Section 9: The Treatment Plan

If the clinician has done his/her work well in preparing a thorough, targeted psychosocial assessment, it will gather the key client information, allowing the clinician to pull together the various aspects of treatment into a unified intervention strategy. This intervention strategy will then need to be organized into a treatment plan.

A treatment plan serves two important purposes for a clinician. First, it provides a concise format for organizing both 1) the most important symptoms and problems on which to focus and 2) the most appropriate approaches to treat those symptoms and problems. Second, from a liability standpoint, it provides a clear demonstration of the clinician’s ability to design appropriate – and evidence based - intervention strategies to meet the needs of the client.

In most private practice cases, the treatment plan does not need to be a very extensive document. However, in order to meet best practices guidelines, the treatment plan should always cover at least the following three main areas:

- Target Problems/Symptoms (this may include comments on functional impairment caused by the symptoms)
- Treatment Objectives
- Specific Interventions to be Used

The treatment plan may also include the following items:

- An Intervention Plan Overview
- An Estimated Time Frame to Completion
- A Prognosis for the success of treatment

Because treatment plans will be updated as a client moves through the treatment process, it is helpful to have a single template that can be used both as an original treatment plan form and as a revised treatment plan form. This means that there should be a place for recording the date of the original treatment plan and the date of the treatment plan update.

An example of a concise treatment plan is shown below.

                                       Pat R. Clinician, LCSW
                                               Treatment Plan

Client: __________________________ Original Date: _________ Revised date:_________

Target Problems/Symptoms:

1) ________________________________________________________________________
2) ________________________________________________________________________
3) ________________________________________________________________________
4) ________________________________________________________________________

Comments/Functional Impairment:

__________________________________________________________________________________________________________________________________________________________________________________ 
Treatment Objectives:

1) ________________________________________________________________________
2) ________________________________________________________________________
3) ________________________________________________________________________
4) ________________________________________________________________________

Interventions:

1) ________________________________________________________________________
2) ________________________________________________________________________
3) ________________________________________________________________________

Intervention Plan Overview / Time Frame:
__________________________________________________________________________________________________________________________________________________________________________________ 

Prognosis: __________________________________________________________________________________________________________________________________________________________________________________ 

Notes: __________________________________________________________________________________________________________________________________________________________________________________ 


Signature: _________________________________________ Date:______________

As we have noted, extremely complex cases with co-morbid problems, multiple providers and a case management component may require the use of a more extensive treatment plan. In a perfect world, this would be a treatment plan that integrates and aligns with both the more comprehensive (bio-psycho-social-systems) assessment form and a case tracking/case note system capable of following and recording each of the many aspects of treatment. If the 12-vector approach from the previous chapter is utilized in the assessment process, it is a relatively straightforward process to bring the information from that format into the development of a more complex treatment plan, using a format that assigns one or more pages to each of the vectors.

Particularly with problems where multiple interventions are required and several parties are involved in the clinical work, it may be even more helpful to have a treatment plan where each target problem is addressed on a separate page. One possible template for this kind of detailed treatment plan is shown below. This is an abbreviated version, shown just to demonstrate the approach taken. The form itself can be flexibly modified and expanded, adding additional boxes as needed for any of the components.

The final treatment plan is likely to consist of a number of pages, and a space has been placed in the form for both a page number and the total number of pages of the complete treatment plan. This helps to assure that no pages of the treatment plan go missing from the clinical record. As with the concise treatment plan form, there is also a space to record the date of the original treatment plan and the date that revisions are made, as intervention strategies are updated.

The advantage of this kind of template lies in its ease of use. It is easy to follow specifically which interventions are to be done and who is supposed to be doing them. This allows for faster and more precise follow up in terms of how well the assigned parties are putting into effect the interventions that have been determined to be most essential.

At the same time, it restricts the amount of unnecessary material that is getting inserted into the treatment plan. It is set up to require a certain measure of concision, helping clinicians to get to the key points of the intervention strategy.

                                                  Pat R. Clinician, LCSW
                                                        Treatment Plan

Client: __________________________ Original Date: _________ Revised date:_________

Treatment Domain Addressed: Medical___ Psychologic___ Social___ System___

Target Problem or Symptom: ____________________________________________________

Comments/Functional Impairment:
__________________________________________________________________________________________________________________________________________________________________________________ 

Intervention Plan Overview / Time Frame:

__________________________________________________________________________________________________________________________________________________________________________________ 

Comments/prognosis:
__________________________________________________________________________________________________________________________________________________________________________________ 

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