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How can two people referred for the same problem, such as depression, receive two very different treatment recommendations? Why is residential treatment recommended for one and outpatient therapy for the other?
A clinician’s task is to determine the modality and level of care she or he believes will lead to the best outcome for the client.
Clinicians use a multifaceted decision matrix that involves weighing several complex and dynamic factors within two broad categories: the presenting problem and the person. Each client is unique so this is not meant to be used as a specific rating system, but rather to describe what typically is considered.
A clinician considers three factors: complexity, history and risk.
Complexity: Clinicians ascertain the full scope of a person’s struggles. The complexity of a presenting problem is based on the number of diagnoses, severity of each diagnosis and other life factors that have been negatively impacted by the problem, such as relationships, ministry or spiritual life. For example, a person referred for depression may also have an underlying alcohol problem or an unresolved trauma history. In general, the more complex the presenting problem, the more complex the treatment.
History: A thorough history helps a clinician ascertain how the problem first manifested, how many times the person struggled in the past, prior treatments and how long the person has been struggling with the problem currently. Generally, newer problems with little history require a lesser level of treatment.
Risk: The level of present and future risk refers to the harm a person may cause to self or to others. A clinician also takes into account any potential for scandal resulting from the presenting problem. Risk requires a greater degree of clinical responsiveness. Because of the sensitivity involved in assessing and treating risk, even a lower risk level may result in a recommendation for a greater level of treatment.
An evaluation also takes into account the individual’s psychosocial history and readiness for therapy, including his stage of change.
Psychosocial History: During an assessment, a clinician gathers a thorough psychosocial history to determine factors that might be contributing to the presenting problem, as well as life experiences that facilitated the development of the person’s strengths and vulnerabilities. Individuals who had significant difficulties in their early life may need more intensive treatment to address those issues.
Readiness: Clinicians examine a client’s readiness to engage in therapy, and determine whether a medical intervention, such a detox program or a psychiatric hospitalization, is indicated. A clinician also assesses a wide variety of psychological functions such as a client’s capacity for learning, managing feelings, communication, self-reflection and insight.
Individuals may benefit from different treatments. Those who demonstrate mid- to high-range psychological functioning often benefit from outpatient or residential therapy. Individuals in need of a medical intervention or with very limited psychological capacities may need treatment geared toward stabilization before they are able to enter into treatment geared toward change.
Where a client falls on the stage-of-change continuum is an important part of client readiness. Intentional behavioral change happens in stages. A person moves from not being aware of a problem to awareness, to thinking about changing, to engaging in change, and finally, to maintaining change. Known as the Transtheoretical Model, research shows that it generally takes up to six months to move from one stage of change to the next.
A client with a dual-diagnosis may be in a different stage for each presenting problem. For example, a client may be fully aware of his depression and motivated to feel better, but be in a state of denial about alcohol use. More intensive therapy usually is recommended when a client is in an earlier stage of change or has relapsed, and outpatient therapy may be suitable for a client in a later stage of change.
Matching treatment with need facilitates optimal change and reduces the likelihood of relapse. Saint Luke’s six- and three-month residential programs, outpatient services, halfway house and continuing care are deliberately designed to provide a continuum of services based on a person’s needs.
For example, the six-month residential program is structured to create enough education and support to help a person move to the next stage of change. The treatment is depth-oriented and addresses the full complexity of the individual. This is important because an individual placed in a program that does not match his or her needs is less likely to achieve long-lasting results, increases the risk for relapse and may be discouraged from seeking out more appropriate treatment in the future.
Author: Taryn Millar, Psy.D., is chief operating officer of Saint Luke Institute
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