Writing a counseling treatment plan

Working as a counselor requires a  significant amount of planning. In order for your sessions with clients to be truly effective, it is essential that you are thoroughly prepared, and arrive at your appointments ready to go. Whilst it is not a universal requirement to create counseling treatment plans, research has shown that they have vast benefits for both practitioners and patients. Because this type of planning is necessarily tailored to the individual client’s needs, they allow you to focus on specific areas and design a treatment method suitable and appropriate for each of your patients. Alternatively, treatment plans allow counselors to identify where progress has been made, allowing them to more effectively assist their clients in achieving positive health outcomes. In this guide, we’ll unpack the various benefits of writing treatment plans for counseling practices, before diving into specific examples of what this may look like for you. Hopefully, after you finish reading, you’ll feel well equipped with the knowledge required to create the perfect treatment plan!

Essentially, a mental health treatment plan is a type of written counseling guide. It outlines the recommended steps and/or instructions for a counselor to take in order to treat a patient. Typically, a treatment plan will include the patient’s name, diagnosis, treatment goals, proposed timeline, and space for reflecting on progress. These documents do not have to be excessively long, provided they contain enough information to guide your sessions effectively. Additionally, talking through the treatment plan with your patient is a necessary part of preparing clients for their first therapy session. Not only do they indicate your expertise and capability, but they also demonstrate to your patients that you value their health and wellbeing.

Purpose of a treatment plan

A good treatment plan can be created either as a hard-copy document or online, with the aim of helping practitioners visualize the structure of their sessions with clients. They should be tailored to the specific needs of the client and can be used to target any disorder, illness, or ailment. Treatment plans also prove beneficial to patients, as they track progress and outline specific goals or target objectives. An effective plan will allow patients to actually visualize their progress, and celebrate improvements. Furthermore, this type of documentation is also often used in insurance situations, as it can help clients have their therapy fees covered.

So what exactly does a treatment plan contain? Whilst the information provided within your plans will largely depend on your client’s individual needs, we have compiled a list of some of the most essential components of an effective counseling treatment plan. 

Demographics: Information regarding the patient’s demographics, including name, age, symptoms, medical history, and diagnosis.

Concerns: This section should explain the concerns that contributed to the patient seeking treatment. It may reiterate symptoms, determine when they began, and how they have impacted the client’s day-to-day life.

Contract: During the first session, the counselor and patient should create a “treatment contract”. This will state the health outcomes that the client is striving for, and propose how many sessions will be necessary.

Goals: The most important aspect of the treatment plan are the goals. You and your client should work together to create achievable target objectives for both short-term and long-term progress. In subsequent sessions, it is important to enquire whether the client has achieved these goals - celebrating small achievements is an important part of receiving treatment!

Interventions: As the counselor, it is essential that you detail the specific interventions and treatment methods that you have introduced to your client. These can be fluid, and you may come to realize that your original intervention isn’t as effective as you’d hoped, but it is important to document these changes.

Progress and outcomes: The improvement of an individual’s mental wellbeing needs to be measurable. By creating goals within your treatment plan, you will also be able to assess whether these have been achieved. At the end of your treatment process, you should be able to look back at your planning documents and identify specific achievements and overall health outcomes.  

As you can see, the information contained within a treatment plan needs to be tailored to the client’s health needs. There are a variety of other important things you need to discuss with your client prior to treatment, including billing guides, insurance, and appointment information, but these conversations should happen externally to your treatment plan.

To help you visualize exactly what a treatment plan should look like, we’ve created a sample for a fictitious patient that has been diagnosed with generalized anxiety disorder. 

Sam has been diagnosed with generalized anxiety disorder and is struggling to adequately complete his usual routine. He has difficulty with sleeping, working, and socializing with friends and family. 

Goal 1: To reduce the intensity and frequency of anxiety so that day-to-day routines and tasks are not impaired. 

Objectives:

1. Sam will learn the cognitive, behavioral, and physiological aspects of anxiety and how these relate to his personal experience.
2. Sam will learn how to introduce calming strategies into his day-to-day life.
3. Sam will learn about the functions of cognitive biases in worsening anxiety symptoms.
4. Sam will acknowledge, reduce and finally eradicate fearful, negative self-talk to be replaced it with positive, empowering self-talk.

Interventions:

1. The therapist will explain how anxiety often leads to unrealistic perceptions of other people and the environment. The therapist will demonstrate how treatment can reduce these perceptions.
2. The therapist will teach Sam mindful breathing, and muscle relaxation, and how to apply these skills to his everyday life. 
3. The therapist will identify the biases in Sam’s self-talk and assign homework for Sam to consistently replace his negative self-talk with practiced forms of positive self-talk. 

Progress:

In the first two sessions, Sam has made notable progress in increasing his level of trust. He now feels comfortable explaining his symptoms and experiences without being prompted by the Therapist. Sam has been reading the assigned text and achieved Objective 1. He is aware of how anxiety is impacting different aspects of his day-to-day life and states he is able to better differentiate between realistic fears and anxiety-induced fears. He is partway through learning calming strategies and is expected to achieve Objective 2 by the next session.

Just like any other area of healthcare, creating, sharing, and storing treatment plans falls under HIPAA guidelines. The information contained within these documents is confidential and it is absolutely essential that your practice maintains the patient’s privacy. If you use electronic methods, you need to ensure the plans are encrypted and stored on secure databases where only authorized users can access them. In saying that, there are a couple of exceptions depending on the clients you treat. Typically, if your patient is a child, their parents are allowed to have a copy of the treatment plan, but you must ensure this is compliant with the laws of your state. On the other hand, family counseling often entails organizing pricing updates and billing procedures through a singular client. If the treatment involves a family session and each member is included within the treatment plan, every member must provide consent prior to the document being shared. Understanding how HIPAA regulations impact your work is an essential aspect of working as a counselor. Before you write up your treatment plans, you need to look up the specific guidelines for your state so you can ensure protection for both you and your clients.

If you are truly interested in the health outcomes of your patients, it is essential that you create effective treatment plans. The first couple that you write will take the longest, but once you make it a habit, they will get easier and easier. Documenting the progress of a patient with specified objectives and goals will allow both you and them to visualize their health goals, and celebrate the small achievements. Additionally, there are occasional instances of a client being unsuitable for your treatment. If this is the case, then a treatment plan will allow you to determine whether or not to continue as their therapist, serving as an effective strategy for terminating counseling treatment. Hopefully, this guide has highlighted the various benefits behind treatment plans and equipped you with enough knowledge to begin writing efficient and effective documentation!

Further Reading:

• Mental Health Treatment Plans: Templates, Goals & Objectives
• Clinicians guide to writing progress notes