A Behavior Treatment Plan as a Psychological MRI By Tom Medlar, LMHC on 2/22/22 - 11:54 AM

As a psychotherapist providing services in nursing facilities, I am accustomed to using a variety of forms, including initial assessment, progress notes, and treatment plans. I have come to appreciate that the behavioral treatment plan may be the most powerful, yet the most overlooked or avoided, clinical form.

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My clinical task is to provide direct assessment and treatment services to nursing facility residents. Yet I also have an obligation to offer insights that help the facility caregivers to better understand and more effectively manage the sometimes-troubling behaviors demonstrated by that resident. Direct care staff persons at the nursing facility might observe only the most obvious and observable element of the resident’s behavior—the unkempt appearance, the irritable defensiveness, the argumentative refusals of care, the unwelcome sexual remarks, the tearfulness, the yelling, the social avoidance, or the aggressive and abusive language aimed at them. In response, the caregiver may react in a personal manner, with expressions of indignation or criticism, or even patronizing efforts at persuasion. What I have often seen lacking is a keen awareness of the inner meanings and motives behind those behaviors; the ways they might reflect or represent symptoms of varied medical and psychological conditions and the ways that the caregivers’ responses might increase or decrease the intensity and duration of those symptomatic behaviors.

Nurses and clinical aides might occasionally notice the assessment and progress notes that I and fellow clinicians generate but at the same time never read those documents. However, the nurse or aide might not readily gain a new understanding of the resident even if they did read those forms. A behavior treatment plan, though, can provide a window into the psychological nuances that illuminate and explain the actions of the resident. The behavior treatment plan can be like a psychological MRI that provides an inside view of factors influencing a resident’s behavior.

A behavior treatment plan is effective because it does not simply get written and quietly entered in the chart. It requires review, explanation, and education so the facility staff persons can understand and implement the plan. Brief staff in-service training follows the writing of a plan so that it can be introduced and clarified. Those trainings allow for discussions that may be a first opportunity for the staff persons to readily understand the psychiatric diagnoses of the residents and how their psychiatric symptoms are behaviorally manifested.

Resident: Leslie (Identifying information has been altered from the example below.)

Diagnosis: 295.70 Schizoaffective Disorder, Bipolar Type; Epilepsy; Developmental Disability due to Fetal Alcohol Syndrome; and PTSD Associated with Childhood Sexual Abuse.

Presenting Problem/Target Behavior: Leslie demonstrates unstable affect with frequent bouts of crying or expressions of anger; fluctuating levels of alertness and mental clarity; and apparent passive-aggressive and/or attention-seeking behaviors such as self-admittedly putting herself on the floor and crawling towards the bathroom to express her anger over perceived delay in staff response to her need to use the toilet. In general, Leslie sometimes displays a child-like manner with inconsistent cooperation with care and treatment and a tendency to over-dramatize daily upsets in ways that elicit comforting and extra involvement of staff persons.

Description of Resident & History of Problem: Leslie is a 51-year-old single woman with epilepsy and major mental illness, developmental problems, and past trauma. Considering the above diagnoses, it is to be anticipated that she might demonstrate problems with her social behaviors and critical thinking skills. It is important to remember that her actions reflect serious problems with brain development and functioning and do not simply represent “bad behavior.” Behavior and cognition can be significantly affected for persons with epilepsy as well as by unwanted effects of antiepileptic drugs. Also, a person with the above diagnoses can be burdened by painful feelings of social stigma and by difficulties establishing and sustaining trusting relationships with others.

Clinical Assessment of Behavior & Resident: Leslie experienced developmental disability due to effects of Fetal Alcohol Syndrome. She later developed Schizoaffective Disorder, Bipolar Type. Her psychosocial development was further undermined by sexual abuse by her father, the forced termination of a resulting pregnancy, and associated traumatic consequences.

It is well known that consequent to long-term institutional care, some persons can develop dysfunctional patterns of behavior referred to as “learned helplessness.” These factors provide a background context in which to view and understand the behavior problems demonstrated by Leslie. The resident is not to be blamed or negatively judged for having acquired a child-like, passive-aggressive, and dependent style of coping and problem solving. At the same time, Leslie cannot be expected to simply snap out of it and immediately display a fully adaptive adult style of coping with daily stresses. Over time and with consistent encouragement and reinforcement, Leslie can be helped to learn and practice dealing with problems and expressing emotions in more reasonable and mature and independent ways. Presently, she is effective in soliciting emotional support and the close and helpful attentions of others by displaying emotional distress (tears or anger) or by taking risks, such as placing herself on the floor in defiance, that draw others closer to her.

Behavioral Interventions: The main purpose or intent of this behavior plan is to foster, encourage, and reward small progressive steps towards more self-reliant adult ways of meeting her needs. Leslie directly contributed to the development of this behavior plan. I shared with her the feedback and observations and stated concerns of staff persons and elicited from Leslie her own ideas for ways to address those concerns.

Leslie offered the following points: “I will not express anger by doing unsafe things like putting myself on the floor; I learned my lesson good.” “I will try to show good emotional self-control.” In the event that she was to again lower herself to the floor, Leslie suggested that staff persons should stand safely nearby and “let me try to pull myself up.” Leslie said, “Let me do more on my own.” “If I am crying or angry, let me alone for a while and I’ll calm myself down.”

Staff persons interacting with Leslie should keep in mind the general principle of promoting her growing maturity and improved ability to soothe her own upset emotions and to work constructively and cooperatively with staff to meet her needs. Avoid correcting her with scolding or display of annoyance, as that could trigger withdrawal or passive-aggression or tearful emotional collapse. Invite Leslie to brainstorm ideas for ways to correct problems, resolve dissatisfactions, compromise with others, or be more compliant with needed care and treatment. Encourage Leslie to take deep breaths and to collect herself emotionally before engaging in such brainstorming or came back later if she needs more time to soothe her emotions. Expect Leslie to adopt a more measured and sensible sets of problem-solving skills, but do not become frustrated or annoyed by the unavoidable delays and lapses she will continue to display along the way. Use your words and actions as ways to invite her into more mutually rewarding adult ways of coping. Guide her toward the acquisition of genuinely adult skills and viewpoints while remaining patiently aware of the deep and longstanding obstacles that interfere with her having already learned those methods.


I met with the unit nurses and aides to review and discuss this treatment plan. Some had not been aware of Leslie’s history of Fetal Alcohol Syndrome, of her hearing voices, or of her history of sexual assault. Some were surprised by the discussion of epilepsy and psychological and behavioral symptoms. Yet a renewed sense of compassion and of helpful mission were awakened by the conversation about ways they might aid her development—even during their ordinary and routine tasks. The workers now applied the new insights and asked thoughtful questions about her specific behaviors. They felt less reactive in a personalized sense, and better prepared to shape their actions so as to improve hers.

File under: The Art of Psychotherapy, Musings and Reflections