Successful outcomes do not come by accident. Sure, we could just tell clients to “get over it” or throw medications at a problem and hope for the best, but we know that there are far better ways to address mental health and substance abuse issues than that.
A good mental health professional will work with the client to carefully construct a treatment plan that provides the best chances of treatment success.
This course will explore treatment plans, how they are constructed, and how they can help ensure positive gains in therapy.
A treatment plan is a document that details a client’s current mental health and/or substance abuse problems and outlines the goals and strategies that will assist the client in overcoming these issues.
A treatment plan should include:
- The patient or client’s personal information
- The diagnosis (or diagnoses, as is often the case with mental illness)
- A general outline of the treatment prescribed
- A method to measure outcomes as the client progresses through treatment.
A treatment plan does many things, the most important of which include:
- Defining the problem or ailment
- Describing the treatment prescribed by the mental health professional
- Setting a timeline for treatment progress (whether it’s more of a vague timeline or includes specific milestones)
- Identifying the major treatment goals
- Noting important milestones and objectives
This documentation of the most important components of treatment helps the therapist and client stay on the same page, provides an opportunity for discussion of the treatment as planned, and can act as a reminder and motivation tool.
A wide range of people can benefit from mental health treatment plans, including:
- People living with a serious mental illness
- People experiencing distress in one or more areas of life
- Children, parents, and/or families
- The elderly
- People with developmental disabilities
- People experiencing sexual or gender identity issues
- People being bullied and/or abused
- Bullies and/or abusers
- People in the criminal justice system
While people in similar circumstances with similar issues may have similar treatment plans, it’s important to understand that each treatment plan is unique. There are often many different ways to treat the same problem – sometimes there are dozens of different paths that treatment could take.
No two treatment plans will be the same, because no two people’s experiences, strengths, obstacles, and weaknesses are the same.
While the basic components of a treatment plan are listed above, there are many more possible additions to a treatment plan. As noted earlier, all treatment plans are different – they are unique products of the discussions between a therapist and client, the therapist’s clinical knowledge, and the client’s shared experience.
Even in identical diagnoses in similar individuals, differences are bound to manifest in any or all of the following components:
- History and Demographics – client’s psychosocial history, history of the symptoms, any past treatment information
- Assessment / Diagnosis – the therapist or clinician’s diagnosis of the client’s mental health woes (if any), any past diagnoses will also be noted
- Presenting Concerns – the problems or symptoms that initially brought the client in
- Treatment Contract – the contract between the therapist and client that summarizes the goals of treatment
- Responsibility – a section on who is responsible for which components of treatment (client will be responsible for many, the therapist for others
- Strengths – the strengths and resources the client brings to treatment (can include family support, character strengths material support, etc.)
- Treatment Goals – the “building blocks” of the plan, which should be specific, realistic, customized for the client, and measurable
- Objectives – goals are the larger, more broad outcomes the therapist and client are working for, while multiple objectives make up each goal; they are small, achievable steps that add up to a goal
- Modality, Frequency, and Targets –different modalities are often applied to different goals, requiring a plan that pairs modalities, frequency of sessions, anticipated completion date, etc., with the respective goal
- Interventions– the techniques, exercises, interventions, etc., that will be applied to work toward each goal
- Progress / Outcomes – a good treatment plan must include space for tracking progress toward objectives and goals
BENEFITS OF USING A TREATMENT PLAN
Besides the obvious benefits that planning usually brings, there are a few specific advantages that mental health treatment plans impart to those who use them.
These benefits include:
- Treatment plans provide a guide to treatment for both the therapist and the client.
- Sticking to treatment plans can reduce the risk of fraud, waste, abuse, and the potential to cause unintentional harm to clients.
- Treatment plans facilitate easy and effective billing since all services rendered are documented.
- Having a treatment plan in place can help smooth any potential bumps in treatment, especially if a client requires a kind of treatment the primary therapist cannot provide (e.g., a certain type of intervention or a prescription for medication) or must see a new therapist for some other reason (e.g., the client or therapist moved, the therapist is on extended leave
GOALS AND OBJECTIVES
Goals and objectives will vary tremendously from one person to the next, especially for those facing very different problems.
Goals are the broadest category of achievement that clients in mental health and/or substance abuse counseling work towards. For instance, a common goal for those struggling with substance abuse may be to quit using their drug of choice or alcohol, while a patient struggling with depression may set a goal to reduce their suicidal thoughts.
In general, these goals should be realistic – they should be reasonable, given the client’s general experience and hopes for the future.
Objectives are goals broken into smaller pieces – many similar or subsequent objectives will make up a goal.
For example, an objective for an individual with extreme anxiety may be to take ten steps outside their front door. The next objective may be to make it to the neighborhood market, or thirty steps outside their front door.
Meeting each objective will eventually lead you to meet the goal.
HOW TO CREATE A TREATMENT PLAN
An effective treatment plan is all about determining what works best for a client. The first step is to gather information regarding current psychological problems, past mental health issues, family history, current substance abuse problems, and current and past social problems with work, school, and relationships. as well as any psychiatric drugs the client has used or is currently on. A psycho-social assessment and mini-mental status may be conducted during this process.
A diagnosis should be given before creating a treatment plan.
Do problem statements reflect the six problem domains?
1 – Medical status
2 – Employment and support
3 – Drug / Alcohol use
4 – Legal status
5 – Family / Social status
6 – Psychiatric status
Are problem statements written in behavioral terms?
Are problem statements written in a non-judgmental and jargon-free manner?
Are problem statements based on priority needs?
- Has the client (and significant others) participated in developing this treatment plan?
- Is the plan dated and signed by all who participated in developing this treatment plan?
The next step would be to discuss goals with the client. Think about what interventions and goals you might want to create for treatment.
For example, if your client has Major Depressive Disorder, a likely goal will be to reduce the symptoms of MDD. Think about possible goals for the symptoms the client is experiencing. Perhaps your client has insomnia, depressed mood, and recent weight gain (all possible symptoms of MDD). You could create a separate goal for each of these prominent issues.
- Do goals address the problem statements?
- Are the goals attainable during the active treatment phase?
- Would the client be able to understand the goals as written?
- Would both the client and the treatment program find these goals acceptable?
- Has the client’s stage of readiness to change been considered in the goal statements?
- Do objectives address the goals?
- Are the goals SMART?
o Specific – Are specific activities included? Could the client understand what is expected?
o Measurable – Can change or progress toward meeting the objectives be documented/evaluated?
o Attainable – Can the client take steps toward meeting the objectives?
o Realistic – Can the client meet the objectives given their current situation?
o Time-Limited / Timely – Is the time frame specified for the objectives?
- Has the client’s stage of readiness to change been considered in the objectives?
The therapeutic interventions are what will ultimately evoke change in clients.
Identify types of treatment or interventions, you might use such as activity scheduling, cognitive-behavioral therapy, cognitive restructuring, behavioral experiments, assigning homework, and teaching coping skills such as relaxation techniques, mindfulness, and grounding.
- Do interventions address the objectives?
- Are the interventions SMART?
o Specific – Are specific staff persons responsible for assisting clients / providing service?
o Measurable – Will the counselor/treatment program be held accountable for the services?
o Attainable – Do interventions reflect the level of care available or are outside referrals used when needed?
o Realistic – Do the interventions reflect the level of functioning or functional impairment of the client?
o Time-Limited / Timely – Is the time frame specified for the interventions?
- Has the client’s stage of readiness to change been considered in the interventions?
- Is this treatment plan individualized to fit the client based on their unique abilities, goals, lifestyle, socio-economic status (SES), work history, educational background, and culture?
- Are the client’s strengths incorporated into the treatment plan?
As noted previously, a treatment plan should include direct input from the client. The counselor and client decide, together, what goals should be included in the treatment plan and the strategies that will be used to reach them.
A treatment plan will have the following information:
- Name of client and diagnosis.
- Long-term goal (such as the client stating, “I want to heal my depression.”)
- Short terms goals or objectives (Client will reduce depression severity from 8/10 to 5/10 within six months). A good treatment plan will have at least three goals.
- Clinical interventions/Type of services (individual, group therapy, Cognitive-behavioral therapy, etc)
- Client involvement (what the client agrees to do such as attend therapy once per week, complete therapy homework assignments, and practice coping skills learned in treatment)
- Dates and signatures of therapist and client
Both the client and the counselor sign the treatment plan to show that there is an agreement on what to focus on in treatment.
Evaluate your client’s progress regularly. Set criteria for tracking progress, and check the treatments your client has undergone and how they affected him/her. Include dates in the future when you will review the progress the client is making. Decisions to continue the current treatment plan or to make changes will be made at that time.
Not every treatment plan will call for each of these items. This is fine since every treatment plan is as individual as the client treated, but it should be noted why the item does not apply.
Committing to a specific plan engages the client in the solution. Plans give measurable markers to show improvement.
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