“It’s the Economy, Stupid!”
There is surely cause for mental health care providers to salute the commitment of series editor, Arthur Jongsma, Jr., and publisher, John Wiley, for their massive roll-out of the Practice Planners series of psychotherapy source books, reference manuals, and treatment planners. The number of titles in the entire series approaches two dozen now, most of which include disks so that therapists can customize forms and paperwork to meet their own practice requirements. Two of the volumes are completely computer-dedicated and offer billing, scheduling, and general office functions, as well as general computerized treatment planning assistance. Providers looking to enhance productivity in their practice will be well-served to consider some or all of the offerings in this series as part of the fiscal difficulties many providers are experiencing in today’s managed care environment are a function of antiquated, inefficient, and redundant treatment planning, documentation, and billing infrastructure and procedures.

The corporatization of just about everything in life today, including some mental health care, can illuminate areas of practice that can benefit from efforts to streamline and economize. Economies of scale and efficient practices will differentiate providers who will survive in the new marketplace from those who will not. As psychotherapy looks to become like any other economic product where issues of marketing and efficiency are paramount, issues of accountability will also be necessary to differentiate providers in the marketplace – at the high-end and for value-shoppers in the vast middle.

It’s the Accountability!
The Practice Planners series will be a useful risk-management strategy to ensure that mental health care is well-documented, consistent, and replicable. Insofar as the series attempts to offer the “best practices” of empirically-based treatment which have influenced other branches of medicine, they also offer a modicum of accountability and consistency. Yet psychotherapy, unlike most other branches of medicine, remains a remarkably unwieldy, unmanageable, and disparate profession, where there is no consensus at all about “best practices” or even what constitutes the evidence to evaluate such questions. Providers remain exceedingly factionalized and must preface every conversation with an introduction about their clinical orientation and thus their ways of seeing. There can be no pre-theoretical conversation in or about psychotherapy.

Many therapists will condemn or ignore the Practice Planners series for the corporatization and the manualization of the always individualized and idiosyncratic process of psychotherapy. But even the Practice Planners series does not go far enough in proffering that the real test of accountability will not be in empirically-validated treatments but rather in empirically validated treaters. While science has revealed over and over that psychotherapy works and that one brand of therapy is just as good as another, it has also revealed is that not all therapists are equally as good.

Some therapists, quite simply, produce better outcomes than others, more consistently and across a wider-range of patients, regardless of therapy model and regardless of homework assignments given in treatment. Some therapists are not only able to provide solid, lasting outcomes, but they are able to do it much more efficiently as well. It is this kind of data which the managed care companies are really interested in tracking, and if providers wish to survive, in either high-volume or boutique practice, they will increasingly be called on to demonstrate their efficacy and outcomes. Certainly medicine is moving this way and psychotherapy in many ways is just as much a part of the mainstream economy as any other service. If the Practice Planners manuals can help therapists pay more attention to their patients, their relationships with their patients, and patient-anchored outcomes, and less to the drudgery of paperwork, then the series will indeed offer therapists a competitive advantage.

In taking a closer look at the specific volumes under review here, we must be mindful of the marketing strategies necessary to differentiate these titles in the marketplace. In reviewing the data about psychotherapy utilization and outcome, it is increasingly well-known that there is no such thing as brief therapy because there is no such thing as long-term therapy. About 90% of all psychotherapy patients come for less than 10 visits with the mean treatment episode being about 4.6 sessions and the modal number of visits being just one (!). Insofar as the three titles under review can help therapists ensure that patients take something useful away from what will be, inevitably, brief therapy, they are well-recommended.

It’s the Motivation!
One of the ironies of the series of Homework Planners is that “homework” is seldom a major contributor to psychotherapy outcome. So as useful as each of these titles are in providing strategies and interventions for a wide range of cross-referenced and indexed symptoms and presenting problems, we must not assume that the proper homework assignment will magically make the difference in treatment.

One of the largest contributors to psychotherapy outcome (about twice as large as the contribution of therapist factors, theory, or homework combined) is patient motivation and willingness to change. These books will be useful to patients who, though not necessarily as a replacement for professional care but perhaps as an adjunct to, are genuinely motivated to do things differently themselves and are willing to try a wide variety of measures to have things be different. Patients with this type of motivation will find the exercises and assignments in these books to be exceedingly useful, not necessarily because of the exercises and suggestions themselves, but because they focus patient motivation and enhance a sense of self-efficacy.

In general, patients are not just looking for ways to help themselves feel less anxious, or grieve, or help their child stop wetting the bed, or get their teenager to school, but for consistent reminders that they want things to be different, are willing to work at it, and have many ideas of their own to try, as well as those in the books. When therapists encounter singularly motivated patients the best strategy is to “stay out of the way of change” and try to feed the patient interventions that best fit the patient’s theory of change, not the therapists’. The therapist will also want to observe and help the patient take credit for the “difference that makes a difference” in eliciting and sustaining change. The best homework usually entails prescribing some variation on things patients and families are doing already that is useful, or that best fits their ideas about what might be helpful (whether writing a letter to the problem or establishing a very behavioral chore chart, to cite just two possibilities).

Unfortunately, however, most patients are not such motivated customers for change. Most patients come to treatment because someone else has made them or because the patient thinks that someone other than him or herself needs to change. These patients are motivated to have things be different, to be sure, but not necessarily to do anything differently themselves. Most patients in reality would either like a spouse, child, teacher (etc.) to change, or the patient might be in treatment to satisfy the requirements of a spouse, a job, a court, DSS, a school or the like. For patients where the personal motivation for change is minimal to nil, homework assignments, however well crafted or matched to presenting problems and diagnosis, will be of little use.

In summary, if the patient is motivated, he or she may not need a therapist (at least initially) and can work on the books independently, or continue to do more of what works independent of the books. If the patient is not motivated, the books will be of little use unless and until the patient’s theory of change can be validated and the patient connected with and coaxed into some willingness to do things differently.

Don’t Do Your Homework!
Even if patients and therapists are working separately or together on assignments in the Homework Planners, as the Introductions to each of the volumes implies, we must not become obsessional about checking the assignments. What’s important in psychotherapy outcome is not just reducing a specific set of symptoms but in enhancing an overall sense of self-efficacy, a sense that regardless of the next set of problems, one would have the past record of success and capacity to trust oneself to try some things differently.

Though these are all large volumes and there are some exceptions, the homework assignments are generally written in terms of reducing problematic behavior (“Not Goals”) rather than in terms of what better would like in terms of specific, concrete, behavioral goals. The first title, Brief Therapy Homework Planner, is the one most oriented toward “Presence Goals,” which makes sense given that it appears partially commissioned and endorsed by Bill O’Hanlon, one of the founders of Solution-Oriented Brief Therapy.

Brief Therapy Homework Planner does indeed stay very close to the formulas of Old-School, Solution-Oriented Therapy which is its greatest strength; however, one’s model of therapy, even of brief therapy, doesn’t contribute much to outcome, and homework is seldom part of the “heart and soul of change.”

In moving beyond formulaic, model-driven psychotherapy to patient-anchored-outcomes-oriented treatment, we realize that it doesn’t much matter if a patient does the homework or not. If a patient didn’t do it, it wouldn’t necessarily be a sign of resistance as much as a sign of low motivation, or at least motivation different than what we had assessed it to be. We know that resistance is not something that simply resides in a patient, but rather emerges in the context of a treatment relationship, and the onus, quite frankly, may be more on the therapist to think about what he or she can do differently to try to stay connected in a collaborative treatment relationship. “Cooperating with the Uncooperative” might sometimes mean helping the patient end treatment for the time being or find another therapist.

What we are interested in as therapists is what the patient had actually done differently and what the patient thinks might be effective in bringing about change. We want to enhance self-efficacy, and cooperate and collaborate with the patient’s theory of change, rather than imposing our own.

Sometimes patients find motivation for change in being educated about their symptoms, illness, and treatment options; more often they don’t. Most patients want to work in a collaborative way with their therapists and we must remain attentive to patients’ creative solutions, and help them reinforce them. What would be useful to observe is not the patient’s homework, but what in general the patient did or did not do, how that was thought up, and to maintain curiosity about what was done, not to what was not done. What was done, even if it wasn’t the homework, will always reveal something about a patient’s motivation, their goals, and theory of change, and allow us to cooperate better with them rather than to struggle with them over homework.

If someone is really not interested in doing homework or taking any action to change a set of problems, it may also be time to recommend a break from therapy altogether. As Steffanie and Bill O’Hanlon explain with regard to homework tasks in the May/June 1998 issue of the Family Therapy Networker:

“When tasks are habitually not done, we use this analogy with clients: ‘I keep firing the starting pistol, but you haven’t left the blocks yet. You say you want to reach the finish line (your goal of fighting less, feeling happier, getting a better job), but you’re still at the starting position looking at me as if to say, “Why aren’t I at the finish line yet?” The task we discussed is the starting pistol. Actions get you off the blocks and to the finish line.’…. (T)he therapist should never be the most motivated person in the room” (p.22). Oh, the Books!
As we’ve mentioned, Brief Therapy Homework Planner is a very useful summary of some of the formulas of Solution-Oriented Therapy with individuals which will make an excellent introduction for a beginning therapist or a nice refresher for a more experienced one. Readers will find chapters which address some of the main tropes of Solution-Oriented Therapy such as “Set Goals,” “Defining the Problem,” “Some Days Are Odd,” “Fake It Til You Make It,” “Express It Differently,” “Do Something Different,” and of course, “Do Something More Different.” Solution-Oriented therapists are always interested in instances of success, exceptions to problems, and what difference would look like. These books will help patients and therapists articulate in “video talk,” the concrete, specific, behavioral, but occasionally kind of vague ways that treatment goals and objectives are addressed.

Though not quite as tightly tied to symptoms and problems as the Brief Adolescent Therapy Homework Planner and the Brief Child Therapy Homework Planner, yet still linked to them for easy reference, the Brief Therapy Homework Planner offers chapters on how to “Make a Choice,” “Clarify Values,” and “Keep on Truckin’,” which can be generalized into a wide range of situations. The authors try to reinforce the always core concerns of any psychotherapy such as resilience, self-efficacy, and competency-transfer in chapter exercises like, “Finding Value in Your Experience” and “Relapse Prevention” (in the largest sense). Thankfully, there is little direct utilization of the over-hyped, generally misunderstood, and often bombastic “Miracle Question” in Brief Therapy Homework Planner. Unfortunately, too little opportunity is given to elicit, amplify, and deeply reinforce the patient’s preferred view of himself which would seem to be always under construction in psychotherapy. Overall, this is an exceedingly useful and user-friendly book which pulls together all the basic treatment strategies of Solution-Oriented Brief Therapy without the excess explanatory and theoretical verbiage of most professional books.

Child vs. Adolescent Homework!
Brief therapy with children remains an enormously controversial issue. Many therapists believe that the perceived ravages of managed mental health care especially should not be extended to the treatment of children and adolescents who are often our most vulnerable patients. Yet the two volumes under review here, Brief Child Therapy Homework Planner and the Brief Adolescent Therapy Homework Planner, will not offend even the most vociferous brief therapy skeptics. The books propose exceedingly sensible psychotherapeutic strategies for dealing with a wide-range of problems, including physical and sexual abuse, which would be useful in psychotherapy regardless of how long it takes or what it calls itself.

These books are organized by problem and symptoms with section headings like “Attention Deficit/Hyperactivity Disorder,” “Depression,” “School Refusal,” and “Sexual Abuse Victim,” and so on. There is nary a whiff of the controversies of suggestion, hypnosis, and recovered memory therapy. In contrast to our previous title, these two titles feature more of a combination of cognitive-behavioral and narrative approaches in their task constructions, so therapists with a philosophical aversion to Solution-Oriented Brief Therapy may find some affinity in these titles. Homework assignments include many cognitive-behaviorally-oriented tasks like, for example, keeping a daily food record in “Reality: Food Intake, Weight, Thoughts, and Feelings,” in the “Eating Disorder” Sections, the “Panic Attack Rating Form” in the “Phobia-Panic/Agoraphobia” Sections, and the essential “No Self-Harm Contract” in the “Suicidal Ideation” Sections. The books also include more narrative means like the “Letter of Empowerment” in the “Physical Abuse Victim” Sections, “Petey’s Journey Through Sadness” in the Grief Section, and several stories/vignettes of other children (like “Dixie Overcomes Her Fears” in the “Low Self-Esteem” Section) to help normalize patients’ experiences in treatment.

It should be noted that Brief Child Therapy Homework Planner and the Brief Adolescent Therapy Homework Planner are virtual mirror images of each other (replace child with adolescent and vice versa and you have the same book) with essentially exactly the same exercises and sequencing, and at about $50 each, it may not be necessary to buy both, just the one that best matches one’s primary patient population.

The End!
Certainly, these three titles will prove to be enormously useful to many readers (experienced and beginning therapists, informed consumers, family members, and interested others) for a variety of reasons (economics, efficiency, self-help, treatment orienting strategies) and the entire series reflects many of the realities and anxieties within today’s managed mental healthcare marketplace. But without motivation, they’re nothing and so are we. If there’s motivation, we may not need the books, and if there isn’t motivation, we may not need the books. The sum total of all three Brief Therapy Homework Planners may be simply to do more of what works, and if it’s not working, do something different.

Categories: Psychotherapy, MentalHealth, Philosophical