Treatment Plan

A therapist with long dark hair writes a treatment plan with the person in treatment, an adult male of colorTreatment plans are documentation tools that are considered essential to the implementation of well-rounded health care. Most providers, especially those in the mental health field, use treatment plans as blueprints to guide services provided. Mental health treatment plans typically highlight important assessment information, define areas of concern, and establish concrete goals for treatment.

Mental Health Care Treatment Plans

Mental health treatment plans are versatile, multi-faceted documents that allow mental health care practitioners and those they are treating to design and monitor therapeutic treatment. These plans are typically used by psychiatrists, psychologists, professional counselors, therapists, and social workers, in most levels of care.

Treatment plans are strength-based and collaborative, and they aim to reflect the best interests of the person in therapy. Concrete representations of the therapeutic alliance between mental health professionals and those they treat (and sometimes the families of those in treatment), treatment plans are agreements that outline a team approach toward problem-solving and empowerment.

Effective mental health treatment plans are often comprised of the following components:

  • History, Assessment, and Demographics: This section can include basic demographic information, psychosocial history, onset of symptoms, diagnoses (past and present), treatment history, and any other assessment information pertinent to well-being.
  • Presenting Concerns: This section details the current concerns and mental health issues that led the individual to seek treatment.
  • Treatment Contract: The treatment contract summarizes the goals for change, often a mutually agreed-upon plan for what will be worked on. It usually details who is responsible for what, as well as what treatment modality will be used.
  • Strengths: Throughout the plan, practitioners often include information about the perceived strengths of the person in treatment. This can empower individuals to tap into their areas of strength to achieve their goals.
  • Modality, Frequency, and Targets: Throughout the plan, each goal typically includes the type of treatment modality that will be used to achieve it. The frequency of sessions and target dates for completion are also often included.
  • Treatment Goals: Goals are the building blocks of the treatment plan. They are designed to be specific, realistic, and tailored to the needs of the person in therapy. The language should also meet the person on their level. Goals are usually measurable—rating scales, target percentages, and behavioral tracking can be incorporated into the goal language to ensure that it is measurable.
  • Objectives: Goals are often broken down into objectives in order to support the person in therapy through the process of taking small, achievable steps toward the completion of the larger goal.
  • Interventions: Goals usually also include the various techniques and interventions the mental health professional will implement in order to support achievement of the larger goal.
  • Progress/Outcomes: Documenting progress toward goals is considered to be one of the most important aspects of mental health treatment plans. Progress and outcomes of the work are typically documented under each goal. When the treatment plan is reviewed, the progress sections summarize how things are going in and out of sessions. This portion of the treatment plan will often intersect with clinical progress notes.

A sample goal, complete with objectives, interventions, and progress:

GOAL 1:

Chris will implement a parenting plan that promotes improved behavior in his son, as rated at least a 6 out of 10, where 10 is excellent.

OBJECTIVES:

  1. Chris will make a list of the household rules.
  2. Chris will make a list of rewards and consequences and will define how to enforce them.
  3. Chris will present his new parenting plan to his son during a family meeting.
  4. Chris will enforce rewards and consequences consistently and will monitor his progress in and out of session.

INTERVENTIONS:

  1. Therapist will provide psychoeducation on positive parenting and will support Chris in developing a concrete parenting plan.
  2. Therapist will provide materials for Chris to document the new house rules, rewards, and consequences system.
  3. Therapist will monitor progress and check in with Chris weekly to ensure that Chris is implementing his plan consistently.

PROGRESS:

Over the past 30 days, Chris was able to achieve objectives 1, 2, and 3. He reported that his son accepted the new system and even seemed excited. Therapist provided Chris with the book Positive Parenting and assigned various readings for homework, which Chris completed consistently. Therapist and Chris created a poster board that detailed the rules, consequences, and rewards system Chris designed for his son. Chris reported that he is ready to begin enforcing his new parenting system. Chris and therapist rated the progress on this goal at a 5, as Chris is already seeing improvement in his ability to parent and in his son’s behavior.

How are Mental Health Care Treatment Plans Used?

Mental health care professionals utilize treatment plans in many ways. Depending on the type of service, there may be specific regulations or best-practice standards that guide the formation of the treatment plan.

Treatment plans are important for mental health care for a number of reasons:

  • Treatment plans can provide a guide to how services may best be delivered.
  • Professionals who do not rely on treatment plans may be at risk for fraud, waste, and abuse, and they could potentially cause harm to people in therapy. Implementing a plan for treatment can protect both the provider and the person being treated, as it ensures that all parties involved have a clear understanding of the progress being made and long-term goals.
  • Treatment plans provide a summary of services rendered, so professionals may use treatment plans as supportive documentation for billing, if necessary.
  • When a person enters the mental health system, they may engage in several types of services throughout the process of treatment. Treatment plans allow for continuous care that takes into consideration a person’s past concerns and treatment as well as current needs. Treatment plans can thus help prevent duplication of service and reduce the likelihood that a person will be offered a treatment that did not work in the past.

Some commercial insurances and most managed care organizations (MCOs) require that treatment plans be completed for every person in treatment. MCOs offer specific guidelines regarding what should go into a treatment plan and how frequently plans should be updated and reviewed. Different types of services are regulated differently; therefore, the expectations for treatment plans can vary. Some service regulations require treatment plans be reviewed every 30 days, while others, like mental health outpatient care, may only require updates every 100 days or so.

Treatment Plans and HIPAA

The Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule grants consumers and people in treatment various privacy rights as they relate to consumer health information, including mental health information. Most documentation and information created or discussed during mental health treatment is kept confidential. More often than not, this information cannot be shared with other providers or family members without a form authorizing the release of information, signed by the person in treatment or their parent (in the case of a minor child).

There are few caveats, however, when it comes to protected mental health information:

  • When children participate in therapy, parents are generally allowed to receive a copy of their minor child’s treatment plan. This may vary in certain states depending on the age of consent.
  • In family therapy, when there is an identified individual through whom services are billed, often the treatment plan focuses primarily on that person’s mental health needs. However, if over the course of treatment it becomes clinically necessary to include family therapy sessions, information pertaining to other family members may be documented in the treatment plan. By law, each family member must provide consent, not just the identified individual, before that treatment plan is shared with other providers.

It is considered best practice for mental health practitioners to be as overt and strength-based as possible when it comes to treatment plan documentation as family members and other providers may see the plan—provided the person in therapy grants the treatment provider the permission to release information.

References:

  1. Children’s mental health Individual treatment plans. (2016, February 5). Retrieved from http://www.dhs.state.mn.us/main/idcplg?IdcService=GET_DYNAMIC_CONVERSION&RevisionSelectionMethod=LatestReleased&dDocName=dhs16_168991
  2. Hansen, M. (1996). Writing effective treatment plans: The Pennsylvania CASSP model. Retrieved from http://www.ccbh.com/pdfs/Providers/healthchoices/articles/TreatmentPlans.pdf
  3. HIPAA privacy rule and sharing information related to mental health. (2014, February 20). Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health
  4. Hutchison, M., Casper, P., Harris, J., Orcutt, J., & Trejo, M. (2008, July 31). The clinician’s guide to writing treatment plans and progress notes. Retrieved from https://www.sccgov.org/sites/dads/Adult%20System%20of%20Care%20Policy%20-%20Procedure/Documents/Clinician_Gde_toolkit.pdf

Last Updated: 08-5-2016

  • 4 comments
  • Leave a Comment
  • Ruby R.

    November 16th, 2016 at 8:11 PM

    I find the information very helpful in my practice.

  • Mike

    March 22nd, 2017 at 12:22 AM

    I didn’t see anything that demonstrated evidence that treatment plans are necessary, helpful, or essential.

    I didn’t see any evidence based citations (research or studies / peer reviewed scientific experiments or statistical analyses) that demonstrate that each component of the treatment plan is helpful, necessary for providing quality treatment.

    The number one principle of evidence based medicine is that each disease, condition, or symptom is treated with the MOST EFFECTIVE treatment available (as identified by science). The essence of a treatment plan is a fundamental assumption that everyone will be treated differently. If everyone is treated differently, then only one person, at most, is receiving the best treatment.

    Is there any evidence from legitimate scientific studies that demonstrate that the treatment plan is useful in the mental/emotional/psychological treatment of a patient? Does it have some value that is beyond what could be obtained by following the standards record keeping practices of physicians in other specialties? Is there evidence that each component of the treatment plan is helpful?

    I’m willing to bet that the treatment plan (at least some parts of it) are a detriment to ultimate psychiatric/psychological/mental health therapy.

  • Thomas A Grugle MD

    June 30th, 2017 at 5:02 AM

    Written treatment plans are essential.

    To getting paid. They are an invention of insurance companies designed to deny payment. I agree that there is scant evidence that a written treatment plan with measurable, time limited goals has any evidence base.

  • Michiko D.

    June 5th, 2017 at 9:28 AM

    Treatment planning is such an important part of the process of therapy, where the clinician and patient can collaborate to create common goals and expectations of treatment. I find this can be the most difficult when working with children and teens, whose goals are often dictated by their parent’s reasons for bringing them into treatment. Still, I have found success in working using Motivational Interviewing to help children and teens identify rewards associated with making changes that their parents want (ie: they will get more privileges, less consequences, have fewer lectures and conflicts).

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