Therapeutic Interventions

Therapeutic Interventions A. Psychotherapy is defined as the intentional, face to face interaction between a mental health professional and a client, either an individual, family, or group, in which a therapeutic relationship is established to help resolve symptoms of the resident’s mental and/or emotional disturbance. B. Individual therapy is defined as psychotherapy that takes place between a mental health therapist and a resident. Individual Therapy must be provided a minimum of one (1) hour each week unless its contraindication is documented in the treatment plan. Individual Therapy must be provided by master’s level mental health therapists. C. Family therapy is defined as psychotherapy that takes place between a mental health therapist and a resident’s family members or guardians, with or without the presence of the resident. If a resident is in the custody of the Department of Human Services (DHS), family therapy may also include others, including DHS representatives and foster family members, acting in loco parentis. Family Therapy must be at least twice a month, unless its contraindication is documented in the treatment plan. 1. Each resident’s family, guardian, or person acting in loco parentis must participate in the family therapy sessions. 2. If the resident’s family is more than a two (2) hour drive from the PRTF, one (1) face-to- face family therapy session and one (1) therapeutic conference call is acceptable. 3. Family Therapy must be therapeutic in nature to include discussing the resident’s functioning, treatment progress, goals and objectives. 4. Social visits or phone calls are not considered family therapy. 5. Family Therapy must be provided by master’s level mental health therapists. 6. Residents who are in the custody of the Department of Human Services (DHS) must complete one (1) face-to-face family therapy session with the social worker in the county of the PRTF, unless the social worker in the home county is available, and complete the second (2nd) family therapy session via telephone with the social worker in the home county. 7. A geographically distant therapist may provide family therapy when there are family issues that must be resolved or ameliorated before face-to-face sessions that include the resident can be productive and therapeutic. a) Distance alone is not justification for prescribing off-site therapy. b) When off-site therapy is appropriate, the treatment plan must identify the off-site therapist, indicate the goals for such therapy, and specify how information will be exchanged between the PRTF and the off-site therapist. c) Collaboration between therapists is the responsibility of the PRTF and must be documented in the clinical record. D. Group therapy is defined as psychotherapy that takes place between a mental health therapist and at least two (2), but not more than eight (8) residents at the same time. 1. Possibilities for groups include, but are not limited to, those which focus on relaxation training, anger management and/or conflict resolution, social skills training, and self- esteem enhancement. 2. Each resident must participate in a minimum of three (3) hours of group therapy, provided in at least three (3) sessions, each week unless contraindication is documented in the treatment plan. 3. The length, frequency and timing of sessions in which services are delivered must be determined by what is developmentally appropriate for each resident. 4. Group therapy must be provided by master’s level mental health therapists although larger groups up to twelve (12) participants can be co-led by a person with a lesser level of training. E. Psychotherapy notes must be documented for each therapy session and include the following essential elements: 1. The date and time in and time out of the session, 2. The type of therapy, either individual, family or group, 3. The person(s) participating in the session, 4. The length of the session, 5. Clinical observations about the resident including their demeanor, mood, affect, mental alertness, thought processes or risks, 6. The content of the session, 7. Therapeutic interventions attempted and the resident’s response to the intervention(s), 8. The resident’s response to any significant others who may be present in the session, 9. The outcome of the session, 10. A statement summarizing the resident’s degree of progress toward the treatment goals, 11. Reference at least monthly to the resident’s progress in relation to the discharge criteria and the estimated discharge date, 12. The signature and printed name, if needed for clarity, of the therapist, and 13. Monthly summaries are not acceptable in lieu of psychotherapy session notes. F. Milieu therapy is defined as residential psychiatric treatment that occurs in the total environment of the closed setting, also referred to as the “therapeutic community.” Milieu therapy must be provided twenty-four (24) hours a day by all PRTF staff. 1. Emphasis is placed on clear, healthy, respectful communication between resident/resident, staff/staff, and staff/resident, and on shared problem-solving and decision-making. 2. The entire environment, not just the limited time spent with an identified therapist, is considered vital to the treatment process. The physical environment of the facility must reflect a warm, child-friendly atmosphere with treatment-oriented information including, but not limited to, motivational/educational posters, schedules of activities, requirements for level systems and rules for unit, written in positive terms and age appropriate language. Materials must be posted in a manner that is highly visible and easily accessible to residents. 3. Milieu notes must be documented daily and: a) Present a clear picture of the resident’s participation and interactions in the therapeutic community. b) Describe the resident’s actions, staff interventions, and the resident’s response to those interventions. c) Are usually completed by direct care staff. d) If a checklist is used, it must be accompanied by at least a brief narrative. e) Must be behaviorally focused. f) Behavior and events should be described rather than labeled. g) Must reflect a pattern of clear, respectful communication between staff and resident, with emphasis on the resident’s involvement and collaboration in his/her own treatment. 4. The community meeting is a required element of milieu therapy. This is a time when all residents and most, if not all, professional and direct care staff meet together to discuss and solve problems that arise in community living, make community decisions, set goals, resolve conflicts and discuss ideas that may enhance treatment. 5. Documentation that community meetings are held at least daily and are attended by all residents and most, if not all, professional and direct care staff. 6. Documentation that the focus of community meetings is good communication and collaboration among residents and staff to solve problems, make community decisions, and introduce/discuss ideas/suggestions that will enhance treatment. 7. Documentation that residents are knowledgeable about their treatment and actively participate in goal-setting and treatment evaluation. 8. Community meeting notes must be clearly identifiable. 9. Each resident’s participation must be documented, or his/her absence justified, in a minimum of one (1) community meeting per day. 10. Notes must reflect that the community meetings are therapeutic in nature and address treatment issues including, but not limited to: a) Problem identification, b) Goal-setting, c) Problem-solving, d) Conflict resolution, e) Behavioral observations/evaluation, f) Problems in community living. 11. The nature of each resident’s participation must be described. 12. If a checklist is used, it must be accompanied by at least a brief narrative. G. Therapeutic Pass/Therapeutic Leave is defined as those times when a resident is permitted time “away” from the PRTF to practice skills learned in treatment or to work on significant relationships in a setting that is less structured and controlled. 1. Therapeutic Pass refers to “away” time of less than eight (8) hours. a) If a resident leaves the facility on a therapeutic pass accompanied by PRTF staff, no documentation is required. b) If a resident leaves the facility on a therapeutic pass with anyone other than staff, including relatives or representatives of DHS, therapeutic goals for the pass must be identified and documented. At the conclusion of the pass, documentation must indicate whether or not the therapeutic goals were met. 2. Therapeutic Leave refers to “away” time of eight (8) hours or more in the same calendar day. A single day of therapeutic leave is determined by the resident’s absence from the facility for eight (8) hours or more between the hours of 12:01 a.m. and 11:59 p.m. on any given day. a) Therapeutic Leave is not allowed during the fourteen (14) day assessment period following admission. b) The attending physician or PMHNP must approve all therapeutic leave days. 3. Documentation at the time a resident leaves the facility must include: a) The date/time of check-out, b) The required time of return, c) The name(s) of the person(s) with whom the leave will be spent, d) The resident’s physical/emotional condition at the time of departure including vital signs, e) The types and amounts of medication being provided and instructions in lay terms for taking them, f) Therapeutic goals for the leave, as related to the goals established in the treatment plan, g) The name and signature of the person with whom the resident is leaving, and h) The signature of the staff person checking the resident out. 4. Documentation at the time of the resident’s return must include: a) The date and time of check-in, b) The resident’s physical/emotional condition at the time of return including vital signs and notation of any physical injury or complaint, c) Whether or not any contraband was found, d) The types and amounts of medication being returned, if any, and explanation of any missed doses, e) An explanation of any early or late return from leave, f) A brief report on the outcome of the leave by the parent or guardian, g) The name and signature of the person returning the resident’s to the facility, h) The signature of the staff person checking resident in, and i) An assessment of the outcome of the leave must be conducted by the resident’s therapist within seventy-two (72) hours of the resident’s return from leave. H. Creative arts therapies is defined as those therapies, including art, movement/dance, music and poetry, which a qualified professional uses the creative process and the resident’s response to the created product to help the resident resolve emotional conflicts, increase self- awareness, develop social skills, manage behavior, solve problems, reduce anxiety, improve reality orientation, and/or increase self-esteem. I. Occupational therapy is defined as the use of purposeful activity, designed and guided by a qualified professional, to help the resident achieve functional outcomes that promote the highest possible level of independence. J. Recreation therapy is defined as a process that utilizes recreation services for purposive intervention in physical, emotional and/or social behavior to bring about a desired change in that behavior and to promote the growth and development of the resident. K. Speech-Language Pathology is defined as remedial assistance with speech and/or language problems provided by a licensed speech-language pathologist. L. When other therapies such as art therapy, recreational therapy, occupational therapy, dance/movement therapy, music therapy, speech/language therapy, are employed, their use must be documented in the clinical record in much the same manner as psychotherapy including date, length, type of session, together with a summary of the session's content, process, outcome and the therapist's name/signature.