Treatment plan

State what you are trying to change, by what means, measured how, and by when.

After formulation, usually sessions 2–4; reviewed at agreed intervals.15 fields

How this document is used well

A treatment plan is a hypothesis with a deadline. Its clinical value is not administrative: agreement on goals and agreement on tasks are two of the three components of the working alliance, which is the most robust process predictor of outcome in the entire literature. Writing the plan with the patient is therefore an intervention, not paperwork about one.

Goals that are usable

In the patient’s language, not the diagnosis’s
Observable — someone else could tell whether it happened
Attached to a measure, even a crude one
Sized so the first one can be reached within weeks
Owned by the patient rather than negotiated into by the therapist

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Title this document

Shows why each item is asked

Basis

Client identifier*Plan date*Working diagnosis / problem statementFormulation in two sentences*Primary approach and the rationale for choosing it*

Say why this approach for this person — evidence base, patient preference, formulation fit, and what was considered instead.

Patient preferences taken into account

Accommodating preference reduces dropout and modestly improves outcome. It is an evidence-based act, not a courtesy.

Goals and objectives

Goals

Structure and review

Frequency and expected number of sessions*Routine outcome measures and how often administeredFormal review point*What we will do if there is no response by the review point*

Deciding this in advance protects against the drift in which a treatment continues because it has been continuing.

Adjunctive and concurrent care — medication, medical, social, groupCrisis arrangements

Patient agreement*

YesPartial — noted belowNo

Any disagreement and how it was handled

8 required fields outstanding: Client identifier; Plan date; Formulation in two sentences …

How this document is used well

Goals that are usable

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What Praxical.Psych is, and is not