How to Create a Treatment Plan for Therapy

A mental health treatment plan is a collaboratively written outline of goals, objectives, and interventions for therapy. Treatment plans should be client-centered, strengths-based, and provide the direction for treatment based on client needs. Below are five general steps to follow when creating a treatment plan.*

Step one: Identify the main concerns

Why is the client seeking therapy? What prompted them to seek out help in the first place? What diagnosis (if any) might you be targeting?

If your clinic requires a diagnosis and has strict documentation requirements, it helps to note the frequency, intensity, and duration of symptoms. Also consider what life areas might be impacted by the client’s concerns. This might include work, school, family life, health, finances, or other life areas.

Example: Jane Doe is in treatment for moderate symptoms of depression, including loss of interest in activities she once enjoyed, social isolation, insomnia, fatigue, and difficulty concentrating. Symptoms have been present for at least 6 months and are impacting her physical health, life at home with family, and productivity at work.

Step two: Identify the therapy goals

What would your client like to see happen differently in their life? What would make things better for them? How would they know that they are ready to transition out of therapy? Goals can help us to target not only the reason behind therapy, but to hone in on helpful interventions. I’ve had clients express a long list of goals across many different life areas. However, if the type of therapy you’re conducting is meant to be short-term (say, 3 to 6 months), try to narrow it down to no more than a few goals.

Example: Jane would like to feel happier and more energetic so that she can enjoy her time with her family again. Jane would also like to improve her sleep and increase her concentration at work.

Step three: Define your objectives

Objectives are how we measure progress throughout treatment. If you’re at a clinic that is required to collect outcomes measures (using assessments such as the CANS or Beck Inventory), examining the client’s scores throughout treatment is a good indicator of progress. Clients might also use subjective scales, such as a simple 1-10 scale with 1 meaning very low and 10 being very high. Objectives should be specific, measurable, and easy for both client and clinician to understand.

Example: Jane reports that her level of depression is at a 8 (on a 1-10 scale) on most days. Jane reports that if she brings this level down to a 4, she can manage her symptoms on her own. Jane also reports that she is getting an average of 4-5 hours of sleep per night, and would like to get at least 7-8 hours of sleep on most nights.

NOTE: Keep in mind how often you will be measuring progress throughout treatment. Some clinicians do this nearly every session with a subjective scale, while others provide a formal measurement every specific number of weeks.

Step four: Identify and define the interventions

Therapy interventions include what action steps will be taken, who will be responsible for them, and how often they will occur. It’s not enough to say that you will provide weekly therapy. Specifically outline what you will do that will target the client’s concerns.

Examples:

• Clinician will provide psychoeducation regarding depression symptoms and treatment. Therapy will focus on cognitive-behavioral strategies to address depressive thinking and healthier coping strategies. Clinician will conduct scaling check-ins at each session and offer the PHQ-9 tool every 4 weeks to monitor treatment progress.

• Jane will start and maintain a sleep diary to monitor sleep levels. Jane will practice sleep hygiene tips reviewed in therapy. She will also seek medical support through her physician to address physical symptoms of depression to rule out medical issues. (Clinician and Jane may evaluate the potential need for medical evaluation if sleep does not improve.)

• Jane will use natural support systems (such as spouse, friends, family members) to reduce social isolation. Jane has agreed to schedule at least two outings per month with a loved one to mitigate isolation.

Step five: Review the plan with your client, revise if needed, and come back to it throughout the course of treatment

It’s important to review the treatment plan with your client to make sure that everyone is on the same page, that the client agrees with it, and/or to determine if something needs to be changed. I’ve had clients change their minds and request that something be added/removed from the treatment plan, and it’s totally okay to do this throughout the treatment process. It’s also important to regularly review the plan to assess progress. If the objectives are not being met, the interventions might need to change. If the objectives have been met, it might be time to work on a new goal and/or to discuss graduation from therapy.

*I emphasize that these are general steps as each clinician, agency, and style of treatment will have a different method for treatment planning. I encourage you to consult with your colleagues/supervisors on what the best method of planning is for your work.