Am I headed in the right direction? Why am I not getting better? Should I be doing something differently?" (And yes, if the patient gets no better after a reasonable period of time and the therapist is not trying new things, then the therapist should request a consult).
Often people get better and keep coming because a) they like coming and b) they have been in very dark places, their sense is that therapy has helped them get better and continuing in therapy keeps them well and they are terrified of going back to those bad place.
Therapy is phenomenally expensive and time consuming, most people leave if it isn't helpful or when they feel they no longer need it, or at the very least, come much less often as they get better.
Interestingly, no patient has ever asked me what my goals for them are.
Steve, I'm not as analytically oriented. If patients are having strong emotional reactions to why I meet for 56 minutes one week and 63 minutes another, then somehow they are generally getting better without exploring such things with me. I'd be interested in knowing how you access all these emotions: do patients tell you they are feeling sadistic towards you?
@Dinah, the types of goal-clashes typical in my practice aren't the ones you cite. Rarely do I harbor even a private opinion about whether someone "should" divorce. Especially at the beginning when I hardly know them, it would seem the height of presumption. There are exceptions — severe substance abuse, suicidal behavior — where I express my goals right away. I assume we're not talking about that.
However, it's very common for patients to present with externalized complaints: my boss is a jerk, my wife doesn't understand me, the world doesn't treat people like me fairly, men are idiots, etc. Unlike many dynamic therapists who silently sit and nod at this for weeks on end, I point out quite early (but gently, and with a little sympathy) that the boss isn't here, I can't do anything about men, and so forth. I can only help the patient work on himself. Sometimes this clash of goals ends our budding relationship right there. The patient wants to pay me to gripe, and since I don't consider that treatment I won't comply. More often, patients recognize they need to modify their goal, i.e., to work on themselves, and then we're off and running.
Maybe another way to say this is that patients' distress always demands respect, but their agendas do not. Agendas are not all consciously motivated. Some patients have straightforward, concrete goals, e.g., to overcome an airplane phobia or to speak up in groups. I refer such patients to CBT, a better place to tackle such goals. Conversely, some agendas are unconscious, as in the patient who wanted me to sweat all week over his potential suicide. While I don't ask such patients if they are feeling sadistic (and clearly they don't offer this spontaneously), if I pay attention to countertransference and allow myself some plausible inferences it isn't hard to hypothesize a feeling behind the action. Dynamic therapy is a continuous series of such inferences, which are then fed back to the patient at appropriate times in the form of "interpretation." I'm not always accurate in this, but I don't have to be. I just have to be curious, humble, and open to new "data" as it comes in. The patient's sadism or whatever will be apparent to both of us soon enough. And when it is, the patient and I will shift our co-consructed goals of treatment to accommodate it.
Dinah, what settings have you worked in where the therapists encouraged cutting out mother's, divorcing spouses, or changing sexuality? Why would any therapist ever think these are goals? I thought they weren't even allowed to talk about changing sexuality with patients. Isn't that called conversion therapy and has been totally debunked? You say there is a danger of therapists forming these kinds of counter goals, but I think there were ethical restrictions that prevented that kind of thing.
I'm not even a therapist and I think the examples you listed are very obnoxious and disrespectful to probably the majority of people who practice psychotherapy.
What about solution focused therapists? They obviously have goal oriented, short term therapy with a road map. They're also quite popular so they must be doing something right. And just because they have their own goals and short term plans of action, I don't think that means they are all pushing their own agendas and could possibly try to encourage someone to switch sexual orientations.
What a wonderful explanation.
I purposely chose over-the-top examples, but there was a time, not so long ago, where homosexuality was defined as a mental illness; and therapists do all sorts of weird stuff -- so it wouldn't be unheard of for a therapist to suggest a patient part from a dysfunctional parent -- what if the parent had been sexually abusive. I have never suggested such a thing, but I might if a patient came to me and said that their parent was threatening their life while pointing a loaded gun at them (I might suggest other things as well). I meant no disrespect to anyone with my over-the-top examples, but I do think patients come to doctors/therapists with a problem and they're concerns should be considered and respected.
Your insomnia example is exactly what the accreditation folks want to see. I just don't know that it always translates into goals that really get met, worked towards, or achieved, and it becomes about using time to articulate quantifiable goals when that's not always what people want. Maybe someone wants to talk about the things that are bothering them, but instead they need to fill out depression or anxiety inventories so it can be documented for the treatment plan. What happens is that the paperwork/regulatory/Electronic Records requirements eat the time that could be used for treatment and the questions posed are not always relevant to an individual patient.
Please don't get me wrong, if a patient likes data and says they want to approach their problems in a more quantifiable way, then I think that should be respected as well.
Here us another example of what makes precise goal setting an illusion: a patient comes in unhappy and discouraged, he cannot sleep well. But what has led to this is another unhappy romantic relationship. He becomes intensely involved with women who end up losing interest in him. Yet he is intelligent and successful professionally.
His goal at the beginning might be that he wants a particular woman to respond to him. He doesn't want to see a pattern, but to get a particular result.
I have never had a patient define specific goals or ask that they be defined, and if they did that in itself would be something to wonder about. This subject, while thought provoking, can be like asking an accountant to define the goals in cooking a meal. You might meet his goals but you won't like the meal.
@Jesse: No worries :-) It sounds like you and Dinah practice psychotherapy differently from how certain others choose to practice.
Ancient one (so like how old are you?):
"Choose" is the operative word here!
Nothing against goals, but for many people it is "to feel better." I don't know any therapists who choose to pick acceptable, quantifiable goals that are satisfactory to regulatory agencies. Most therapists I know like working with people and hate required paperwork, especially when it's not meaningful to the patient and doesn't further the treatment.
So the patient comes in and you say we have to fill out the treatment plan now, and what are your longterm and short term goals. Sometimes the patient has no goals --perhaps they have schizophrenia and mental retardation, they live with a family member, they go to a day program, they are fine with life the way it is, their family member says they are doing well, they come in once every 3 months and their only real goal is to get a refill of the medication that keeps them well and safe and out of the hospital. It's really hard to quantify that.
@Dinah: I am ancient. I am timeless. I have existed since before time began. My followers and I are legion. We scour the internet fearlessly, feeding off of discussions before returning to Valhalla in order to nest and recuperate. Bwahahaha!
I'm sure the goal of the mentally retarded person with schizophrenia is maintain current level of functioing on meds. If the patient worsens, the goal would be to adjust meds until stabilized. How is that hard to quantify? Success is measured through not being hospitalized. Pretty straightforward.
I have met therapists who believe in limited psychotherapy that is based on fulfilling quantifiable goals. Goals are lined out in the first session. They can be changed. The therapist thinks of ways to try to meet those goals. It's all starightforward.
Some of these therapists also admit that they were not trained in the diagnosis of mentally ill persons. They don't manage severe mental illness. They were only trained to tackle specific problems. Their training was specific to achieving quantifiable goals, and they know of no other way to practice.
Again, it just depends on the way you choose to practice. And there are a lot of therapists who choose to use goals and roadmaps to get results with patients, because that was the nature of their training.
There's the rub. You have to have quantifiable goals that are acceptable to the auditing agency.
"If patient gets sick, will adjust medicine," won't cut it.
"To remain out of the hospital" won't cut it.
To sleep 6-7 hours a night within 4 weeks, that will cut it.
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