In psychology and psychiatry, a mental health treatment plan is an extremely useful tool for both the patient and the therapist/doctor. If you were ever curious about what a therapist writes down in a notebook during a session, it’s most probably used in a mental health treatment plan.

We will show a detailed view of how mental health treatment plans work, how they are created and applied in therapy.

What Is a Mental Health Treatment Plan?

A mental health treatment plan is a tool that helps therapists, counselors, and doctors define and monitor the focus of the mental treatment of a patient.[1] It is based on a preliminary evaluation followed by talking to the patient. This process is used to gather the information needed to create the actual mental health plan, which will be used throughout the therapy process.

A mental health treatment plan is a tool that helps therapists, counselors, and doctors define and monitor the focus of the mental treatment of a patient.

Therapists may use digital templates to create an online treatment plan for a more organized approach, but the logistics will all come down to their preferences and how well they work with a certain style of planning.

Sometimes, the structure of a mental health treatment plan is imposed by the patient’s insurance company or by the institution where the therapist works, but there will always be a personal influence of the professional creating it and working on it.

As a patient, you can truly benefit from having a mental health treatment plan that you will contribute to and use as well, so you can consider it a bivalent tool that keeps on improving as you and your therapist add information to it. Working in the absence of such a plan can sometimes prolong the treatment and decrease its effectiveness in the long term.[2][3]

When Is a Mental Health Treatment Plan Needed?

Even if it seems like a clinical tool that would only be applied in the case of mental illness, a mental health treatment plan can be used to help anyone going through emotional or psychological challenges. Seeking help is the first big step for anyone in that situation, and starting by creating a treatment plan will increase the likelihood of following along with the therapy or e-therapy.

We will give some examples of the people who can benefit from a treatment plan, but the list does not stop here.

  • Patients who are diagnosed with mental illness – including, but not limited to bipolar disorder, autism, psychosis, schizoaffective disorders, PTSD, etc.
  • People who are struggling with certain areas of their lives – like career, health, school, family, or romantic relationships.)
  • People who are part of vulnerable groups – for example, the elderly, children, victims of abuse, individuals experiencing gender, sexuality, or identity issues, etc.
  • People who have behavioral issues – such as bullies, abusers, individuals with addictions or anger issues
  • Parents and educators – who want to develop better tools for caring for children.
  • Patients with developmental disabilities – such as Down syndrome, fetal alcohol syndrome, or cerebral palsy.

These examples are shown to give you an idea of how comprehensive a mental treatment is and how it can be applied to a wide range of situations. The fact is that a mental health treatment plan is tailored for each case, and will contain unique information.

Creating a Mental Health Plan

A mental health treatment plan starts off with an initial evaluation and an interview of the patient. At this stage, the therapist can use a template to make the information gathering easier, since it’s a more clinical part of the process. The patient may be required to bring previous medical records related to the issue and will be asked about the current problems they are facing.

The therapist will also take the opportunity to explain the limits of confidentiality, get informed consent on the therapy process, and discuss practical things like the scheduling procedure, preferred communication channels, or fees that will be applied.[3]

Important Questions to Ask

The main outlines of the mental health treatment plan are then settled.

There are some important questions that need to be answered when creating the treatment plan, for example[4][5].

Questions To Consider
  • Why are you going for treatment? What’s your biggest issue, the one that needs to be solved most urgently, or that needs the most attention?
  • What are your present symptoms?
  • How long have you been struggling with this issue and how did it evolve?
  • How is your issue affecting your day-to-day life?
  • What medication are you on or have taken recently?
  • Information about your personal history, from infancy to current age. You will discuss details like adapting to school, closeness to your parents, early romantic relationships, struggles in your career, etc.
  • Diagnosis: a very important part of your treatment plan is the initial diagnosis because it’s going to dictate the medication you will be prescribed and the therapy method that will be applied

Once an initial evaluation has been completed, practitioners can use it to create a list of goals and milestones to be achieved; each can be split into smaller tasks. An estimated timeline of the therapy process will help you and your therapist get a clearer view of how you will progress through your mental health program over time.

Next, let’s talk about how a mental health treatment plan is applied.

What Are SMART Goals in Therapy?

Many therapists define the goals in their treatment plans according to the SMART criteria, an acronym that lists the characteristics that these goals must have the following SMART elements.[6][7]

Criteria

Details

S for Specific

Treatment plan goals must be explicit in order to be operationalized.

Vague goals are subjective and can lead to potential disagreements between the patient and the therapist, which is why clear sentences are encouraged.

For example, instead of a patient writing “Being more sociable” in a mental health treatment plan, therapists might work with them to find a goal like “Participate in social gatherings” or “Meet a friend for a talk every week”.

M for Measurable

Progress can often be felt after some time in therapy, but a means of measuring it can be greatly motivating for both patient and therapist.

A journal can help when measuring successes, as patients can count the times they overcome difficulties and conquer new milestones.

A for Attainable

Setting unrealistic goals may seem ambitious, but can do harm in the long term.

Failure is inevitable when setting unattainable goals, and can lead to patients feeling discouraged, or like therapy was a waste of time.

What’s attainable or not will all depend on an individual patient’s time, resources, location, and mindset.

R for Relevant

Intrinsic motivation is the best way to drive behavior. This means setting goals that are relevant to them personally, and not others in their lives, like family members, employers, or a court.

Even patients who need to achieve certain results that don’t necessarily resonate with them, they can work together with a therapist to find creative ways to make that achievement relevant.

For example, someone who struggles with social anxiety but is not willing to meet new people may be motivated by a hobby that takes place in a social setting.

T for Time-based

This may be an answer to the question “How long will my treatment last?”

While the real timeline can differ from the initial estimate, it’s still important to set a date or a period of time to reach each milestone and the final goal.

A useful tip to setting a deadline for your final goal is to make it realistic. Too far in the future, and patients may become discouraged.

Writing down this type of SMART goals and structuring them correctly with the help of the therapist marks the beginning of your mental health solution while solidifying the commitment.

The way you collaborate with the therapist for creating your mental health treatment plan will also model the base of your relationship. A good relationship between the therapist and his patient is one of the most helping things in therapy.

Related: What is Applied Behavior Analysis? 5 Apps to Try

What Happens Without a Treatment Plan?

If you think that a mental health treatment plan is too official and formal, consider the consequences of not following a plan for mental health therapy. Even if the therapist is extra careful to follow your progress closely, mistakes are easily made when there isn’t any structured report to refer to during your therapy process.

A mental health treatment plan that involves teamwork from the therapist and the patient can greatly enhance client engagement.

Professionals who do not follow a treatment plan might skip certain important parts, duplicate them, or do something irrelevant for your progress. Keeping track of the goals you have set initially contributes greatly to the efficiency of therapy.[8]

Another important role of a mental health treatment plan is to record your treatment and progress for the next therapist who might take over. Having a clear indicator of the methods you have tried and what results they had so far will help the new therapist a lot when creating their own treatment plan.

A more bureaucratic aspect of writing down a mental health treatment plan is that it could be used as hard evidence when you request coverage from the insurance company, or when you are in a lawsuit as a victim and you need to present the judges the extent of your mental condition.

Mental therapy treatment plans can be relaxed, informal and creative, while others follow a strict template and include many details. Your therapist can choose the style that they work best with, being careful to make it accessible for you as well. After all, a mental health treatment plan that involves teamwork from the therapist and the patient can greatly enhance client engagement.[8][9]

Examples of Elements Included in a Mental Health Treatment Plan

For an even clearer picture of what treatment plans look like, here’s a raw template of a simple plan.

In this plan, you’ll find some of the most basic, but essential elements for successful therapy:

Element

Details

Patient information

  • The patient’s full name
  • Their Social Security Number
  • Date of commencing treatment
  • Insurance details for reimbursement

Diagnostic

  • Their current diagnosis
  • Any pertinent information about past and present symptoms

Electronic Health Records (EHR) information may be relevant here, for a fuller snapshot of the patient’s current and past mental state.

Personal History

  • A few relevant details from the patient’s background can go a long way to establishing a stronger therapeutic alliance and building engagement.

Goals, Milestones, and Timeline

  • Main goals are listed
  • Broken into smaller tasks or sub-goals
  • May be linked with an expected deadline.
Confidentiality Agreement
  • A section where confidentiality and privacy terms are explained and defined.
  • Signed, Informed Consent data can be included

Signatures

  • Signatures from both the patient and therapist.

Software for Mental Health Treatment Plans

Today’s connectivity has allowed telemedicine to take over a wider part of the public, reaching patients in remote areas, and helping them get the needed treatment. For therapists who like using technology in their job, there are many mental health software solutions that enable them to write their notes and create a mental health treatment plan faster and easier than with conventional tools.

Blended Care: Integrating Technology

The electronic format of a patient’s medical records (EMR) is also easier to store and give to the next specialist in case they need to check what was done before. Of course, there is always a concern regarding the security of digital medical data, but companies who specialize in medical software also invest a lot of their resources in data security and protective measures such as HITECH- and HIPAA-compliance.

Software often provides templates and examples of mental health treatment plans, with user-friendly interfaces that make note-taking much simpler.

Such software often provides templates and examples of mental health treatment plans, with user-friendly interfaces that make note-taking much simpler. At the same time, they also allow for a comfortable way to check a patient’s past records. Companies who create digital clinical software also offer training for therapists to understand their application perfectly and use it with maximum efficiency in virtual care.

For the patient, it means a therapist with more time to spend on the actual therapy, rather than filling in paperwork by hand and searching past records for important data.

Final Thoughts

A mental health treatment plan is an incredibly useful tool for a therapist or a doctor treating their patients. It allows both doctor and patient to understand how therapy will go and what to expect from it.

Knowing how to work together to create the most fitting plan for the patient’s situation can create stronger patient-therapist bonds, often leading to better treatment outcomes, health engagement, and improved mental well-being.

What elements do you consider vital in a high-quality mental health treatment plan? Share your thoughts and join the conversation below.

References

  1. ^ Betterhealth.vic.gov.au. (2015). Mental Health Treatment Planning. Retrieved from https://www.betterhealth.vic.gov.au/health/ServicesAndSupport/mental-health-treatment-planning
  2. ^ Corcoran, K. J., & Vandiver, V. (1996). Maneuvering the maze of managed care: Skills for mental health practitioners. NY: Simon and Schuster.
  3. ^ Yalom, I. D. (2002). The gift of therapy: An open letter to a new generation of therapists and their patients. NY: HarperCollins Publishers.
  4. ^ Hansen, M. (1999). Writing effective treatment plans: the Pennsylvania CASSP Model. Harrisburg: Pennsylvania CASSP Training and Technical Assistance Institute, Department of Education.
  5. ^ Hutchison, M., Casper, P., Harris, J., Orcutt, J., & Trejo, M. (2008). The clinician’s guide to writing treatment plans and progress notes. Retrieved from https://www.sccgov.org/sites/bhd-p/Policies-Procedures/adult-system-of-care--policy-procedure/Documents/Clinician_Gde_toolkit.pdf
  6. ^ Doran, G. T. (1981). There’sa SMART way to write management’s goals and objectives. Management Review, 70(11), 35.
  7. ^ Wade DT. (2009). Goal setting in rehabilitation: an overview of what, why and how. Clinical Rehabilitation, 23, 291.
  8. ^ Rose, G., & Smith, L. (2018). Mental health recovery, goal setting and working alliance in an Australian community-managed organisation. Health Psychology Open, 5(1), 2055102918774674.
  9. ^ Storm, M., & Edwards, A. (2013). Models of user involvement in the mental health context: intentions and implementation challenges. Psychiatric Quarterly, 84(3), 313.

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