What is a Mental Health Treatment Plan and How to Write One?

The Mental Health Treatment Plans are a collaborative process between the client with mental health issues and the therapist. They are a necessity for most payors as insurance companies want to see how the therapist will help the client meet their goals. Treatment plans also easily help therapists track client progress and identify barriers and obstacles to the client meeting their goals.

Treatment plans don't have to be complicated to write. The more you get used to writing goals and objectives, the easier it becomes to write them like a pro. Writing them well is essential, as treatment plans summarize the client's work. Well-written treatment plans tell you, the psychologist, where your client is progressing and where there may be obstacles. Writing treatment plans helps everyone involved in the client's treatment adjust when necessary.

How to write a treatment plan?

If you're a mental health professional, writing good treatment plans can feel overwhelming, and you may not know where to start. Mentalyc Inc. recently surveyed active users to assess what they are using to create treatment plans.

One key finding from the survey about treatment plan templates includes:

• 1/3 of users use Wiley Treatment Planners
• 1/3 of users design their own treatment plans
• 1/3 of users use a different template that isn't Wiley

Treatment plans must also include required information from insurance companies to determine the medical necessity for treatment. You should also consider how you are tracking your client's progress. You will want a treatment plan format that makes it easy to follow the client's established goals and objectives for therapy.

Some typical sections that a treatment plan may included are:

• Goals
• Interventions
• Frequency of treatment
• Definition of the problem
• Diagnosis
• Modality administered
• Type of counseling, i.e. (individual, couple, group)
• Objectives
• Strengths of the clients
• Areas for improvement
• Referral for additional services

Our members included many of the areas listed above in a survey regarding treatment plans. Often, the goals set in treatment plans must also have an objective date for meeting the goals.

Here are some tips for writing effective treatment plans:

• Pull your information from the intake assessment
• Use client quotes of what they want to work on for their goals
• Be detailed about the interventions you will use
• Add a timeframe to the goals stated
• Have measurable objectives to determine the client's progress
• Write about the client's progress in your treatment plan

Treatment plans are a collaborative process between you and the client. The more client input you can gather, the better.

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Why are treatment plans useful?

Psychotherapy should be client-focused. Treatment plans give you a place to write about why the client is there and what they want to accomplish in short-form and long-term goals.

Additionally, treatment plans help you tailor your interventions to the client's needs. You allow the client to identify their target objective and treatment goals and describe how they can reach them.

Updating Treatment Plans

Treatment plans are typically updated every 3-6 months. If you accept insurance, you will want to inquire how often each insurance company requires treatment plan updates.

When you update a treatment plan, you will want to evaluate your client's progress on their original goals. If your client has met their initial goals, you will want to note their progress. In many EHR's you can copy and paste the old treatment plan, update goal progress, and add new smart goals if necessary.

If a client's diagnosis has changed since their initial treatment plan, you will also want to update their diagnosis. However, it may be best not to delete the original treatment plan because it can show your client's progress in the first few months of therapy.

Updating your treatment plans is essential for tracking client progress and shifting directions in therapy if needed. Your client may have new goals and objectives after a few months that they want to work.

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What do insurance companies require in treatment plans?

When you write treatment plans, you should always check the requirements of the insurance companies you're working with. Each insurance company may have different requirements. What's important is that the insurance company can see a medical need for the client to receive treatment from the therapist—also known as a medical necessity.

Proving medical necessity may be tied to a client's challenges at work, school, or relationships. You might ask yourself, "Why does the client need therapy?"

So, you may wonder what insurance companies require in their treatment plans?

Many insurance companies require these sections:

• A diagnosis
• Goals and Objectives
• A timeframe for goals and objectives
• How many sessions it will take to achieve the set goals
• Therapist interventions
• Therapist modalities
• An overview of the client's progress.

Some insurance plans require that treatment plans are updated every three months. According to a survey of active Mentalyc users, updating treatment plans at the 3-month mark is the most common, followed by treatment plan updates every six months.

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Example of a treatment plan for a client with anxiety

Problem: Bob is a 42-year-old male that works as an accountant. He reports an increased workload at his place of employment and is having trouble keeping up with his demanding workload. Due to increased stress, he dreads going to work. When he thinks about how behind he is, he feels overwhelmed and tends to shut down and avoid work. He reports feelings of constant dread. He feels sweaty and has difficulty focusing when approaching a task. Bob has sleep difficulties and constantly worries about work, especially at night. He says that he has thought loops where he obsesses over work repeatedly. Bob has withdrawn from his significant other and often does not want to leave the house anymore. He worries that his significant other will be upset if he loses his job.

Diagnosis: Bob has a diagnosis of Generalized Anxiety Disorder.

Goal: Bob wants to reduce his overall anxiety and see improvements within the next six months.

Objective(s):

1. Bob will learn three skills to help assess and manage his anxiety.

Intervention and Modality:

Bob will use a CBT thought record to record his anxious thoughts. Then, Bob will work on replacing his anxious thoughts with more helpful thinking patterns by identifying cognitive distortions. Next, the clinician will educate the client on Generalized Anxiety Disorder. Finally, the clinician will model skills for the client to help reduce overall anxiety, such as thought-stopping, meditation, breathing techniques, and tapping exercises.

Strengths: Bob consistently shows up for appointments. Bob states, "I'm willing to try any skills necessary to help reduce my anxiety."

Areas for improvement: Bob lacks consistent social support except for his wife.

Referrals: Bob will be referred to his primary care physician for anxiety medication.

Example of a treatment plan for a client with ADHD

Problem: Stacy presents for therapy, wanting to work on symptoms associated with what she believes to be ADHD. Stacy is a 25-year-old female. Stacy states that she has had problems focusing at work and completing tasks promptly. Stacy works as a paralegal and has a lot of paperwork she has to deal with. Stacy reports that she has had trouble doing her work over the past few months. She has difficulty initiating tasks and often finds that she can't complete tasks unless there is a sense of urgency or a deadline approaching, causing her to procrastinate. Stacy also states that she is having relationship difficulties with her partner. She reports that her partner listens to their music loudly most nights of the week, and it is hard for her to feel relaxed in her home. Stacy says that when it is too loud, she often snaps, yells at her partner, and wishes for "some peace and quiet."

Diagnosis: Stacy has a diagnosis of ADHD.

Goal: Stacy wants to learn ways to cope with ADHD and how to initiate and focus better on her work tasks. Stacy also reports wishing to get along better with her partner and deal with overwhelming emotions more effectively.

Objective(s):

1. Stacy will learn 3-5 new skills she can implement to assist with task initiation and focusing on tasks.
2. Stacy will learn what triggers sensory overload and three methods for coping with sensory overload.
3. Stacy will undergo a neuropsychological assessment to confirm the diagnosis of ADHD to assist with a possible medication referral.

Intervention and Modality: The therapist will employ a holistic approach to treating the client's ADHD. The therapist will teach Stacy skills such as body doubling, setting timers, making a game out of tasks, and having an accountability partner for task initiation and focus. The therapist will explore sensory overload with Stacy, teach her what it is, and discuss tools that may be effective for limiting sensory input. The therapist will also model effective strategies for Stacy that may help when sensory input can't be limited, such as meditation, tapping techniques, and deep breathing exercises. The therapist will explore Stacy's attitudes regarding receiving a full neuropsychological assessment to obtain medication. The therapist will provide Stacy with the appropriate referrals for the evaluation.

Strengths: Stacy has adequate social support, such as friends, family members, and her partner, that supports her mental health. Stacy is willingly engaged in treatment and eager to learn and implement new strategies that may be helpful to her.

Areas for improvement: Stacy lacks financial management skills due to her ADHD; therefore, managing money and affording a neuropsychologist referral may be difficult.

Referrals: The therapist will refer Stacy to receive a neuropsychological assessment to confirm her diagnosis of ADHD and also assess for any additional mental health diagnoses. Her assessment results will be used to refer her to a Psychiatrist or Primary Care Physician for potential medication for her ADHD.

Recap

Treatment plans serve as a guide for therapy. Treatment plans should tell you the therapist's roles and responsibilities and the client's roles and responsibilities. Treatment plans have many necessary sections for insurance purposes and should be updated every 3-6 months to examine the client's progress and per insurance companies requirements. Treatment plans should be a client-focused collaborative process that provides a clear path of how the client can reach their goals. Strengths and potential barriers to progress should be explored as this can help plan for any obstacles that can get in the client's way of reaching their goals.