Lessons That Were Not Taught to Me in Graduate School Part 3 of 5: Writing Measurable Treatment Plans

This is the third in a series of five articles about lessons that I have learned in the school of experience and hard knocks, rather than in graduate school.  The first dealt with the ethical considerations when you leave a practice.  The second focused on the necessity of proper documentation and the potential consequences of not properly documenting mental health services.  This article describes the importance of writing treatment plans in which clients’ progress can be measured and evaluated in clear, not vague, terms.

My training:  In graduate school I was taught that treatment plans were a description of the intended services to be provided to a client (i.e., the plan for treatment).  The information was to include the diagnosis, the type of therapy (e.g. individual or group), the mode of therapy (or school of thought), the number of expected sessions, a list of problem areas to be addressed in the counseling, the goals and objectives for client change, plus a list of client’s strengths and areas of concern. We were taught to have at least three goals and at least three objectives for each goal.

What has changed over the years?:  Although I learned this information about 30 years ago, most treatment plan formats haven’t changed much since that time.  The training regarding what needs to be in the treatment plan has remained quite consistent.  But the expected content of what is written in a treatment plan has led to more accountability of providing evidence that the treatment is on target and that it is designed to provide services that are medically necessary and designed to alleviate functional impairments. That is, the treatment plan, in conjunction with progress notes, must provide more empirical evidence of the effects of the services being provided, compared to in the past.

Concerns about older treatment plans are mainly that they were much too vague and not measurable in their outcomes.  Thus, it was very difficult for an outside auditor, or even a clinical supervisor, to review a client’s record and determine the treatment’s effectiveness.  That is, vague goals and objectives lead to vague outcomes.  This is clearly unfair to the both the client, the party paying for the services, the reputation of the therapist, the clinic, and the public’s view of psychotherapy.

I currently specialize in conducting psychological evaluations for people with various disabilities.  Many of them either currently or previously received counseling services elsewhere. When I ask them if the counseling is helpful, a common response it that they feel good during the session, but they continue feeling just as depressed or anxious the rest of the week.  They typically say that they were not aware of any specific goals or objectives, but rather, they went to counseling mainly to have someone to talk to, or to feel better during the session.  It is as if each session is helpful while they see the therapist, but the effect wears off soon afterward.  This is sometimes referred to as “maintenance therapy.”  However, the main purpose of psychotherapy is to improve one’s mental health, not simply “maintain” a certain level of functioning.  A vague treatment plan often leads to accomplishing little more than a session of chit-chat or going over the same material each session.  There must be a “plan.”  The client-therapist relationship sometimes becomes more of a supportive role, rather than mental health treatment.  This, in itself, is not harmful to the client, and may be viewed as beneficial, but it is not considered efficacious by the bulk of third-party payers or auditors.

Treatment plan goals and objectives are based on functional impairments.  When people seek counseling services, they come in because of difficulties functioning in areas treated by mental health professionals.  The goal of counseling is to restore or increase functioning.  Thus, a thorough diagnostic interview includes not just validating a DSM-5 diagnosis, but also determining the functional, emotional, and behavioral effects of the mental health disorder.  The treatment plan should focus on the behaviors that are functionally impairing, instead of serving as an endorsement of symptoms.  For example, everyone experiences some depression, anxiety, unusual thoughts, and other mental health symptoms.  This is also called “being human.”  But treatment is needed when the clinical symptoms and impairments are at a level in which, without treatment, the client is likely to decline or not improve.  Then, treatment is medically necessary.

A well-written treatment plan takes into account the severity of the client’s condition.  It allows for a reasonable amount of time for expected improvements to take place.  The treatment plan for clients with severe mental health disorders require a treatment plan that increases the therapy objectives in much smaller steps than those who would benefit best by short-term therapy.  But in either case, the documentation must provide sufficient, measurable evidence of client change.  Therefore, the treatment plan must be quite explicit.  When it is clear that the current therapy is not working, it is time to either change the treatment plan or refer the client to another professional who might be a better fit for the client’s needs.  There is no therapist who can benefit every client.  Let’s not allow our egos to get in the way of what is in the best interest of our clients!

Vague vs Measurable Treatment Plans:  Some treatment plans include goals that are much too vague or unrealistic to evaluate the effectiveness of therapy.  Measurable treatment plans contain both goals and objectives.  Goals are typically somewhat vague; they are often stated in terms similar to DSM-5 symptoms, such as social withdrawal.  For example, if a treatment plan goal is to “increase social interactions,” it provides little information, other than there are some concerns in socializing.  The goal is not measurable because it does not provide a baseline, nor does it provide a clear picture of what is being desired as the outcomes of therapy.  In this example, if one of the goals is to increase social interactions, that goal should be followed by specific, quantifiable objectives that clearly describe a timely alleviation of functional impairments.  Treatment plan objectives that contain timelines of specific behaviors, in which the desired behavior, or results of the therapy, are listed and periodically evaluated, are excellent means of both staying on track.  In addition, when the treatment plan is followed and monitored with the client, it can be very motivating for them as goals and objectives are met.  Knowledge of how to document psychotherapy outcomes is becoming increasingly more important in our field.

Example:  The following provides an example of a vague vs. specific treatment plan goal.

Vague Treatment Plan Goal:

Increase social interactions

Treatment strategies: Individual psychotherapy

In this case, we have no idea what needs to be worked on in treatment.  We know very little about the client.  The goal is so vague that it could apply to anyone, even people who are quite sociable, but would like to be even more outgoing.  Anyone reviewing the treatment plan would have no idea what is being treated.

Specific Treatment Plan Goals/Objectives:  This information would have been collected during the diagnostic interview, in which the client describes various problem areas.  It is revised throughout the course of treatment as progress and setbacks take place.  An example of one goal and three objectives for the goal are listed below.  Typically, a few more goals, with their objectives, are included in treatment plans.

Goal 1: Increase social interactions.

Objective 1:  Initiate at least two conversations with co-workers once per week by June 25th.

Baseline: He currently interacts with co-workers 0-1 times per week.

Objective 2:  Increase the time spent in social conversations to at least three minutes by June 25th.

Baseline:  He currently has brief social conversations of less than one minute, only when necessary.

Objective 3:  Invite at least one person at work to have lunch together by June 25th.

Baseline:  He currently eats lunch alone at work 100% of the time.

In this case, the goal is the same as the vague goal, but the objectives are measurable.  A review of the client’s progress will take place at the therapy session on or about June 25th, in which the client and therapist will discuss the client’s progress on the objectives.  This type of feedback to the client often helps increase their level of insight and motivation to continue.

For the objectives that have been met, the frequency of the desired behavior would be increased as the treatment plan is revised.  For example, once the client is able to start two conversations per week, the revised objective would be increased to perhaps four conversations by a later date. When objectives are not met, this is evidence that something should be revised in the treatment.  Objectives are revised until there is no longer functional impairment in that area, at which point services are no longer medically necessary for the client to function socially.  The desired result is that the skills and insights gained in therapy will have the effect of no longer needing treatment in that area.  Treatment ends when it is no longer medically necessary.  Both the intake notes and progress notes must regularly document the medical necessity of ongoing treatment.

Bottom Line:  Treatment plans typically cover at least three goals and specific objectives for each goal.  The goals are decided in collaboration with the client.  Sometimes the least stressful concerns are the first topics of treatment, while some therapists and clients prefer to work on the most impairing areas first.  Treatment plans should never be canned or obtained from outside sources that focus on general symptoms; this is why a treatment plan is often called an “Individual Treatment Plan.”  Just as no two people are alike, neither should this be the case for treatment plans.

Lesson Learned:  I had excellent teachers in graduate school and received some fine supervision.  They were satisfied with my treatment plans, which worked fine at that time.  However, documentation requirements have become more stringent.  In the past, we rarely discussed providing evidence of the effects of therapy.  This has changed, and will continue to evolve.

Imagine yourself as the owner of an insurance company or a third-party payer.  You would want to be sure the funds that you were paying to therapists were being well-appropriated.  This can only be verified by having evidence that the treatment for the providing therapist has been beneficial in decreasing functional impairments.  When documentation is poor, there is little or no evidence that the services are medically necessary.  Unnecessary services do little more than raise the cost of health insurance.  Then, people who truly need services might not be able to be treated at the level needed.  There is only so much money in the pot!

However, the most important aspect of a clear treatment plan is how it benefits the client.  It helps keep the therapy on track, gives direction for future sessions, and can motivate the client as objectives and goals are attained.

Coming Up:  The 4th part of this series will discuss writing progress notes.  Progress notes are extremely important in documenting the implementation of the treatment plan.  The final installment, Part 5 will discuss demonstrating outcomes of treatment.

Donald E. Wiger, Ph.D., LP, is a licensed psychologist with a private practice in St. Paul.  He has conducted seminars and consultations in documentation since the 1990s.  He has written several books on topics such as clinical documentation, practice management, clinical interviewing, and record keeping.  Dr. Wiger earned his Ph.D. in 1989 from Fordham University in New York City from the Department of Psychology, specializing in psychometrics.  He has an MA (1986) in experimental psychology/psychometrics from Fordham University and an MS (Ed.) (1984) degree in counselor education from the State University of New York.

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Comments on "Lessons That Were Not Taught to Me in Graduate School Part 3 of 5: Writing Measurable Treatment Plans"

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Richard Sethre - Saturday, January 13, 2018

Thanks to Donald for this article. His book "Psychotherapy Documentation Primer" not only helped me do a better job of treatment plan documentation but helped me be a better therapist.

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