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Essentials
of Treatment Planning
Second Edition

Mark E. Maruish
This edition first published 2020
© 2020 John Wiley & Sons, Inc.

Edition History
1e, 2002, © John Wiley & Sons, Inc.

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For Louie.
CONTENTS

Acknowledgmentsxi

One Introduction1

Two Patient Assessment 21

Three Contributions of Psychological Testing to

Clinical Assessment and Treatment Planning 75

Four Case Formulation 107

Five Developing a Treatment Plan 131

Six Monitoring Treatment Progress: Implications

for Treatment Planning 191

References227

Annotated Bibliography 249

About the Author 253

Subject Index 255

ix
Acknowledgments

P
ortions of this book are reproduced or adapted from the following sources:

Maruish, M. E. (1999). “Introduction,” in M. E. Maruish (Ed.), The Use of

Psychological Testing for Treatment Planning and Outcomes Assessment
(2nd ed.; pp. 1–39). Republished with permission of Taylor and Francis Group,
LLC, a division of Informa plc; permission conveyed through Copyright
Clearance Center, Inc.
Maruish, M. E. (2000). “Introduction,” in M. E. Maruish (Ed.), Handbook of
Psychological Assessment in Primary Care Settings (pp. 3–41). Republished with
permission of Taylor and Francis Group, LLC, a division of Informa plc;
permission conveyed through Copyright Clearance Center, Inc.
Maruish, M. E. (2002). Psychological Testing in the Age of Managed Behavioral
Health Care. Republished with permission of Taylor and Francis Group, LLC,
a division of Informa plc; permission conveyed through Copyright Clearance
Center, Inc.
Maruish, M. E. (2014). “The clinical interview,” in R. P. Archer & S. R. Smith
(Eds.), Personality Assessment (2nd ed.; pp. 37–88). Republished with permission
of Taylor and Francis Group, LLC, a division of Informa plc; permission
conveyed through Copyright Clearance Center, Inc.

xi
 One

INTRODUCTION

P
sychologists, psychiatrists, clinical social workers, and other behavioral
health care professionals are all aware of the importance having a specific,
individualized plan to guide the treatment of their patients. Many of these
same people might be surprised to know that formalized planning is a relatively
new component of mental health and substance abuse treatment. Harkness and
Lilienfeld (1997) noted that in the 1950s and 1960s, this part of the therapeutic
endeavor was often allowed to develop from the treatment sessions themselves.
And in some schools of thought, the development of a formalized plan would
have been considered contradictory to the basic tenets of the theoretical approach
(e.g., the importance of free association in psychodynamic approaches, the genu-
ineness of client-centered approach). According to Jongsma and Peterson (1999),
the treatment plans developed for mental health and substance abuse patients
were “bare-bones” and generalizable across most patients. Naglieri and Pfeiffer
(2004) made similar observations. Treatment goals and objectives were not clear,
interventions were not patient-specific, and outcomes were not measurable.
It wasn’t until the 1970s and 1980s that formal treatment planning in behav-
ioral health care began to grow in importance as a standard part of good clinical
care. Jongsma and Peterson (1999) attributed the increased recognition of the
importance of treatment plan development during this period to the beginning
of two significant movements in the behavioral health care industry. The first
was the pursuit of accreditation by mental health and substance abuse treat-
ment facilities and agencies from organizations such as the Joint Commission.

Essentials of Treatment Planning, Second Edition. Mark E. Maruish.

© 2020 John Wiley & Sons, Inc. Published 2020 by John Wiley & Sons, Inc.
1
2 Essentials of Treatment Planning

Such accreditation was necessary to qualify for third-party reimbursements. The

accreditation standards of the Joint Commission and other accrediting bodies
required providers to be more thorough in their development and documenta-
tion of individual treatment plans. The Joint Commission and other accrediting
bodies such as the National Committee for Quality Assurance (NCQA) con-
tinue to maintain treatment planning standards for initial and re-accreditation of
behavioral health care organizations (see Chapter 5).
The other significant movement identified by Jongsma and Peterson
(1999) as influencing the growing importance of treatment planning was the
advent of managed care in the 1980s. As they most succinctly summarized
the matter:

Managed care systems insist that clinicians move rapidly from assessment of
the problem to the formulation and implementation of the treatment plan.
The goal…is to expedite the treatment process by prompting the [patient]
and the treatment provider to focus on identifying and changing behavio-
ral problems as quickly as possible. Treatment plans must be specific as to
the problems and interventions, individualized to meet the client’s needs
and goals, and measurable in terms of setting milestones that can be used
to chart the patient’s progress. (p. 1)

It is unfortunate that external pressures have served as a major impetus for

behavioral health care professionals to be more attentive to what is now consid-
ered a basic part of clinical service delivery. However, as is discussed later in this
chapter, there are many other reasons why the development of an individualized
treatment plan is an important part of the standard care that should be delivered
to mental health and substance abuse patients.

TREATMENT PLANNING: A BRIEF OVERVIEW

What is treatment planning? Why do we do it? The answers to these questions

provide a context for understanding, completing, and successfully implementing
this important component of any behavioral health intervention.

What Is Treatment Planning?

Treatment planning is a term that may mean different things to different peo-
ple. At one level, treatment planning can be defined as “an organized, conceptual
effort to design a program that outlines in advance what must happen if we are
 INTRODUCTION  3

to provide the most effective help for our patients” (Makover, 2016, p. 7). But at
another level, treatment planning can be described as “a complex process involv-
ing sequential decisions, with weighting of information concerning patient char-
acteristics (including but not limited to, patient diagnoses and problem areas),
treatment context, relation variables, and treatment strategies and techniques”
(Clarkin & Kendall, 1992, p. 906). This latter definition highlights the fact that
treatment planning is not the application of a cookie-cutter, one-size-fits-all
approach to intervention. Rather, it is an activity which, if “done right,” requires
serious deliberation and clinical skill on the part of the clinician. And as noted by
Magnavita, Critchfield, and Castonguay (2010), “Given the complexity of pos-
sible combinations tailored to unique client circumstances, the treatment plan-
ning…is inevitably an art that, when done well, is based on clinical expertise and
knowledge and informed by empirical evidence” (p. 287). These facts are borne
out by the content of this book.

Common Elements in Treatment Planning

The manner in which a treatment plan may be developed can vary greatly. This
author’s recommended approach to treatment plan content and development
is detailed in Chapter 5. Chances are that the reader can refer to other works
that address the topic of treatment planning and find approaches that differ in
varying degrees. Regardless of the extent to which the structure and content of
treatment plans may differ, most if not all written plans share common elements
(e.g., see Beutler, 1991; Ingram, 2016; Jongsma & Peterson, 1999; Makover,
2016; Mumma, 1998; United Behavioral Systems [UBS], 1994). These include
basic identifying and background information, a listing of the problems that will be
addressed through treatment, the goals and objectives of that treatment, and the
intervention strategies and tactics that will be employed to achieve those goals and
objectives. In addition, an element of flexibility in the plan during the course of
treatment is usually implied.

Identifying and Background Information

Generally, one will find that treatment plans begin with the presentation of basic
patient identification information (e.g., name, age, marital and employment sta-
tuses), the patient’s stated reason for seeking treatment, and relevant historical
and assessment-related information (GoodTherapy.org, 2016). Also included is
information pertaining to previous and current medical and behavioral health
problems, diagnoses, and treatments.
4 Essentials of Treatment Planning

Problem Identification
A list of problems derived from the patient’s case formulation is included. Jong-
sma and Peterson (1999) discussed two important aspects of problem iden-
tification. First, with the likelihood of the patient presenting with multiple
problems, both clinician and patient must work to identify and prioritize the
most significant problems to work on during treatment. As they noted, “An
effective treatment plan can only deal with a few selected problems or treat-
ment will lose its direction” (p. 4). Second, the problems must be defined in
a manner that indicates how the problems manifest themselves in the patient.
This will not only help the clinician and patient maintain the focus of treat-
ment, but it will also help to establish criteria for successful completion of that
treatment.

Diagnosis
Even if only tentative, one or more diagnoses of the patient’s condition based
on the criteria of the current version of the American Psychiatric Association’s
Diagnostic and Statistical Manual of Mental Disorders typically is indicated in
the treatment plan. At the time of the publication of this book, the fifth edition
(DSM-5; 2013) was the most up-to-date version of the manual.

Aims and Goals

Treatment must always be directed to achieving something for the patient. This
something is usually referred to as the “goals” of treatment. In Makover’s (2016)
four-level, outcome-based treatment planning structure, goals actually are concep-
tualized as being subordinate to the “aim” of treatment. He defines an aim as
“the single desired outcome of a period of therapy” (p. 37). When identified,
the intent is that achieving the aim through therapy will result in a resolution of
the patient’s stress, a return to at least the previous level of functioning, and the
ability for growth and development. Aims should be inclusive, specific, realistic,
and require an economy of effort to achieve.
A goal, on the other hand, is “one of the subsidiary objectives of therapeutic
work and therefore a component of the aim” (Makover, 2016, p. 53). Multiple
goals may need to be achieved in order to achieve the aim of treatment. Makover
suggested the identification of appropriate goals of treatment can be facilitated if
the clinician asks, “What must change for the patient to achieve the aim of the
therapy?” (p. 54).
 INTRODUCTION  5

It would seem that what Makover referred to as “aims” and “goals” are essen-
tially what most others would refer to as “goals” and “objectives,” respectively.
These latter terms will be used from this point on because of the audience’s likely
greater familiarity with them. In addition, the use of this terminology avoids the
implication that there is a “single overall desired outcome” of treatment, a con-
ceptualization that many clinicians may not agree with.

Strategies and Tactics

Planned interventions in the hierarchical treatment planning scheme are con-
ceptualized in terms of strategies and tactics. According to Makover (2016), a
strategy refers to the general therapeutic process or approach (e.g., psychotropic
medication, cognitive-behavioral therapy) that the clinician will use to move the
patient toward one or more goals. In other words, it is the therapeutic modality
selected to accomplish the goal of the treatment. A tactic is a specific task that
is undertaken or a technique that is used within the context of the strategy to
help achieve a goal. Multiple strategies can be used to achieve a goal; similarly,
multiple tactics can be employed within each strategy. As an example, a clinician
may opt to employ a combination of cognitive-behavioral therapy and psychop-
harmacological strategies for treating
a patient’s depression. The tactics that
will be used within these approaches Caution 1.1
may include initiating a regimen of
Like case formulations, treatment
a specific antidepressant medication,
plans should not be carved in stone.
teaching the patient to challenge They should be modified as additional
irrational thoughts, and establishing information about the patient is
a behavior modification system that obtained.
rewards increased involvement in pos-
itive social activities.
Also, perhaps best considered under the strategies and tactics umbrella are
specifics about the frequency and length of treatment. This would include the
proposed frequency of psychotherapeutic or other intervention visits and a pro-
jected timeline for the completion of the stated treatment goals.

Flexibility
Even when manualized treatments are employed, most experts would espouse a
flexible approach to treatment planning. Thus, a change in a case formulation
6 Essentials of Treatment Planning

based on additional information or a

Don’t Forget 1.1 lack of responsiveness to an existing
Common Elements in course of treatment should prompt
Treatment Planning the evaluation and possible modifi-
cation of the patient’s treatment plan.
• Identifying and background Failing to do so may result in less than
information the desired outcome of treatment, an
• Problem identification unnecessary extension of the episode
• Diagnosis of care, or exacerbation of the prob-
• Goals and objectives lems for which the patient is seeking
• Flexibility help.

INTENDED USERS OF THE TREATMENT PLAN

Setting aside the issues related to “Will anyone even look at it?” one must assume
that the treatment plan will be read and indeed be meaningful to various stake-
holders in the patient’s treatment. The question then becomes, “Who will be the
audience for the document that will reflect the intended course of treatment?” At
the minimum, one must consider the treating clinician (who in most circumstances
develops the plan), the patient, and relevant third parties. Each will likely have his
or her own unique interest in and view of the plan, so it behooves the clinician to
develop the plan in such a way that all potential stakeholders’ needs are met.

The Treating Clinician

In reality, the clinician should be considered the primary audience for the writ-
ten treatment plan. As indicated earlier, it will (or at least should) serve as a
map or guide for conducting the patient’s treatment (Seligman, 1993), and thus
something that the clinician should regularly refer to in order to ensure that the
planned treatment is on track. As such, it can be viewed as a tool for the clinician
to facilitate the process of therapeutic intervention. The clinician likely will refer
to or make use of it more frequently than anyone else.
In most cases, the clinician who develops the treatment plan for a patient will also
be the clinician who assumes primary responsibility for that patient. The treatment
plan therefore should be developed in a way that organizes the assessing clinician’s
understanding of the patient and the patient’s therapeutic needs. In cases where the
assessing clinician is not the treating clinician, clear and complete communication of
this information is very important. In its absence, misunderstandings can occur and
may result in less than maximum therapeutic efficiency and benefit for the patient.
 INTRODUCTION  7

The Patient
As with the case formulation, the treatment plan should be developed and shared
with the patient. The patient needs to agree with the identified problems, treat-
ment goals, and interventions indicated in the plan prior to the initiation of treat-
ment. The patient’s “buy-in” is critical to achieving the stated goals of treatment.
In one sense, the treatment plan serves as a contract between the clinician
and the patient, something that the patient can refer to when questions about
the who, what, when, and/or why of some aspect of the therapeutic process arises
during the course of treatment. As such, it can be a source of reassurance to the
patient. It also can serve as a means of holding both the clinician and the patient
accountable for the roles and responsibilities they mutually agreed upon prior to
the initiation of treatment. Here again, the clarity and completeness of the plan
are important.

Insurers
As discussed earlier, there may be times when insurers require the submission of
a treatment plan more as a formality than as a means of ensuring quality of care.
Assuming this is not the case, the treatment plan can be a means of conveying to
the insurer that appropriate, adequate care is or will be provided to its health plan
member. Perhaps more importantly, it can provide evidence that the treatment is
“medically necessary,” and thus is covered by the patient’s behavioral health plan
benefits. Being able to describe the patient’s problems, their proposed treatment,
and the mutually agreed upon therapeutic goals in a manner that is consist-
ent with medical necessity guidelines established by the insurer can facilitate the
approval of requested services and thus the initiation of treatment.
The same focus is important when updated treatment plans are submitted to
the insurer in support of requests for additional authorized services. Here, it also
is important to document progress (if any) that has been made during the most
recent period of authorized services as well as the need for continued behavioral
health services. If progress has not been made, the clinician will also have to pro-
vide justification for either continuation of the same therapeutic strategy or the
implementation of a new strategy or approach.

Other Third-Party Stakeholders

Depending on the particular circumstances, there may be other parties that have
a stake in the patient’s treatment. In many of these cases, the interested party
may require a treatment plan. This will likely necessitate a focus in the written
plan that differs from the clinician’s “standard” treatment plan. Such a focus may