My Top Tip for Therapists Writing Treatment Plans

Have you been avoiding writing treatment plans?

Maybe you don’t see them as helpful, or don’t feel you have time, so you don’t write them?

Well, you’re not alone—it seems a large number of therapists I consult with also don’t write treatment plans for their clients.

However, this is something that you might want to rethink.

Most insurance plans require therapists to submit treatment plans and many professional association ethics codes and state laws require them to be part of a client’s chart.

And, perhaps, the best reason to write treatment plans for your client? They can help improve your treatment and increase client engagement.

I’ll share my favorite tip for making treatment plans quicker and easier…

Start Writing Treatment Plans in Session With These 5 Client Questions 

Near the end of the intake session, grab your pen, tablet, or laptop and tell your client you want to be sure that they get what they need from their therapy sessions.

Help identify your client’s goals with questions such as:

1. 1. “When you originally contacted me, how were you hoping these sessions could help you?”
   2. “When you think of our last session together, and you no longer feel the need to come anymore, how will you be feeling differently?”
   3. “And if you were feeling differently, what would you be doing differently (more/less)?”
   4. “What questions will you have answered about yourself or your life that you are now struggling to answer?”
   5. “What do you want from me to reach these goals?  What do you NOT want from me?”

With a little practice, you will learn to turn the answers into specific, measurable, and objective goals, and maybe a few ideas for interventions—in other words, a treatment plan that’s half-written before the session ends.

It’s also a hopeful and upbeat way to end your first session: Having the client visualize the two of you working together toward the same goals, and to imagine feeling better—what that looks and feels like.

And how can this plan aid treatment? You’ll find out if you bring it out occasionally during treatment, as a sort of therapy evaluation.

A treatment plan can be especially useful when it feels like the work has lost focus or plateaued.

It can be a great tool in helping clients to identify progress they hadn’t noticed, which may help them feel better about the work you are doing. When reading the goals they outlined in their initial session, clients often tell me “Wow, I don’t remember feeling that bad, or saying that!”
This review can help them focus on the part of their plan they’d like to work on next.

You may, of course, add new goals together, and discuss how you’ll work on those.

Finally, if some goal hasn’t been reached, it is a great opportunity to non-defensively discuss with the client whether they may need a change in approach, more intensive treatment, or additional therapy adjuncts.

And, since we are always in need of time savers, adjustments to the treatment plan can also be written in session.