Standards of Practice: 2007 Written Treatment Plans

I’ve opened my folder of teaching tools for teaching documentation of therapy.  It’s from 2007, long before I even knew that “parental alienation” existed.  I was in trauma world, working with kids in the foster care system. These documentation standards are from that time period.

This is a treatment plan form for the San Bernardino Department of Behavioral Health.  They were the county funding agency for mental health services in the foster care system.

SB-DBH Treatment Plan Form

The actual form is on blue paper, and it extends over several paper pages, so I just transcribed it to a Word table format and condensed redundancy. 

Those three empty boxes in the middle… that’s where all the action is on this form; Objectives, Clinical Interventions, and Outcomes.  It’s in those three empty boxes that we’d write our answers to those three important questions; goals, how are you going to get there, did it work?

Objectives – Clinical Interventions – Outcome

That’s the structural backbone of a written treatment plan.

What is the goal to be achieved by therapy (Objectives)?

How are you going to achieve those goals (Clinical Interventions)?

Did you achieve those goals (Outcome)?

I’ll go into each of these areas in a moment, but before leaving the form I want to point out a couple of other important features of a written treatment plan demonstrated by this county form.

First, notice that right above the Signatures box there’s a Frequency of Care Plan Review line, with boxes for 30 Days, 3 Months, 6 Month, and 12 Months.  Those time-frames are typically considered the standard of practice review points for treatment plans.  Treatment goals should typically be for a three- to six-month range for resolution of the pathology.  Short-term goals in the four- to six-week range are helpful progress milestones toward achieving the longer 3 to 6-month solutions. 

That’s what a treatment plan does, it lays out the course for solution, and that course is reviewed regularly; we’d hope for a treatment plan with a 3 to 6-month resolution of the pathology.

Notice too, the box off to the side of the signatures that says, “Client Received a Copy of the Care Plan” with a place for the client’s initials and date.  The written treatment plan is reviewed with the client, and the client gets a copy of it.  In fact, the Department of Behavioral Health wants to make certain that the client has a copy of the written treatment plan.  This documents that we reviewed the treatment plan with the client… at 3 months, and 6 months, and 1 year; each time the client initials a new signature line with a new date.

That’s considered standard of practice in county work in the foster care system.  Written treatment plan, review it with the client, client gets a copy of the written treatment plan.

Let’s take a closer look at those three empty boxes, and see what the county Department of Behavioral Health wants.

Objectives

OBJECTIVES: (Must be specific, measurable/quantifiable, attainable, realistic, time-bound.  Must be related to assessment, presenting problems/symptoms and functional impairment.  Include cultural/linguistic, co-occurring factors, if appropriate.  Include Med Support and Targeted Case Management, if appropriate)

Let me highlight a couple of things from this documentation requirement – measurable/quantifiable – time-bound.  Those features of the treatment plan are not optional, they are part of the list of required components.   Notice the instructions say “Must be” – not “Should be” – Must be… measurable and time-bound Objectives are requirements of the written treatment plan.

We must be able to measure treatment outcome, and our treatment goals must be time-bound.

Let me also highlight that the goals of treatment must be linked to the assessment information, to the presenting problem and symptoms, and to the impairment caused by the symptoms. The treatment plan describes what the problem is, and how to fix it.

Treatment plans link to the assessment data and describe a coherently organized approach to fixing the presenting problem – to solving things.

If a mental health professional cannot develop a written treatment plan for a pathology, then that mental health professional should not be working with that pathology.  Simple as that.

If I’m working with eating disorders, I must be able to develop an effective treatment plan for eating disorders.  If I am working with depression, I must be able to come up with an effective treatment plan for depression.  In professional psychology, that’s called “boundaries of competence,” that I only work with types of pathology that I know about, for which I am able to develop a written treatment plan.

If you know what you’re doing, then you have a plan for treatment. If you have a plan for treatment, write it down on a piece of paper and tell everyone what the plan is.   A written treatment plan.  A standard of professional practice – Department of Behavioral Health, San Bernardino County.

Clinical Interventions

CLINICAL INTERVENTIONS: (Must be related to objective. List clinical intervention for each group/individual service.  Includes Med Support and Targeted Case Management, if appropriate).

Tell us what you’re going to do.  This is the application of knowledge section of the treatment plan.  Objectives is being able to define goals in achievable and measurable ways, Clinical Interventions is knowing what to do about it.

Personally, I’d apply the scientifically established knowledge of professional psychology, in whatever domain of pathology I was working in, from geriatrics, to ADHD, or autism.  What’s the science say, that’s where I’ll be.  For this court-involved family conflict pathology, I apply the knowledge from attachment, and family systems therapy, personality disorders, complex trauma, and the neuro-development of the brain during childhood.  I think it’s tremendously relevant information that helps make sense of everything.

I’d recommend it; attachment, family systems therapy, personality disorders, complex trauma, and the neuro-development of the brain in childhood.

But everyone’s free to apply the knowledge they’d like.  A psychoanalytically oriented psychologist might apply Adler or Kohut, a humanistic psychologist might apply Rogers and Pearls, a CBT therapist will apply learning theory and Beck.  What knowledge is applied in this box, Clinical Interventions, is given broad latitude… but it is documented in the treatment plan.

It doesn’t matter what you do… just tell us what it is.

Because, you see, in telling us what it is you’re going to do to fix things, we’ll be able to tell if you know what you’re doing.  First, if you can’t tell us anything at all about how you are going to fix things (the clinical interventions), then you don’t know what you’re doing.  So that’s an easy one right there.

Then, for those therapists who do provide a description of their clinical interventions, we can look at their case formulation and applied knowledge to see what information and knowledge from professional psychology they used in their case conceptualization and treatment approach.  This will allow parents to make informed decisions regarding treatment, a requirement of informed consent to treatment.  It’s the informed part.

Don’t care what the answer is to this box, Clinical Interventions, just tell us what you plan to do.  After that, then we’ll care about what the answer is to this box.  But for right now, just tell us what you’re going to do to fix things.  Whatever you think is best.

Outcome

OUTCOMES/date/initials: To be completed at the end of the Care Plan Review timeframe, 30 days, 3, 6, 12 months or more frequently as appropriate

At every outcome review point specified in the treatment plan (typically 3-month and 6-month, and by then things should be substantially solved), the treatment goals and clinical interventions to achieve those goals are reviewed.  Remember, the treatment objectives are identified in ways that are “measurable” and “time-bound” – permitting review of goal accomplishment.

In child and family therapy, clinical impact is typically targeted for four to six-weeks.  Even in autism, significant measurable impact of clinical involvement should be evident by four to six weeks.  For autism, the clinical impact in six weeks would not necessarily be directly measurable in the child’s symptoms, but the caregivers should have substantially increased knowledge and skills in how to respond to the child (changes in caregiver stress and responding skills that are measurable).  The improved responding from the caregivers then leads to the more productive longer-range progress toward the treatment goals, gains which should become directly evident in the child’s symptoms on the 3-month and 6-month reviews of the treatment goals. 

So even with autism pathology, we would expect to see measurable gains in caregiver response competence in a four to six week period of initial intervention, leading toward longer-range goal achievement.

This is true for all pathology, from autism to oppositional defiant disorder.  It’s usually reasonable to expect a positive impact from intervention on some measurable area of functioning in four to six weeks, improvements moving toward a 3- to 6-month resolution of the presenting problem.

Does treatment with some childhood pathology take longer than six months to solve?  Of course.  But for each time-period longer than six months, professional concerns about the accuracy of the case conceptualization and treatment plan increase.   Treatment should solve things.  If treatment is not solving things within three to six months, we need to closely examine the diagnostic premise and clinical approach involved.

If we treat diabetes with insulin but the patient actually has cancer and needs chemotherapy, then the sooner we re-evaluate our diagnosis based on absence of treatment progress the sooner we will be able to get the proper diagnosis of cancer and the proper treatment of chemotherapy.  If things aren’t working, it’s time to look closely at possibly changing what we’re doing.

Does that mean that longer treatment is always due to earlier misdiagnosis?  No.  It just means that with each increment of time over six months, the review scrutiny of the case conceptualization, diagnosis, and clinical interventions used to achieve a solution becomes more exacting.

Even for chronic pathologies like autism that will require years of developmentally supportive intervention, we would want to achieve a stabilization of intervention where the child is receiving the proper intervention at the proper dosage level, and measurable progress from the intervention is continuing.  Continuing measurable gains from the consistent application of developmentally supportive intervention becomes a steady state treatment plan, measurable and time-bound review, and the same in its consistency of measurable effectiveness. 

This is the desired steady-state treatment plan we want for chronic pathology, always then closely monitoring scientific advancements that can improve the treatment plan for increasingly positive outcome.

If, however, the child ceases to make gains in a time-frame of review, then a reconsideration of case conceptualization and treatment plan is indicated.  When progress is not made, we develop a new treatment plan.  This may involve altering our case conceptualization, or altering the clinical interventions applied.

The important thing is that the progress is measurable, and that the treatment plan is time-bound to periods for review and modification.

School IEP

If an additional example is needed for a written treatment plan related to commonly occurring childhood pathology, I would refer to the school IEP (Individual Education Program).  The school IEP represents a written treatment plan surrounding a variety of possible issues, some possibly medical, some possibly emotional and psychological. 

What does the school do about the presenting problem referred for an individualized educational approach; the IEP referral?  The school develops a written treatment plan, discusses this written treatment plan with the parents, obtains the parent’s approval for the written treatment plan, and then the school implements the treatment plan as described by the written treatment plan. 

Once implemented, this written treatment plan of the IEP is reviewed on a periodic schedule to ensure measurable gains from the education-related treatment plan described by the IEP.

The school IEP is an education-related treatment plan, but many of the issues addressed by the IEP are emotional and psychological disturbances of childhood, so often the educational intervention co-occurs within the context of the psychological intervention.

A written treatment plan is everyday standard of practice in the school system.  The county of San Bernardino Department of Behavioral Health mandated a written treatment plan as a requirement for funding treatment of children and families in the foster care system.  In the world I come from, a written treatment plan is common standard of professional practice.  No big deal.

What are the Objectives of treatment (measurable and time-bound), what are the Clinical Interventions to be used to achieve those Objectives, and did it work, what is the Outcome?

The standard of professional practice in clinical psychology is for written treatment plans.

Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857