How to Develop a Psychotherapy Treatment Plan

2024 Author: Samantha Chapman | [email protected]. Last modified: 2023-12-17 09:13

A psychotherapy treatment plan is a document that describes the patient's psycho-clinical picture and defines the goals and strategies that allow him to solve his mental health problems. To be able to process it, the psychologist must interrogate the patient and use the information gathered during the initial interview.

Steps

Part 1 of 3: Performing a Comprehensive Assessment of the Patient's Mental Condition

Step 1. Collect the information

Psychological assessment consists in the acquisition of elements by a mental health professional (psychological counselor, psychotherapist, social worker, psychologist or psychiatrist) through an interview with the patient about his present and past psychological distress, previous family cases and his recent and past relational difficulties in the workplace, school and social. In addition, the meeting may focus on past and current problems relating to drug abuse and current or past use of psychotropic drugs.

• During the evaluation, the psychological operator could also make use of the medical and psychodiagnostic reports. Make sure that the documents for the release of the information have been properly signed.
• Also, clarify confidentiality constraints. He reassures the patient that everything he reports is protected by professional secrecy, as long as he does not express the intention to harm himself and others or is aware of violence occurring in the reality in which he lives.
• Be prepared to stop the evaluation if it becomes clear that the patient is going through a crisis. For example, if you have thoughts of suicide or homicide, you must immediately change your approach and adopt the methods of intervention foreseen for this type of case.

Step 2. Follow the steps of the psychological assessment

Almost all structures operating in the field of mental health provide the psychological operator with forms and evaluation schemes to be filled in during the interview with the patient. For example, the psychological assessment could take place according to the following steps (in order):

• Reason for the request

  • Why does the client start the treatment?
  • How did you find out?

• Current symptoms and behaviors

  Depressed mood, anxiety, altered appetite, sleep disturbances, etc

• Evolution of the problem

  • When it started?
  • What is the intensity, frequency and duration?
  • What attempts have been made to solve it?

• Worsening of the quality of life

  Problems in family, school, work, relationships

• Psychological / psychiatric background

  Previous care and treatments, hospitalizations, etc

• Current risks and personal safety problems

  • Intention to harm themselves or others.
  • If the patient reports these concerns, stop the evaluation and follow the crisis intervention procedures.

• Previous and current medications, taken for physical and mental health problems

  Include the names of the drugs, the dosage, the duration of the intake and specify if the patient takes them according to the prescriptions

• Current or past drug use

  Use or abuse of alcohol and drugs

• Family atmosphere

  • Socio-economic level
  • Parents profession
  • Marital status of parents (married / separated / divorced)
  • Cultural context
  • Physical and emotional health problems
  • Family relationships

• Personal history

  • Childhood: various stages of development, frequency of contact with parents, personal hygiene, physical health problems during childhood
  • Early and middle childhood: acclimatization to school, academic performance, relationships with peers, hobbies / activities / interests
  • Adolescence: first dating in love, behavior during puberty, destructive behaviors
  • Early and middle youth: career / profession, achievement of life goals, interpersonal relationships, marriage, economic stability, physical and emotional health problems, relationship with parents
  • Late adulthood: physical health problems, reaction to difficulties due to the decline of cognitive and functional abilities, economic stability

• Mental state

  Personal care and hygiene, speech, mood, emotional side, etc

• Various

  Self-image (positive / negative), happy / sad memories, fears, early memories, most significant or recurring dreams

• Summary and clinical impressions

  A brief summary of the patient's problems and symptoms should be written in narrative form. In this section, the counselor can include observations on how the patient behaved and reacted during the assessment

• Diagnosis

  To produce a descriptive diagnosis, use the information gathered or entrusted to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)

• Recommendations

  Psychotherapy, psychiatric consultation, drug therapy, etc. Recommendations should be based on diagnosis and clinical impressions. An effective treatment plan will result in the patient being discharged

Step 3. Make observations about behavior

The psychologist will perform a Mini-Mental State Examination (MMSE) which involves observing the patient's physical appearance and his interactions with staff and other patients in the facility. He will also have to take into consideration his mood (sad, angry, indifferent) and the affective side (ie the emotional manifestations, which can alternate between a strong expansiveness and a marked apathy). These observations help the psychologist make a diagnosis and write an appropriate treatment plan. Here are some examples of the characteristics to take into account when examining the mental status:

• Personal care and hygiene (neat or unkempt appearance)
• Eye contact (receding, poor, none or normal)
• Motor activity (quiet, nervous, stiff or agitated)
• Speech (slow, loud, fast, or gibbering)
• Way of interacting (theatrical, sensitive, collaborative, senseless)
• Orientation (the subject does not know the time, date and situation in which he is)
• Intellectual functions (impaired, not impaired)
• Memory (compromised, not compromised)
• Mood (euthymic, irritable, crying, anxious, depressed)
• Affective side (normal, labile, brutal, indifferent)
• Disturbances in perception (hallucinations)
• Disorders of cognitive processes (which impair concentration, ability to discern, mental clarity)
• Thought content disorders (delusions, obsessions, suicidal thoughts)
• Behavioral disorders (aggression, loss of impulse control, demanding temperament)

Step 4. Make a diagnosis

Diagnosis is the most important element. Sometimes, a patient receives more than one diagnosis, such as major depressive disorder and alcohol abuse. Whatever it is, it must be produced before completing the treatment plan.

• Diagnosis is based on the client's symptoms and criteria listed in the DSM. The Diagnostic and Statistical Manual of Mental Disorders, also known as DSM, is the diagnostic classification system created by the American Psychiatric Association (APA). To find the correct diagnosis, use the latest version (DSM-5).
• If you don't own the fifth edition, ask a coordinator or colleague to borrow it. Don't rely on online resources to establish the right diagnosis.
• Based on the main symptoms the patient is experiencing to arrive at a reliable diagnosis.
• If you are unsure or need the help of a more experienced person, contact your coordinator or consult a professional who is competent in this field.

Part 2 of 3: Set Goals

Step 1. Identify possible goals

Once the initial evaluation is complete and the diagnosis is established, you will need to reflect on the interventions and goals to be achieved during treatment. Generally, patients have a hard time identifying which path to take, so you should prepare yourself before talking to the person you are caring for.

• For example, if you have major depressive disorder, one of your goals may be to relieve symptoms caused by your condition.
• Reflect on possible goals by considering the symptoms presented by the patient. For example, if you are sleepless, depressed, and put on weight (all possible symptoms of major depressive disorder), you might want to set a goal for each of these problems.

Step 2. Think about the different interventions

The interventions constitute the main nucleus of the change in therapy, as they ultimately allow to modify the mental state of the patient.

• Identify treatments or interventions you might use, including: activity planning, cognitive-behavioral therapy and cognitive restructuring, behavioral experiments, assigning homework, and teaching methods for coping with difficulties, such as relaxation techniques, full awareness and grounding.
• Try to stick to what you know. To be an ethically correct professional and not to jeopardize the patient's progress, you must limit yourself to your area of expertise. Don't try therapies you don't know if you don't work with an experienced colleague.
• If you are a beginner, try using a protocol or manual to guide you in the type of therapy you have chosen to apply. It might help you get on the right track.

Step 3. Discuss goals with the patient

Once the initial assessment has been made, the therapist and patient must work together to establish suitable goals for treatment. These decisions must be made before developing the treatment plan.

• A treatment plan should include direct patient cooperation. The latter together with the psychologist decides the objectives to be included in the treatment program and the strategies to be used to achieve them.
• Ask the patient what he expects from his therapeutic path. He may reply: "I wish I felt less depressed." If so, suggest what he can do to relieve symptoms of depression (such as following cognitive-behavioral therapy).

• To set goals, find a pattern on the Internet. Try asking the patient the following questions:

  • What would you like to achieve with psychotherapy? What would you like to change?
  • What steps could you take to achieve it? Offer tips and ideas if it gets stuck.
  • On a scale of 0 to 10, where 0 is not achieved and 10 is fully achieved, where do you stand in relation to this goal? This question helps make goals measurable.

  

  Step 4. Set concrete goals for treatment

  The goals of the treatment must motivate the patient to follow the chosen therapeutic path. They are also an important element of the treatment plan. Try using a SMART goals-based approach:

  • S. stands for specific: be as clear as possible, how to relieve depression or reduce insomnia.
  • M. stands for measurable: how do you know if you have reached your goal? Make sure it's quantifiable, such as reducing depression from 9 to 6 on a scale of 0 to 10 or limiting insomnia to 3 to 1 night per week.
  • TO stands for achievable - make sure your goals are achievable and not prohibitive. For example, reducing insomnia from 7 to 0 nights a week could be a difficult goal to achieve in a short period of time. Change it to 4 nights a week. After that, once you reach that, you can set the goal of zero nights.
  • R. stands for realistic and resourced (realistic and relevant from an organizational point of view): is it conceivable to set a specific goal with the resources you have available? Are other means necessary to achieve it? How can you access these resources?
  • T. stands for time-limited: set a time limit for each goal, for example 3 or 6 months.
  • A thoughtfully formulated goal could be: the patient will need to reduce insomnia from 3 to 1 night per week over the next three months.

  Part 3 of 3: Creating the Treatment Plan

  

  Step 1. Write down the elements that make up the treatment program

  The treatment plan consists of the goals set by the psychologist. In many structures that operate in the field of mental health it is structured on schemes or forms filled in by the psychologist. Part of the form may contain boxes in which to describe the client's symptoms. Usually, a treatment plan contains the following information:

  • Patient name and diagnosis.
  • Long-term goal (for example, the patient states: "I want to cure depression").
  • Short-term goals (the patient will relieve depression from 8 to 5 on a scale of 0 to 10 within six months). A great treatment plan contains at least three goals.
  • Clinical interventions / Type of services (individual therapy, group therapy, cognitive-behavioral therapy, etc.)
  • Involvement of the patient (what you agree to do, for example therapy once a week, follow instructions yourself and practice the methods acquired during the treatment)
  • Date and signature of the therapist and patient

  

  Step 2. Write down your goals

  They need to be as clear and concise as possible. Remember SMART goals and make sure that each goal is specific, measurable, achievable, realistic and defined over time.

  It is likely that on the form you will have to record each goal separately, along with the related interventions, and what the client agrees to do

  

  Step 3. Indicate the interventions you are going to use

  The psychologist must enter the therapeutic strategies that the client has agreed to follow and specify the therapeutic path that will be adopted to achieve the established goals, such as individual or family therapy, drug abuse treatment and drug treatments.

  

  Step 4. Sign the treatment plan

  Both the patient and the psychologist must sign the treatment plan to demonstrate that they have come to an agreement on the steps that comprise it.

  • Make sure that the signatures are made as soon as you have finished developing the treatment program. Also, make sure that the dates are correct and that the patient agrees on the goals defined in the document to be signed.
  • If it is not subscribed, the insurance company will not pay for the services rendered.

  

  Step 5. Review the plan and improve it if necessary

  As the patient achieves his goals, you will need to establish new ones. The treatment plan should include deadlines by which to analyze the progress made and decide whether to proceed along the same therapeutic path or make changes.