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Forensic Psychology: Standards of Practice

This is a work product sample of what I run across from forensic psychology.  I redacted red for the sentences of the Evaluator, and blue for direct quotes.

Notice the extent of direct quotes.  She tape recorded the sessions and simply used the transcripts from the sessions as her History and Symptoms.  Then she provided three paragraphs in the concluding “Opinions” section of her report, giving her judgement; her decree on the child custody schedule.

Forensic Psychology: Standard of Practice

When the Checklist for Applied Knowledge is used on her report, her report evidenced the application of no knowledge from any domain of professional psychology.  The red-redacted sentences in the body of the report were mostly transitional statements from one block quote to the next in the recorded transcript.  Her final three paragraphs were entirely her opinion and judgement recommendations.

Her “Opinions” recommended that because the 12 year-old son didn’t want to live with his mother that the father should have sole physical custody of him, and even though the 10 year-old daughter explicitly said in the direct quotes in the report of the Evaluator that she wanted 50-50% shared custody visitation with both parents when the custody Evaluator asked her what she wanted, the Evaluator said said the daughter’s custody visitation schedule should only be every-other-weekend with the mother, with no rationale given.


Commentary:

This is considered an acceptable standard of practice child custody assessment in forensic psychology. 

Notice the signature line for this psychologist, all the puffy titles, Queen protector of the realm of Zambeezeland.  Sounds impressive, doesn’t it.

I say “sounds impressive” because I have her actual work product.  I know what this psychologist actually does.  Now you do too.  You’re pretty much looking at it. She tape records her sessions, uses the transcript as her History and Symptoms, she applies no effort, no knowledge, nothing to the actual analysis of anything, then she just writes three paragraphs at the end saying, “The 12 year-old child says he doesn’t want to live with XYZ parent so full custody should go to ABC parent” – Next…

Unbelievable, but oh so true.  I run into this abysmal level of professional practice from forensic psychology all the time – and much-much worse – every single day.  I exaggerate.  Three times a week, four tops.

Look at the lines of her signature. She’s one of the “top people” in forensic psychology.  She’s one of their supposedly best people… and this is her actual work product.  She’s a fraud.

Holy cow, do you understand the implications of that?  One of the top people in forensic psychology is a fraud.  Ask me if I’m surprised.  I read their stuff all they time.  Typically, they’re better at hiding it.  Typically it’s not this completely and utterly lazy and incompetent.

She didn’t know that anyone in the world would be reviewing her report, and certainly not Dr. Childress.  She probably would have done things differently if she had known her report was going to be “reviewed” by somebody who actually knew something about professional psychology.  Which is what makes it perfect… this is an example of what they do.  Routinely.

Did you know it’s illegal for me to have an opinion about the work of a forensic psychologist.  Yeah, only other forensic psychologists are allowed to express an opinion about the work of a forensic psychologist.  So you’ll never hear me express an opinion about the actual practice involved with a specific child custody evaluation.  I’m legally not allowed to do that, only they can “review” their work – and this is one of their top people who would do the “review” – APA you MUST come look at this – from the outside – do NOT let forensic psychology review itself.  This is an example of their “top people”.

I’m different, though.  I’m a clinical psychologist.  I’m treatment guy.  My focus is on treatment plans for the family.  What do we do about things.

The forensic psychology report almost always refers for therapy.  That’s me, I’m therapy psychologist.  I’m the one who catches the family as they’re jettisoned from the child custody “evaluation”.  That’s where I come into the mix, talking about treatment issues of concern surrounding the family data.

Do I have an opinion about the child custody evaluation?  Oh yeah.  I’ve made my opinions about child custody evaluations abundantly clear.  No inter-rater reliability, no validity (by definition if there’s no reliability), voodoo assessments, rattle some beads, chant some incantations, and read the entrails of a goat.  That’s my opinion.

But I just can’t say that about any specific forensic psychology evaluation.  Only they are allowed to critique each other’s work.  How… convenient.

I am in professional jeopardy because of my critical statements about forensic psychology.  This is a prominent financial industry for them.  They will NOT like me calling attention to their deficits and critiquing their work.  They’re not used to having their work critiqued by “outsiders” like me.

Don’t care.  Standard 1.04 and 1.05 of the APA ethics code are clear.

Because of the professional threat to me personally from forensic psychology’s retaliation, this full redaction of one of their reports is great, because it is so incredibly blatant.  From someone who is considered a “top” forensic psychologist.  One of their best.  Honest to god, this is the standard of practice.  It is arrogance, arrogance, arrogance through and through.  Do you know why?  No oversight or review.

Their reports are sealed by the court to protect the child, and only other forensic psychologists can review what each other do… and this is considered standard of practice.  Anything is.  Usually it is more structured, but that’s for the big nine-month version for lots of money.  This psychologist appears to have thrown this one off in a few sessions.  The family probably didn’t have enough money for the longer version.

This is considered top-level standard of practice in forensic psychology.  Look at the credentials she cites for herself.  Hey, American Board of Assessment Psychology, this is the standard of practice work for one of your “Diplomats” – this is the product of your training – you – the American Board of Assessment Psychology – are confirming the quality of her work… See, right there in her signature line to her court report, she’s saying she’s a Diplomat of your training.  Her quality of work is your product. This is the quality of work produced by your Diplomats.

The forensic psychology people (I refuse to call them professionals until they start acting like professionals; standard of practice) may start making noises about this redacted report being an “exception” – no.  Actually it’s not. I read their reports all the time.  This is typical, they even get worse.  Most are irrational and lazy.  Then there’s the behemoth 9-month $40,000 monstrosities.

No application of any knowledge, no diagnosis, everybody just makes stuff up.  Look.  Right there.  See.  This forensic psychologist just made something up.  That’s all over the place, they all do it.  That is considered normal everyday run-of-the mill sort of stuff for this psychologist.  For all of them.  I read their reports.  Listen carefully – I – read – their – reports.

And my head is exploding at how bad it is.  Have we even touched on cultural competence yet?  Holy cow, is that a nightmare and a thousand over here in forensic psychology.  But they review themselves.  Don’t you see the problem with that?  They – review – themselves.  And this report is from one of their “top” forensic psychology people.  She’s one of the people they’d ask to review the reports of other forensic psychologists.  You don’t see the problem with that?

If you don’t believe me, just look for yourself.  Please.  Come over here and look.  APA.  I’m pleading with the APA, please, please, please come look at this “forensic psychology” world, it’s a nightmare of professional ignorance and professional sloth – and a true paradise of pathological narcissism… in the mental health professionals.

Haughty arrogance.  You see that in this report can’t you?  Of course.  That sense of haughty and arrogant entitlement, she’s above the rules, the rules don’t apply to her.  All the lines following her name, she’s a sham grandiosity – an outward appearance of pompous grandiosity without substance.  Don’t believe me?  Look at her work product.  That’s who she actually is.  A sham.  A fraud.  But showy pomp.

THAT is her actual work product.  I didn’t produce that report, SHE did.  That is her work product.  Do you think that is in any way acceptable professional practice?  Yikes cowabunga not from my world of clinical psychology.  That is not even practicum student level.  If an intern gives me that report, I’m booting the intern out of the training program and contacting the graduate school about their inferior training of their students.

And this person is considered a “top” person in forensic psychology. APA, this needs OUTSIDE review.  Bring cultural, bring psychometrics, bring clinical, bring ethics.  Do NOT let forensic psychology “review” themselves.  This is one of their “top people” – this person is who will be doing their “review” of themselves.

That’s standard of practice in forensic psychology.  She’s just one of the gang.  In fact, she’s one of the top in their gang.  She’s a leader of their little group of “forensic Evaluators” – she’s a Diplomat in Assessment.  Wow, she’s their best.

And this is her work product.

Defend it forensic psychology.  Defend this report.  Tell me that amount of block quotes and a three paragraph summary that entirely lacks the application of any professional knowledge, tell me that’s “okay”.  That this is acceptable standard of practice.

Because… if you don’t… then this psychologist is going to face a malpractice lawsuit from mom, and she’s going to get one of you forensic psychologists to “review” the work of this psychologist for “standards of practice” related to fraud and incompetence.  It will be based on your testimony, forensic psychology – remember, I’m not legally allowed to review the work of forensic psychologists, so mom is going to ask you… forensic psychology… is this fraud and incompetence?

What’s your answer forensic psychology?  Is this fraud and incompetence?

These people’s lives hang in the balance, her opinion holds the lives of these people.  The child’s development, the child’s life, is in this woman’s hands. 

Is this level of professional practice what you would want from your “Evaluator” if your children and your lives depended on the “Opinion” you received from “the Evaluator”?

Doesn’t that even sound creepy?  The “Evaluator” – the child custody “Evaluator” – like the Inquisitor from the Church of forensic psychology, who judges parents and decides the fates of children and parents, whether parents “deserve” to have children.  The child custody “Evaluator”.

They abrogate the obligations of the court.  The “Evaluator” from forensic psychology hears evidence (the history of the conflict in vivid and voyeuristic detail), they make a finding of fact (regarding the supposed cause of the conflict), and they order the remedy (of child custody and visitation schedules; who should have the children and when).

Isn’t that the court’s job, to hear evidence, make a finding of fact, and determine the remedy? 

Why is a child custody “Evaluator” doing that, based on this sort of shoddy report?  She tape records sessions, uses the transcript as her History and Symptoms, and gives a three-paragraph pronouncement of her rulings from the bench – excuse me, from the couch.

Isn’t hearing evidence, making a finding of fact (based on the law, not opinion), and making an order for the custody and visitation schedule (based on the law, not opinion), isn’t that the court’s obligation?  How is it that we have an “Evaluator” doing this, this… one person.  Why them?  Why any of it?   We should be focused on treatment, not custody.

The courts can make decisions.  Professional psychology is about pathology and treatment.  This isn’t a child custody issue, it’s a family pathology and treatment issue.  Professional psychology needs to stay away from custody and visitation schedules.  I don’t care.

Three options:

1.)  50-50.  That’s my recommendation as a clinical child and family psychologist. That is the best I can come up with if you ask me. Mother-daugher, father-daughter, mother-son, father-son, all unique, all equally important, 50-50.  Like kindergarten and Legos, we learn to share.

2.)  Every-other-weekend.  If, for some reason a shared 50-50 isn’t workable, then the default is primacy to one parent and the other parent gets every-other-weekend and one weekday (maybe dinner, maybe overnight) during the week.  Still okay. Everything is fine.

3.) School year/vacations.  If distance factors make an every-other-weekend schedule impractical, then the next default is primacy to one parent during the school year and vacation bonus time to the other parent.  This is not great, we’d prefer every other weekend, and we’d actually prefer 50-50, but the world has its limitations and context.

Which of these three options the court chooses is for the court to decide based on the application of its legal criteria for its decision-making.  Psychologists do not make decisions about custody and visitation schedules, courts do.

I can provide counsel to the court on family pathology, it’s treatment and it’s resolution.  Here’s my counsel surrounding custody visitation schedules.

First, I don’t care what the schedule is.  The only thing that’s important is the flow of love from the parent to the child – we always want 100 mom-love and 100 dad-love reaching the child whenever they see each other.   Zero mom-love or Zero dad love is a very-very-very bad thing.  If there are problems, we fix them.

Second, the only time we ever separate a child from a parent is for child abuse and child protection.

When we act for child protection, it should accompany a DSM-5 diagnosis of child abuse.  If there is no DSM-5 diagnosis of child abuse, then there is no justification for restrictions on the child’s access to the parent.  The directional flow of love that is of professional concern is from the parent to the child, we want the child receiving and accepting abundant parental love from each and both parents.

The only justification for interrupting the flow of love from the parent to the child is a threat of child abuse.  A threat of child abuse should be documented by a corresponding DSM-5 diagnosis of child abuse. 

Designating someone a “bad parent” based on arbitrary criteria arbitrarily applied is frightening in its implications – and it’s application.  The “Evaluator” system of forensic psychology is a frightening system, both traumatic and abusive.

Look at her “credentials” – her vitae gets even puffier… she’s a big-wig I’m sure.  A full narcissist display of show without substance.

Work product assessment is the best assessment there is – bar none.  If you want to know what somebody’s work is going to be like, get a sample.  Work product sample is a lock assessment.

This is a report from a big-wig in forensic psychology, standard of practice in forensic psychology.  Please, APA, get over here to look at this.

The review committee should include representation from cultural psychology, from psychometrics, from trauma, from attachment, from clinical psychology, and from ethics.

DO NOT allow “forensic psychology” to review itself.  They will select this person or someone similar to “review” the work of forensic psychology.  You will be decieved by the lines following their names.  THIS is an actual sample of their work product. 

Please, APA.  Bring review and scrutiny to the world of “forensic psychology” from OUTSIDE of forensic psychology.  They must NOT be allowed to continue to self-review.  The “Evaluator” system of judgment with no oversight or review is not working.  Severely not working.

There is zero application of knowledge. 

Professional review needs – needs – to include representation from psychometrics and assessment design.  Please, please, please, they have constructed a nightmare assessment of narcissistic self-indulgence.  Please, APA, we need psychometrics to review the evaluation procedures.

Lest forensic psychology start to babble at me at this point, I have three words – inter-rater reliability.  What is the inter-rater reliability for your assessment procedure?  Zero.  If there is no reliability to the assessment procedure, it cannot possibly be a valid assessment of anything.  That is axiomatic in the psychometrics of assessment design, construction, and use.

I have a professional obligation under Standards 1.04 and 1.05 of the APA ethics code to speak, and to continue to speak until appropriate professional review and oversight occurs.

This – this report – is considered high-quality standard of practice in forensic psychology.

If an intern gave me a report like that, I’m terminating the intern’s placement at my agency and I’m contacting the graduate school immediately to express my deep-deep concerns about their training program – and I’m not accepting another intern from that school.

That’s for an intern. This is from what’s considered to be a “top professional” in forensic psychology.  This is top-quality work product in forensic psychology.

This is not unusual.  I run into this level, and worse, routinely.

I am appalled.  Standard 1.04 and 1.05 are applicable.

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

Standards of Practice: 2007 Written Treatment Plans

I’ve opened my folder of teaching tools for teaching documentation of therapy.  It’s from 2007, long before I even knew that “parental alienation” existed.  I was in trauma world, working with kids in the foster care system. These documentation standards are from that time period.

This is a treatment plan form for the San Bernardino Department of Behavioral Health.  They were the county funding agency for mental health services in the foster care system.

SB-DBH Treatment Plan Form

The actual form is on blue paper, and it extends over several paper pages, so I just transcribed it to a Word table format and condensed redundancy. 

Those three empty boxes in the middle… that’s where all the action is on this form; Objectives, Clinical Interventions, and Outcomes.  It’s in those three empty boxes that we’d write our answers to those three important questions; goals, how are you going to get there, did it work?

Objectives – Clinical Interventions – Outcome

That’s the structural backbone of a written treatment plan.

What is the goal to be achieved by therapy (Objectives)?

How are you going to achieve those goals (Clinical Interventions)?

Did you achieve those goals (Outcome)?

I’ll go into each of these areas in a moment, but before leaving the form I want to point out a couple of other important features of a written treatment plan demonstrated by this county form.

First, notice that right above the Signatures box there’s a Frequency of Care Plan Review line, with boxes for 30 Days, 3 Months, 6 Month, and 12 Months.  Those time-frames are typically considered the standard of practice review points for treatment plans.  Treatment goals should typically be for a three- to six-month range for resolution of the pathology.  Short-term goals in the four- to six-week range are helpful progress milestones toward achieving the longer 3 to 6-month solutions. 

That’s what a treatment plan does, it lays out the course for solution, and that course is reviewed regularly; we’d hope for a treatment plan with a 3 to 6-month resolution of the pathology.

Notice too, the box off to the side of the signatures that says, “Client Received a Copy of the Care Plan” with a place for the client’s initials and date.  The written treatment plan is reviewed with the client, and the client gets a copy of it.  In fact, the Department of Behavioral Health wants to make certain that the client has a copy of the written treatment plan.  This documents that we reviewed the treatment plan with the client… at 3 months, and 6 months, and 1 year; each time the client initials a new signature line with a new date.

That’s considered standard of practice in county work in the foster care system.  Written treatment plan, review it with the client, client gets a copy of the written treatment plan.

Let’s take a closer look at those three empty boxes, and see what the county Department of Behavioral Health wants.

Objectives

OBJECTIVES: (Must be specific, measurable/quantifiable, attainable, realistic, time-bound.  Must be related to assessment, presenting problems/symptoms and functional impairment.  Include cultural/linguistic, co-occurring factors, if appropriate.  Include Med Support and Targeted Case Management, if appropriate)

Let me highlight a couple of things from this documentation requirement – measurable/quantifiable – time-bound.  Those features of the treatment plan are not optional, they are part of the list of required components.   Notice the instructions say “Must be” – not “Should be” – Must be… measurable and time-bound Objectives are requirements of the written treatment plan.

We must be able to measure treatment outcome, and our treatment goals must be time-bound.

Let me also highlight that the goals of treatment must be linked to the assessment information, to the presenting problem and symptoms, and to the impairment caused by the symptoms. The treatment plan describes what the problem is, and how to fix it.

Treatment plans link to the assessment data and describe a coherently organized approach to fixing the presenting problem – to solving things.

If a mental health professional cannot develop a written treatment plan for a pathology, then that mental health professional should not be working with that pathology.  Simple as that.

If I’m working with eating disorders, I must be able to develop an effective treatment plan for eating disorders.  If I am working with depression, I must be able to come up with an effective treatment plan for depression.  In professional psychology, that’s called “boundaries of competence,” that I only work with types of pathology that I know about, for which I am able to develop a written treatment plan.

If you know what you’re doing, then you have a plan for treatment. If you have a plan for treatment, write it down on a piece of paper and tell everyone what the plan is.   A written treatment plan.  A standard of professional practice – Department of Behavioral Health, San Bernardino County.

Clinical Interventions

CLINICAL INTERVENTIONS: (Must be related to objective. List clinical intervention for each group/individual service.  Includes Med Support and Targeted Case Management, if appropriate).

Tell us what you’re going to do.  This is the application of knowledge section of the treatment plan.  Objectives is being able to define goals in achievable and measurable ways, Clinical Interventions is knowing what to do about it.

Personally, I’d apply the scientifically established knowledge of professional psychology, in whatever domain of pathology I was working in, from geriatrics, to ADHD, or autism.  What’s the science say, that’s where I’ll be.  For this court-involved family conflict pathology, I apply the knowledge from attachment, and family systems therapy, personality disorders, complex trauma, and the neuro-development of the brain during childhood.  I think it’s tremendously relevant information that helps make sense of everything.

I’d recommend it; attachment, family systems therapy, personality disorders, complex trauma, and the neuro-development of the brain in childhood.

But everyone’s free to apply the knowledge they’d like.  A psychoanalytically oriented psychologist might apply Adler or Kohut, a humanistic psychologist might apply Rogers and Pearls, a CBT therapist will apply learning theory and Beck.  What knowledge is applied in this box, Clinical Interventions, is given broad latitude… but it is documented in the treatment plan.

It doesn’t matter what you do… just tell us what it is.

Because, you see, in telling us what it is your going to do to fix things, we’ll be able to tell if you know what you’re doing.  First, if you can’t tell us anything at all about how you are going to fix things (the clinical interventions), then you don’t know what you’re doing.  So that’s an easy one right there.

Then, for those therapists who do provide a description of their clinical interventions, we can look at their case formulation and applied knowledge to see what information and knowledge from professional psychology they used in their case conceptualization and treatment approach.  This will allow parents to make informed decisions regarding treatment, a requirement of informed consent to treatment.  It’s the informed part.

Don’t care what the answer is to this box, Clinical Interventions, just tell us what you plan to do.  After that, then we’ll care about what the answer is to this box.  But for right now, just tell us what you’re going to do to fix things.  Whatever you think is best.

Outcome

OUTCOMES/date/initials: To be completed at the end of the Care Plan Review timeframe, 30 days, 3, 6, 12 months or more frequently as appropriate

At every outcome review point specified in the treatment plan (typically 3-month and 6-month, and by then things should be substantially solved), the treatment goals and clinical interventions to achieve those goals are reviewed.  Remember, the treatment objectives are identified in ways that are “measurable” and “time-bound” – permitting review of goal accomplishment.

In child and family therapy, clinical impact is typically targeted for four to six-weeks.  Even in autism, significant measurable impact of clinical involvement should be evident by four to six weeks.  For autism, the clinical impact in six weeks would not necessarily be directly measurable in the child’s symptoms, but the caregivers should have substantially increased knowledge and skills in how to respond to the child (changes in caregiver stress and responding skills that are measurable).  The improved responding from the caregivers then leads to the more productive longer-range progress toward the treatment goals, gains which should become directly evident in the child’s symptoms on the 3-month and 6-month reviews of the treatment goals. 

So even with autism pathology, we would expect to see measurable gains in caregiver response competence in a four to six week period of initial intervention, leading toward longer-range goal achievement.

This is true for all pathology, from autism to oppositional defiant disorder.  It’s usually reasonable to expect a positive impact from intervention on some measurable area of functioning in four to six weeks, improvements moving toward a 3- to 6-month resolution of the presenting problem.

Does treatment with some childhood pathology take longer than six months to solve?  Of course.  But for each time-period longer than six months, professional concerns about the accuracy of the case conceptualization and treatment plan increase.   Treatment should solve things.  If treatment is not solving things within three to six months, we need to closely examine the diagnostic premise and clinical approach involved.

If we treat diabetes with insulin but the patient actually has cancer and needs chemotherapy, then the sooner we re-evaluate our diagnosis based on absence of treatment progress the sooner we will be able to get the proper diagnosis of cancer and the proper treatment of chemotherapy.  If things aren’t working, it’s time to look closely at possibly changing what we’re doing.

Does that mean that longer treatment is always due to earlier misdiagnosis?  No.  It just means that with each increment of time over six months, the review scrutiny of the case conceptualization, diagnosis, and clinical interventions used to achieve a solution becomes more exacting.

Even for chronic pathologies like autism that will require years of developmentally supportive intervention, we would want to achieve a stabilization of intervention where the child is receiving the proper intervention at the proper dosage level, and measurable progress from the intervention is continuing.  Continuing measurable gains from the consistent application of developmentally supportive intervention becomes a steady state treatment plan, measurable and time-bound review, and the same in its consistency of measurable effectiveness. 

This is the desired steady-state treatment plan we want for chronic pathology, always then closely monitoring scientific advancements that can improve the treatment plan for increasingly positive outcome.

If, however, the child ceases to make gains in a time-frame of review, then a reconsideration of case conceptualization and treatment plan is indicated.  When progress is not made, we develop a new treatment plan.  This may involve altering our case conceptualization, or altering the clinical interventions applied.

The important thing is that the progress is measurable, and that the treatment plan is time-bound to periods for review and modification.

School IEP

If an additional example is needed for a written treatment plan related to commonly occurring childhood pathology, I would refer to the school IEP (Individual Education Program).  The school IEP represents a written treatment plan surrounding a variety of possible issues, some possibly medical, some possibly emotional and psychological. 

What does the school do about the presenting problem referred for an individualized educational approach; the IEP referral?  The school develops a written treatment plan, discusses this written treatment plan with the parents, obtains the parent’s approval for the written treatment plan, and then then the school implements the treatment plan as described by the written treatment plan. 

Once implemented, this written treatment plan of the IEP is reviewed on a periodic schedule to ensure measurable gains from the education-related treatment plan described by the IEP.

The school IEP is an education-related treatment plan, but many of the issues addressed by the IEP are emotional and psychological disturbances of childhood, so often the educational intervention co-occurs within the context of the psychological intervention.

A written treatment plan is everyday standard of practice in the school system.  The county of San Bernardino Department of Behavioral Health mandated a written treatment plan as a requirement for funding treatment of children and families in the foster care system.  In the world I come from, a written treatment plan is common standard of professional practice.  No big deal.

What are the Objectives of treatment (measurable and time-bound), what are the Clinical Interventions to be used to achieve those Objectives, and did it work, what is the Outcome?

The standard of professional practice in clinical psychology is for written treatment plans.

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

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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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