Treatment Planning 101

“We didn’t really do that in our graduate program…”

I probably uttered that phrase meekly to my supervisor in 2006, willing my cheeks not to redden or my eyes to fill with tears of embarrassment and inadequacy. Since that time, I’ve heard it dozens—perhaps hundreds—of times from interns and new graduates. My theory on the general avoidance of treatment planning in graduate programs is twofold. First, I think most therapy interns are just trying not to break anyone. The goal is to sit/ make eye contact/ attune/ listen/ reflect/ encourage/ challenge/ redirect/ assess/ demonstrate cultural humility/ hold boundaries carefully enough that the client will experience a benefit and come back the next week. Please. I need 240 hours to graduate. Please come back! Second, unlike the DSM for diagnosing, there isn’t a universal standard or uniformity in treatment planning, so graduate programs leave it to the future places of employment to determine a standard. Plus, they probably hate teaching it as much as students hate learning it. But I digress.

Through Washington state auditors, regional auditors, CMS guidelines, Washington Administrative Code 246-341-0640 (1d), colleagues, students, and this handy book by Jongsma, Peterson, and Bruce, I’ve come to settle on a general approach to treatment planning that I share with the people I supervise in Washington state.

General Considerations

First, you have to do one. Let’s get that out of the way [groan]. Even in cash practices, clients may submit superbills for reimbursement and poor documentation holds the potential to jeopardize their reimbursement. It’s also a matter of clinical integrity.

The treatment plan is for both the client and the therapist. It gives a sense of what to expect and helps the therapist gather a general sense of direction. It should be respectful, strengths-based, optimistic, and flexible. It should take into consideration the unique person, including applicable cultural factors. It should be written in plain language. “No psychobabble!” as one state auditor hollered at me.

Format

Problem—what symptoms of the diagnosis are causing the client misery? Depressed mood? Poor sleep? Interpersonal conflict? Suicidal thoughts? Upset stomach due to anxiety? History of hospitalization? Non-stop worry?

Goal—Envision the last session with the client at the conclusion of treatment. What is different from the first session? How do you know they’re ready to launch? What did they want as a result of coming to you for therapy? Use the SMART goal format—specific, measurable, attainable, relevant, and time-bound. Self-report on a Likert scale is one easy way to knock out a measurable goal. Another is to administer baseline questionnaires and set goals from there.

Objectives—What things need to happen in order to meet the goal? In some cases, it makes more sense to make the objectives measurable than the goal. Gold star if you do both!

Interventions—CMS (Centers for Medicare and Medicaid Services) says in its guideline for outpatient psychiatry and psychology services for Medicare beneficiaries that treatment plans “must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals” (CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 6, Section 70.1).

Type: Individual therapy, group therapy, family therapy, medication management, etc.

Amount: 1 hour, 30 minutes, 90 minutes, etc.

Frequency: Weekly, biweekly, monthly, etc.

Duration: For the next three months, six months, etc. (up to 180 days)

Sample Plan

Problem: “I’ve been an absolute mess since we separated. I cry at weird times. The house is a mess. I can’t sleep. I snap at my coworkers and they’re getting sick of me.” Buster has had a difficult time adjusting to the separation from his wife three months ago.

Goal: “I want to pull myself together, start living life again. I need to be a better dad.” Buster rates his sense of being “together” as 2/10 where 1 is a disaster and 10 is his baseline functioning prior to the separation. His goal is to rate himself at 8/10 or higher by June when he will have his kids for the summer.

Objectives:

1. Take time to grieve the loss of the relationship, including learning about phases in the grief process and taking a personal inventory.

2. Read a handout on sleep hygiene and incorporate at least three new elements in order to improve sleep. Complete this in the first week of therapy and work with the therapist to identify additional steps that may be needed.

3. Itemize the areas of life that are falling apart, including the house. Prioritize the list into urgent tasks for the next week, tasks for the next month, tasks to be completed by June, and tasks that can be let go.

4. Use the Feelings Wheel to recognize and name feelings more accurately in order to minimize explosions at work and with others.

5. Learn and practice three coping skills consistently to help regulate distressing emotions.

Interventions:

1. One hour [amount] of individual therapy [type] each week [frequency] for six weeks, then every two weeks [frequency] for the following three months [duration].

That wasn’t so bad, was it? The therapy will undoubtedly take twists and turns that neither you nor the client can imagine. That’s okay. You can change the plan! No biggie. As a sidebar, there are a lot of different ways to write a treatment plan. This is just one way. Take what you wish, and discard what doesn’t work.