Elements of a Clear Treatment Plan |

Elements of a Complete Treatment Plan

I would like to emphasize again, that this treatment planning guide is not your individualized treatment plan, you and I will create one together that will have the following elements:

1. History, Background, and Assessments: This section will contain basic demographic information about you, past and present diagnosis, and when the presenting problems first started to occur. If you have seen a counselor or other mental health professional in the past, you’ll describe the prior treatment history. The results of any formal assessments will go in this section too.

2. Problem Statements: Also referred to as behavioral definitions, we will list in detail what presenting problems have led you to seek mental health care. What questions or symptoms were you experiencing that prompted you to seek professional help?

3. Strengths: The strengths section is an essential but sometimes-overlooked element of a counseling treatment plan. Here, you’ll verbalize and document (self-stated) personal strengths, values, and available family supports. When the going gets tough, reviewing this information with me can help provide you with encouragement and hope.

4. Treatment Contract: The Informed Consent to Therapy and Agreement to Treatment is a part of this. A treatment contract also details who’s responsible for what. It lists out actions that both parties are responsible for completing during treatment. The contract summarizes your goals for counseling and the plan for achieving them. Including a treatment plan in the therapy agreement can help create a sense of ownership.

5. Long Term Goals: Long Term goals form the bedrock of any treatment plan. They define what successful therapy looks like. Goals should be specific, realistic, achievable, concrete, and tailored to meet your unique needs.

6. Objectives: If a goal is a story, objectives are the individual chapters within that story. Treatment objectives are small, incremental steps that together will result in the achievement of a treatment goal.

7. Interventions: I will use various philosophies, approaches, techniques, interventions, and strategies to help you meet your treatment goals. The interventions section is where I will list the methods I plan to use with you. Interventions will also be specific and relevant to the objective.

8. Progress Tracking: Documenting client progress is one of the most important aspects of a counseling treatment plan. As treatment progresses, being able to look back on past successes is a significant source of inspiration to stay the course. Insurers also require documentation of client progress.

9. Outcome measure: How will you know when you no longer need to be in therapy, when you no longer meet medical necessity, or when a higher or lower level of care is needed. I will ask you to complete assessments in the beginning and toward the end of therapy.

10. Follow Up and Termination: What maintenance plans can you implement? How will you maintain the gains you have made? How will you and your counselor end the relationship? What referrals to other services or professionals would you need?

SAMHSA Model of Recovery

Many of the objectives and interventions in your therapy action plan will adhere to the 10 core principles developed by a multidisciplinary panel at the 2004 National Consensus Conference on Mental Health Recovery and Mental Health Care Systems Transformation convened by the Substance Abuse and Mental Health Services Administration (SAMHSA, 2004). The following principles were edited to express ideas in a more natural and unifying way. For example, words like consumers become people in recovery, nation becomes society, America becomes community:

Self-direction: People in recovery lead, control, exercise choice over, and determine their own path of recovery by optimizing autonomy, independence, and control of resources to achieve a self-determined life. By definition, the recovery process must be self-directed by the individual, who defines their own life goals and designs a unique path toward those goals.
Individualized and person-centered: There are multiple pathways to recovery based on an individual’s unique values, strengths and resiliencies as well as his or her needs, preferences, experiences (including past trauma), and cultural background in all of its diverse representations. Individuals also identify recovery as being an ongoing journey and an end result as well as an overall paradigm for achieving wellness and optimal mental health.
Empowerment: People in recovery have the authority to choose from a range of options and to participate in all decisions-including the allocation of resources-that will affect their lives, and are educated and supported in so doing. They have the ability to join with other consumers to collectively and effectively speak for themselves about their needs, wants, desires, and through empowerment, an individual gains control of his or her own destiny and influences the organizational and societal structures in their life.
Holistic: Recovery encompasses an individual’s whole life, including mind, body, spirit, and community. Recovery embraces all aspects of life, including housing, employment, education, mental health and healthcare treatment and services, complementary and naturalistic services, addictions treatment, spirituality, creativity, social networks, community participation, and family supports as determined by the person. Families, providers, organizations, systems, communities, and society play crucial roles in creating and maintaining meaningful opportunities for consumer access to these supports.
Nonlinear: Recovery is not a step-by-step process but one based on continual growth, occasional setbacks, and learning from experience. Recovery begins with an initial stage of awareness in which a person recognizes that positive change is possible. This awareness enables them to move on to fully engage in the work of recovery.
Strengths-based: Recovery focuses on valuing and building on the multiple capacities, resiliencies, talents, coping abilities, and inherent worth of individuals. By building on these strengths, they can leave stymied life roles behind and engage in new life roles (e.g., partner, caregiver, friend, student, employee). The process of recovery moves forward through interaction with others in supportive, connected, trust-based relationships.
Peer Support: Mutual support-including the sharing of experiential knowledge and skills and social learning-plays an invaluable role in recovery. People in recovery encourage and engage other people in recovery and provide each other with a sense of belonging, supportive relationships, valued roles, and community.
Respect: Community, systems, and societal acceptance and appreciation of people in recovery, including protecting their rights and eliminating discrimination and stigma-are crucial in achieving recovery. Self acceptance and regaining belief in one’s self are particularly vital. Respect ensures the inclusion and full participation of consumers in all aspects of their lives.
Responsibility: People in recovery have a personal responsibility for their own self-care and journeys of recovery. Taking steps toward their goals may require great courage. They must strive to understand and give meaning to their experiences and identify coping strategies and healing processes to promote their own wellness.
Hope: Recovery provides the essential and motivating message of a better future that people can overcome the barriers and obstacles that confront them. Hope is internalized, but can be fostered by peers, families, friends, providers, and others. Hope is the catalyst of the recovery process. Mental health recovery not only benefits individuals with mental health disabilities by focusing on their abilities to live, work, learn, and fully participate in our society, but also enriches the texture of community life. Communities reap the benefits of the contributions individuals with mental disabilities can make, ultimately becoming a stronger and healthier society.