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treatment_plans [2021/09/25 15:06] – [Targets, Goals and Outcomes] andrewtaustintreatment_plans [2026/09/28 14:16] (current) – Correct the link to the governing-principles evidence section andrewtaustin
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 ====== IEMT Treatment Plans ====== ====== IEMT Treatment Plans ======
  
-===== For clients facing complex mental health, emotional and psychological challenges =====+===== Planning and reviewing practice through an adaptation framework =====
  
 +A useful IEMT plan connects the client's chosen outcome with an explanation of the difficulty, a reason for the proposed intervention and a way to review its effects in everyday life. A brief piece of work may need only a short record. More complex needs call for more detailed planning, coordination and review.
  
-A treatment plan is a set of written instructions and records pertaining to the treatment and management of a mental health condition and/or crisis. A treatment plan should include the client’s key personal information, the diagnosis and/or presenting problem, an outline of the treatment under consideration, expected and intended outcomes, and the measurement of these outcomes during, and at the conclusion of, treatment.+This page translates the proposed [[governing_principles|Roy-informed governing principles]] into a practical workflow. It is an application developed for this wiki, not a validated assessment instrument, an established IEMT standard or a protocol authored by Callista Roy. It does not expand a practitioner's qualifications or scope of practice.
  
-A treatment plan should include:+**Start with what the person wants to become possible. Assess the response and its circumstances, agree an appropriate action, and review both the experience and the practical outcome.**
  
-  * A definition, qualification, and quantification of the presenting problem +Use the [[adaptive_formulation|Adaptive Formulation and Outcome Review Sheet]] to make a concise record. The examples below illustrate how the same framework can support a decision to use IEMT or to prioritise other assistance.
-  * A description of the treatment proposed by the coach/therapist +
-  * A timeline for treatment, including frequency and duration of sessions +
-  * Identification of the major treatment goals in the SMART format+
  
-Whilst for many clients a treatment plan is not necessary there are many scenarios and presenting problems for which a treatment plan will offer an opportunity for the client to collaborate in their treatment and to provide a structured framework for treatment. Many clients with complex issues and who may be new to therapy/treatment may find this reassuring, professional and motivating.+===== Contents of a Treatment Plan =====
  
-Where the appropriate permissions exist the treatment plans may be shared with mental health professionals and community support teams in order to increase multi-disciplinary communication, cooperation, and collaboration.+The plan is an agreement developed with the client. Include only information relevant to understanding the work, making decisions and providing appropriate continuity of care.
  
-IEMT Practitioners should consider a treatment plan in the following scenarios:+  * **Purpose:** the client's presenting concern, chosen life outcome and reasons it matters. 
 +  * **Starting point:** what the client reports, what the practitioner observes, existing strengths and relevant circumstances. 
 +  * **Formulation:** a provisional explanation, its supporting observations and what remains uncertain. 
 +  * **Action:** an IEMT target if appropriate, other options, practical support, responsibilities and consent. 
 +  * **Review:** indicators of progress, possible unwanted effects, the review date and the decision about further work. 
 +  * **Coordination:** relevant existing care, agreed communication and any needs that require another professional or service.
  
-  * Clients experiencing serious mental illness or distress +Record diagnoses already made by an appropriately qualified professional with their source where relevant. An IEMT formulation describes the proposed relationship between a difficulty and its circumstances; it is not a medical or psychiatric diagnosis.
-  * Clients experiencing multiple issues affecting them emotionally, physically, socially, and psychologically +
-  * Clients with serious physical health issues +
-  * Clients engaged in the criminal justice system +
-  * Clients under compulsory treatment orders +
-  * Clients engaged with multiple care/support/treatment agencies +
-  * Clients referred by employers +
-  * Working with teenagers and/or their families +
-  * The vulnerable elderly +
-  * Clients with developmental disabilities and/or intellectual challenges +
-  * Clients experiencing sexual orientation or gender identity issues +
-  * Clients who are being bullied and/or abused and/or exploited +
-  * Clients with little socio-economic resource, minimal opportunities, and poor prospects+
  
-Each treatment plan is unique to each individual though many similarities and recurring themes will undoubtedly arise over time.+For brief work, these elements may fit on one page. Where several services are involved, clarify who is responsible for each action and how the plan connects with existing care. Age, disability, culture, language and communication preferences may affect how planning is conducted. Sexual orientation and gender identity are not themselves problems to be treated; attend to the person's actual concerns and any discrimination or lack of support they face.
  
 +===== From assessment to action =====
  
-===== Contents of a Treatment Plan =====+==== 1. Agree the outcome and establish a baseline ====
  
-All treatment plans are specific to each client. They are the collaborative result of the discussions and agreements that exist between the coach/therapist and the client.+Ask what the client would like to do, experience or sustain differently. Translate a broad request such as "I want to stop feeling anxious" into a personally meaningful outcome, while retaining the client's own language.
  
-Differences in the care plans between different clients are most likely to manifest in any or all of the following components:+For example: "I want to contribute an idea during our weekly team meeting, even if I still feel some nervousness." Record what currently happens: the client has stayed silent at the last three meetings and reports anticipatory distress of about 7 out of 10. The distress rating and participation record describe different aspects of the starting point.
  
-  * Demographics and personal history +Agree the reference situation, scale anchors if using a rating, and a review point. A range, a verbal description or "I cannot tell yet" may be more accurate than a precise number. Do not make a zero distress rating a universal requirement for success.
-  * Assessment/diagnosis – whilst many people may share the same diagnosis, the experience of the client will be unique as will the context in which the presenting problem/illness/distress occurs +
-  * The presenting problem – i.e. the problems or symptoms that initially brought the client to treatment +
-  * Existing resources – the pre-existing resources that the client brings to treatment. These will be either intrinsic (i.e. clients own strengths and characteristics) and extrinsic (i.e. family support, financial aid, social support) +
-  * Treatment contract – the agreement between the therapist and client that summarises the intentions of treatment +
-  * Responsibilities – a section on who is responsible for which components of treatment, including the coach/therapist and other agencies across the multi-disciplinary and community support agencies +
-  * Treatment outcomes – what are the intended and expected outcomes of treatment +
-  * Specific interventions – the techniques, exercises, and interventions deployed by the coach/therapist +
-  * Session frequency, duration, and number +
-  * Progress/outcomes – the ability, rate, range, and degree of therapeutic progress will vary enormously between clients+
  
-===== Behavioural Observations =====+==== 2. Describe the response before explaining it ====
  
-**Note behavioral observations of the client's presentation of self.** The coach/practitioner should assess the client's overall mental state which involves observing their physical appearance and interactions with others.+Explore what occurs, when it occurs, what follows, when it is absent and what already helps. Distinguish the client's account from direct observation and from either person's interpretation.
  
-The coach/practitioner should also assess the client's overall mood (i.e.//sad, angry, indifferent//) and overall affect (//range, scope, and articulation of emotional expression//). These observations assist the coach/practitioner in making an effective diagnosis and developing an appropriate treatment plan. +"The client reports a racing heart before speaking" is a report. "The client paused for several seconds" is an observation. "The pause protects against criticism" is a hypothesis requiring exploration. An early memory offered during IEMT work does not, by appearing, establish the cause of the current problem.
  
-Examples of observations that constitute the mental status exam include:+Consider whether a response provides useful protection as well as creating difficulty. Do not assume every response has a discoverable protective purpose. The plan should preserve useful options and make room for alternatives.
  
-  * Orientation to time, date, and place +==== 3. Map the current demands and resources ====
-  * Self-grooming and hygiene (also observe fingernails, breath, odour, the freshness of clothing, etc) +
-  * Eye contact - avoidant, little, none, or normal +
-  * Mood - angry, withdrawn, irritable, tearful, anxious, depressed, etc +
-  * Affect - appropriate/inappropriate, labile, stoical, blunted, flat +
-  * Thought content disturbances - i.e. delusions, hallucinations, obsessions, intrusions, suicidal thoughts +
-  * Behavioral disturbances such as aggression, poor impulse control, unreasonable demands +
-  * Motor activity - agitation, calm, restless, rigid +
-  * Speech (volume, speed, coherence) +
-  * Interactional style (i) - i.e. nervous giggling, bombastic, cooperative, erratic +
-  * Interactional style (ii) - active participant, passive, failure to initiate, conversationally domineering, etc +
-  * Intellectual functioning (impaired, unimpaired) +
-  * Memory - short term, long term +
-  * Perceptual disturbances - i.e. hallucinations, the agency of communication and meaning +
-  * Attention span - ability to focus and concentrate+
  
 +Roy distinguishes three stimulus categories: **focal**, the internal or external stimulus most immediately confronting the person; **contextual**, other factors contributing to its effect; and **residual**, factors whose influence in the current situation remains unclear. [[https://www.msmu.edu/learning-and-research-communities/roy-adaptation-association/roy-adaptation-model/|Roy Adaptation Association: model terminology]].
  
 +Use the categories as a working description, revisable as understanding changes. A remembered event or an imagined future conversation can be the focal stimulus now. "Residual" does not mean "past trauma". The wiki's term "prospective" describes anticipated content rather than a fourth category attributed to Roy.
  
 +Ask about practical constraints and resources: workload, rest, access to help, illness, finances, housing, relationships, relevant skills and existing care. Record what the person can influence, what depends on others and what is currently outside their control. Adaptation may require changing or leaving a situation, challenging an expectation or obtaining support.
  
 +==== 4. Review the four adaptive modes ====
  
 +For individuals, Roy's four modes are physiological, self-concept, role function and interdependence. The questions below are proposed IEMT planning prompts; they are not a diagnostic checklist. [[https://www.msmu.edu/learning-and-research-communities/roy-adaptation-association/roy-adaptation-model/|Roy Adaptation Association: adaptive modes]].
 +
 +^ Mode ^ Explore with the client ^ What could be reviewed? ^
 +| Physiological | Rest, bodily comfort, daily activity and relevant health needs. | Sleep interrupted by worry; ability to undertake a chosen activity; need for health assessment. |
 +| Self-concept | Meanings about oneself, personal values and any conflict between them. | Whether a difficult experience still becomes a global judgement of personal worth. |
 +| Role function | Responsibilities, expectations, skills and limits. | Participation in a valued task, or an agreed reduction in an unsustainable demand. |
 +| Interdependence | Giving, receiving and declining support; relationships and boundaries. | A request for help, the response received and whether the support is usable. |
 +
 +Record strengths as well as difficulties. Every mode need not become a treatment target. Bodily symptoms requiring assessment belong with an appropriately qualified professional, rather than being presumed to be emotional imprints.
 +
 +==== 5. Write a working formulation and choose an action ====
 +
 +Summarise the proposed relationship among the response, circumstances and desired outcome. Include uncertainty and at least one plausible alternative explanation. For example:
 +
 +> When anticipating speaking in a meeting, the client recalls a humiliating presentation and expects renewed criticism. This may contribute to avoidance. Limited preparation time and the meeting format also matter. We have not established that the remembered event caused the difficulty.
 +
 +Then explain why the proposed action fits. An IEMT target might be a particular reported emotional response or identity statement, where work on that target is within the practitioner's competence and the client chooses it. Other actions might include practising a skill, arranging assistance, changing a demand or obtaining assessment from another professional.
 +
 +Discuss the intended benefit, uncertainty, relevant risks and alternatives, including deferring or declining the intervention. Agree how to pause or stop. Shared decision making includes the person's priorities and their ability to change a decision; these principles are also described in NICE's healthcare guidance. That guidance does not constitute an endorsement of IEMT. [[https://www.nice.org.uk/guidance/ng197/chapter/Recommendations|NICE NG197: shared decision making]].
 +
 +Where needs exceed the practitioner's competence, seek suitable supervision, referral or coordinated care. Urgent medical, mental-health or safeguarding concerns require the appropriate local response. Neither the Roy framework nor this worksheet supplies validated IEMT triage thresholds.
 +
 +==== 6. Record what was done and review what followed ====
 +
 +Record the agreed target, what was actually undertaken, any modification or stopping of the work, and the client's account afterwards. Immediate relief is one observation. Review whether it persists and whether the intended life change becomes possible.
 +
 +Use the same reference situation and measurement method where possible. Ask about unchanged difficulties, unwanted effects and relevant changes elsewhere, including support, workload or other treatment. Record missed follow-up as an unknown outcome. Avoid attributing all change to IEMT simply because it followed a session.
 +
 +==== 7. Decide the next step together ====
 +
 +^ Finding at review ^ Implication for the next decision ^
 +| The agreed life outcome improves and the client finds the change useful. | Consider concluding or reducing the work, or agreeing a further goal if the client wants one. |
 +| The target feeling changes but the intended activity remains difficult. | Review skills, opportunities, resources, environmental barriers and whether the original formulation was adequate. |
 +| There is no useful change. | Reconsider the target, intervention, explanation and suitability of IEMT; discuss alternatives or referral. |
 +| There are unwanted effects, deterioration or loss of consent. | Pause or stop the relevant procedure and assess what response or additional care is needed. |
 +| Circumstances or the client's priorities have changed. | Revise the plan and its indicators rather than treating the previous goal as compulsory. |
 +
 +Reporting no improvement, a remaining difficulty or a wish to stop is legitimate feedback. It does not by itself establish a [[iemt#patterns_of_chronicity|Pattern of Chronicity]].
 +
 +===== Behavioural Observations =====
 +
 +Document relevant observations in descriptive language. "The client asked to pause and looked away" preserves what happened. Calling the same behaviour "manipulative" or "resistant" adds an interpretation that may be wrong.
 +
 +Check the meaning with the client and consider communication style, culture, disability, fatigue and the interaction itself. Eye contact, emotional expression or uncertain language alone does not establish motivation, mental capacity or a diagnosis. A formal mental status examination or diagnostic assessment requires the relevant competence; IEMT training alone should not be treated as conferring it.
 +
 +===== Specific Assessment Tools =====
 +
 +Choose a measure because it answers a relevant question and suits the person's circumstances. A short record of a chosen activity, the client's description of a response and an agreed rating may be sufficient for a narrowly defined goal. These do not replace clinical assessment where that is needed.
 +
 +Where using a standardised instrument, follow its current instructions, permissions, population, time frame and interpretation requirements. Record the version used. Do not turn a change in a screening score into a diagnosis or proof of an intervention's mechanism.
 +
 +For example, the PTSD Checklist for DSM-5 (PCL-5) can support symptom monitoring and screening, but its publisher specifies clinician interpretation and distinguishes it from a structured diagnostic interview. It is not a universal IEMT outcome measure. [[https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp|US National Center for PTSD: PCL-5 guidance]].
  
 ===== Targets, Goals and Outcomes ===== ===== Targets, Goals and Outcomes =====
  
-To evaluate the effectiveness of the treatment plan, the coach/practitioner needs to track the client's progress and measure the efficacy of treatment and interventions. In some instances, it may be beneficial to ask the client to keep track of their inner experiences and behaviours in a log, chart, or diary so that progress can be monitored.+Keep three records distinct: 
 + 
 +  * **Target:** the specific experience or pattern being addressed in the session. 
 +  * **Life outcome:** what the client wants to become possible beyond the session. 
 +  * **Evidence at review:** what the client reports, what was observed and what remains unknown. 
 + 
 +A lower distress rating with continued inability to perform a valued activity is a partial result. Participation despite some continuing distress may be meaningful progress. The interpretation depends on the client's agreed purpose, not on a universal threshold imposed by the practitioner. 
 + 
 +==== SMART Goals ==== 
 + 
 +SMART can be used as a writing aid: make a goal specific, measurable, achievable, relevant and time-bound. It is optional, and writing a SMART goal does not establish that the treatment will work. Use a practical indicator or a clear description where a number would be misleading. A review date is a point for learning and revising, not a promised recovery deadline. 
 + 
 +For example: "Over the next two team meetings, I would like to contribute one prepared idea at each. At our review we will discuss what happened, how it felt and whether the meeting conditions supported this."
  
-People in treatment are more likely to complete objectives when the goals are personally important to them, thus all goals should add value or meaning to the client's situation. +Include dependencies: participation also requires an opportunity to speak and a workable setting. Goals concerning another person's cooperation should identify the client's own possible action and separately record the response from others.
  
-<WRAP center round tip 80%> +===== Worked examples =====
-“//People are not lazy. They simply have impotent goals—that is, goals that do not inspire them.//” — **Tony Robbins** +
-"//If you want to live a happy life, tie it to a goal, not to people or things.//” — **Albert Einstein** +
-</WRAP>+
  
 +//Both examples are fictional planning illustrations. Their review scenarios are hypothetical, not treatment results or evidence of effectiveness.//
  
-===== SMART Goals =====+==== Example 1: a possible IEMT target within a wider plan ====
  
-All outcomes, aims and treatment goals should be measurable using the SMART criteria:+**Situation and outcome.** Alex avoids contributing at otherwise supportive team meetings and wants to offer one prepared idea at each of the next two meetings. Alex recalls an embarrassing presentation and reports distress of approximately 7 out of 10 when anticipating speaking.
  
-  * **Specific** – target a specific area for improvement. (//what//) +**Formulation.** The immediate focal stimulus is the anticipated meeting. Limited preparation time and a rapidly moving discussion are contextual factors. The recalled embarrassment is relevant material to explore, but its causal role has not been established. If its current influence remains unclear, record that uncertainty. Do not classify it as residual merely because it happened in the past.
-  * **Measurable** – quantify or at least suggest an indicator of progress. (//how much//) +
-  * **Assignable** – specify who will do it. (//who//) +
-  * **Realistic** – state what results can realistically be achieved, given available resources. (//why//) +
-  * **Time-related** – specify when the result(s) can be achieved. (//when//)+
  
 +**Four-mode review.** Alex reports restless sleep before meetings, a self-description of being incompetent, difficulty fulfilling a valued work role and reluctance to ask a supportive colleague for help. Existing strengths include subject knowledge and successful conversations in smaller groups.
  
-The term S.M.A.R.T. Goals and S.M.A.R.T. Objectives are often used. Although the acronym SMART generally stays the same, //objectives// and //goals// can differ. Goals are the distinct purpose that is to be anticipated from the assignment or project, while objectives, on the other hand, are the determined steps that will direct the full completion of the project goals. (**SAMHSA Native Connections.** "//Setting Goals and Developing Specific, Measurable, Achievable, Relevant, and Time-bound Objectives" (PDF). Substance Abuse and Mental Health Services Administration//.")+**Agreed action.** If assessment supports its suitability and Alex chooses it, the practitioner proposes IEMT work on the agreed emotional response within their training. Alex also prepares a short contribution and considers asking the chair for an opportunity to speak. The practitioner explains uncertainty about benefit and agrees a stopping signal and review after the two meetings.
  
-Two additional criteria create the SMARTER system:+**Review scenarios.** Reduced distress together with useful participation would support discussing whether the agreed work is complete. Reduced distress without participation would prompt review of preparation, meeting conditions and remaining difficulty. No improvement would prompt reconsideration of the plan; it would not prove that Alex was resisting change.
  
-  * **Evaluate** - The sixth step in goal setting using the S.M.AR.T.E.R. method is to ensure that all progress towards each goal is evaluated. +==== Example 2: practical support takes priority ====
-  * **Readjust** - The seventh step is to adjust treatment according to the evaluation. +
-   +
-===== SAMPLEs - not for inclusion =====+
  
 +**Situation and outcome.** Morgan is caring for a relative while working changing shifts. Morgan asks to remove the guilt associated with saying no, but also reports persistent exhaustion and insufficient help. The chosen outcome is a sustainable arrangement for care and rest.
  
 +**Formulation.** An immediate request to cover another night of care is the focal stimulus. Existing workload, interrupted rest and limited available help are contextual factors. A family expectation about always being available is a possible influence to explore, not an assumed cause.
  
-{{:4c16008b3d0516530846d4426b9f75ff--psychotic-disorder-mental-health-nursing.jpg?800|}}+**Four-mode review.** The discussion identifies lack of rest, a belief that asking for assistance means failure, competing work and caring roles, and a support network with real limits. Morgan already has a clear understanding of the care required.
  
-{{:f1.large.jpg?800|}}+**Agreed action.** The first plan is to explore available care support and renegotiate responsibilities, with relevant health assessment for the exhaustion. Morgan chooses whom to approach; the practitioner helps clarify the request and works within their role. Emotional or identity work may be considered later if wanted and appropriate. Reducing guilt alone would not supply missing care or rest.
  
-{{:flowerbluenew.jpg?800|}}+**Review scenarios.** Review whether help was accessible, whether the workload became manageable and how Morgan experienced the changes. If support is unavailable, revise the practical plan. Continuing difficulty in those circumstances does not demonstrate a failed attitude, a defective identity or a Pattern of Chronicity.
  
-{{:gr1_lrg.jpg?800|}}+===== Using and evaluating the framework =====
  
-{{ :slide_9.jpg?800 |}}+Use the [[adaptive_formulation|formulation and review sheet]] alongside any records required in the practitioner's setting. Store completed records in an appropriate secure practice system; do not enter identifiable client material on this public wiki.
  
-{{ :608d54_b4e42a2fb23f45cda004c507044fcfc4_mv2.jpg?800 |}}+The framework's usefulness should also be examined: does it help identify unmet needs, explain choices, notice lack of benefit and guide better next decisions? A coherent formulation is not proof of IEMT efficacy. Keep evidence for the procedure, evidence for the proposed explanation and evidence for the planning framework distinct. See [[governing_principles#keep_the_framework_procedure_and_evidence_distinct|the governing principles' discussion of evidence]].
  
-{{ :c4073d55901aaa80704987948cc96fc9bbbaf0ec-365x800.png?800 |}}+===== See also =====
  
-{{ :slide_9.jpg?800 |}}+  * [[governing_principles|Roy's Adaptation Model as Governing Principles for IEMT Practice]] 
 +  * [[adaptive_formulation|Adaptive Formulation and Outcome Review Sheet]] 
 +  * [[adapt|Integral Eye Movement Therapy (IEMT): An Adaptive Model]] 
 +  * [[model|The IEMT Model]]
  
-{{ :stepped-care-model-1280x786.png?800 |}}+{{tag>IEMT training diagnosis anxiety depression pain practice}}
  
-{{ :stepped.jpg?800 |}} 
  • Last modified: 2021/09/25 14:06
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