Welcome to What’s Better This Week? Episode 7: Making Treatment Plans Solutions FocusedWhen we last left off, we had collected some superfluous data and some pee, and now, here in our fourth appointment, we need to make a treatment plan that we’re going to refer back to regularly for a host of reasons. First, and foremost, at least in New York State, where we are mandated to by the Office of Mental Health: patients’ discharge planning is actually begun at their admission, or at least we have to check a box that says “discharge planning has begun.” Why? Because someone on the state or funding level has said that it is vitally critical that we make it apparent that we’re not trying to create patients for life, and that we are actively working on moving our patients along. For someone who is a Solutions Focused Brief Therapist, this is a no-brainer: the Brief, in SFBT means that we never keep a patient a micro-second longer than they want, to be in treatment. We don’t want patient’s for life, it means we’re n to doing our jobs. It is antithetical to our treatment model. However, part of proving that we’re being honest with the finances of insurance companies (who again, dominate this industry far more than they should) is that we indicate that we have already begun discharge planning by our fourth apartment (right after admitting our patient) and we continue this through the collaborative creation of a treatment plan.Additionally, the Treatment Plan ensures (or, in theory it works to try to ensure) for therapists and counselors who are not Solution Focused, that they are working with a goals/objective modality of therapy, rather than just talk therapy: those paying for therapy want to make sure that something more than a therapeutic relationship is happening…they want to make sure that patients are getting somewhere and that somewhere is “cured” and out the door. It is the Medical, not the Sociological model. Goal/Objective therapy removes “talk therapy” largely as an option, because a patient must consistently be doing something, to consistently be moving toward their goals…for my astute listeners, you will note that this is actually placing (or can have the trap of placing) many patients into some kind of pass/fail model of therapy, where they're “not making progress” quickly enough…and it’s largely nonsense; it also serves two interests: first the funders/insurance companies, and second, those clinicians who don’t take a step or two step down approach, but rather wish to seem superior to their patients who don’t “make enough” progress in their own eyes.So what do we do about this nonsense? And how on EARTH do we ethically and honestly connect Solution Focused Brief Therapy work into this insurance based, financially based, diagnostically riddled model? Actually, quite easily - but we have to be careful about it.First, our treatment plans follow a Problem -> Goal -> Objective -> Intervention model. This means that we have to share what our patient’s problem is, what their goal is, how they’re going to get to their goal, and what specific intervention is going to get them there. We call it a “PGOI” for short. Ergh.When working with patients, I will often explain - much like when I explain that all a diagnosis is, is a title heading that works to explain a combination of symptoms that go together, a treatment plan works like a journal, to log what we’ve been working on, and to make sure that I understand them correctly. I also - much like we have discussed to date - will then have to balance out the patient’s wants, needs, desires, and goals - my own, as an SFBT therapist - and the state’s, as our licensor, and of course the insurance company (as funder, and of course sometimes that’s the state).So first is working with the patient to explain to them all of the reasons that we have to co-create this document together, and then explain how on earth we can make it useful (“it’s like a journal, you can use it to hold us accountable, you probably wouldn’t want to go into a teacher’s classroom if she didn’t have a lesson plan, or go to a Doctor’s office where they gave everyone the same shot…”). Then we work on the treatment plan itself.So, let’s say a patient came in, and we had to diagnose them (because again, we’re making SFBT fit in a clinical, insurance based, environment) with depression; first we would discuss the “problem.” However, we’re going to discuss it in a solution’s focused way. So rather than say “John Doe is having depression!” or “John Doe is suffering from depression!” or “John doe is depressed!” (right, all normally “good” problem statements”) we’ll phrase it as “John desires to reduce the impact of symptoms of depression on his daily life.” I am not saying that John *IS* depressed or *IS* depression. I’m not saying he has anything. We’re merely, factually, stating that through SFBT language John has identified as wanting to have these barriers reduced. Then we’re going to come up with a goal.Of course the Goals are more, or less, pre-selected for us. So we’re probably going to select that John Doe wants to reduce the intensity and frequency of his symptoms. All good and well. So how are we going to get there? Well, John now has to pick an objective, and 99.99% of the time, that Objective will be “Learn & Practice New Coping Skills.” So what on EARTH does that look like in the Solutions Focused world?Normally the pre-fill starts with “John Doe will learn x number of new coping skills in order to reduce mental health symptoms.” Okay…great. So John Doe is going to learn his “lucky number” of coping skills to reduce mental health symptoms. BUT Solutions Focused work is a process and it’s a way of thinking (and for many it becomes a way of life). This isn’t DBT where there’s manualized therapy and you can give a worksheet, go over it, and check it off that the patient is “making progress” or “not.” How do you document a journey? How do you do so ethically? How do you bring Insurance Companies on board and do so ethically?First, in the objective, we add that “John doe will learn 5 new coping skills, through a solution focused lens, in order to reduce mental health symptoms.” (document, document, document)”. In our intervention, we obviously note down “individual therapy” and how many times a week.Okay, so we add in anything else that we may be working on in a similar fashion, we add in “Physical Health” because New York State says that we have to (never mind that it should be a patient’s choice, no matter how important it is!), along with Tobacco if the patient is a smoker (again, who’s the patient/client here?); and then we get to the thorny part: how do we make this, this treatment plan, this document, that we have to link everything to, make sense? How do we make an SFBT session where a patient comes in and talks about something seemingly unrelated make sense when it “has to” be related to a patient’s depression, right?A patient can only work on what's in their treatment plan, every session has to link to the treatment plan, there can be no deviation from the treatment plan, or we have to add it to the treatment plan, because otherwise we're not being ethical, we have to document and it has to link to the treatment plan, every single session must somehow be linked to the treatment plan, so the answer is openly, honestly, and sincerely: through good SFBT practice. I’ll talk more about how we document and connect it in our notes in our next episode (when we get into documentation) but for now, how do we have our conversation? We start with “What’s better this week?” we then follow that up with “What is your best hope’s for this session?” and usually scaling questions, we move into what I refer to as “discernment” where we use change talk, and come up with an experiment…and then follow that up with (somewhere in there) a question about “and, if this experiment works, do you think this will help you to reduce symptoms of your depression?” and all of a sudden…SFBT becomes clinical; because the patient, themselves, will give you - IN THEIR OWN WORDS, how the experiment that they came up with, fits into their treatment plan, even if it seemingly had NOTHING TO DO with depression at all…maybe they were worried about what they were going to have for dinner…the point is that not that you were able to connect everything together, but that the patient, the client was, and you were able to document it, all by asking the very simple question of “how does it fit?".Which is why it's very important that you look at the treatment plan before each session, so you know how you can guide the patient to connect it, what you're working on, in the solution focused process, to what you are allowed to work on and bill through, and that is how you make solution focused function in this clinical environment legally and ethically.And since this seems a good a place as any to end off as any, we’ll do so and close here. Next week, we’ll discuss documentation, and then after, we’ll move into more of a “everything Solution Focused” format.Thank you for listening. Please tune in again next Sunday, as we continue forward together down our solutions focused path. Comments, constructive criticism, feedback, and questions can be sent to [email protected]. Yes we’re on Social Media @WBTWCast on all of the platforms you’d think to look at. I’m @TheMattSchwartz, and it’s time for some self-care with my cat, Akiva, who is patiently waiting for cuddles while I record this.The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you next Sunday with more; until then, make good choices.

Welcome to What’s Better This Week? Episode 5: More Superfluous Data & Pee

 

When we last left off, we covered what happens in the second assessment appointment, and we put our pinky toe in the water for how solutions focused counselors begin to address the concept of diagnosis with patients, while balancing out clinical requirements to New York State, the Office of Mental Health, the Office of Substance Alcohol and Substance Abuse Services, and payers like Medicare and Medicaid.

 

So what happens in our Third Assessment Appointment? During the third assessment appointment, we will again be gathering data that is less relevant for our work with our patient, and that benefits, on the whole, the Department of Health’s mission to gather statistics for the sake of gathering statistics: what is your Tuberculosis status? What is your Hepatitis Status? What is your HIV Status? If a patient really wants services they’re not necessarily going to be forthcoming with us, and they may not necessarily know, and even if we *give* them referral information they may take it and throw it in the trash which is why these screening questions are - at best - superfluous, and at worst a waste of time: I don’t want to say that this *isn’t* our job (I do believe in the “it takes a village” concept toward community health) but I do believe that we should be providing the services that patients have come to us for, not what we *think* they need. If a patient has come to me for counseling, it’s not to receive the Department of Health’s Statistical Questionnaire. We then provide our patients with printed information on all of the above without cause or concern for their ability to read and comprehend that information (more on that in a future episode, because we will be working with patients who have a variety of different cognitive abilities).

 

So it is VERY easy to see why our patients can think that we’re totally out of touch, and totally out to lunch…because here it is, week THREE, and we’re not doing counseling…we’re still asking them questions…and now we’re asking them healthcare questions…so it’s vital that we take a solutions focused approach to this: “I know that this information isn’t what you want to talk about today; and I apologize that we’re required to ask it. Let’s try and get through it efficiently so we can get to what’s really important: the reason why you’re here. I’ll absolutely work to save a good half an hour today so we can talk with one another.”

 

After asking these health questions, we will then ask some more questions about orientation, and identity, straight off the bat, with only two previous sessions of rapport built up, which can be terrifyingly forward for our patients (since we’re the one’s asking the questions, rather than eliciting information through a Solution Focused model) - but it’s there on an assessment form, and we have to provide a response: because if we don’t we’re not doing our duty to our agency, and we cannot simply respond with our own guess work, and we have to also respect the personal right of our patients to also choose to respond (or not) to their comfort levels to these assessment questions (and some are perfectly fine responding to any and all questions asked, having been socialized to do so).

 

After this, we’ll then ask intimate questions about their relationship with their partner or spouse or significant other, and then their relationship to their family as a whole.

 

Finally, we’ll ask them for information on their CPS connection, and then we’ll ask for legal information (criminal background, arrests, any criminal justice hearings pending, etc.).

 

Here’s the thing: in ANY Solution Focused Brief Therapy session…if ANY of this was at ALL relevant to the work that the patient wanted, or felt needed to be done…it would COME OUT, all on its own…so once we’re done with this display of superfluous data gathering for the sake of gathering data, then we have to go and get some pee. Why? There is a clinical justification for this…but it doesn’t flow with Solutions Focused work. The clinical justification is that the DSM-V (you know, the one with poor interrupter reliability? The one that no one else but the United States uses? Yeah, that DSM-V…that masterpiece brought to us by the American Psychiatric Association) is always asking clinicians to rule out substance use before making a diagnosis…because they don’t want a clinician to diagnose for say…Bipolar Disorder when it’s really Cocaine Use. Fair enough…but what if, like I do, we don’t find diagnosis generally beneficial or necessary in order to treat the patient (especially when the interrupter reliability is so low…and it’s just so unnecessary)…well, then, we’re just engaging in this process because, again, it somehow appeases an outside force, not because it’s in the best interest of our patient.

 

If Substance Use is impacting our patient’s lives, we will get there in an SFBT session - be sure of it; but because of regulations, we will collect a cup of pee, for this golden cup to act as a neutral arbiter of any “secrets” that our patients are keeping from us (which is their right to do, by the way).

 

So, now, hopefully, having gathered data that you as an SFBT practitioner will probably never look at again, now at last, you will at least have some time to talk with your patient - in a Solution Focused manner, have a good half hour, and make a real connection…because you’re going to need it…because the most important part (at least, the part that lets us justify and bring Solution Focused Brief Therapy to outpatient and inpatient Mental Health Settings in the United States) comes in the next session: it’s the Treatment Planning Session, which justifies funding, and has to be linked to in every single subsequent session…and this one we’ll cover in Episode Six, available next Sunday.

 

Thank you for listening. Please tune in again next Sunday, as we continue forward together down our solutions focused path. Comments, constructive criticism, feedback, and questions can be sent to [email protected]. Yes we’re on Social Media @WBTWCast on all of the platforms you’d think to look at. I’m @TheMattSchwartz, and it’s time for some self care with my cat, Akiva, who is patiently waiting for cuddles while I record this.

 

The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you next Sunday with more; until then, make good choices.

Hello Everyone and welcome back! I apologize for the brief hiatus with no notice! Since the last episode two things happened at the exact same time: first I got very sick, and second (and more important) I bought and moved into my very own home. Personally, I hope it is my last move ever, because honestly it was a lot. Since then I’ve been recovering (and with a suppressed immune system and chronic illness, it’s taken longer than I’ve hoped for). This sadly hasn’t lent itself to working on a podcast…to say nothing of attempting to find my podcasting gear in all of the boxes that were set aside in my home office.

 

However, my home office is now setup, and I have found my podcasting gear, which means that as you are listening to this, I am recording this Sunday’s episode…uploading it, and setting it to auto publish! So please tune in this Sunday as we continue forward together down our solutions focused path. Thank you for bearing with me,

 

The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you this Sunday with more; until then, make good choices.

Welcome to What’s Better This Week? Episode 3: What’s A Diagnosis Anyway?

 

Last week we covered what happens in an initial assessment session, the complications that assessment appointments bring when attempting to have a solutions focused practice in a clinical environment, and we finished with our hypothetical patient leaving their first (of three) assessment appointments. 

 

So what happens after they leave my office? What do we do during their second assessment appointment? How do we prepare them for their third assessment appointment? All good questions. I’m glad you asked them. 

 

After I’ve walked the patient back to the waiting room, there are certain things I have to go back and do that are not in line with solutions focused practice.

 

I have to add a mental status exam note (or MSE) to my documentation. This is a requirement in clinical practice. But just because something’s a requirement doesn’t mean that we can’t be solutions focused about it.

 

Generally speaking any standard MSE might read like: 

Patient presented through Same Day Access, dressed appropriately, appeared alert and well-oriented. There was no evidence of disruption in speech flow or content, memory, or perception. Current mood observed as dysphoric with affect congruent to mood. Thoughts were organized and goal-directed. Judgment appeared good, and insight appeared moderate.

Patient presented with:

Stressors regarding housing

Stressors regarding living situation.

Symptoms of depression.

But what is we reframed the presenting symptoms to be not only more solutions focused, but more accurate to the patients truth, and more in line with our practice of taking a step down approach, and honestly more accurate to the patients presentation in general and instead the it read:

Desire to decrease stressors regarding housing

Desire to decrease stressors regarding living situation.

Hopes to increase mood, and desire to decrease feelings of depression.

Well, look at that. By reframing the “objective” (if there ever can be such a thing) MSE’s presenting “ problems to be solutions focused we reorient ourselves and our patient’s documentation away from the typical “patient is depressed,” “patient is angry” to where our patients are back in control, and are being proactive. My what a different way of thinking about our patients. What a different way of framing them to our colleagues. What a way of taking back control from the insurance companies where we must ethically, in a clinical fashion, report clinical symptoms each and every session (which means that everything we do to assist our patients, somehow, must also ethically link to these symptoms and further the patients goals of decreasing them or improving them!). It takes something that is antithetical to SFBT practice, and moves it in a way that most aligns to our core beliefs.

 

Then, and this is of course where my scruff gets a little more ruffled. I have to provide some kind of diagnosis, because if I don’t, insurance won’t pay for the session. And if we, as an agency, don’t receive insurance payments we can’t continue to function as a clinic; and I, as a practitioner, deserve to receive compensation for my labor. I have to eat. I have to pay my bills. And so, I have to provide a diagnosis.

 

Here is another touchpoint. 

 

We must remain ethical. We must remain truthful. We must remain solutions focused. We must balance each session and conversation in order to connect our patients conversation and scaling and best hopes to their mental health concerns which means we must, at times, also guide them in ways we might not have to in a pure SFBT environment. And so diagnosis becomes tricky, and important, because it will become relevant every single session 

 

That said, how we approach the concept of diagnosis with regard to a computer screen, and with regard to a human patient, remain two very different things.

 

Sometime during the first session, when I am given permission to provide psychoeducation on SFBT to my patients, I will discuss with them that a diagnosis is only important to us if it’s relevant to the patient, and that some patients find it relieving, or useful in establishing a framework to understand what has been going on in their lives, and others require it for state or federal benefits. I stress the greater importance of removing barriers, and that the work we’ll be doing together does not require a diagnosis, nor does it require great discussion on what someone’s diagnosis is. I also share that generally the institution most concerned with a diagnosis is the insurance company, so they’ll pay for treatment. I provide psychoeducation that all a diagnosis is, is a label for a cluster of symptoms, and that what we’re concerned with is how those cluster of symptoms come together to create barriers for them, and what we’re going to do to reduce, mitigate, and remove those barriers so they (that is to say our patients) can live the lives they want.

 

So, here is where you will have a dialectic: while you’re going through this process for purposes of explaining to the insurance company, and justifying your SFBT practice, you are going to have on your clinical, psychopathology hat, because you need to. Because otherwise marginalized communities can’t receive SFBT treatment. You will formulate and postulate and pontificate once in your case conceptualization somewhere in the assessment document and be done with it (though you will have to be extraordinarily accurate, so I urge you to take your time - all of your SFBT work will have to come together and connect with this later, and we’ll get much deeper into that as we go on). 

 

The other side of the dialectic coin is that, because you’ve taken time to explain the meaning of what a diagnosis actually is (a cluster of symptoms) and what you and the patient are going to be concerned with (how those symptoms create barriers) you are then free to continue in a solutions focused way (“how did you make that work?”, “that sounds hard, how have you been coping”) to complete the rest of the assessment tabs. 

 

So whether a patient is “screening positive” for trauma, schizophrenia, mood, eating disorders, gambling disorders, substance use disorders, we can use the same solutions focused skills as discussed in last weeks episode, because when it does come time to discuss these (during the treatment planning session), we won’t be using the clinical labels of diagnosis, we’ll be using the solutions focused language of barriers. In situations where we would have to refer out (ie. Eating Disorders for parallel treatment) the same is still true in our individual sessions where we discuss everything else under the sun.

 

This is the balance. We are literally being honest to ourselves (in maintaining our SFBT practice); our patients in explaining to them why we talk in terms of barriers and not diagnosis (while still providing them the opportunity to talk about diagnosis if they want), and the insurance company by providing them with as accurate a diagnosis as the DSM-V can muster, which we will link all treatment to in the future. We are, in essence, creating multiple work products out of the same session, or presenting the same data in different ways, so it can be processed and assessed in the ways that it needs to be, so that each receiver of our information can receive it best (and if that’s not Solutions Focused, I’m really not sure what is). 

 

There’s an excellent article on Alpha, Para, and Infrasignal I will link to in the podcast notes that is heavily correlated to this.

 

So now, we have completed the information gathering necessary for our second assessment session. 

 

I then explain where we are in the assessment process. I explain at their next appointment I’ll be asking them some final questions about themselves and their world, and asking for a urine sample. The time has now come to summarize what has been completed with the patient. I ask them what questions they have (not “if” they have questions, but what questions they have). I check with each and every patient as to whether or not they have thoughts, plans, or intents or harming themselves or others, and then I get them scheduled for their third and final assessment appointment.

 

so Next Week: the third appointment, which again comes right before the treatment planning session. These seems like a good place to leave off because, again, if you’re frustrated by not getting more imagine what our patients are frustrated by , by having to wait a total of four sessions before they can finally begin treatment.

 

Thank you for listening. Please tune in again next Sunday, as we continue forward together down our solutions focused path. I’m @TheMattSchwartz, and it’s time for some self care with my cat, Akiva, who is, actually not  patiently waiting for cuddles, but sitting on top of me while I record this.

 

The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you next Sunday with more; until then, make good choices.

Welcome to What’s Better This Week? Episode 2: Starting From the Beginning.

 

So I’ve put a lot of thought into the best way to show the juxtaposition of Solutions Focused Work in a clinical setting, especially in a New York State, Office of Mental Health Licensed, Outpatient Community Mental Health Clinic.

 

What I’ve come up with (and we’ll see if it pans out, and if it doesn’t, we’ll change tracks) is to go through (at least for the very start of this program) what our patients experience when connecting to the process by going through the process itself, step by step; so I can show where the potential for clashes with the modality and clinical reality are, and how I address and account for them (where possible) in a solutions focused way, and how I make solutions focused work in all of this in general. Then, after that, each week, we’ll tackle general solutions focused stuff that comes up in the clinical world: advances, techniques, new evidenced based research, how we continue to make it all fit together, and more.

 

This Podcast probably isn’t the best for those entirely new to Solutions Focused work, though It will be beneficial for students who want to be SFBT clinicians in the field one day (especially in the states). So that said, I’m going to make one big assumption, and that assumption is that you’re already familiar with SFBT, and have a pretty decent handle on how to conduct a session (at least theoretically) or you’re already an SFBT practitioner.

 

If you don’t or aren't, that’s okay. I think of all of the modalities, SFBT is the modality where we most want to create new practitioners. My suggestion is that if you’re new to this branch of therapy or counseling or coaching (depending on what country you’re listening from) is to get super familiar with it really quick, by reading the works of Insoo Kim Berg, Steve De Shazer, and also watching and reading the works and videos of Scott D. Miller (and there are many more to choose from, and of course, YouTube…which is where I’ve learned everything from how to fix my cars headlights to how to pick a lock, all valuable skills as a former case manager).

 

That said, I’m going to jump right into the podcast. You are welcome back at any time, or you can stick around, and if you find that it’s not making sense maybe it’s time to hit the pause button, and do some light reading.

 

Let’s talk terms. In this podcast, I’m going to refer to clinical work to mean outpatient behavioral health care in an environment which requires the acceptance of insurance in order to treat clients or patients who otherwise could not afford mental health care, and I’m going to refer to SFBT or Solutions Focused to mean Solutions Focused Brief Therapy.

 

So, the first two issues that we run up against in the clinical vs. SFBT divide is that SFBT doesn’t rely on a  diagnosis (in fact, we generally eschew diagnosing patients, and it isn’t necessary for the modality at all)…and, in SFBT we also begin work immediately in the first session, which just doesn’t happen in a clinical setting.

 

In the United States, and certainly in my practice in New York, I am required to provide a diagnosis at the end of the very first visit (despite the fact that we are trained, almost universally across the board of the helping professions) that diagnosing on the first visit or interaction is the worst practice and shouldn’t be done. Insurance requires it, so we make some ethical leaps and bounds, and et viola, we all do it, because otherwise no one would get care (and none of us have risen up en masse to put the insurance companies in their rightful place...yet).

 

The second, most noticeable difference is that in “pure SFBT” we begin the session with the patient or client immediately when they are in our office, at their first appointment. Sure, maybe they sign a couple of forms and releases at the front desk (or online if they register through a portal), but as soon as they sit down, we start. Not so in a clinical environment. First, there’s a patient intake process, and confirming insurance (at my clinic patient’s do this in a little phone booth). Then there’s another intake process to get more information in the waiting room (which is done on a clipboard). Then we are required to complete an in person assessment process which takes (up to, and sometimes standardized to) three sessions, where we are required to ask a myriad of questions on an electronic form of which, as a solutions focused counselor, I find unhelpful, unnecessary, and generally useless (all of the information in this assessment will come out, if it’s relevant, during session). However, they’re mandatory…because someone (other than me) has determined that they’re mandatory (oftentimes the state agencies that license our clinics, and are what allow us to provide services to the most marginalized and in need in our communities).

 

What an incredible difference: In true SFBT practice, we begin our treatment of the patient from the word “go.” In clinical practice we don’t begin treatment until the fifth appointment. That’s because the first three appointments are assessment appointments (which, of course, benefits the clinician and the agency more than they benefit the patient). We also take a urine sample somewhere in there to establish a baseline measure so we can appease the DSM-V’s “rule out substances” clause, and then the fourth visit is when a collaborative treatment plan is made (more on that later, because it becomes incredibly important when we look at solutions focused work in a clinical environment…legally, ethically, and for billing purposes).

 

So…wow...that’s a month and a week of appointments before we get down to helping a patient help themselves figure out what to do for why they walked in our doors in the first place.

 

To be fair to my agency, we have been working diligently (across all modalities) to ensure that patients do receive some time in each assessment appointment to talk, or learn coping skills…but they are clearly not therapy sessions.

 

So besides the fact that this flies in the face of patient centered treatment; and the fact that it’s antithetical to solutions focused treatment, one of the bigger problems is that the statistical mode (the most common number of all sessions a patient or client will have in therapy) is one. This means that we spend a ton of time gathering information, and data (again, usually because a regulatory bureaucrat thinks that it's important) instead of helping patients in what may be their only interaction with a therapist ever.

 

So, why would I - or why would you, as a solutions focused person, ever want to get involved in this nonsense? It’s not because you want to get your C or your -R credential (editorial note: I’m heavily biased toward Social Work). It’s because it is absolutely vital that marginalized communities (of which these community mental health clinics serve) be given the opportunity to receive this same level of evidence based, person centered, empowering care, that otherwise only those who have extra, disposable income could afford. That’s why. And I’m going to encourage you to stick around with me, and to become experts on making it work…because we have to. Because people need this modality. And we have to be able to offer it to them.

 

So let’s dive in a bit further: There’s little I can do about the process (right now) before someone gets into my office. However, once someone is in my office, I have a great deal of control…it’s my space.

 

The first thing that I do when I sit down with a patient, after explaining confidentiality, is I ask them “What brings you in?” and then, after they let me know what brought them in, I ask “how can I be helpful?" (shout how to Denise Krause at the UB School of Social Work for teaching me that question, it’s one of my go to questions, especially when I get stuck. Then I genuinely listen. I don’t listen to respond. I just listen to listen. 

 

Already, the tenor of a typical “assessment” appointment has changed. First, I’m not rapid firing questions at them, and I’m not talking about myself, my philosophy, my agency, or our process. There’s one person that’s important here. The patient (and their needs). Once they have expressed themselves enough to answer this question, I use a Solutions Focused Formulation to share back with them why they’re here.

 

I then share that I use collaborative documentation in order to take notes (we’ll come back to this - since I don’t use a pad or a computer during anything but the last five minutes of session after this process), and I ask for permission to begin the assessment process. I then wait to receive that permission. (it’s at this point I turn around, and unlock my computer screen). I then take everything that the patient and I have discussed, and - instead of asking it in the form of assessment questions all over again. Type what the patient has already shared with me into the corresponding boxes. I type while speaking out loud what it is that I’m typing, so if I make a mistake the patient can correct me (that’s part of the collaborative documentation part) . I will then ask for filler, or clarifying information as needed. In doing this, I show that I’ve listened to the patient. I then ask an assessment question, in a very solutions focused way.

 

Instead of asking the question that’s on the assessment (that was added to encourage clinicians to work with patients on some of their needs during the assessment process, which is “what is one thing we can work on today to make you feel hopeful about this and other sessions”), I ask the SFBT question of “so what’s your best hope for Today’s session, so when you leave here today, you’ll know that it wasn’t a waste of time, and that you really got something out of it?” I then make sure that we work on that.

 

This has, likely, used up around no more than 20 or so minutes of our time (all said and done). Assessment appointments (since they’re billed at a higher reimbursement rate, hence why there’s three of them, because three of them are allowed, and community health clinics are floundering financially as it is…) last an hour. This means that we have another forty minutes together. Within the first session there are certain tabs on our EMR’s intake assessment that must be completed. The biographical tab, the depression screen tab, the lethality tab, and then I always do the safety plan tab because, honestly, it does happen to be a great intervention. The depression tab has to be completed even if the patient has never, ever, ever, ever been depressed a day in their life. Totally antithetical to SFBT. That said, the questions don’t have to be. If a patient is “scoring” (as if it’s a sports match) low or high on the screen, we can still move it into SFBT languages (we cannot change the language of the screening tool…because then it will no longer be the evidenced based screening tool…).

 

So instead of saying “wow, you’re really depressed!” or “it seems that you’re very depressed!” we can say “wow, that all must be very difficult…how have you been coping?” or “wow, how have you managed, despite things being so difficult, to make sure that you’re mood’s been okay?” The same is true for questions on the lethality tab where we also do risk assessment, and have to ask about things such as past arrests (“That sounds very frightening, how did you get through that?”) or the safety/coping plan (“it seems that you have a lot of supports, and a lot of people who really care about you, how did you develop such a great support network?” or “that seems really difficult, not having many people to rely on, how are you coping right now?”).

 

So finally, we’ve made it through most of these tabs, and - if everything has gone right…there’s twenty or so minutes to go, where I can say “excellent, so we have twenty or so minutes remaining to talk, thank you so much for bearing through that process, let’s get you scheduled for your next appointment so we can finish out using the remaining time to brainstorm around what brought you in here, in the first place, when you mentioned what your best hopes for today’s session were, what I heard you say was…”

 

This seems as good a place as any to stop…since it’s where I have to stop with my patients during their first week of the assessment process. Next week, we’ll cover what happens after the patient leaves my office after their first session, as well as the second week of the assessment process. We’ll also go a little more in depth as we explore the notion of diagnosis, what it means to assess for past treatment history, trauma, schizophrenia, mood, eating disorders, gambling disorders, substance use disorders, and more as a solutions focused counselor, and what it looks like to prep the patient for their third assessment appointment.

 

Thank you for listening. Please tune in again next Sunday, as we continue forward together down our solutions focused path. I’m @TheMattSchwartz, and it’s time for some self care with my cat, Akiva, who is patiently waiting for cuddles while I record this.

 

The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. One day, when I have enough subscribers, I may even purchase one of their pretty cool professional licenses licenses (you should check them out, NPR even uses them, they’re that snazzy). I’ll see you next Sunday with more; until then, make good choices.

Welcome to What’s Better This Week? My newly rebranded podcast. I had taken around a year off because I wasn’t really sure where I was going with my podcast, and because I needed to upgrade some of my technology (thank you Sony voice recorder, and iPad pro). However, I recently attended the Solutions Focused Brief Therapy Association’s 2019 Annual Conference and, while there, I realized that - in many ways - my practice of Solutions Focused Brief Therapy is unique. While many practitioners work in schools, or in Solutions Focused Centers, or in countries where socialized or nationalized healthcare is the norm, my practice is at a community mental health clinic, licensed underneath New York State’s Office of Mental Health, where I have to balance the requirements of New York State’s Goal/Objective oriented treatment plans, Medicaid, Medicare, and other Insurance Companies insurance requirements, and the need for Diagnosis at the first session with Solution Focused Brief Therapy which (in many ways) is at the antithesis of this…and I have to do it ethically. Fortunately, I’m supported by an incredible agency, which lets my have an entirely Solutions Focused practice at a community behavioral health clinic. What I realized though, is that this should really be the focus of my program, because I think that we need *more* access to SFBT in community clinics, to those who traditionally aren’t able to access this practice…and so I want to share with folks how I’m making it work (and if you’re also making it work in these settings, I want to interview you). So, I figured this would be a good introduction episode.

 

As for the show’s title, well…it’s the first question I ask each and every patient, each and every week…so it seemed fitting.

 

Anyway, I’m @TheMattSchwartz, and it’s time for some self care with my cat, Akiva, who is patiently waiting for cuddles at the end of my bed where I’m recording this.

 

 

The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions" generously shared through a creative commons license. Please find more of their music at www.sessions.blue, that’s w-w-w- dot s-e-s-s-i-o-n-s- dot b-l-u-e. I’ll see you on Sunday; until then, make good choices.

Welcome to TheMattSchwartz(Cast) where each week we dive into the world of Social Work in Mental Health & Counseling Settings and hopefully provide you with some inspiration to start your week! I’m your host, Matt Schwartz. This week’s episode is Episode 3: Self Care & Sniffles.

So last episode I said we would start getting into Caseload Management techniques, and we are…but then I came down with an awful chest infection, missed a couple of weeks of podcasting, went on a wonderful vacation to Vienna, Austria for the holidays, came back to work, had a blizzard (had the furnace go out on the first day of the blizzard), and then have been in a flareup for the past few days (we’ll get back to that in a minute).

During all of this, I had a bit of an epiphany: you can’t actually talk about Caseload Management in Social Work (clinical or otherwise) unless you first talk about self-care. Like…actual self-care. Meaningful self-care. For realsies self-care.

As social workers, we hear a lot about self-care - from the moment we enter Grad School, until the day we retire and beyond. We’re told to do yoga, drink water, seek supervision, meditate, find hobbies, and more. This is all, generally speaking, great advice. The University at Buffalo School of Social Work even has a fantastic Self Care Starter Kit on their website (which you can find at socialwork.buffalo.edu). All of these things are wonderful to do, and can help keep us centered and improve our wellness. However, no amount of tending to office plants (no matter how much I want to personally believe otherwise) will prevent burnout if we don’t make the necessary time for self-care, and if we don’t set up the appropriate, and necessary boundaries.

What I’ve found missing from the conversation - and I preface this with the standard disclaimer that these thoughts are my own, and don’t represent any organization I work for, have worked for, or may ever work for in the future - are two things. The first, is how are agencies actually supporting their workers in conducting self-care on the job (which I maintain is an ethical imperative)?; and the second is, how are we - as social workers - working to build it into our schedules, time management, and caseload management practices whether our employers or agencies want to support us in these endeavors or not? And I don’t mean in some covert way that Human Resources can never find out about. I mean in a very transparent “I require self-care to do my job, and some of that self-care happens on the clock, look, it’s right there in my schedule…” sort of way.

The answer that I have found for myself (and I promise we’ll get back to base camp if I bring us too far off the beaten path for a while) is Bullet Journaling, or BuJo-ing. I have always been a journaler, writer, blogger, and obsessive calendar keeper and office supply aficionado (some might even say hoarder)…I fell into Bullet Journaling a few years ago because it worked with how my brain worked (and it turns out that the inventor, Ryder Carroll and I have some similarities in that area, and I’m willing even to bet that parts of our notebooks might have even looked the same if we were to compare them back when we were in High School)…but Ryder found a way to really create a way of systemizing his process, and combining his method with CBT, mindfulness, and - while I don’t think it was intentional - even a bit of DBT.

I fell into BuJo-ing even further when I was a medical case manager, and - after having woken up almost entirely paralyzed one morning I entered a medical Odyssey for physical disabilities that I had never thought I’d have to consider. I grew up being neurologically divergent, and learning disabled…but I had never had to contend with physical disabilities or overtly visible disabilities…or chronic pain. I needed a way to walk into a medical professional’s office, and drop something down on a table with data about symptoms: dates, times, feelings, the weather when things happened, my blood sugar, any possible trigger that was nearby, where on my body things hurt. Something like two years later I finally had something as close to a solid diagnosis of a diagnosis as I would ever get. Rheumatoid Arthritis, Polymyositis, and Fibromyalgia.

So when Ryder Carroll released his book, last year, The Bullet Journal Method I was curious to read it; and incorporate it into my self-care practice at work (or more of it than I had gathered on the various FaceBook groups I had been a member of). I started rapid logging during the day as I went. Every single task (obviously no PHI, but reminders of things that needed to get done, events, thoughts, to-dos). I also continued to keep track of the internal side-eye toward things I had agreed to do, but that were likely time-sucks…or that I was beginning to feel were taking up time I could be otherwise using for other things…or that was becoming too physically hard on my body to justify continuing with (I’m super good at providing brain-support; but don’t ask me to show up at your board meeting or committee meeting, it probably won’t happen, especially if it’s after a full’s day work).

Through my own practices, buttressed by Ryder Carroll’s and the BuJo community (which is an endlessly supportive community online, by the way) I was able to become more mindful of my time (to say nothing of always being on top of my case notes, treatment plans, and other tasks). I continue to monitor my symptoms…and I continue to focus on my self-care. Through mindfulness, and intentionality of “why am I doing this? (which Ryder preachers a lot in his book) I was able to truly, for the first time, start saying “no” in a meaningful way (…mind you, the last convention I went to, I took a 45 minute workshop where we all stood up and practiced saying “No” together in a variety of different voices…so clearly it’s an issue in our field). Think of it as the KonMari method for “Does This Bring You Joy” but in your professional life. We can’t do everything. We can’t be everything to all people. We can’t save everyone. We have to take care of ourselves. To do that, we have to honestly, and as self-critically as possible look at where we are spending the incredible valuable amount of time we get a day…and then liberate as much of it as is ethically and feasibly possible and possible to do.

So next Sunday when I share with you some of my custom made templates for case management (who doesn’t love a good DOC/PDF download combo?) I’m going to entreat you to think about your own intentionality, your own time management (at home and at work), your own boundaries first. I’m going to ask you to reflect on why you’re doing what you’re doing…because if we can’t manage our own time effectively, if we can’t determine how and when we’re going to take care of ourselves: at work, at home, with friends, on the road…then we’re going to burn out. I’m also going to ask that when the notion of self-care comes up at work (as no doubt it will) that we begin discussing these things openly, and at a deeper level than squish balls and water bottles.

2018 was a hard year for most of us (despite some amazing successes, personal growth, and transformations). Let’s make sure that we practice radical self-care in 2019, even if we have to bring our agencies kicking and screaming forward into the future with us…because we need you to remain a Social Worker from now until you retire…and then we need you to become a mentor after that. The world needs you and your talents…and we all lose out if you leave the field of Social Work due to burn out.

The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions” generously shared through a creative commons license, found through the Free Music Archive. Please find more of their music at www.sessions.blue. You can interact with me on twitter by @‘ing TheMattSchwartz. I’ll see you next week, until then, make good choices.

Welcome to TheMattSchwartz(Cast) where each week we dive into the world of Social Work in Mental Health & Counseling Settings, and hopefully provide you with some inspiration to start your week! I’m your host, Matt Schwartz. This week’s episode is Episode 2: Getting a Clinical Field Placement.

I was asked by Michael Lynch, a Clinical Assistant Professor for Field Education at the University at Buffalo School of Social Work to make a short three-minute video on what it takes to prepare for and obtain a clinical field placement...abbbboooouuuuuuuuut six months ago. He asked me to make a video about it because apparently, Social Work students were having a hard time getting into clinical field placements. I will admit that the process of obtaining my placements were pretty grueling.

I tried making the video (I honestly did), and it just wasn’t working out, and sometimes you just have to go with what you know (so sorry for the delay and radio silence, Mike!), um it’s just that I have found the medium of a podcast much easier to manage, and - if you want to get into a clinical field placement - you’re going to have to be willing to listen to something longer than a three minute YouTube clip anyway...so hopefully you can listen to this on your way to class or while you’re circling UB attempting to find a parking space (and remember there’s always the Center For Tomorrow lot…)

So today we’re going to talk about a few things, more or less, first we’re going to talk about preparing for a clinical field placement, we’re going to talk about what expectations at a clinical field placement look like, what my trajectory looked like (to give you an idea of what to expect), and we’ll have some keep in mind's sprinkled throughout.

As a new meme that’s been going around on Facebook says Social Workers are really good at pointing at the elephant in the room and saying “So, this is Bartholomew…”

So, let’s address the Elephant in the Room right now: Clinical Field placements and internships take more time than other field placements. Speaking not just from my experience, which I’ll get to in a bit, I also spoke to other former internship and practicum directors when I was preparing for this podcast. They all said they had similar expectations when and if they were willing to accept Social Work students into the programs: be prepared to sign and agree to more hours than what the Field Office requires. In the view of many of the people I spoke with, they are training you for the real world and providing you with an opportunity that fewer people get, so they want something back in return, and they want it back in terms of labor. This means instead of the 15 hours a week, I was doing more than 20, and that was with some pretty firm boundaries set.

So if you’re going to prepare for a clinical field placement, I am going to strongly recommend (now, as soon as you can) that you prepare to drop down to be a part-time student in the program. You’re going to want to have the time necessary to do your homework, to study, to practice self-care (yes, really), and to be flexible enough with your class schedule that you can accept a clinical position, because they’re not (necessarily) going to be flexible with their schedule for you: they still have a clinic to run, they still have weekly meetings scheduled months in advance, and they’re going to need you at many of those meetings, and you’re going to want to be at those meetings.

Now here’s the Catch-22: you need experience to get experience, and I’m sure you’ve heard that before. To get the experience that you’ll need to have a shot at a clinical field placement, you’ll need to either work as a case manager (if you’re in New York State, Health Homes are a great way to get this experience), or to volunteer in any role where you’ll formally be providing some kind of counseling as part of your position (remember: counseling does NOT equal psychotherapy). You can provide counseling on housing rights, counseling on benefits, etc. Work as a volunteer on a crisis hotline (bonus: free crisis training)!

Which gets me back to our friend Bartholomew: if you aren’t already working as a case manager, or as a counselor, when are you going to have time to volunteer or work to get this experience, alongside all of your other obligations, if you aren’t doing the MSW program part-time?

I’ve had a few people ask me why they need this experience when the point of field education is to train MSW students. The answer is that field education trains students but to a point, and not in what the field educators view as education the students should already have.

When you get to a clinical field placement site the expectations are that you can a) provide counseling, b) are familiar with the DSM-V, the ICD-10, have taken Psychopathology, and have a passing familiarity with differential diagnosis (you don’t have to be an expert on it yet), and c) that you are prepared to hit the ground running, and that you can work with as little supervision as is necessary (so i.e. that you can function as a professional). They don’t have time to babysit or hold your hand. They’ll be with their own clients, their own patients. They’ll be there for you in an emergency, but they really do expect you to be able to work on your own.

So the experience that you gain when working as a case manager, or as a volunteer counselor show to the clinical site that they can trust that you already know how to function on your own, that you can manage your own calendar, that you understand deadlines, can be trusted to work, understand privacy rights and rules, and have the basic skills necessary to handle the patients that the will allow you to start off seeing.

Also - and this is Bartholomew the Elephant’s Best Friend, Wilhelmina we’re going to talk about for a moment getting comfortable with any hangups you have about presenting regularly in front of other people. You will need to be able to talk about yourself, your credentials, your philosophy to counseling - and if you don’t have one, please get one - your approach to social work.

As a future clinician you’ll be presenting your cases regularly in disposition often (also sometimes called case conference depending on where you work). As a clinical intern, you’ll be expected to present in front of senior staff weekly. Also, you have to be ready to talk about your skills, and what you bring to the table during your interviews…and even if you don’t yet believe it about yourself (and I assure you that you will, one day, sooner than you think), you’ll need to sound convincing about your skills and what you know…so fake it until you make it! Find some workshops at your school. Be prepared to get comfortable volunteering, to be the first to speak in class, the first to present, the first to do things. Learn to get comfortable with discomfort and shades of grey.

So what did my trajectory look like?

Well, I started as a part-time student at the University at Buffalo School of Social Work, and I knew (as an older student - I started in my 30s) that I wanted to be a clinical social worker. Because I was a part-time student, my foundation year field placement didn’t start until my second year in the program. I made it clear with no less than a thousand emails that I wanted a clinical field placement, and that I did not - in any way - want to work with children. I met with the then Director of Field Education, Zoe, who was willing to meet me part way. She said that she had a school that had a Family Solutions Center where they did counseling for the community, as well as for the parents and kids in the school district at night, but that part of the field placement was only one day a week, the other day was doing school social work with kids.

Zoe reminded me - quite rightly - that adults have kids, and that even if I didn’t want to work with children, children are part of families and, taking an ecological perspective…I should take it as a learning opportunity. I am so incredibly grateful that I did. First, Solutions Focused Therapy is still my main modality (to this day). I am the only one on my counseling team who practices it, which means I’ve become somewhat of a content area specialist at my workplace. I am a giant solutions focused nerd…I can’t get enough of it Second, I learned that I can work with children (even if I don’t like to) and that was really important to learn, for me…because it showed me, like “hey, you can do this thing, that you didn’t think you can do, and that you don’t generally like doing anyway,” so that was good to know.

At this Field Placement, I did my best to make the most of the parts that weren’t totally interesting to me, and to learn from, them, and to grow from them: and guess what I found? Today, when I’m dealing with a really, really, really angry adult raging in the waiting room…the reason I’m so calm, is because I learned patience from dealing with really, really angry kindergarteners who were also raging…just in the classroom. I draw on those experiences almost daily. I also had counseling opportunities, every single day, even if they weren’t clinical opportunities - when I was working with the kids as a School Social Work intern, that gave me something to talk about during my interview (along with my work experience as a case manager).

Also, important to note, during the proceeding semesters I also took Psychopathology, Motivational Interviewing and Cognitive Behavioral Therapy (which was the crux of my Interventions with Adults course). This meant when it was time to interview and they asked me about my modalities, I could - honestly - tell them that my primary modality was Solutions Focused Brief Therapy, but that I also practiced Motivational Interviewing, and Cognitive Behavioral Therapy. I had a toolkit!

I also spent time writing out my Treatment Philosophy - and having folks who are much more adept with the English language than I am (shout out to Jackie Verruso, at Verrusology) edit it. I needed to be able to effectively and articulately explain how I approached Social Work. What did it mean to be a Postmodern Social Worker in actual practice? Because during your interview, they’re going to ask you about your treatment philosophy…and they’re going to challenge you on it, too.

So when it came time to put in my list of agencies that I wanted to intern at for my advanced year placement, I chose only clinical sites (this was also at the urging of Dr. Elze, who encouraged me to find a placement that would give me as many hours of clinical work as possible, rather than accept any kind of situation where I was doing part research/part clinical work - and I thank her for her guidance). I was offered an interview at the Buffalo State College Counseling Center. I will happily share that the interview was intimidating, and I nearly vomited on my way home. That said, the most intimidating person in that interview, Dr. Rivera, became my Field Educator, as well as my mentor, and now a dear friend.

I spent 10 months, with my own caseload, working with individual students, providing clinical social work services, individual counseling, group therapy, and more. It was absolutely amazing, and truly a transformative and life-changing opportunity.

The experience, as I outlined at the start - is intense. You are expected to hit the ground running. You occupy an awkward grey space of professional, and not-yet-professional enough; you are expected to come in with oodles of knowledge, and then learn more, all while managing a caseload…and at the end of the day, I would do it all over again - happily. I can’t promise that what worked for me, will work for you. But I can share that before I graduated I was given a job offer by a Top 10 company to work for, that’s literally the Best in Class Provider for Mental Health & Addictions in Western New York and that I’m still working there quite happily. Perhaps more importantly, I very much using the skills that I learned at both of my field placements every single day.

So, please take what works, leave what doesn’t. Clinical work is not for everyone. It is not the end all and be all of the wide, wide world of Social Work, but if it’s for you, you’ll be amazed at the lives you’ll be able to change.

Well, that’s all for this episode. Next week’s episode we’ll be looking at caseload management, and some caseload management techniques. Remember, practice radical self-care always, because you’re you, and that means that you’re worth it.

The music you’re listening to in the background today is Boston Landing on “Blue Dot Sessions” generously shared through a creative commons license, found through the Free Music Archive. Please find more of their music at www.sessions.blue. You can interact with me on twitter by @‘ing TheMattSchwartz. I’ll see you next Sunday until then, make good choices.

What's Better This Week? is a weekly podcast focusing on balancing the practice of Solutions Focused Brief Therapy with the realities and the demands of a clinical environment in the USA.

What's Better This Week? is a weekly podcast focusing on balancing the practice of Solutions Focused Brief Therapy with the realities and the demands of a clinical environment in the USA.