CLINICAL HANDBOOK OF SCHIZOPHRENIA

146 II. ASSESSMENT AND DIAGNOSISWHO CREATES THE TREATMENT PLAN?The treatment plan is a synthetic document that incorporates the goals of the treatmentteam and of the patient. Substantial research has shown that patient participation intreatment planning and decision making improves outcomes. It is essential that the treatmentplan capture the goals and aspirations of the patient, as well as those of his or hertreatment team. Patient goals are typically not framed in medical terms, such as absenceof psychotic symptoms, but are expressed as desired functional outcomes (“working,”“married,” etc.). A critical aspect of creating and reshaping the treatment plan is to bringpatient and treatment team goals into alignment with one another. When patients see arelationship between, for example, reducing symptoms by taking medication regularlyand achieving their own goals in life, they are more likely to adopt the treatment teamgoals relative to medication adherence.HOW ARE TREATMENT PLAN ELEMENTS PRIORITIZED?One can think of treatment plan goals along different dimensions, such as urgency, criticality,and feasibility. Urgent goals typically deal with acute problems, such as decompensationor living situation difficulties, and take precedence over long-term goals, becauseprogress on long-term goals does not occur until the urgent problems are resolved. Criticalgoals are those that form the building blocks for achievement of other goals. Earninga general equivalency degree (GED), for example, may be a critical goal en route to a particularemployment goal. Whereas urgent goals usually deal with critical issues, criticalgoals are not necessarily urgent. Much of the work of formulating the long-term treatmentplan goes into achieving treatment team and patient consensus about critical stepson the paths toward long-term goals. Criticality changes both with illness stage (stable vs.unstable) and with progress along goal paths, requiring ongoing reassessment. Feasibility(achievability) of treatment plan goals must also be factored into decisions about how toprioritize use of time and resources. There is nothing wrong with having lofty aims, but acompilation of unattainable goals is an invitation to discouragement with and abandonmentof the treatment planning process. When goals are very remote in time or seeminglybeyond the patient’s present capabilities, it is important to establish intermediate goals—logical steps along the way that are within reach. Ultimately, decisions about prioritizationof treatment plan elements need to be made by a team leader who knows the planand the patient well, and who has decision-making authority.WHEN SHOULD THE TREATMENT PLAN BE CHANGED?Treatment plan changes are prompted by one of two events: (1) change in patient status,or (2) availability of relevant new treatments or knowledge about existing treatments.Treatment plan changes most often occur at team meetings, with provider andpatient input. If the document and plan are to be dynamic, however, they should reflectcurrent realities rather than catching up with them weeks or months later. This meansthat it should be the task of one treatment team member to update the treatment planin real time. Electronic medical records on computer networks greatly simplify the logisticsof changing the treatment plan and communicating it to other treatment teammembers.