Keeping your treatment from stalling or going astray can be a challenge. This chapter gives you a powerful tool to prevent that.
Going off in different directions at each appointment isn’t good care. To avoid this, you need a current and up-to-date plan. It should reflect everyone’s best understanding of your illness and treatment. We call this a living treatment plan because it grows and changes over time. It is a plan that is easily updated and that everyone works from.
A living treatment plan maps out your care, showing both the big picture and details. It tracks the best available treatment options and how to implement them. It ensures you use your time wisely and focus on treatments that are working. If you’re waiting for a specialist, getting confirmation of a diagnosis, trying a medication, or engaging in therapy, your plan suggests other things you could also be doing. When you ask, “What should I be doing now?” you’re not starting from scratch. You can turn to your plan.
Your living treatment plan is also a communications tool. It keeps everyone involved in your care on the same page. They should all understand your treatment goals, symptoms, as well as which interventions have and haven’t worked, and those still to be tried.
You’ll often hear your care providers refer to your treatment plan. A treatment plan describes your symptoms and diagnosis, along with a strategy to improve your mental health, such as using a certain medication. Often, these plans are written summaries created by your treatment provider after your first visit.
Unfortunately, these plans are frequently out of date as soon as they’re written. You may not respond as hoped to a planned treatment. Choices that looked promising earlier now look iffy. Initial assumptions are rejected as your provider learns more about your experiences. Rather than providing ongoing guidance, your treatment plan is left to collect dust. We like to refer to these as dead treatment plans.
Without a plan, you’re left with episodic care. Your appointments focus on short-term circumstances at the expense of the big picture. Sure, your treatment providers have some idea of where you’re headed, however imprecise. Their chart notes are too detailed to help much. But with more patients and shorter and less frequent appointments, remembering the overall context and details of your plan gets harder. Increasingly, the focus is how you are feeling during the current visit. Next month it may be something completely different. Your treatment becomes reactive rather than proactive. You have no idea if you’re making progress or if your current treatment is helping. It gets even worse if you have multiple treatment providers. Each one reacts to what they see each time they meet with you. And none of them may have any idea what your other treatment providers have just changed or what they’ll do next.
Finding effective mental health treatment is a process of trial and error in which each trial can take weeks or months. You don’t want to go down the wrong path, stay too long on an initially promising but ultimately unsuccessful treatment, or abandon what could have been an effective treatment too soon. Each misstep prolongs your return to wellness. Gaps in care such as waiting for specialists add delays and may derail your care entirely.
So, what does a living treatment plan look like? Check out Figure 2.
There’s a lot going on here. We’ll describe each piece in a moment, but you can see at a glance a variety of interventions and the results of trying them. Your treatment plan is a snapshot of your current situation, a record of what you’ve recently tried, and ideas you might try soon. As your treatment moves forward, your plan should adjust accordingly. To do that, it must be:
quick and easy to create;
quick and easy to modify;
flexible enough to add all kinds of information;
easy to show someone else; and
compact enough to fit on one page (or screen).
The visual appearance of the plan isn’t important. This example uses several spatially grouped textual outlines. It could just as well be represented as a mind map, a jumble of shapes and arrows, or a collection of scribbled sticky notes. It might use different colours, emojis, or other symbols to convey meaning. You can write it by hand in a notebook, use a word processor, drawing program, or outlining tool on a computer or tablet. The important thing is to use what works for you.
Portions of two alternative forms of the same plan are shown below. The one on the left shows all the interventions as a single outline, not broken down by categories. The flowchart-like one on the right uses different symbols to represent different types of elements.
We’ll start by looking at the four main sections of the plan: symptoms, goals, diagnosis, and current and potential interventions.
You’ll see shortly that the content of the plan can come from everyone on your treatment team, including yourself. Most of these sections may start out empty but will be filled out over time.
Your symptoms are the foundation for every other component of your living treatment plan. We covered labelling and measuring them in the Describing Your Symptoms chapter. Your living treatment plan identifies your main symptoms, as well as their severity or impact (the number in brackets).
This section lists your diagnosis or diagnoses. Initially, this may be unclear. It may include possibilities to consider further. Over time, as you and your treatment providers work together, it will begin to solidify.
A list of diagnoses can inspire ideas for treatments and other interventions. Including possible diagnoses also reminds everyone to keep an open mind. If several treatment attempts have been unsuccessful, it may be worth revisiting your diagnosis.
This list of possible diagnoses is called the differential diagnosis. Adding a diagnosis to the differential is like asking, “Do I have X?” but not demanding an immediate answer. Think of it as a reminder to consider the diagnosis more closely in the future.
While most patients like to know their exact diagnosis, it’s often not that clear-cut. You’ll often see more tentative language, e.g., “rule out,” “by history,” and “possible.” Confidence in your diagnosis can increase or come into doubt as you uncover more details about your illness. With enough evidence, it may be confirmed or ruled out.
Be open if your doctor suggests adding a diagnosis to consider even if it may feel uncomfortable. At the same time, you may have read about an illness that strikes a chord. Discuss with your doctor.
This section describes your treatment goals. These may be nothing more than “to not be sick anymore.” But if you have many symptoms, goals help you prioritize what is most important to you. Often, your goals relate to how your overall quality of life has suffered due to your illness. What improvements do you most want to see? What activity would you like to start doing again? As with other parts of your plan, your goals may change over time.
A popular framework for goal setting is SMART goals. This acronym has several variations. Here is one:
Specific: While “getting better” is a bit vague, “sleep through the night” is something more concrete to work on.
Measurable: It should be easy to check if you’ve met your goal. For example, “at least six hours of sleep and felt well-rested in the morning, at least five days a week.”
Achievable: Be realistic. If you’re sleeping two hours a night, “well-rested, optimal concentration and energy every day, without more sleep” sets you up for failure.
Relevant: Goals should address aspects of your illness that most affect you. Don’t focus on sleep if that’s only a small part of what’s bothering you.
Time-based: Goals should have a timeframe for completion. This sets expectations and can impact the choice of treatments. If you want to sleep better by next week, you’re going to need medications or supplements. If you have more time, other solutions such as therapy become possibilities.
Writing down explicit SMART goals helps ensure both you and your treatment providers have similar expectations. When goals are visible, it becomes easier to see when people have conflicting ideas. That can spark a valuable conversation that leads to a better, shared understanding. The alternative, where differences stay hidden, inevitably leads to frustration and people working at cross purposes.
Rather than treatments, we’ll speak more generally about interventions. An intervention can be a trial of a medication or a course of psychotherapy. It could be a lab test to rule out a vitamin deficiency or completion of a symptom scale to clarify a diagnosis. It may be doing more research to suggest alternative explanations for a problem.
Identifying potential interventions is a starting point. You also need to consider which are most likely to be effective at achieving your goals. These educated guesses help you choose which interventions to try next. You and your treatment providers should take into account not only clinical evidence, but also factors such as availability, cost, insurance coverage, and timeframe.
Potential interventions come from many places, including
common (and less-common) treatments for your diagnosis;
common (and less-common) treatments for particular symptoms;
things that have worked well for you in the past;
interventions suggested by other aspects of your medical history;
things that have worked well for family members; and
research.
The remainder of the book covers many different treatments and interventions. As you read further, consider which ones you might add to your treatment plan. Remember that finding the right treatments involves a certain amount of guesswork. Many ideal treatments (on paper) for your illness may not help you, while others will despite being intended for different uses. Better to include too many possibilities than too few. You’re not committing to trying every single one of them.
There’s more going on in our example living treatment plan than just lists of items in each section. We’ll now draw your attention to several features of the plan that help to emphasize, differentiate, track, and manage each piece of your treatment. As you’re reading, try to focus on what information each feature conveys and why it’s important.
Your plan should highlight those things you’re certain of versus those that are partially explored or future possibilities. Certainty may mean confirming a diagnosis, verifying you have a vitamin deficiency, or showing improvement on a medication. Whether noted with a check mark, gold star, or bright yellow highlighter, quickly picking out these items is important.
Less obviously, you should note interventions and other items that were once possibilities but are no longer. You found they either didn’t apply or didn’t work. For example, you’ll notice several crossed-out items in the plan. You and your doctor initially considered several possible diagnoses, but after further discussion, you’ve ruled out a bipolar disorder. Here’s another example. Using the medication Zoloft was a potential treatment option you considered, but after trying it, you found it made you too nauseous. Cross these out or move them to a “ruled-out” area but keep them somewhere.
Tracking things you’ve tried but that weren’t helpful can serve as a reminder not to accidentally try them again later. Writing down what happened that made you change directions can also help. Review your medical records or try to recall treatments you’ve tried in the distant past as well.
Just because something didn’t work at one point doesn’t mean it won’t work in the future. Your anxiety could have been too high to benefit from psychotherapy, or the particular therapist may have been a poor fit. You might not have tried a medication long enough or at an adequate dose. Look back at what didn’t help you every so often. Has anything changed that might make revisiting an earlier intervention worthwhile?
Early in your treatment, there will be many more things you don’t know than things you’re confident about. But even in the beginning, you will consider some items in your plan more important than others. You might expect some interventions dealing with central issues to help, while others you may consider long shots. Making priority or importance explicit in your plan reminds you which items to pay more attention to and what steps you’re likely to take next.
The example living treatment plan shows priority and importance in several different ways:
The list of symptoms includes a number beside each to indicate its current severity or impact. A 1 is very minor, while a 10 is as bad as could be imagined.
Ordering of lists can indicate likelihood or priority. For example, the list of diagnoses has the most likely ones at the top, with less likely ones further down.
Different symbols can show priorities, such as one or more question marks (?) or asterisks (*). Some people use A, B, C or [H]igh, [M]edium, and [L]ow.
Other common ways to show priority include changing the size of an item, the weight of the font, using different colours, adding boxes, lines, arrows, etc. Remember that the priority you assign to items may change over time.
You’ll notice that the Effexor intervention in the example is an outline several levels deep. This shows the relationships between different items. Why is an item in your plan? What are you taking that medication for? The outline puts each item in context. It reminds you how each part of your plan fits into the bigger picture. This global view keeps you from having tunnel vision and focusing too much on one small part of your treatment. Seeing everything is the reason we recommend your plan fit on one page or screen.
The example treatment plan shows several different relationships.
Potential interventions are broken down into categories such as physical health, psychotherapy, etc. Medications currently contains one type: antidepressants. Antidepressants is itself a category with four particular examples: Zoloft, Effexor, Cymbalta, and Wellbutrin.
Within Effexor, you have two steps detailing how to start and then continue the medication.
Look at the sweating side effect. The solution below that is in response to the sweating, which in turn was in response to the Effexor.
Why do these relationships matter? If you’re having trouble dealing with the sweating side effect, they remind you that it’s only a problem because of the Effexor. Does the Effexor even work well? If not, don’t waste your time addressing its side effect.
Another concept incorporated in a living treatment plan is time. Unlike an antibiotic that can kill off an infection in a few days, hardly anything in mental health happens quickly. Few people know what to expect from treatments including how long they take to work. Explicitly noting time in your treatment plans sets and communicates expectations. It reminds you to schedule evaluations to measure how well a treatment works. This helps avoid two common errors made treating mental illness. The first is spending far more time than needed on a remedy that isn’t helping instead of stopping it and trying something else. The second is not spending enough time on a treatment to know if it will or won’t work. You don’t want to discard what could be an effective treatment without giving it a decent chance to work.
Notice the plan includes time as a duration, e.g., “recheck blood level in 3 mo” but also an absolute date, e.g., “1st week Sept.” You might track those dates within your living treatment plan itself or on a separate calendar. Remember that as plans change, such as time spent dealing with a side effect before increasing a medication dose, you may need to adjust those dates.
Is time a significant consideration in your overall goals? Everyone would like to feel better sooner rather than later, but do you have a specific (and realistic) timeframe in mind? That affects the treatments you choose and whether you try more than one at a time. How long until you know if a treatment works? Some forms of psychotherapy work on very long timeframes, many months or years. Others can help in weeks. Some medications take effect in a matter of hours or days, but others can take weeks, after slowly increasing the dose. Knowing your goals helps your treatment providers suggest interventions that are appropriate for your desired timeframes and goals.
A living treatment plan shows an overview of your current care, including your symptoms, goals, diagnoses, treatments, and other interventions. This includes potential treatments to be considered in the future.
You update the plan as your situation changes, as you learn more about your illness, or discover potential treatments. It helps you see where you are now and plan for what might be next.
Now Available! A MSP-supported live course for BC residents based on the book. [Mar/2023]
While you can read it for free online, there are conditions on sharing it with others (see below). You can also still purchase copies in paperback or e-book (PDF, Kindle, Kobo, etc.).
Now Available! A MSP-supported live course for BC residents based on the book.
