Issues with Treatment Planning

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According to ICANotes, an electronic health records (EHR) company, “Psychiatrists, psychologists, mental health counselors, social workers, and other behavioral health professionals use treatment planning as a tool to effectively treat patients. Without a clear plan in place, it can be hard to track progress, stay organized, and keep a record of individual patient care” (Sandy, 2018).

Treatment planning is an integral part of the documentation that supports treatment. Think of a treatment plan as a foundation of a house: since the treatment plan leads to the treatment and the treatment leads to the outcome, in this analogy, if the foundation of the house (i.e., the treatment plan) is not solid, then it cannot support and guide the treatment. This reduces the chances for positive treatment outcomes.

In this process, the first step is screening followed by a comprehensive assessment. The problems identified in the assessment find their way onto the treatment plan. The method employed when using the ASAM assessment is that problems are identified in the six ASAM Dimensions are assigned five different levels of risk or severity (Mee-Lee, 2013). These levels constitute a rating scale as follows:

0. No problem
1. Mild
2. Moderate
3. Substantial
4. Severe

Items with a risk rating of zero or one generally do not find their way onto the treatment plan. However, problems receiving a risk rating of two may appear in the treatment plan as issues to be monitored (Mee-Lee, 2013). One example of this is a patient who has a diagnosis of alcohol disorder (mild) and major depression (mild) who has been using alcohol to manage depressive symptoms. Now that the individual is in treatment for the alcohol use disorder, the drinking must stop. Does that mean the depressive symptoms will get worse?

Problems rated as “substantial” or “severe” must be reflected in the treatment plan. When ASAM Dimension 1 (acute intoxication/withdrawal potential), Dimension 2 (biomedical conditions and complications), or Dimension 3 (emotional, behavioral, cognitive conditions and complications) are rated as “severe,” hospitalization is indicated because of the high risk. This is not true of Dimensions 4 (readiness to change), Dimension 5 (relapse, continued use, continued problem potential), and Dimension 6 (recovery environment; Mee-Lee, 2013).

ASAM Dimension 4 (readiness to change) should prompt the use of motivational enhancement strategies regardless of the risk rating. Furthermore, when assigning a stage of change, do it for each drug of abuse, each mental health problem, and each other problem included in the treatment plan separately. Do not aggregate all problematic factors, because doing so averages the different issues and eliminates opportunities for treatment intervention. For example, a patient may be in the preparation stage of change about alcohol use disorder, but in the precontemplation stage of change about cannabis use disorder (Mee-Lee, 2013).

So now that the assessment is complete, begin working with the patient on the patient’s treatment plan. Even though it is common knowledge that the patient must be involved in the development of his or her treatment plan, the problems, goals, and objectives are generally written in third person (e.g., “The patient will” or “John will”). If you are to be truly patient centered, you must write treatment plan problems, goals, and objectives in the patient’s own words, and substitute “I will” for “The patient will.”

(See the sidebar “Useful Verbs for Writing Measurable Objectives” here.)

Goals for Treatment Plans

Ideally, a treatment plan goal is a “fix” for the problems while objectives stay measurable. In my experience as a program consultant, I find one of the most common errors is that objectives are not measurable. How, then, do we assess treatment progress? One of the most common documentation shortcomings is writing treatment plan objectives that are not measurable, such as, “I will work on my anger issues.” A couple ways to make things measurable are to make them specific and add a target date. For example, a specific goal would be, “I will invite my wife to attend the family program,” and then add a target date such as, “…within the next three days.”

Goals versus Objectives

Goals are broad, intangible, abstract, general intentions that are normally difficult to measure. Objectives, on the other hand, are narrow, precise, tangible, concrete, and measurable. Useful verbs for writing measurable objectives may be seen in the sidebar.

A simple way of determining whether an objective is measurable is that you should be able to observe it when it occurs (e.g., see it, read it, hear it).

In my program consulting experience, I commonly find group notes that state, “The patient was on time for group, was dressed appropriately, and gave feedback.” This type of note has nothing to do with the patient’s treatment plan and thus cannot be used to measure progress. One suggestion is to have each patient bring his or her written treatment plan to group. At the beginning of group, each patient has ten seconds to tell the rest of the group members what objectives he or she will be working on today. This focuses both the patient and the counselor on the treatment plan.

References

Mee-Lee, D. (Ed). (2013). The ASAM criteria: Treatment criteria for addictive, substance-related, and co-occurring conditions (3rd ed.). Rockville, MD: American Society of Addiction Medicine.
Sandy. (2018). Guide to creating mental health treatment plans. Retrieved from https://www.icanotes.com/2018/08/24/guide-to-creating-mental-health-treatment-plans/

Gerald Shulman, MA, MAC, FACATA

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Gerald Shulman, MA, MAC, FACATA, is a clinical psychologist and fellow of the American College of Addiction Treatment Administrators. He has been providing treatment or clinically or administratively supervising the delivery of care to alcoholics and drug addicts since 1962.