Creating a Treatment Plan for Substance Abuse: What to Include + Example

Addiction can be described as a chronic and progressive disease because most individuals find that the severity of their symptoms and the impairment caused by their use worsens the longer they use. Comprehensive and individualized care is common among substance abuse treatment facilities and can help individuals successfully navigate the changes in their lives that come with sobriety. The U.S. Department of Health and Human Services and the Substance Abuse and Mental Health Services Administration released the National Survey on Drug Use and Health for 2021. This report indicated that 16.5% of the U.S. population was living with a substance use disorder, more specifically, 29.5 individuals had an alcohol use disorder, and 24 million were living with a drug use disorder. Keep reading to learn how to create a treatment plan for substance abuse, with an example client.

View all of our Substance Abuse Worksheets

13.5% of adults, ages 18 to 25, were experiencing a co-occurring mental health illness in addition to their substance use disorder. When we look at individuals who have had a substance use disorder, over 70% considered themselves to be in recovery during 2021. Most individuals who were struggling with addiction and did not participate in treatment during the same time didn’t believe that their use warranted the need for therapy and other treatment interventions.

Substance use disorders can affect nearly every aspect of a person’s life, including their physical and mental health, relationships, work and school performance, finances, and contribute to new or worsening legal concerns. Because of this, treatment facilities tend to take a whole-person approach, so that individuals are equipped with the tools and resources they need to successfully navigate their recovery. Individuals who find themselves living with a co-occurring mental health condition have better treatment outcomes when they receive concurrent care, addressing both conditions simultaneously. Because of the individualized nature of substance use disorders, there is no standard or “one size fits all” approach.

Treatment for substance use disorders is dependent on the severity of an individual’s use disorder, their impairment, and the presence of other health conditions. Commonly used treatment programs include detoxification, inpatient rehabilitation programs, partial hospitalization programs (PHP), intensive outpatient programs (IOP), and general outpatient or aftercare programming. Evidence-based treatment programs that are commonly used within these various treatment programs include:

  • Cognitive-behavioral therapy (CBT)
  • Motivational interviewing (MI)
  • Contingency Management (CM)
  • Dialectical-behavioral therapy (DBT)
  • Medication-assisted treatment (MAT)
  • Family therapy
  • Trauma-informed therapy

Setting Goals and Objectives With Clients in Your Treatment Plan for Substance Abuse

As you begin developing a substance abuse treatment plan, you will need to determine if it is medically necessary for your client to receive medical support and supervision in a detox program. This is an important detail to investigate for several reasons. First and foremost, detoxing from drugs and alcohol can be an uncomfortable, painful, and in some cases, dangerous transition. Drugs and alcohol have a profound effect on our brains and bodies, which contributes to withdrawal symptoms. Additionally, individuals who are experiencing withdrawal symptoms will likely be unable to devote their attention to clinical work because of the physical and psychological symptoms they are experiencing. 

To determine the severity of your client’s use and the symptoms they are experiencing, you may choose to use some of the following assessments and screeners:

  • The Alcohol Use Disorders Identification Test (AUDIT)
  • Drug Abuse Screening Test (DAST-10)
  • CAGE Questionnaire
  • Screening, Brief Intervention, and Referral to Treatment (SBIRT)
  • Michigan Alcohol Screening Test (MAST)
  • Substance Abuse Subtle Screening Inventory (SASSI)
  • RAFFT Questions

Your evaluation will likely explore the presence of other mental health conditions, including trauma or life events, that could be a force behind your client’s addiction. The different levels of care available for substance abuse treatment are designed with different intensities and frequencies, to reflect the different levels of support commonly needed in recovery. Additionally, it is important to understand your client’s motivation for recovery and determine where they fall within the stages of change. Clients who are motivated by external factors, or are in the contemplation phase, may benefit from the use of MI to help them find reasons they find appealing to modify their behaviors. 

What to Include in a Treatment Plan for a Substance Abuse + Example

Once you have completed an intake assessment, you will have the information you need to complete a treatment plan for substance abuse disorders. To outline the various components of an addiction treatment plan, we will be following a sample treatment plan for substance abuse counseling, that aligns with the customizable treatment plan available at TherapyByPro.

Case Example for John:

John S. is a 38-year-old man who has been struggling with drinking for several years. He began drinking heavily in his early twenties as a way to cope with stress from work. Over time, his alcohol consumption escalated, and he found himself unable to control his drinking despite the negative consequences he experienced. His wife has verbalized concerns several times, and he has been unsuccessful in his attempts to stop drinking. He was recently arrested for driving while intoxicated (DWI), which ultimately contributed to his wife moving out of their home with his two children until he could stay sober. John’s lawyer recommended that he seek treatment at an inpatient rehabilitation facility, which he was agreeable to. He completed a 7-day detox before coming to work with you in the inpatient rehab program.  John reported that he was drinking daily, to the point of intoxication, noting that he often has little control over how much he drinks. He noted that he has had to increase his use over the years and that he was experiencing withdrawal symptoms.  He reported that he knew his drinking was a problem and that it caused problems with his wife, and work. He noted that he missed his children’s sporting events frequently because of drinking, which upset his children. John shared that he sees some benefits to sobriety, but is unsure if this is something he is capable of. John was referred to treatment by his lawyer, and primary health physician after his DWI. While in detox, John’s physician began him on a medication regimen including Campral to support him in his recovery.

Agencies Involved and Plans for Care Coordination

John was referred to your inpatient rehabilitation program by his primary care physician after his arrest, which would warrant care coordination. This allows you to communicate with his doctor about his participation in treatment, and coordinate aftercare plans if his discharge plan includes the continued use of addiction medications.

Example for John:

Other Agency: Primary Care Physician, Doctor Smith

Plan to Coordinate: Contact to inform of admission to treatment, coordinate at the time of discharge

Clinical Diagnoses

John’s symptoms indicate that he is experiencing alcohol use disorder (AUD). His symptoms should continuously be monitored, to ensure that he is receiving proper support. The severity of his use disorder is severe because he has more than 6 of the 11 diagnostic criteria. Specific symptoms that support this diagnosis include:

  • John has a history of unsuccessful attempts to reduce his drinking
  • John has missed important activities and events because of this drinking
  • His drinking has led to concerns at home with his wife and children
  • He has continued to drink despite the social and interpersonal problems it has causes
  • He has a history of drinking in dangerous situations, including driving while impaired
  • John reported developing a tolerance
  • John indicated the presence of withdrawal symptoms

Example for John:

Clinical Diagnosis: Alcohol Use Disorder, Severe F10.21

Supporting Assessments:

  • Alcohol Use Disorders Identification Test (AUDIT): 25
  • Severity of Alcohol Dependency Questionnaire (SADQ): 30

Current Medications and Responses

While in a detoxification program, John’s doctor began prescribing him Campral to help reduce the frequency of cravings and to provide relief from withdrawal symptoms. He is agreeable to continuing the use of this medication in the early stages of his recovery.

Example for John:

Medications: Campral X mg, X times per day

Presenting Problem and Related Symptoms

In this section of your treatment plan, you will provide a clinical summary of your client’s presenting concerns and relevant factors. This description should provide other professionals with a thorough snapshot of John’s case so that they have an understanding of his symptoms, level of impairment, and overall mental health.

Example for John:

John presents with symptoms consistent with severe Alcohol Use Disorder (AUD) as per the DSM-5 criteria. He reports compulsive drinking, unsuccessful attempts to cut down or control his alcohol use, spending significant time obtaining and recovering from alcohol, intense cravings for alcohol, and continued use despite negative consequences of legal problems and relationship conflicts. John has developed a tolerance to alcohol, requiring increasing amounts to achieve the desired effects, and experiences physical and psychological symptoms of withdrawal when attempting to abstain from alcohol. In addition to his AUD symptoms, John has limited coping skills for stress, as this was indicated as a trigger for his use. 

Goals and Objectives

The goals and objectives of your substance abuse treatment plan should be specific to your client, being mindful of their capabilities and resources, and something that they can realistically accomplish. Goals on a treatment plan are often long-term goals your client is working towards, with objectives describing short-term goals that work towards their overarching goal. Your treatment plan can note the therapeutic approach and interventions you’ll be using.

Example for John:

Goal 1: Increase Motivation for Change and Commitment to Sobriety

  • Objective 1: Utilize MI techniques to explore and strengthen John’s intrinsic motivation for sobriety by identifying and reinforcing his values and goals related to health, relationships, and future goals.
  • Objective 2:  Identify and address ambivalence towards change by exploring the pros and cons of continued alcohol use versus sobriety, using MI’s decisional balance exercise.
  • Objective 3:  Enhance John’s confidence and self-efficacy for change by exploring and emphasizing his previous successful experiences with positive coping strategies, utilizing MI’s change talk techniques.

Goal 2: Develop Coping Skills to Manage Alcohol Cravings and High-Risk Situations

  • Objective 1:  Implement CBT strategies to identify triggers for alcohol use, including environmental, emotional, and social cues, through exercises and self-monitoring.
  • Objective 2: Utilize CBT techniques such as cognitive restructuring to challenge and modify maladaptive thoughts and beliefs about alcohol use, replacing them with healthier alternatives that support sobriety.
  • Objective 3: Practice relapse prevention skills, including urge surfing, distraction techniques, and assertive communication, to effectively cope with cravings and navigate high-risk situations without resorting to alcohol use.

Goal 3: Enhance Emotional Regulation and Coping Skills to Address Co-occurring Anxiety and Depression

  • Objective 1: Integrate mindfulness-based practices, such as deep breathing exercises and progressive muscle relaxation, to increase John’s awareness of emotional states and promote emotional regulation.
  • Objective 2: Identify and challenge cognitive distortions associated with his mental health using CBT techniques such as cognitive restructuring, thought records, and examining evidence for and against negative beliefs.
  • Objective 3: Develop adaptive coping strategies to manage anxiety and depression symptoms, including engaging in pleasurable activities, seeking social support, and implementing problem-solving skills to address stressors effectively.

Specific Interventions to Be Used

Therapeutic interventions should be easily incorporated into your goals and objectives, ideally, using evidence-based approaches. The interventions that you use should support your client, and be relevant to their related goals for recovery. You can use this section as a brief reminder for specific interventions or methods that you would like to incorporate into future sessions. Making a note of who is responsible for acting can also be used as a reference point for accountability.

Example for John:

Intervention/Action 1

Create a decisional balance exercise exploring the pros and cons of Sobriety

Responsible Person: Counselor A and John

Intervention/Action 2

Educate and incorporate change talk into therapeutic sessions to improve his self-confidence

Responsible Person: Counselor A and John

Intervention/Action 3

Utilize cognitive restructuring techniques to catch and modify maladaptive thoughts and beliefs about alcohol use

Responsible Person: Counselor A

Intervention/Action 4

Use relapse prevention skills including, but not limited to, distraction techniques and urge surfing

Responsible Person: John

Intervention/Action5

Incorporate mindfulness skills into daily routines, such as deep breathing, guided imagery, and progressive muscle relaxation.

Responsible Person: Counselor A and John

Family Involvement

Substance use disorders can cause significant distress within interpersonal relationships. It is not uncommon to see enabling and care-taking behaviors when a loved one is struggling with drugs or alcohol. Family involvement is often an available treatment option in inpatient rehab programs, including educational and therapeutic opportunities. Family can be a great source of support for individuals. In John’s case, his use has had a profound effect on his marriage, as evidenced by his wife leaving their family home with their children. In this case, family counseling would be an ideal service to offer and may include his children, depending on the appropriateness of their age.

Example for John:

John’s wife for family counseling and education

Estimation for Completion

The duration of substance abuse counseling depends on the level of care that is being provided. Inpatient rehabilitation programs can vary from a few weeks to a few months, depending on the individual’s needs. In Johns’s case, he does not appear to have a dual diagnosis, so he may be able to complete his program in 8 weeks. This time can always be adjusted to better reflect his needs if appropriate.

Example for John:

8 weeks of inpatient rehabilitation care including group therapy, individual sessions, educational sessions, and supportive services. To be adjusted as needed

Aftercare Plans

Aftercare plans are often modified as your client progresses through treatment. They should be representative of your client’s current needs, should they be discharged or terminated early. With inpatient rehabilitation programs, this section could look quite different for the beginning and the end of treatment.

Example for John:

Aftercare plans:

  • Continued therapy and counseling at an inpatient rehabilitation program
  • Family Counseling 
  • Active involvement with peer-led support groups, such as
  • alcoholics anonymous (AA)

Final Thoughts On Creating a Treatment Plan for Substance Abuse

Substance use disorders are often complex and individualized because of the physical and psychological components associated with addiction. Effective treatment plans meet clients where they are, and provide them with knowledge and tools to reach their goals. Some clients may come into counseling unsure about recovery, and that’s okay! Motivational interviewing can be a great resource for clinicians who find themselves working with clients to find intrinsic motivation and reasons for changing unhealthy behaviors.

If you find that using worksheets enhances your therapy sessions, we encourage you to consider the TherapyByPro Substance Use Disorder Worksheets and their Substance Abuse Treatment Plan

TherapyByPro is an online mental health directory that connects mental health pros with clients in need. If you’re a mental health professional, you can Join our community and add your practice listing here. We have assessments, practice forms, and worksheet templates mental health professionals can use to streamline their practice. View all of our mental health worksheets here.

View all of our Substance Abuse Worksheets

Resources:

Kayla Loibl, MA, LMHC
Author: Kayla Loibl, MA, LMHC

Kayla is a Mental Health Counselor who earned her degree from Niagara University in Lewiston, New York. She has provided psychotherapy in a residential treatment program and an outpatient addiction treatment facility in New York as well as an inpatient addiction rehab in Ontario, Canada. She has experience working with individuals living with a variety of mental health concerns including depression, anxiety, bipolar disorder, borderline personality disorder, and trauma.

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