Treat Plan Elements and Examples

Treatment plans should always be client driven and treatment team supported. Further they should help the client consider how alcohol or substance abuse is impacting all aspects of your client’s life, including the client’s mental, physical, social, financial and legal histories. This document should be fluid and must be updated as the client’s needs change over time or as goals are met. All treatment plans contain the following elements in a treatment plan.

A Diagnostic Summary

The clinical provider will meet with the client and discuss their alcohol and/or substance use patterns, medical history, mental health disorders and legal issues. Based on these assessments, the provider will summarize the main problems that brought the client in for treatment, and recommendations like medication and behavioral therapy based on acceptable treatment practices and possible facility limitations.

A Problem List

The problem list addresses specific issues that the client wants to target during treatment and a summary of the signs and symptoms that highlight the individual problem(s).

Problem (1): Angel has the inability to reduce or stop alcohol and substance intake. This is evidenced by: Angel having both a DUI and a domestic violence arrest in the past year. This is evidenced by: Angel’s Extensive alcohol use (on average six vodka shooters and a six- pack of beer daily) multiple times per week. This is in conjunction with marijuana usage in the morning and right before he retires for the night.

Goal List

After the client and provider create the problem list, the goal list encourages forward thinking about possible solutions. Goals are brief statements about what the client wants to change.

· Based on the client’s problem list (these should directly relate to the alcohol or substance abuse or fall out from the use)

· Comprehensive (focused on how to replace a harmful behavior with a healthy one)

 

Examples:

Learn new anger management skills.

Learn how to have difficult discussions with my wife.

Objectives

Goals are things you want to change, while objectives are individual steps you will take to achieve each of those goals. Objectives should be “SMART”:

· Specific

· Measurable (actions that can be seen) 

· Attainable (reasonable to achieve within the treatment period)

· Relevant (related to the issues on your problem list)

· Time-limited (have a target date for completion before discharge)

 

Examples:

Gain new insight in how to live sober by going to group counseling

Find a sponsor for myself at the Dragons Den 12-step meeting

Complete steps 1-4 of Alcoholics Anonymous with my sponsor

Interventions

These are the methods your treatment team will use to help you achieve each of your objectives.

Examples:

1. Problem: Angel has the inability to reduce or stop alcohol and substance intake

2. Goal: Learn new coping skills

3. Objective: Find a sponsor for myself at the Dragons Den 12-step meeting

4. Intervention: Treatment team will provide a pass for the client to attend the Dragon’s Den 12-step meeting, monitor weekly 12-step attendance, and help resolve barriers to attendance, such as providing light rail passes.

Tracking and Evaluating Progress

Your treatment team will keep client treatment notes in your jacket to track your progress and evaluate whether a treatment plan is working. The notes have details about the client’s response to treatment, changes in the client’s condition, and changes or updates to the plan. Charts may also include worksheets that include the clients’ thoughts, feelings, and behaviors or journal entries.

Relapse prevention planning

During treatment planning, your clinician should discuss discharge planning and the creation of a relapse prevention plan. After the client has successfully completed the initial treatment program, the client’s relapse prevention plan may include:

· Maintaining attendance at 12-step meetings

· Starting work with a peer recovery coach

· Beginning Medication Assisted Therapy (MAT) for alcohol use

· Contact my sponsor if I am triggered and have using thoughts