Treatment Plan
Treatment plans are documentation tools often considered essential to providing well-rounded health care. Most providers, especially those in the mental health field, use treatment plans as blueprints to outline services provided. Mental health treatment plans typically highlight important assessment information, define areas of concern, and establish concrete goals for treatment.
What Are 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 often contain the following:
- 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 and outcomes: Documenting progress toward goals is considered to be one of the most important aspects of a mental health treatment plan. 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 within and outside of sessions. This portion of the treatment plan will often intersect with clinical progress notes.
Who Are Treatment Plans For?
Treatment plans can be used by therapists to help individuals in therapy address a wide variety of concerns. A treatment plan may outline a plan for treating a mental health condition such as depression, anxiety, or a personality disorder. Treatment plans can also be applied to help individuals work through addictions, relationship problems, or other emotional concerns.
While treatment plans can prove beneficial for a variety of individuals, they may be most likely to be used when the person in therapy is using insurance to cover their therapy fee. In these cases, a therapist may be required to submit a treatment plan to the client’s insurance company.
Sample Treatment Plan for Mental Health Care
Wondering how to write a treatment plan? Here is a treatment plan example template, 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:
- Chris will make a list of the household rules.
- Chris will make a list of rewards and consequences and will define how to enforce them.
- Chris will present his new parenting plan to his son during a family meeting.
- Chris will enforce rewards and consequences consistently and will monitor his progress in and out of session.
INTERVENTIONS:
- Therapist will provide psychoeducation on positive parenting and will support Chris in developing a concrete parenting plan.
- Therapist will provide materials for Chris to document the new house rules, rewards, and consequences system.
- 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:
- Hansen, M. (1996). Writing effective treatment plans: The Pennsylvania CASSP model. Retrieved from http://www.ccbh.com/pdfs/Providers/healthchoices/articles/TreatmentPlans.pdf
- HIPAA privacy rule and sharing information related to mental health. (2017, December 19). Retrieved from http://www.hhs.gov/hipaa/for-professionals/special-topics/mental-health
- 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/bhd-p/Policies-Procedures/adult-system-of-care–policy-procedure/Documents/Clinician_Gde_toolkit.pdf
- Individual treatment plans. (2017, April 7). Retrieved from https://mn.gov/dhs/partners-and-providers/training-conferences/childrens-mental-health/individual-treatment-plans.jsp
Last Updated: 09-25-2019
- 20 comments
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Ruby R.
November 16th, 2016 at 8:11 PMI find the information very helpful in my practice.
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Mike
March 22nd, 2017 at 12:22 AMI 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.
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Thomas A Grugle MD
June 30th, 2017 at 5:02 AMWritten 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.
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Kim Kline
November 14th, 2017 at 6:25 PMTreatment plans are required if you accept 3rd party reimbursement and are just good practice. They are a road map to treatment. They are fluid and are developed with the client/patient. Pretty much necessary if you are doing your job as a therapist.
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Mr. Ward
February 11th, 2018 at 8:55 PMIndividualized treatment plans are to be patient-centered. And individuals should simply not always be compared to one another.
Effective is the idea. The treatment plan is just one facet in wholesome care. Effects of thw treatment plan will be aided by wholesome care in other aspects of the treated individual’s life.
Critical thinking ia good. It is very important in mental health. But let your critical thinking be not in vain. Try again.
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Michiko D.
June 5th, 2017 at 9:28 AMTreatment 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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Me
August 17th, 2017 at 6:00 AMI am wondering when treatment plans are supposed to be done. I went to one therapist, and never even heard of this kind of plan, and we spend the whole session in therapy. Now I go to someone at the county mental health, and we are constantly having to interrupt therapy to do this thing. I only see her once or twice a month, due to the high cost of my copay, and this things takes about 20 to 30 minutes, in which I am mostly sitting there in the chair with her back to me while she types. Is it usual for a therapist to do this work during session?
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meli0655
August 23rd, 2017 at 6:05 PMHaving some experience at using the mental health center in your county, generally your therapist will be booked every 30 minutes to one hour with therapy appointments. That can translate out to 7 one hour appointments or 14 thirty minute appointments. They are not given much time to write up their therapy notes that the state requires to be written a certain way. The therapist has to juggle trying to provide good sound counsel in that brief amount of time and have accurate documentation that the state comes to review every 2 years. Most of the time, your therapist will be doing the best that they can to help you learn to manage your symptoms in healthier ways while also having to satisfy the agency’s requirements as their
employer. There is nothing wrong with asking your therapist for a copy of your treatment plan or at least to write down or verbally discuss what your goals are. For instance, if you are being treated for depression, then at least one goal on your treatment plan should be helping you to build skills that help you manage your depression better. You can’t rely fully on medications. There is not magic pill that fixes how we feel and everything that effects how we feel. At least by knowing your goals, between sessions, you can be working on ways to achieve your goals or at least be able to talk about what skills you have practiced between sessions. And you HAVE to practice the skills. Nothing comes naturally. By practicing them, they become second nature. For example, if you panic before going into Walmart, your therapist can demonstrate breathing skills that you can use before going in and then after you are back to your car to help you calm down quicker. That will help your therapist write the progress note (which is documenting the progress you have made since your last session) and then you will have time to talk about the things you need to talk about. Remember, you are there to get their assistance. make them work for you. If you have questions about your psychiatric condition, ask them for more information. Ask them to help you build coping skills. You are not there for an oil change. You are there to talk about things you can trust will stay within their office. Best wishes. -
Janine C
August 19th, 2019 at 8:18 AMMy post was not about the importance of a treatment plan. I object to the plan being done on my time that is supposed to be for therapy, that my insurance and myself, through a substantial copay, are funding. I was in therapy several years with a private therapist who never did this, but at the mental health place, it was taking up too much time from my actual therapy. I am back in private care, now.
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Jeff
August 17th, 2017 at 12:15 PMReading the comments here. Take treatment plans wiht a grain of salt. You get out what you put into it.
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Ashley B
August 30th, 2017 at 7:23 AMI need some help with making an overall treatment/goal plan for my therapist to work with and I am unsure where to start or if there is somewhere that there is a layout I can go by.
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shari
September 10th, 2018 at 11:04 AMdid you ever find one I am having the same issue???
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Edward
August 18th, 2019 at 3:43 PMA treatment plan is essential. The patient is captain of their own ship and knows why they voluntarily sought therapy and what their goals are. Working without a treatment with a treatment plan and goals is performing therapy in a vacuum and disenfranchises the patient and their third party payee by not allowing to express clearly what their needs are and how the doctor can help them so
They participate in the process as a team with the doctor! -
Mr.
December 3rd, 2019 at 11:05 AMI understanding the importance of advocating for the profession, but from reading these responses it appears some of the people leaving messages need a treatment plan via context symptom clues (Geeze!). If your so concerned about peer reviewed research then it is OBVIOUS that you’re of the wrong site looking for peer reviewed research on treatment plans. I swear I see some DSM-V symptoms. There is a variety of information online, and if you’re credentialed, you know where to find scholarly journals that have been peer reviewed and met criteria via the ACA Code Of Ethics. So the dramatics are unnecessary.
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Cheryl Dulac
January 15th, 2020 at 2:13 AMA medical treatment plan helps a better position to explain what options are available to you. Medical treatment plan increases the importance of our life.
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Lee
October 4th, 2020 at 12:29 PMCan you recommend a book I can buy to help writing treatment plans using Person centered SMART goals and objectives?
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Mercy
October 18th, 2021 at 7:04 AMAm a junior occupational therapist and what l can say is that treatment plan is very essential to any therapist as it helps put forward the interventions for better treatment of a patient as you attend to a patient with a holistic approach using therapeutic approaches with an aim of restoring function of a client and promote independence of a client to his/ her activities of daily living as a final goal expected from a therapist by a patient
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Jen
January 4th, 2022 at 9:02 AMAs a therapist a treatment plan as a general guide for documenting the client’s goals and progress towards them is mildly helpful. I rarely look back to them after writing them, however, the map is in my head as I work wit the client. In general, the idea is that the treatment plan is created with the client, but that might look differently with each therapist. I don’t like to take up time in session working on mapping out months of treatment and formulating the plan, but at intake, I am collecting information in the session about the client’s goals and how we will likely approach them (goals, objectives and interventions). I will not write the plan with the client, but it is a verbal discussion that ultimately becomes the treatment plan document. I agree with the person that said the document itself is just for auditors and insurance companies as a tool to limit the time a client has with a therapist. I don’t feel client’s benefit from the document itself in any way, though I do always get clarification and buy-in from the client about a game plan for their treatment. That’s my REAL treatment plan and that is done verbally. In previous agency work, they will require you to sit down with the client, write the document, have the client sign it, and believe that is buy in. The client signing isn’t where the real therapeutic contract is forged though. That is done when you build trust and create a therapeutic bond. When a client knows you are listening and will help them move towards their desired outcomes, that’s when you get buy-in and they will put in the work.
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Me
January 6th, 2022 at 9:08 AMMy therapist changed to private practice, and I go to her in private now. So she no longer has to pause forward progress by this pain-in-the-neck treatment plan stuff every several visits. It was the Mental Health Department, apparently, making her do that. Glad to be free of it, and have been making more progress without the frequent pauses.
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Berl
December 15th, 2022 at 1:57 PMVery nice summary of treatment plan components. More than a little baffled by the resistance to doing plans in some of these comments.
If the plan is not mirrored back in written form to the patient, how else can you be sure you understand the problem correctly? Misinterpreation from verbal comments is extremely common! Also, how can you proritize treatments if the issues are not itemized? Further, if you don’t define and document measures for achieving goals, how do you know when the patient is done with their treatment or can at least reduce their treatment. The resistance seems to me more like a desire to maintain patients in endless therapy (endless revenue stream) rather than a desire to make real, measurable progress.
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