Guideposts for Treatment Planning and Goal Setting

One general guidepost is that the more severe the personality pathology and the more poorly the individual is functioning, the more appropriate it is that the therapy/intervention be directed at the level of the environment. The obverse also bears stating. The more intact and highly functioning is the individual, the more appropriate are therapies directed at the deeper level of the individual, including the more psychodynamic therapies.

When considering treatment planning, a seminal question is: Where in the individual or the system can I anticipate the least resistance and the greatest openness to positive change?

The assessment of personality disorders was addressed in Chapter 9. To summarize, the basic elements need to include: chart review, clinical interview of the patient, interview with informants (e.g., from the family or the setting), and standardized assessment measures (e.g., personality inventories and structured interviews). Assessment rules of thumb lead to the diagnosis of treatable conditions, determination of the baselines of the patient's usual level of functioning, highest level of functioning, and the trajectory and rate of change.

Goal setting determines the course for the treatment and informs the options to be considered. In thinking about treatment goals, the critical questions include: Whose goal is it? Does the patient support the goal? Does the patient support how the goal is to be reached? Is the goal feasible for this patient at this time? How will the clinician and patient know that the goal has been reached? Will reaching the goal expose another problem?

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