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February 01, 2006

Treatment planning has been an obsession that has haunted behavioral healthcare professionals throughout the field's evolution. Some of us might at times even fall into the trap of judging our professional success based on the number of treatment plans we have completed. But out of all the recovery stories we have heard, we have yet to hear anyone mention that he owes his recovery to the treatment plan.

Instead, people tell us that they didn't know they had one or that they remember signing something but they don't remember anything about it. In fact, we need to be honest with ourselves as to the accountability value of a person's signature on the treatment plan. The signature, in reality, does not mean the person believes it is his plan, has participated in the planning, or will follow the plan. In the end, the person's signature is just that—a scribble on paper that has little meaning for the person.

This probably comes as no surprise to you. We all know that people don't have much interest in most of the plans we make for them. Yet remarkably enough, we continue to spend hours writing treatment plans, and sometimes even more time complaining about paperwork. We are also known to complain about the people we make plans for, who after all our hard work, remain unimpressed, unappreciative, and unmotivated by our planning efforts. In our frustration, we might even blame them for the plans’ failure, labeling them as “noncompliant,” “treatment resistant,” and/or “difficult to engage” in their charts.

In our search for a solution, we might try revising the planning format, making it longer or shorter, more complex or simpler, or more frequent or less often. We might even add more assessment tools, thinking that if we just had a better grip on the problem, the treatment plan would work better. Yet after all our effort, the plan's importance continues to go unrecognized by seemingly ungrateful people.

Please don't misunderstand us: We really do believe that treatment plans are an important part of the recovery process. Treatment plans can offer hope that change is possible and positive. They are the vehicle for engaging in a positive relationship. They provide opportunities for people to practice setting goals and exploring their interests and past successes, as well as their hopes and dreams. When any of us take the time to think through our next steps, it brings our dreams into focus. We rise from the mire of the day to day and begin to remember where we had hoped to go. We see the space between where we are and where we want to be. We gain a sense of direction, and moving ahead now appears to be a reasonable option after all.

Here is the problem: Much of the time it becomes our treatment plan, not the plan of the person we are helping. We write them, count them, own them and, at the end of the day, we file them in our charts and put them in our filing cabinets; we might even feel a sense of accomplishment for having compiled them. We lean back in our treatment-planning chairs and breathe a sigh of satisfaction. For a moment we enjoy the illusion of having a plan that will tell us what we are doing and where we are going with each person. Our jobs’ ambiguity is lessened, and we settle into our comfort zone—that is, until the person ostensibly messes everything up by not even remembering the plan, much less following it. Now the really confusing, messy, and boring part begins—we have to rewrite the darn thing!

There is a better way. The key to transforming the planning process is that the plan has to be the person's plan. The first question we need to ask ourselves when engaging in the planning process is, “Who is guiding the process?” If it's us, not much is going to come of the plan, other than that the auditors might like it. While it's always a relief to have happy auditors, this is not necessarily a sign that anything meaningful is happening for the person.

The next question forces us to make a choice: Do we want to have a tidy, nice-looking plan, with all the blanks filled in just right, or do we want the person to have a plan that works for him? Obviously, the real goal is to have a meaningful plan for each person that helps him move forward in his recovery journey. Here are some approaches we've tried that have improved the treatment-planning process:

  • Rewrite forms in first-person language so each person can complete the answers in ways that relate specifically to his own situation.

  • Do not invest extensive effort in completing long assessments that describe past problems in agonizing detail. This type of history taking often destroys—rather than promotes—readiness for change. Instead, create a “personal resources assessment” that prompts the person to identify past accomplishments, strengths, and interests that can be mobilized for the recovery process.

  • Identify meaningful contributions the person can make to establish a valued social role, which is critical to the recovery process. Recovery is rooted in a sense of self-worth, which can be established when we see that we have something valuable to contribute to others. This validates our existence, builds self-efficacy, and gives us a sense of meaning and purpose in life.

  • Stay focused on each person, not on his problems. This way, you are more likely to develop an authentic connection with the person. Transformation happens in the context of a genuine relationship, not in the context of paperwork and forms.

  • At various points during a planning session, estimate your amount of eye contact with the person. Are you connecting to the plan instead of the person? If so, this is a good indicator that the plan will probably not be meaningful to the person.

  • Describe the planning process in everyday language that, according to psychiatrist Harry Stack Sullivan, “even a newsboy can understand.” For example, “We are going to help you figure out what you want and then help you figure out how to get it.”

Key to developing a plan that the person owns is the planning process itself, not the completed plan or the signature on it. Supervisors need to make sure staff are paying attention to the planning process. Also, interview a sample of the people you see. Did staff listen to and understand them? Did they receive help in determining what they want to do? Do they know some of the things that need to be accomplished to achieve their goals? Answers to questions such as these help an organization see how well the planning process is going and what changes might need to be made.

Lori Ashcraft, PhD, directs the Recovery Education Center at META Services, Inc., in Phoenix.
William A. Anthony, PhD, is Director of the Center for Psychiatric Rehabilitation at Boston University.
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