Treatment planning is an important part of the therapeutic process for individuals and the families that we serve. The treatment plans you write serve as roadmaps for the clients' recovery process while in your care. When you're learning how to write a treatment plan for substance abuse, it begins with a thorough biopsychosocial assessment of the client. This assessment will include the client's family history, major life events, history of trauma, substance use history, employment, legal, medical, and financial history. It will also include how his or her substance use has impacted all of the above. Most EMR systems should have a simple biopsychosocial assessment available to use. When you write a treatment plan be sure to use these four steps:

  1. Identifying the behavioral definitions
  2. Goals
  3. Objectives
  4. Interventions

The behavioral definitions, also known as “problem statements,” are based on the information that was collected from the biopsychosocial assessment. This assessment should few brief sentences outlining your clients' condition(s) for which they are seeking treatment. Typically, the clinician will identify a few highlighted problem areas to focus on for the behavioral definitions, which often relate to the diagnosis from the biopsychosocial. 

Some examples of behavioral definitions from the Wiley Treatment Planners are: “Continued substance use despite knowledge of experiencing persistent physical, legal, financial, vocational, social, and/or relationship problems that are directly caused by the use of the substance. Demonstrates a maladaptive pattern of substance use, manifested by increased tolerance and withdrawal. Reports suspension of important social, recreational, or occupational activities because they interfere with using.”

Treatment plan goal identification

The next step in writing a treatment plan is goal identification. What does your client want to change while in treatment? Typically, a well-written substance abuse treatment plan will have two to three goals to accomplish while in treatment--unless the treatment stay is short, such as in detox facilities. Keep in mind that along with each goal, you need to write an objective that defines what the patient will do to accomplish the goal, as well as intervention, which defines what the clinician will do to help the patient complete the objective.

Goal: Improve the quality of life by maintaining ongoing abstinence from all mood-altering chemicals.

Objective: The client will learn new coping strategies for difficult emotions and identify, challenge, and replace destructive, high-risk self-talk with positive, strength-building self-talk. I will discuss this in a group setting and with my counselor within the first 30 days of treatment.

Intervention: Assign the client a homework exercise in which he/she identifies high-risk self-talk, identifies biases in the self-talk, generates alternatives, and tests through behavioral experiments. Challenge the client to share in a group setting with his or her peers. 

Goals and objectives are commonly confused with one another in the treatment planning process. A general guideline is that if you cannot actually see the client do something, then it's a goal. A good example of this is patients improving their lives. You can't see that. If you can see the client do something, such as learn new coping strategies, then it is an objective.  It is highly valuable for objectives and interventions to be linked to the “SMART” methodologies. This focuses on the qualities of being “Specific, Measureable, Attainable, Relevant, Time Sensitive.” 

Conclusion: How to write a treatment plan for substance abuse

It's important for you to remember that once the treatment plan is written it doesn’t end there. The idea is that the treatment plan is treated as a living document. It is updated regularly throughout the course of treatment as the client improves and meets target dates on his or her treatment plan. 

In Alleva, we have all of the Wiley Treatment Planners integrated as templates for clinicians to utilize, as well as all of the corresponding homework assignments, making treatment plans a breeze to individualize for your clients. You can even update the treatment plan and assign homework to the patient each time you meet with them for individual therapy.

It's important to do a thorough job on the treatment plan you create. It's also incredibly valuable to have an EHR or EMR to help both clinicians and clients to build the best individualized plan for them. You can see the features of our EMR here that include the Wiley Treatment Planners and corresponding homework. If you need help understanding EMR vs EHR, you can read about it here.

 

If you're interested in learning more about how Alleva can support your treatment center, schedule a demo or fill out this form for more detailed information.

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Source: https://www.wiley.com/learn/practice_planners/practiceplanners.html