Topic from the field:  A problem with treatment plans

Disclaimer:  nothing in this post should be taken or held as clinical instruction, clinical supervision, or advisory concerning patient care. 

A colleague in the field submitted a specific problem related to treatment plans for me to comment on here at Recovery Review.

“What’s the specific issue?”, I asked. 

They replied, “When treatment plans are individualized to the counselor, rather than the person served.”

I asked this colleague if they wanted me to comment on the problem, or make suggestions about preventing this problem.  The answer was, “Both.” 

To make the topic clearer the colleague added that addiction counselors, while attempting to meet and maintain fidelity to individualized treatment planning, can fall into a trap. This results in their treatment plans being individualized to themselves, rather than to the patient.  They went further and provided an example of a counselor using some of the exact same elements on all treatment plans for all patients. 

To handle this requested topic, the current post will serve as Part 1 and focus on the problem.  My next post will serve as Part 2 and address considerations toward preventing this problem.  

Part 1: “Treatment plans individualized to the counselor but not the patient”

The reader might assume this problem is not happening among treatment plans they are familiar with.  Here are some ways to make the lack of sufficient individualization in treatment plans more evident.  I’ll cover these in order:

1. Read the plan aloud and try to name the patient.
2. The plan sounds like the former workplace, not like the patient.
3. Fidelity to person-centered methods, but failing anyway.

Read the treatment plan aloud. Can you name the counselor?  Can you name the patient?

Around 20 years ago I learned a great method from an accreditation surveyor to help evaluate treatment plans. The surveyor outlined the method as follows:

1. Have all the counselors get together, along with the nurses. 
2. Have the program manager or clinical supervisor bring treatment plans – one open chart and one closed chart – for each counselor. 
3. Next, the supervisor picks a treatment plan at random and hides the name of the patient and counselor.  They tell the assembled staff that the task is to try to figure out who the patient is while the treatment plan is being read. 
4. Then the supervisor simply starts to read the treatment plan.

For a team that hasn’t experienced this before, or developed past this level of scrutiny, the process usually goes quickly.  And it’s quite clarifying about how common it is for treatment planning to be rather poor.  Typically, the result is that the team members quickly blurt out the name of the counselor, and find it much harder or impossible to identify the patient.

The treatment plan sounds more like the counselor’s previous workplace than the current patient 

In my experience, there is another source of latent influence that informs the basic approach counselors take to treatment planning:  the framework required by their most influential previous place of employment. That is to say, we can often tell who wrote the plan because it sounds less centered in the person served and more needlessly steeped in the thinking and methods from one of these frameworks: 

• Probation office 
• Criminal justice referral source 
• Job readiness service
• ACT residential or ACT outpatient 
• Medicaid requirements 
• Drug court services 
• Strengths-based psychosocial rehab for SPMI patients 
• Family-reunification services
• Person-centered SUD services 

Fidelity that fails 

Now the reader might be surprised to see me put “person centered SUD services” on the list of things that can get in the way. And the reader might be of the opinion that careful adherence to person centered documentation and treatment planning is a preventative measure or antidote to the problem of counselors reflecting themselves more than the person served in the written treatment plans or personal recovery plans they prepare. 

Hardly. 

Some of the plans for which it is easiest to identify the author and hardest to identify the patient are written by clinicians who ace fidelity to person centered language.  And yet, while doing so, still fail at the main point of the project. 

Consider that as you read on. 

One of my favorite examples of this kind of failure is treatment plans that are “personalized, not individualized”.  One source of so-called individualization is that the word “patient” or “client” or “individual” is replaced by the patient’s name.  But everything else remains the same.  In this instance the entire plan is so exclusively derived from the dry mechanics of person-centered methods it fails to be individualized. 

The surveyor’s suggested exercise of reading the treatment plan aloud, while skipping over the patient’s name, tends to reveal just how clinician-centered some “person-centered” plans really are.

Has the counselor reflected the person of the patient in the plan?  And how transparent is that reflection? 

Or have we as counselors internalized a dry and detached kind of algorithm that drives our creation of so-called “person-centered plans”?  And have we become a kind of AI that seems to approximate person-centered methods while we engage our treatment planning function? 

What can be considered to help reduce this problem and promote the individualization of treatment plans?

Stay tuned for Part 2, which will also include a longer-than-usual resource list.