So now that you’ve seen all the different pieces of your living treatment plan and you understand why they’re important, how do you use it?
This chapter answers that question in a few different ways. We’ll first cover some basic principles for using your living treatment plan. Next, we’ll look at various activities, such as starting a new treatment or evaluating a current one. We’ll then show how time spent before, after, and between appointments can make the limited time available during appointments more productive and improve your overall treatment. Finally, we’ll revisit some of the failure scenarios we described earlier to see how your living treatment plan corrects them.
As you read, keep in mind that reviewing and updating your plan is a great opportunity to involve family, friends, or other supports in your care.
Your living treatment plan, whether ink on a page or pixels on a screen, is a road map. It helps you plan your mental health journey, and keep track of where you’ve been and where you’re going. This isn’t a solo journey. How you use your living treatment plan should reflect that.
Your living treatment plan is first and foremost a communication tool. It’s a picture of your treatment shared between you, your doctors and other treatment providers, and those family members or close friends you involve in your care. It makes explicit all the essential aspects of your current situation, goals, and treatment. This tool can help clarify any misunderstandings, especially when people involved have different expectations.
Ideally, your living treatment plan is an opportunity for collaboration between you and your care providers. If your treatment starts to deviate from the plan without warning, bring it up. It’s important to raise issues proactively.
Your doctors or other treatment providers may choose to ignore your living treatment plan altogether when you try to share it with them. That’s perfectly fine. It still helps for you to keep track of your treatment, clarify decisions, identify questions, and request advice from others. Your treatment provider may ignore the visible representation of your plan, but everyone still benefits as it helps you to actively contribute to your care.
Who actually makes changes to the living treatment plan document, in your notebook or electronic device?
We believe it’s essential that you (possibly with help from family or friends), and not your doctor or another provider, be the caretaker of your living treatment plan. This helps you take ownership of your treatment and clarify and organize your care. It’s especially important if several providers are involved. The onus is on you to update your plan.
Next, consider a slightly trickier question. Who decides what to do at a specific time? Your living treatment plan contains elements such as diagnoses and interventions. Some items are for possible consideration in the future, some are more immediate. When it comes to choosing the treatments you’ll actually pursue, who has the final say?
These decisions are ultimately up to both you and your treatment team. Your providers will help you do what they think is best in your situation. Your treatment plan helps you discuss your options with them, including positives and negatives from different peoples’ perspectives. You may suggest options they would not have otherwise considered. But, at the end of the day, they’re going to make decisions they’re comfortable with.
You, on the other hand, have the right to consent (or not) to any particular treatment. That can admittedly be tricky, given the power differential, and often the scarcity of alternative treatment options. Your treatment plan can help you communicate your rationale and concerns about the alternatives. Ultimately, you decide if you want to proceed in a given direction. It’s your life, after all.
Not every treatment needs someone else’s approval or assistance for you to pursue it. You don’t need anyone’s permission to join a yoga class, take an over-the-counter supplement, or increase your exercise. Even so, include these in your plan. This keeps everyone aware of all your current interventions.
Let’s look at the main activities your living treatment plan will be used for.
If your living treatment plan is primarily a communication tool, sharing it with others is essential.
When you meet a new provider, they want to know your concerns, what you’ve tried so far, and who else you’re working with. Walking them through your plan can quickly get them up to speed. If they ask about why you’re using a treatment, your plan should help you answer.
For current providers, use your plan to highlight what’s changed since a previous visit. You may focus on small pieces, but the person you’re talking with will view them in context, not in isolation.
Bring a copy of your plan to all appointments or when discussing your illness with family and friends. Sharing a single copy allows anyone to point to or otherwise emphasize elements of the plan. When physical circumstances don’t allow, e.g., your therapist sits more than a few feet away from you, ensuring everyone has their own copy is a satisfactory alternative.
Your plan contains concrete information such as what treatments or other interventions you’re now engaged in. But it also includes the goals, symptoms, and even diagnoses that inform treatment decisions. Potential treatments to consider in the future are included for the same reason.
Add new elements to your plan to reflect a new understanding of your illness or for future consideration. Remove those that are no longer relevant. If a treatment didn’t help, mark it as ruled out. Reprioritize elements so that the ones you feel are most relevant are up front and visible, while less important ones are examined only on a detailed read.
Where do all these elements come from? Your goals almost always come from you. Symptoms often come from you or those around you. Your care providers will ask you to track other symptoms they know are important. Your providers traditionally supply most diagnoses and treatment options. But possible diagnoses and treatments might also come from you, based on things you’ve read, including the material on treatments in the rest of the book. Add them to your plan as a reminder to discuss them at a future visit.
Remember, the point of including possible diagnoses and treatments is to help make future decisions. If you’re not familiar with something that’s added, it’s a cue to learn more to consider if or how it might apply to you.
Your treatment plan will grow to include multiple possible interventions. Whether starting fresh or after stopping another treatment that didn’t pan out, you need to decide what to try next.
You and your treatment providers can rank them by priority. Consider how likely they are to work (based on clinical evidence), but also how much time, effort, or other resources they require. Personal preferences and convenience are important, too. Having options in front of you is a good starting point. What to do next? Pick one of the higher-ranked items! You may favour one while a treatment provider prefers another, but a conversation around risks and benefits should highlight any tradeoffs.
Could you do more than one thing at a time? Sometimes it makes sense to try one thing before going on to the next. If you’ve decided to try an antidepressant and have five choices, don’t start them all at once. Try one, and if it doesn’t work, move on to the next.
At other times, it can make sense to try several things simultaneously. Let’s say that your plan includes three possible treatments: take an iron supplement to correct a known deficiency, try an antidepressant, or start psychotherapy. You could try them one at a time. But it’s also perfectly reasonable to pursue two or even all three at once.
There is one downside to trying several things at once. If your symptoms improve, you can’t be sure which of the things you’ve been doing made the difference. It could have been all of them, each contributing a bit, or just one—the others, were in some sense wasted efforts.
Suppose all the improvements in the above scenario were from psychotherapy. But you don’t know that, so you stay on the medication. That’s one reason why people often try things sequentially. If you do try several things at once, add a reminder to your treatment plan to sort it out later with your treatment providers.
You’ve decided which treatment or intervention you’re going to start next. If what you chose has been in your plan for a while, you had the opportunity to learn something about it. You’ll undoubtedly still have questions, and your provider will want to emphasize certain things about the treatment.
When you begin anything new, it’s important to set expectations. What’s the plan for implementing the treatment, and what are your responsibilities? This may be straightforward if it means taking a pill or it may be more involved in some forms of therapy. What if something unexpected happens, e.g., side effects? Are there particular concerns to watch for?
You’re trying this new treatment to see if it will work. What’s the expected benefit if it does? How will you measure it? How long should it take to work? Is this a multi-step process? With many medications, for example, you start at a low dose, see if you can tolerate it, and gradually increase. You often won’t see much benefit until you reach higher doses. Each step should still have a timeframe for evaluation in your living treatment plan.
You’ll undoubtedly have more questions as you progress with the treatment or intervention. But in the beginning, you should broadly understand what the treatment looks like and what to expect.
As you work through a treatment or intervention, sometimes you’ll follow the plan that was sketched out when you first started it. Other times, changes will arise. With medications, for example, you may need to slow down or spread out increases in dosage. During therapy, you and your therapist might change course, bring in new concepts, spend more time exploring others, or add more sessions for another reason.
These types of changes are common. They often come about as everyone gains a better understanding of your illness and how to best tailor your treatment to you. However, be sure to update the timeframes and evaluation points in your treatment plan accordingly. When you adjust treatments, review your plan to see if these dates need to change. Make sure evaluation points are always scheduled for every intervention. The last thing you want is to make a change and then forget to check if that change, or the overall intervention, is actually helping you.
Sometimes changes will involve starting new treatments in conjunction with your current one, such as starting a new medication to resolve a side effect of another. Again, make sure you know what to expect and update your plan, including timeframes and evaluations.
You’ve scheduled evaluations, but how do you check if a treatment is working? Go back to your symptoms! In the Describing Your Symptoms chapter, we explained severity (e.g., 1-10) as a way to measure them. We also talked about self-report rating scales and mood tracking apps. A before-and-after comparison of symptoms and severity should be part of each evaluation.
During treatment, watch for new symptoms or side effects emerging. Report them to your treatment provider and track them like your original symptoms. You can measure your progress on your own. This frees up your valuable appointment time for clarification and other activities. Your treatment providers will also ask questions and make observations as they determine if the intervention is helping or introducing new problems.
Be careful not to base your evaluations only on your symptoms if other factors are present. If the week leading up to an evaluation was unusually busy and you got some bad news, should you blame the drop in your mood on the treatment? Probably not. Speak up before someone changes your treatment without having all the facts.
A final question to consider: how good is good enough? Most guidelines recommend adjusting your treatment until all your symptoms are completely gone. Discuss this with your treatment providers after you’re feeling a lot better. It’s a decision based on your goals, your diagnosis, and the interventions you are using.
You’ve just seen some of the most important activities that relate to your living treatment plan. How do you tie them all together? We’ll look at that in the context of appointments with your treatment providers.
Most passive patients only think about their treatment and plan during all too brief appointments. But you’re active in your care and guided by your living treatment plan. You spend time and effort before you arrive at your appointment and after you leave. That way, you get the very most out of each appointment. Let’s see how.
Prepare for your appointment by asking yourself a series of questions:
What’s new or what has changed since the last time you saw this provider? Has a different provider made changes to a treatment, suggested a diagnosis, or referred you for tests or other care?
Have you added, removed, or reprioritized any elements in your plan?
How are you doing overall? Consider updating the severity of symptoms in the plan. Any new problems or symptoms? Have there been any significant events or changes in your life since you last saw this treatment provider?
Are you at an evaluation point? Check all dates in your plan for treatment steps or evaluation points. Often, appointments are scheduled to coincide with these. Can you provide a clear answer to whether the intervention is helping, or are you not sure?
Do you have a course of action you’d like to propose at this appointment? A treatment change? A new alternative to consider? Something specific to focus on?
Take that information and make a concise list or set of notes to bring to your appointment. Your notes should help you summarize each point in a sentence or two. Make sure the most important points are upfront. You may be able to incorporate this into your living treatment plan or a copy. For example, you might use a highlighter to show which parts have changed or which you want to discuss in more detail.
All that preparation beforehand will pay off during your appointment. You shouldn’t need to think on your feet about the basics. Be ready to share what you’ve prepared. Raise any significant changes or life events at the beginning.
If you’re evaluating one step in an existing treatment, you’ll have feedback to share, and your provider will probably have questions. They may review your diagnosis or discuss possibilities for future treatments. You may have things to contribute in these areas.
If decisions are needed, they’re likely not coming out of the blue, but are already part of your living treatment plan. Regardless, make sure you know the risks, benefits, and alternatives. Speak up if you’re uncomfortable or consider asking to postpone the decision to the next appointment so you can do some research in the meantime. Ask for recommended sources of information, if appropriate.
If making changes, ensure you know what to do and what to expect, including timeframes. Ask questions. Keep in mind what questions need answers now and which can wait until later.
Ideally, you (or someone you brought with you) were able to take quick notes during the appointment itself. Otherwise, it’s time for a memory dump immediately after your appointment. Spend a few minutes in the waiting room or in your car before driving off, but don’t wait until hours later.
Preferably sooner rather than later, turn your quick notes into something you’ll be able to understand later, filling in details. If you brought someone with you, doing it together will help clarify things. If you’ve got questions as you go, write them down. You may be able to find the answers yourself or you may need to check with your treatment provider, either at the next appointment or even before.
When you have time, update your living treatment plan with any changes or new information. If changes are made that affect other pieces of the plan, such as dates, adjust them as necessary.
In the time between appointments, you can do a lot of housekeeping work with your living treatment plan. Keep your plan tidy and relevant. Scan through it once in a while. Is everything up to date? Are priorities for each item current? Do diagnoses and interventions reflect everyone’s latest insights? Did anyone suggest possible diagnoses or interventions you should add to the plan? Are some things so unlikely you can remove them from the plan altogether? When will you next be evaluating each current intervention? Is anything overdue? Things such as repeating labs, which have timeframes of many months, often slip. Have you updated the severity of your symptoms in the plan recently?
Beyond housekeeping, there may be some deep work that can significantly move your plan forward. Just like a series of experiments, your treatment plan evolves by eliminating unknowns. Whether a treatment works or not is only one part of this. Are there elements of your plan that could benefit from further reading or research? The Paging Dr. Google chapter can help with this. If some items in the plan need further investigation, is there anything you can do? If it’s a possible diagnosis, are there symptom self-report scales or other reading you could do that might help your providers? Do you have old medical records that might help? If you are considering an intervention, do you understand it well enough to see how it could fit into your plan? What are its good and bad points from your perspective?
In the Working with Your Family Doctor chapter, we gave examples showing how a family doctor’s challenges can affect your treatment. Let’s revisit some of them here and see what difference a living treatment plan makes.
Along with your low mood, you mention being always tired and having memory problems. Your doctor prescribes you an antidepressant and, two months later, a different one—neither help. What they didn’t do is check your iron level and find an easily fixed deficiency that can quickly improve your energy and memory.
Your doctor identified only a single treatment option (antidepressant medication). When it didn’t work, they tried a variation of the same thing. Even early on, the treatment plan should have identified other options. Those could include blood work to look for a metabolic cause of your symptoms. These tests are cheap and fast. There’s no reason not to do them before or at the same time as trying a medication. Other options you might add to the plan, even if not done immediately, would be diagnostic imaging, cognitive testing, or psychotherapy.
Living treatment plans identify alternatives, so you avoid tunnel vision. They help break out of the one-thing-at-a-time mindset that episodic care encourages.
Your doctor tries you on an antidepressant and books a follow-up in three weeks. At that visit, you complain of nausea and brain fog. They stop the antidepressant due to side effects. Because it’s such a short appointment, you do not discuss that you only filled the prescription three days ago due to your anxiety. You miss out on a medication that could have worked very well once your system got used to it.
Here, a treatment is being eliminated from the plan prematurely. Chalk this up to poor communication. The doctor thinks you’ve been on the medication for three weeks. You didn’t know that some side effects go away with time and didn’t think to mention you just filled the prescription. One key aspect of good treatment plans is that they explicitly include the length of time before evaluating treatments. This helps avoid these miscommunications.
Your family doctor refers you to a local mental health clinic. They complete a quick intake appointment and put you in an eight-week mindfulness course. While interesting, it doesn’t help address your particular mental health symptoms. Your family doctor assumes your mental health concerns were taken care of at the clinic. They don’t pursue any other possible avenues of treatment.
Several things are happening. First, the clinic created their own (traditional) treatment plan at the intake: “do mindfulness course.” It describes what they think is the most promising option based on what they know at the start. There’s no evaluation or other treatment alternative.
Your doctor thinks they’ve entirely handed off your care to the clinic. The clinic is worrying about the mindfulness course. Nobody is considering any alternatives. A single, comprehensive living treatment plan shared by your doctor, the clinic, and you would ensure that every intervention (e.g., “send to mental health clinic”) has both a timeline and an evaluation phase. Your doctor would find out if your symptoms haven’t improved and why, leading to a new intervention.
They refer you to a psychiatrist with a 12- to 18-month waiting list. When asked what to do in the meantime, they shrug and say, “I’ve already referred you to someone, what more do you want?”
Again, a good plan highlights alternatives, which may not need to take place one after the other. There’s no reason not to try other treatments while you are waiting to see a psychiatrist. In the meantime, what worked and what didn’t would be passed on to the psychiatrist.
You’re in charge of your living treatment plan document, but decision making about treatments is shared between you and your treatment providers.
Preparing for your appointments with treatment providers helps you get the most out of the limited time you have available with them during appointments.
The time between appointments can be used to both update and organize your living treatment plan, and for reading, research, and other activities to significantly enhance your overall treatment.
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.
