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Guidelines for Writing a Treatment Plan

The process of developing a treatment plan involves a series of steps that is guided by the assessment and diagnosis. Assessment data may be gathered from a social history, a physical exam, a clinical interview, a psychological testing, metrics, and or communication with significant others, which leads to the formulation of a diagnosis. In the same way, if the diagnosis were posttraumatic stress disorder, then, following goal determination, the treatment plan would address relief of the client's negative impacting behaviors and implementing behaviors that would promote healing, acceptance of past events, and responsible living.

Goals and interventions must be attainable by the client, given the client's strengths and vulnerabilities. Treatment modality must also reflect the best possible approaches given the client's personality, strengths, and limitations.

The following is one format for writing a treatment plan. In writing your treatment plan, it must be combined with the assessment and diagnosis for a comprehensive treatment plan.

Problem Selection and Assessment

1) Using a provided scenario, a contrived scenario, or an imagined client, describe the assessment data and information determined about the client’s situation.

2) Identify the primary problem and secondary problems. Some other problems may need to be set aside if not urgent enough to require treatment at this time. An effective treatment plan can only deal with a few selected problems or treatment will lose its focus. As problems are revealed to the counselor, it is important to include the client’s prioritization of issues for which help is being sought

Problem Definition and Diagnosis

1) Using the DSM-IV-TR (Diagnostic and Statistical Manual) identify the diagnostic criteria and codes associated with the previously described assessment information and problem selection.

Goals of Treatment

The best way to establish goals is to ask the client the following questions: "What do you want to change" and "what would that change look like?" Together, you can formulate attainable goals.

Remember, goals are outcomes for the client and should be worded accordingly. That is, you would not classify learn progressive relaxation skills as a goal, as this is an intervention for the purpose of relief of anxiety symptoms.

You may also set short-term goals and long-term goals. A short-term goal might be to decrease anxiety symptoms. A long-term goal might be to resolve the cause of the anxiety, such as the employment issues. The following are examples.

• Short-term goal

o Relief of symptoms of anxiety

o Restoration of activities and social contacts to previous level

• Long-term goal

o Resolution of employment issues

o Improved sense of financial security

Objective and Interventions Identification

Objectives and interventions are both used to meet the client’s treatment goals. Each objective should be developed as a step toward attaining the goals of the treatment plan. Interventions are the actions of the counselor designed to help the client complete the objectives.

This section of the treatment plan should identify at least three objectives and interventions appropriate to the assessment and identified goals. The following is an example.

• Objective: Identify the symptoms of Post-Traumatic Stress Disorder (PSTD) that have caused distress and impaired functioning.

o Interventions:

• Ask the client to identify how the traumatic event has negatively affected his or her personal relationship, functioning at work or school, and social and recreational life.

• Ask the client to list and then rank order the strength of his or her symptoms of PTSD.

Mode, Frequency, and Duration

Identify the theoretical modality or approach by which you will treat this client, including the number, frequency and duration of treatment sessions.

Referral Resources

Include any possible outside referrals that may support or expand the client's progress toward attaining his or her goals. The following are examples of referrals.

1. Career exploration class at a community college

2. Medical examination to rule out physical causes for symptoms

3. Anxiety support group

Justification

Write a concluding justification for the determination of your diagnosis, goals, objectives, and overall treatment plan based on the information described in the scenario and assessment. Important questions to address include the following:

• IS THE APPROACH APPROPRIATE GIVEN THE PRESENTED PROBLEM AND THE CLIENT'S PERSONALITY AND MOTIVATION?

• DOES THE PLAN REFLECT WHAT THE CLIENT WANTS TO ACHIEVE?

• WHAT IS YOUR JUSTIFICATION OF SELECTION OF GOALS, OBJECTIVES, AND INTERVENTIONS?

• IDENTIFY THE PROGRESSION OF THE COUNSELING RELATIONSHIP THROUGH INTERVENTION AND TERMINATION.

• IDENTIFY STRATEGIES TO ADDRESS CLIENT RESISTANCES AT VARIOUS POINTS IN THE THERAPEUTIC RELATIONSHIP.

• DEFINE THE ROLE OF TERMINATION AND REFERRAL IN THE COUNSELING RELATIONSHIP AS IT APPLIES TO THIS CLIENT’S TREATMENT PLAN.

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