Treatment Plans

Few therapists enter the field because of a love of paperwork. We accept paperwork as part of the job, but value face-to-face interactions with patients over dotting i’s and crossing t’s. When time gets tight and sessions run past the allotted 45 minutes, it’s easy to defer progress notes.

And while most therapists include treatment plans as part of their documentation, how many of us regularly review and update those treatment plans as part of our ongoing work with patients?

Treatment plans provide a useful framework for therapists and patients to work towards specific goals and monitor progress. In addition, they can be used to identify when it’s time for termination, either because of a plateau in progress or because treatment goals have been met. Finally, most insurance companies require treatment plans to be written and reviewed on a regular basis as part of their documentation requirements.

Ideally, treatment plans are the product of collaboration between therapist and patient. By soliciting your patients’ concerns, hopes, and expectations, you empower them to take ownership of the therapeutic process. Thus, the treatment plan serves as a shared reference point, ensuring that both you and your patients have a mutual understanding of the therapeutic approach and focus.

The components of a treatment plan can vary depending on the requirements of the patient’s insurance plan and/or your place of work. However, most treatment plans include the following:

1. Client information– Jot down any relevant demographic details such as age, occupation, gender at birth, preferred pronouns, and marital status. You can also include a brief summary of the history of the client’s presenting problem.

2. Assessment– Provide an overview of the patient’s symptoms, strengths, challenges, and any relevant diagnoses.

3. Goals and objectives– While in common parlance, goals and objectives are synonymous when it comes to treatment plans, they differ in several important ways:

• Goals are the broad outcomes that patients wish to achieve in therapy, while objectives are the specific steps patients will take to achieve those goals.

• While patients often enter therapy with a clear goal in mind, they are usually less clear on how to attain those goals. Thus, goals are often in the patient’s own words, while objectives are more of a collaboration between therapist and patient.

• Objectives should be specific, measurable, attainable, relevant to the presenting problem, and time-bound, (often abbreviated with the acronym “SMART”).

For example, if a patient’s goal is to learn how to more effectively manage anxiety, an objective could be to practice a guided meditation 5 times per week for 10 minutes.

4. Interventions– Identify the specific interventions, techniques, and strategies you will use to address the client’s concerns. These may include modalities like cognitive-behavioral therapy, psychodynamic therapy, or mindfulness-based approaches.

5. Progress measurement– Outline how you will measure progress towards the established goals, whether via standardized assessment tools, self-report, or direct observation.

6. Frequency and duration– Specify the anticipated frequency and duration of therapy sessions– for example, weekly for 9-12 months. You can always revise this projection later, but this will help to establish the commitment required from both therapist and client, and insurance companies often ask for a general idea of how long treatment will last.

7. Crisis or safety plans– If there is any risk of harm to self or others, you may want to include crisis management strategies or a contract for safety within the treatment plan. This plan could include warning signs or triggers, coping strategies, social supports, and other resources available in the case of a clinical emergency.

If this feels like a lot of information to gather over the course of an initial evaluation, consider digitizing some of your intake paperwork and asking your patient to fill in some details ahead of time. Blended care platforms like Simple Practice include a variety of electronic health records, including treatment plans with preset goals and objectives organized by diagnosis. Some of these platforms will even send automated reminders to review and update treatment plans.

Psychologist Donald Meichenbaum, professor emeritus at the University of Waterloo and one of the founders of CBT, likens a therapist without a treatment plan to “a captain of a ship without a rudder, aimlessly floating about with little or no direction.” While this may feel like hyperbole, treatment plans do provide structure, guidance, and accountability to both therapist and client. By writing and regularly reviewing treatment plans, therapists promote positive therapeutic outcomes and support clients on their journey toward personal growth and well-being.