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Standard of Practice: 2007 Documentation of Court-Involved Case Management

Standards of Practice: 2007 Documentation of Child Therapy Session

This is an actual therapy progress note from February of 2007.  It’s from the intern doing child therapy with a foster care child now adopted, probably about the 3 to 4 year-old age range judging by the treatment interventions being described.

These de-identified treatment notes I’m sharing come from a time before I was involved in the court-involved divorce-related conflict that I’m currently working with.

In those days I worked with kids in trauma and foster care.  We had a two-therapist treatment model, with one child therapist working directly in session with the child, and a second therapist meeting collaterally with the parent, or foster parent, or adoptive parent – whoever was the day-to-day adult caregiver for the child.

This treatment note indicates that I was serving as the collateral therapist for the adults while the intern worked directly with the child.  Our interns typically did the direct child therapy, while our licensed staff did the collateral caregiver therapy work.  Our post-docs straddled the two.  Post-docs are trainees who have earned a doctorate degree and they already have a full year of pre-doctoral supervised internship training, but now they need an additional year of post-doctoral supervised training before they can be licensed.

Licensing in psychology takes two full years of supervised clinical training, one year pre-doctoral and one year post-doctoral.  This note is likely from one of our post-docs, she’s reporting on some sensitive work with the child’s anger modulation system.

I used these de-identified notes in training interns and post-docs on features of treatment and treatment documentation.  For example, one of the things I might use this note for is to demonstrate expected specificity in treatment documentation.  It’s not a long note, but the therapist does a nice job of presenting what happened in terms of therapy. What were the therapy interventions, and what were the results. 

Not in blow-by-blow detail of “he did then I did”; but in an organized description using constructs that have meaning.  For example, the therapist notes that, “client began to demonstrate a turn-taking rhythm” – a turn-taking rhythm is an important feature of anger modulation therapy. 

Anger is explosive and draws the person into a self-engaged focus of venting.  In therapy for developing anger-modulation networks, we want to keep the child socially engaged with us, so that we can help in regulating the child’s anger and frustrations.  Once the child collapses out of the social field, anger is vented.  As long as we can keep the anger contained in the social field, we build the neural networks needed for anger modulation.

The basic rhythm of social engagement is the turn-taking rhythm of back-and-forth dialogue.  It starts with eye-gaze and smiling dialogues of infancy, pre-verbal dialogues of babbling, and into verbal dialogues of speech and the social rhythms of back-and-forth turn-taking conversation and dialogue.

All of this is captured by this intern in that one notation phrase.  Not only did the therapist and client make an important step forward in anger modulation for the child when mid-way through the session the child “began to demonstrate a turn-taking rhythm”  This documentation shows that the therapist knows what she’s doing.  If she’s noting an incident of establishing a turn-taking rhythm, she knows how to build the anger-modulation system of the brain’s emotional networks.

There are two levels of a chart note description.  The first is the reporting the pattern.  The documentation needs to describe the clinical psychology features of note; in this case the turn-taking rhythm.  The second level is the documenting the evidence of the pattern, in this note it’s the specific notation of the child saying “Wait” to manage the back-and-forth rhythm.  Specifics do not exist of their own importance, only related to the pattern they reveal. It’s the pattern of interaction that’s important.  And when the therapist knows what they’re doing, they document the patterns and use details only to support descriptions of patterns.

Notice in the therapist’s description how chaotic the child’s activity is.  The child asks to leave the session to find the mother but when outside the session office the child didn’t seek mom’s therapy room,  but instead began to play with other toys in other areas of the clinic.  The child didn’t want to find mom, the child just wanted – well, that’s not exactly clear – disorganized wants, no clear focus or purpose.

That’s such a classic symptom of trauma.  Disorganization; to behavior, to emotions, to thinking.  The impact of trauma is that we cannot organize our states, any state.  Our arousal level is too high, and in children it’s a “building the brain networks” thing for modulating arousal and anxiety, and anger, and sadness, and love… love is called attachment and empathy in the professional literature.

How does this exceptionally good child therapist respond to the child’s disorganization?  With gently applied containment.  Boundaries by which to establish self and other.  Poor kid.  Someone had so overwhelmed his boundaries that he had none left, he was flowing in a continual sea of chaos and fear management.  The therapist in this note was going into his world to find him, and recover him to us.

The headings for the note structure were mandated documentation format by the county Department of Behavioral Health.  Standard of ordinary practice in foster care world.


MHS: Individual Therapy

Client’s Role (Mental Status/Verbalizations)

Client was accompanied to the session by his adoptive parents.  He appeared clean, well groomed, and was dressed in age appropriate casual clothing.  Therapist was greeted with appropriate eye contact, but no smile. Client willingly accompanied therapist to play room.

Role of Significant Others (Verbalizations)

Client’s adoptive parents were in session with Dr. Childress, and were therefore not present during the session.

Therapist’s Role (Actions/Interventions)

Maintained focus on providing a supportive and responsive relationship with the child to foster his ability to cooperate.  This therapist provided client with craft activities and set limits on what toys client could access to help organize his play.  Actively established appropriate boundaries to help client understand that aggressive behavior is not acceptable.

Client’s Response to Above

Client presented as disinterested in craft activities provided by therapist as evidenced by stating he needed to see his mother.  Therapist followed client, who did not seek his mother, but attempted to retrieve toys from a different room.  When therapist re-directed client to return to the session room client complied.  Mid-way through session client began to demonstrate a turn-taking rhythm with therapist by stating “Wait” when he and therapist were cutting strips of paper.  During this activity the client began to “cut” the therapist’s hand with the child-safety scissors.  When therapist distanced herself and verbally stated that aggressiveness was not OK, client waited approx. 30 seconds while watching therapist and then asked for therapist to reengage stating “I’ll be nice”.  Client watchfulness may be indicative of his monitoring to see if therapist was angry and would abandon him.

Clinical Plan for Upcoming Session

Therapist will continue to introduce minor intrusions into client’s activities to strengthen client flexibility in organizing his behavior around adult directives without aggression and/or opposition.  Will actively maintain appropriate boundaries with client to provide modulated stress experiences that will help the child to reduce his aggressive behavior.



That’s the clinical chart note.  That was a case where the child had been abused, moved into the foster care system, and the abusive parent could not be recovered, parental rights were terminated and the child was adopted.  This was one of those cases.  The adoptive parent is sometimes the foster parent who has been with the child for awhile.

We were untangling all the impacts of childhood trauma.  The child therapist was skillfully working with the child to build social-related networks involved in emotional regulation flowing into behavioral regulation (containment of anxiety).  In a separate session the collateral therapist for the parents (adoptive parents in this case) would be teaching the parent about trauma-informed responding in ways that support the child’s recovery. 

Chart notes need to reflect the treatment plan.  What’s the problem, and how do we fix it.  This therapist clearly understands what she’s doing to fix things, and we can feel the treatment plan concepts that guide her work.  That’s what a chart note should do, document the application of a coherent treatment framework for child and family therapy.

Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857

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Standard of Practice: 2007 Documentation of Court-Involved Case Management

Standard of Practice: 2007 Documentation of Court-Involved Case Management

I want to share something with you. Actual progress notes from therapy, not with this pathology of complex family conflict surrounding divorce, but from therapy with abused children in the foster care system. 

The physical and sexual abuse of these children was confirmed by the Department of Children’s Services, and they had placed these children in foster care.  For treatment, they were sent to my clinic.  I was the Clinical Director for a three-university collaboration treating the impact of childhood trauma within our foster care system.

In my role as the Clinical Director, I supervised interns and post-docs, which meant I signed off on their chart notes.  I also trained them in how to do trauma therapy with children, and how to document the therapy in their chart notes.  Over time in my training role as Clinical Director I de-identified some of the notes that came across my desk to use in the training of interns and post-docs regarding treatment, and treatment documentation.

When I left to enter private practice I apparently kept a file of these de-identified sample notes from actual cases tucked in a file cabinet in my garage.  I had forgotten I had them.  My goodness, they’re from 2007, tucked in a file folder in a file cabinet in my garage.  I now recollect thinking that these de-identified chart note samples might be useful if I ever entered another supervisory training role, as training examples of child trauma therapy and therapy documentation.

I’ve been going through and organizing the stuff in my garage.  My last round of doing this was with my books, this time is with my journal articles and folders.  I’m clearing my emotional-psychological decks for action; opening the gun ports in preparation for the upcoming ship-to-ship engagement, so to speak.  In going through stuff folder-by-folder I came across my folder of sample notes, and I started to read them.

Interesting stuff.  Not to me.  It’s just work stuff to me from 2007, long before I came to work with families of court-involved divorce.  But these notes reveal important stuff about professional standards of practice, because they are not created for this pathology of post-divorce family conflict, and they are not related to anything controversial.  They are just standard of ordinary practice from 2007.

At the time of these notes, and at the time they were archived away in my files, I had plans to die happily in complete obscurity, and having never even heard of anything called “parental alienation.”   In 2007, I had never heard the term, “parental alienation.”  This note is from trauma.  These are the actual notes for therapy with young kids in the foster care system. 

This one documenting court-involved case management is from a post-doc psychologist.  It’s a case-management note for billing her report for the guardian (probably grandparents) regarding treatment progress which will be submitted to the court.  I’ve been a court-involved clinical psychologist before, just not a divorce-involved one.  I’ve been trauma and child abuse court-involved clinical psychologist.

You know how the pathogenic parent is so concerned about the supposed “abuse” of their child?  I am exactly the psychologist that you want to send an abused child to.  I am that psychologist – except now I’m here with divorce-related pathology.  But I am an abuse and trauma clinical psychologist.  Foster care.  Early childhood, ages birth to five, up to eight…).

For all of these kids discussed in these actual chart notes, the pathology is confirmed physical or sexual child abuse, often including parental drug use, and possible prenatal exposure of the child to drugs and alcohol.  Anything that gets a child from birth to age 6 into the foster care system; that was our client population; the child and the siblings were our client, along with the (hopefully) recovering parents, the grandparent guardians providing kinship care, the foster parents with four to seven children in their care, adoptive parents adjusting to trauma in children, the social workers in child protective services, and the court.

Been there.  Here is a case management note.


Case Management with the Court

Purpose of Case Management

For the courts to make an educated decision regarding <child name>’s future , it is necessary for the court to consider the child’s mental health and functioning in her current placement.  Consultation and linkage with the client guardian’s legal counsel is meant to facilitate the continued stability and progress of the client.  The legal proceedings regarding guardianship will determine <child name>’s contact with her biological mother, which would have a direct impact on her behavioral and emotional functioning.

Summary of Case Management/Linkage Provided

In her placement with the current guardians, <child name> has made significant gains in the reduction of anxiety and aggression. This therapist wrote a progress letter at the request of the current guardians and their legal counsel to inform the guardianship proceedings.  Specifically legal counsel was interested in the progress that <child name> has made in therapy while in the care of her current guardians, dates of attendance, and wanted to know if her biological mother had participated in treatment.

Treatment Recommendations/Considerations

Recommended that if client mother resumes caregiving involvement she be required to participate in collateral therapy to prevent deterioration in reported gains.  Noted that <child name>’s progress can be attributed in large part to the current secure and stable caregiving environment.  For specific progress and treatment recommendations please refer to the document in client file.

Care Plan

Goal Objective

By 8/13/07, will reduce the severity of client’s anxious/distressed presentation upon separation from 7 times a week to four times a week as measured by parent report, will reduce client lying about significant events to 3 times per week as measured by parent report, will reduce non-compliant behavior in the home from 3 to less than 1 time per week based on parent report, client will follow caregiver direction with only two prompts 90% of the time based on parental report.

Intervention

Will provide linkage and consultation with the court through the legal counsel for client’s guardian in order to support placement decisions that provide the necessary stability and security needed for client’s continuing treatment progress.

Client Will Participate By

Clinical functioning and progress will be reported to the court through the legal counsel of the client’s guardian.



That’s the note example.

Documentation Standard of Practice

I would estimate that the child described in this note by Dr. Excellent has been physically abused, mother is probably meth-addicted, the child is probably in the 5 to 6 year old age-range.  I can tell all that based on how the post-doc worded things.  I know the post-doc who wrote this, and if it was sexual abuse there would be different sentences.  The treatment goals she describes are consistent with physical abuse, and the lying is probably neglect from a meth-addicted mother (neglect leaves an imprint where the child takes whatever they want on impulse and then lies without remorse; it’s a survival symptom of neglect, particularly characteristic of meth-addicted mothers).

Notice the category headings for the note, these are standard mandated headings for a case management note for county-funded work.  We were county funded, foster-care work.  We had county mandated documentation requirements.  All of these note examples are county-level standard of practice for documentation.

This note is for billing purposes.  The post-doc is doing non-treatment activity and is billing the county under a billing code for case management.  This is her billing documentation note.  She has to justify the time spent.  This starts by identifying the child’s needs that are being addressed by the case management.

Note that she is working with the guardian’s attorney to provide information about treatment recovery to the court.  The guardian is likely the grandparent, and they are probably worried about the potential return of the child to an actively meth-addicted and physically abusive mother (the grandparent’s daughter).  The post-doc therapist is working with the grandparent to help stabilize the child’s recovery.

Childhood Trauma and Abuse

This note is from 2007.  This is the world I come from; the treatment of childhood trauma.

Forensic psychology uses the words trauma and abuse a lot, but they don’t actually ever work with trauma and abuse, just this court-involved divorce related family conflict. 

They don’t actually treat children in the foster care system who have been physically and sexually abused by parents.  I do.  Those are my clients.  I’m that guy,  that clinical psychologist, my clinic, that’s where they sent the abused kids for treatment.  To me.

I’ve worked with the courts before this current family-divorce pathology.  Only back then, I was on the foster care child abuse consultation side.  But I’m completely familiar with court-involved consultation surrounding child abuse, and in my world – this is what a case management note looks like.

Notice the treatment plan documentation.  Standard of practice on every progress note…. progress note.  That’s just on the note, there’s a whole four to six page treatment plan in another section of the chart. 

We do in-house QA on our charts every six months – no fun, Saturdays with pizza, and our charts are audited by the county – at random intervals.  Standard of practice, at CHLA, at Choc, at my clinic in 2007.

This is what I would consider a standard of practice note for case management in my world as a clinical psychologist.

Craig Childress, Psy.D.                             
Clinical Psychologist, PSY 18857

Director of Psychological Services,
CCPI; Custody Resolution Method

 

 

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