Treatment plans are central to psychotherapy, but the way in which they are regularly created and utilized can pose ethical problems.
The treatment plan is a document created by the therapist and client that identifies the client’s presenting problems, their desired goals, and objectives that, if completed, should lead toward achieving those identified goals. It is expected that the treatment plan is finalized and implemented within the first few sessions after initial intake.
Most therapists and agencies commonly use the rational/planning approach to creating treatment plans. This approach is related to a standard medical model of treatment:
- Initial sessions highlight the presenting problems
- A course of action is planned in order to resolve the client’s problem
- Pathology is discovered and/or diagnosed
- A treatment plan is put in motion
The medical model of treatment is forced by insurance companies, licensing boards, and mental health agencies. Identifying a defined problem early during the initial assessments and working all clinical efforts toward achieving a clear goal that resolves the client’s problem is a noble intention. The rational/planning approach is believed to guide therapy in a clear linear way, reducing cost, providing mutually agreed upon goals, and clearly defining an ending point to therapy. And I want to be clear; streamlining the therapeutic process is not a bad desire.
The rational/planning approach is often taught to students and therapists, and it is what the real world of therapy (insurers) wants.
But people are not all the same, and the therapeutic relationship is never uniform. So how can the rational/planning approach be the best and most appropriately ethical option for treatment planning? According to Rune Mølbak in his article titled Cultivating the Therapeutic Moment: From Planning to Receptivity in Therapeutic Practice, there are three assumptions that the rational/planning approach is based upon, and those assumptions raise ethical therapeutic concerns.
The first assumption is that we can define a client’s problem ahead of time, through a diagnostic interview, psychological testing, or a rational collaborative discussion with the client.
A therapist should not have faith in the client’s, and their own, ability to know what the best trajectory of psychotherapy will be before psychotherapy develops. The journey of discovering things about yourself – things like “what problems and goals am I truly dealing with?” – happen as psychotherapy unfolds, not during initial intake. Additionally, this therapeutic discovery happens at different paces for different people.
The second assumption is that therapy is a linear process in which goals can be determined in advance and will remain steady throughout the course of therapy.
No therapeutic trajectory has ever been clearly linear. To help illustrate this: when have you, in your own life, ever solved a major emotional or behavioral problem quickly, efficiently, and with no failures or waning in motivation? Living the human life is hard and full of distractions and failures, and any course of treatment, both psychological or medical, will have also have moments of failure and the need to try new approaches.
The third assumption is that the therapist is in control of the therapeutic process and is able to direct treatment in a rational and goal-oriented manner.
Due to the millions of factors that contribute toward normal, non-linear psychotherapy, therapists do not have control of the therapeutic process; at least, not in the way that the rational/planning approach assumes. A more ethical approach to psychotherapy is non-controlling, working toward creating an environment where clients are active agents in their lives.
Mølbak goes into great depths as to the problems of these assumptions, and his arguments are compelling, highlighting the previously stated three assumptions as the problem to the rational/planning approach.
It’s easy to poke holes in a theory and then walk away, creating more harm than good, but Mølbak goes on to explain an alternative approach to psychotherapy, that of a process-oriented approach built on three different assumptions:
- The objective of therapy is to discover what the problem is rather than to provide a solution to a problem that has been defined at the beginning of therapy.
- The process of therapy transforms goals rather than leading to their realization in some progressive and linear way.
- A therapist is most therapeutic, not when they plan out and administer universal interventions, but when they respond to what emerges in the moment in a contextual and well-timed manner.
Mølbak’s process-oriented approach is a better and more ethical approach to treatment planning, in that it doesn’t presume upon the client their problems and goals in an inappropriately premature and inflexible manner.
But how can a process-oriented approach be utilized in a therapeutic system that rewards the medical rational planning model and demands proof of medical necessity and expedited outcomes?
Might an ethical implementation of treatment planning include attempting to initially identify problems as best as possible to begin guided treatment, like a rational/planning approach, but to also allow the treatment plan to be an iterative document that welcomes changes due to the unpredictable therapeutic process?
This is the ideal situation, and it requires that the client and therapist feel empowered to be actively involved in defining problems and goals as they journey through psychotherapy.
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