Clinical care starts with the first diagnostic interview. Therapeutic
planning and prognosis should be based on competently conductedand documented
comprehensive diagnosis, i.e. a standardisedmulti-axial formulation covering
clinical disorders, disabilities,contextual problems and quality of life, as
well as an idiographicor personalised formulation articulating the
perspectives ofthe clinician with those of the patient and family on
contextualisedclinical problems, the patient's positive factors, and
expectationsabout restoration and promotion of health.
The treatment or care plan involves a listing of clinical problemsas
targets for treatment and the formulation of a programmeof care for each one
of them.
The elements for constructing a list of clinical problems comefrom the set
of clinical disorders, disabilities and contextualfactors presented in the
multi-axial diagnostic formulationas well as from considerations presented in
the idiographicformulation. Each problem should be delineated as a target of
a cohesive programme of care. The list of problems should bekept reasonably
short to prevent any duplication of treatmentprogrammes and to avoid
burdening the clinician with excessivedocumentation.
The programme of care planned for each identified problem mightinclude
biological (e.g. pharmacological and electroconvulsivetherapy), psychological
(e.g. psychodynamic and cognitivebehaviouraltherapy) and social (e.g.
family and group therapies, educationaland vocational rehabilitation, housing
assistance) therapiesas well as additional diagnostic studies (e.g. imaging,
IQtesting, cultural consultation). Every planned interventionshould be
specifically and clearly described.
Although disorder-based treatment algorithms and practice guidelinesmay be
helpful as references, actual programmes of care shouldbe personalised,
giving attention to illness complexity (e.g.comorbidity, pattern of
disabilities and contextual factors),range of patient's assets, and local
treatment resources andhealth care norms.
All elements of the care plan listing of clinical problemsand
specific interventions should be worked out collaborativelybetween
the clinician and the patient (and family members whereappropriate). Efforts
should be made to reconcile expectationsabout treatment goals and to achieve
shared awareness of thelikely benefits and side-effects of the selected
therapies.
As multi-disciplinary teams are usually required for effectivehealth care,
all key members of the team must participate inthe design of the treatment
plan. This plan should facilitateprofessional communication among all team
members working witha particular patient, and promote fully coordinated
therapeuticefforts.
Prognosis should be based on a comprehensive diagnostic formulationrather
than just on a single disorder. Comorbid psychopathological,substance misuse
and personality disorders, concomitant generalmedical conditions,
occupational and interpersonal disabilities,available social supports and
therapeutic resources, as wellas idiographic perspectives on contextualised
clinical problems,patient's assets and expectations, are all relevant to the
prediction of illness course and therapeutic outcome. Outcomeitself is a
pluralistic concept, involving symptom remission,functional improvement,
activation of supports and enhancementof quality of life.
Clinicianpatient engagement and partnership is as importantfor care
planning as it is for diagnostic formulation. Suchengagement involves
awareness of the cultural framework ofboth the experience of illness and the
process of seeking andproviding help. Clinical care includes not only
curative effortsbut also empathic consolation and promotion of healthy
behaviourand quality of life. Engaging the patient is critical for the
attainment of therapeutic effectiveness and the fulfilment ofethical
responsibilities.
The linking of comprehensive diagnosis to comprehensive treatmentcan be
facilitated by the use of a treatment plan format. Thisshould be completed
jointly by all members of the clinicalteam working with the patient (who
should also be involvedin the process). A prototype treatment plan form,
enablingthe listing of clinical problems to be linked with specific
interventions and allowing space for special observations, isset out in
Fig. 9.1.
Cournos, F. & Cabaniss, D. L. (2000)
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