Psychiatrists, psychologists, mental health counselors, social workers, and other behavioral health professionals use treatment planning as a tool to effectively treat patients.
Without a clear plan in place, it can be hard to track progress, stay organized and keep a record of individual patient care.
Every patient needs individually tailored treatment. When a mental health professional creates a comprehensive treatment plan specially designed to meet their patient’s needs, they give their patient directions towards growth and healing.
Although not all mental health professionals are required to produce treatment plans, it’s a beneficial practice to both the counselor and the patient.
In this guide, we’ll show you why mental health treatment plans are essential and how to create psychiatric treatment plans that will make a difference in your and your patient’s lives.
If paperwork isn’t your favorite part of being a therapist, you’re not alone. Many clinicians love the personal interactions they get to have in their work, and may put off time-consuming documentation tasks, like completing counseling treatment plans. There are a lot of different types of notes you can use in your private practice, and you may need to use different kinds in different situations. Here is a breakdown of counseling treatment plans, and what you might include in yours.
What is a treatment plan in counseling?
A treatment plan is a document in each client file that identifies the goals, plan, and method of therapy that the clinician and client agree to move forward with. It’s the clinician’s guide to identify how a client is progressing, and is a platform for dialogue about treatment satisfaction. When a clinician co-constructs a treatment plan with the client, the client can easily buy into the process—which creates rapport, and an agreed upon path towards symptom reduction.
What should a counseling treatment plan include?
A counseling treatment plan typically will include one or more goals, objectives, and interventions. It will also usually include space for your client’s personal information, psychological history, and demographics, as well as a space for tracking progress. One goal may have multiple objectives and interventions if the clinician will be recommending more than one approach. This is important in culturally responsive therapy where collateral support may be needed such as inclusion of spiritual leaders, community partners, or family members.
Here are the components of a treatment plan broken down with more specifics:
Goal:
The goal of your treatment plan should be a broad statement about what the client would like to accomplish in therapy. While it’s ultimately your job as the clinician to put the treatment plan together as part of clinical documentation, the plan can be designed in session in collaboration with the client to make sure they’re fully involved and invested in the process.
You can ask your client what they hope to have achieved or accomplished by the time they’re done in therapy, or what they’d like to see be different in their life when they’re done. If this is too future-oriented for your client, or if they’re struggling to name any goals, you can share a few general ideas, and ask questions to help tailor the goals to fit their therapeutic needs.
Objective:
Your treatment plan objective should be a realistic, measurable, time-framed, and achievable description of your goal. If your objective is too broad—or doesn’t include measurable time frames—it’ll be hard for you or your clients to know if you’ve actually made any progress together. By narrowing your focus and keeping this section very clear, it’ll be easier for you both to track how your clients are doing.
Intervention:
The intervention section of your treatment plan should lay out what method will be used to achieve the goal. You can also include details like who will provide the intervention, what will the intervention be, when (the duration and frequency) and where will the intervention take place.
When it comes to the intervention, keep in mind that the client may have a good idea of what has already worked for them and what hasn’t. If a client has been in counseling before, you can ask them what they’ve liked or disliked in therapy before, and use that (where clinically appropriate) to inform your plans.
This is also a good time to discuss if your client has any additional people, spiritual practices, culturally relevant practices, or rituals they would like to see incorporated into the intervention. Depending on how they respond, you may want to get a release of information to have someone intermittently join sessions, or to share information outside of a session. This approach would work best for clients who are used to a more collectivist style of healing, or who have a worldview that conflicts with the usual 1-to-1 therapy model.
Counseling treatment plan example
Here is an example of what a counseling treatment might look like to help give each section more context.
Goal: The client will experience days that are free from anxiety
Objective: In 8 weeks, the client will learn and implement three skills to reduce experiencing anxiety symptoms from seven days a week to three or fewer days a week.
Intervention: I/we will use breathwork protocols, M-CBT and talk therapy to help the client develop a minimum of 3 skills to reduce anxiety symptoms. It is recommended that the client attend weekly 50-minute telehealth sessions for 8 weeks.
Why are treatment plans important in counseling?
Therapy is one of the few places where a client gets to take part in the design of their treatment, and that can be very empowering. It could also be overwhelming, and some may simply be unable to participate in the goal-planning process. But at the very least, the client should be presented with the treatment plan and asked if they agree with it, and if there’s anything they would like to discuss changing.
A treatment plan is a working document that will be updated depending on the progression of treatment. On occasion, you might want to change a treatment goal altogether, or pause one goal to focus on a more acute issue. It’s not likely that you’ll focus on every goal in every session. The work you do will depend on the needs of the client on a given day, and clients may have more than one goal they are trying to achieve.
It’s also important to review your treatment plans regularly, so that you know when a client isn’t making progress toward a specific goal. If you notice this happening often, it might be a good time to seek consultation for an outside perspective on whether you’ve identified the true clinical need or not. If your plan appears to address the right therapeutic need and your client still isn’t making progress, it might be time to refer out. Not every therapist is a good fit for every client, and sometimes a different approach or clinician will prompt the change the client is hoping a treatment plan will facilitate.
How to use treatment plans with your EHR
To create treatment plans with your EHR, you can either upload a template of your own, or follow the structure within your software. Most top-rated EHRs will have a dedicated section for notes and documentation, as well as a template library with easy-to-use templates that are built right into the platform.
If you’re looking for a fully integrated EHR that works for behavioral health practitioners like you, try SimplePractice for a free 30 days. SimplePractice makes it easy to streamline your notes and documentation, while also improving your clients’ experience.
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Planning – some of us love it, some of us hate it, and some of us just don’t have any idea how to do it!
Part of effective mental health treatment is the development of a treatment plan.
A good mental health professional will work collaboratively with the client to construct a treatment plan that has achievable goals that provide the best chances of treatment success.
Read on to learn more about mental health treatment plans, how they are constructed, and how they can help.
Before you continue, we thought you might like to download our three Positive Psychology Exercises for free. These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.
What is a Treatment Plan? A Definition
At the most basic level, a mental health treatment plan is simply a set of written instructions and records relating to the treatment of an ailment or illness. A treatment plan will 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, and space to measure outcomes as the client progresses through treatment.
A treatment plan does many things, the most important of which include (Leahy, Holland, & McGinn, 2011; PHN, 2017):
- Defining the problem or ailment
- Describing the treatment prescribed by the health/mental health professional
- Setting a timeline for treatment progress (whether it’s 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 motivational 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
- Individuals
- Couples
- 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
- Employers and/or employees (Croft, 2015).
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 exactly the same, because no two people’s experiences are exactly the same.
What, Exactly, is in a Treatment Plan?
While the basic components of a mental health 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 issues, and 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 make up a goal.
- Modality, Frequency, and Targets – different modalities are often applied to different goals, requiring a plan that pairs modalities, a frequency of sessions, anticipated completion date, etc., with the respective goal.
- Interventions – the techniques, exercises, interventions, etc., that will be applied in order to work toward each goal.
- Progress/Outcomes – a good treatment plan must include space for tracking progress towards objectives and goals (Hansen, 1996)
The therapist and client will work together to get this information down on paper, with the therapist contributing his or her expertise in treatments and treatment outcomes, and the client contributing expertise in his or her own life and experiences.
Why Use 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 client.
- 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.
- Treatment plans 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., if the client or therapist has moved, or the therapist is on extended leave, PHN, 2017).
While treatment plans are quite popular in mental health treatment, it should be noted that not every therapist or clinician will use one. Treatment plans are not necessarily required to give or receive successful treatment, but they can be extremely helpful in facilitating a smooth and hassle-free treatment experience.
Goals and Objectives of a Treatment Plan
Goals and objectives will vary tremendously from one person to the next, especially those facing very different problems.
If you or your client is committed to change but isn’t quite sure where to begin, this link of potential goals can spark a useful discussion about where to go from here.
Goals are the broadest category of achievement that clients in mental health 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 basically 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 10 steps outside their front door. The next objective may be to make it to the neighborhood market, or up to 30 steps outside their front door.
Meeting each objective will eventually lead you to meet the goal.
How to Create a Treatment Plan
There are many resources out there on how to create a mental health treatment plan – there’s even a WikiHow page on the subject!
This checklist is an especially good resource for treatment planning, due in part to how brief and to-the-point it is. The checklist breaks down treatment plans into five sections: Problem Statements, Goals, Objectives, Interventions, and General Checklist.
The checklist items are presented by section as follows:
Problem Statements
- 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?
What does the client want to achieve during treatment?
- 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?
Objectives
What will the client say or do? Under what circumstances? How often will he/she say or do this?
- 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?
Interventions
What will the counselor/staff do to assist the client? Under what circumstances?
- Do interventions address the objectives?
- Are the interventions SMART (Locke & Latham, 1990)?
o Specific – Are specific staff persons responsible for assisting client/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 (Rollnick, Heather, Gold, & Hall, 1992)?
General Checklist
- 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?
- 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?
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.
When each item is “checked” off the list (or addressed in writing if it is not applicable), the treatment plan is likely a good one – or, at least, it has the basics of a good treatment plan!
If you work with children and would like some tips on preparing a good treatment plan for a young client, check out the Pennsylvania CASSP Training and Technical Assistance Institute’s publication on this subject here.
Technologies to Support Mental Health Treatment Plans (Incl. Quenza)
At face value, executing all the components of a mental health treatment plan may seem like a lot to address in a series of fifty-minute therapy sessions.
However, therapists are increasingly leveraging the benefits of technology in creative ways to help develop, execute, and evaluate mental health treatment plans using a blended care approach.
Blended care involves the provision of psychological services using telecommunication technologies.
Among these technologies are many digital platforms that therapists can use to supplement real-time therapy sessions to help accomplish the steps included in mental health treatment plans.
For example, using a blended care platform such as Quenza, a therapist may carry out some of the initial steps in the assessment/diagnosis phase of a treatment plan, such as by inviting the client to complete a digital diagnostic questionnaire.
Likewise, the plan may incorporate various psychoeducational interventions which can be delivered digitally, such as guided meditations, reflection exercises, or self-paced learning modules.
A therapist may even use these tools following the conclusion of a client’s in-person treatment as part of a follow-up, such as to assess whether a client has remained psychologically well a few months down the line or requires additional support.
These are just a few ideas for how you might use a blended care tool such as Quenza to help carry out some steps in a mental health treatment plan.
Examples of Mental Health Treatment Plans
There are several examples of mental health treatment plans to be found online, and several are linked below:
This sample treatment plan is for a young Medicaid recipient struggling with symptoms of depression and suicidal thoughts.
This treatment plan is written for the treatment of a man suffering from schizoaffective disorder who is experiencing side effects from his medication.
If you’d like to see more, this website has a ton of useful example treatment plans and templates.
A Treatment Plan Template
As noted earlier, one template will not cover all of the possibilities for a client’s treatment plan, but this template can at least provide a starting point.
Feel free to rearrange, remove, and add as needed, but make sure to properly cite the source if you use it for profit or publish it somewhere (source information is at the bottom of the template).
A Take-Home Message
In this article, we’ve discussed the purpose and general description of a mental health treatment plan.
We hope you have a better idea of how treatment plans work, why therapists use them, and how they can help individuals struggling with mental health problems.
Have you ever created a mental health treatment plan? Have you ever had a mental health treatment plan created for you? Let us know in the comments!
As always, thank you for reading!
We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.
References
- Croft, H. (2015). What is a mental health treatment plan? Why is it important? GoodTherapy. Retrieved from https://www.healthyplace.com/other-info/mental-illness-overview/what-is-a-mental-health-treatment-plan-why-is-it-important/
- Hansen, M. (1996). Writing effective treatment plans: The Pennsylvania CASSP model. Retrieved from http://www.ccbh.com/pdfs/Providers/healthchoices/articles/TreatmentPlans.pdf
- Leahy, R. L., Holland, S. J., & McGinn, L. K. (2011). Treatment plans and interventions for depression and anxiety disorders. New York, NY: Guilford Press.
- Locke, E. A. & Latham, G. P. (1990). A theory of goal setting and task performance. Upper
Saddle River, NJ: Prentice-Hall. - PHN. (2017). Mental health treatment plans: A guide for health professionals working in general or private practice. Retrieved from https://www.nwmh.org.au/sites/default/files/2017-06/Mental%20Health%20Treatment%20Plans%20North%20Western%20Melbourne%20PHN.pdf
- Rollnick, S., Heather, N., Gold, R., & Hall, W. (1992). Development of a short ‘readiness to change’ questionnaire for use in brief, opportunistic interventions among excessive drinkers. British Journal of Addiction, 87(5), 743-754.
