The Court has the right to expect the highest standards of professional practice from psychotherapists who conduct therapy in response to Court orders.
The professional practices of therapists who provide Court-ordered psychotherapy to children and families should therefore reflect the highest standards of professional practice.
Professionally established guidelines exist that define standards of professional practice for forensic psychologists (Specialty Guidelines for Forensic Psychology, 2013) and guidelines have been proposed for professional standards of best practice regarding child custody evaluations (Patel, & Choate, 2014), yet no professional guidelines have been proposed or established for mental health therapists providing Court-ordered therapy.
I would propose that this is easily rectified: Mental health therapists should always render services at the highest professional standard of practice.
If our child had cancer, wouldn’t we want THE BEST doctors and THE BEST treatment available anywhere for the treatment of our child. Why should we expect any less from psychotherapy? Children’s futures, their healthy or unhealthy development, their future success, struggles, and pain, can all depend on the quality of the psychotherapy services they and their families receive. This is an awesome professional responsibility.
Mental health therapists should provide to their clients exactly the same standard of professional care that the therapist would want for his own daughter or for her own son. For our own children we would want the best possible treatment, whether for cancer or psychological issues. Why should we provide less professional competence to our client children and families than we would want for our own children and families?
Mental health therapists should always render services at the highest standard of professional practice.
And Courts have the right to expect the highest standard of professional practice for child and family litigants referred by the Court for therapy.
Defining the Quality of Care
For many years now I have taught clinical assessment and treatment planning to Master’s level students seeking to become psychotherapists. Prior to my entering private practice I served as a psychologist on medical staff at Children’s Hospital of Orange County where I supervised pre-doctoral and post-doctoral psychology interns and fellows in the APA accredited internship at the hospital. I later served as the Clinical Director for a children’s assessment and treatment center, where I trained and provided clinical supervision in child and family therapy for psychology interns and post-doctoral fellows treating young children who were primarily referred through the Department of Children’s Services and the foster care system.
The following framework for clinical assessment represents the professional standard of practice that I would EXPECT from any graduate student I teach or therapist I supervise if they were to provide Court-ordered family therapy to restore a fractured parent-child relationship, and the following framework would definitely be what I would expect of therapists at the professional level who provide Court-ordered psychotherapy to children and families.
The Court and our clients have the right to expect the highest standard of professional practice from psychotherapists who provide Court-ordered psychotherapy to children and families, and therapists who provide Court-ordered psychotherapy to children and families should expect to provide the highest quality of care to their clients.
Source of Clinical Information
Therapists conducting Court-ordered therapy to treat and resolve parent-child conflict should collect appropriately comprehensive clinical data necessary to develop an accurate case conceptualization which is needed for the development of an effective treatment plan.
For child and family issues, the collection of appropriately comprehensive clinical information would typically involve collecting information from the following sources:
Parental Clinical Interviews: Clinical interviews conducted with each parent individually to obtain each parent’s perspective on background history and symptom information.
Parent-Child Assessment: Initial parent-child therapy assessment sessions with the parent and child who are the clients targeted for treatment, to observe and conduct clinical probes of individual functioning and conjoint relationship dynamics, including client responses to clinical intervention probes.
Child Assessment: Separate child clinical assessment interviews that include clinical probes and assessment of the child’s emotional and psychological functioning.
Relevant Collateral Sources: Review of relevant reports and documents and clinical interviews with relevant collateral sources of information, such as additional family members.
Written Case Conceptualization and Treatment Plan
Therapists providing Court-ordered psychotherapy to restore a fractured parent-child relationship should, within 4 to 6 weeks of the initial intake assessment, produce a written case conceptualization and treatment plan.
Content Domains of the Case Conceptualization
This written case conceptualization should document the following:
- Presenting Problem: A brief introduction to the issues and symptoms that necessitate therapy
- History of the Presenting Problem: A description of how the presenting problem emerged, its developmental course over time, and its severity
- Family History: A description of current family relationships, the family’s history, and relevant information about the parents’ family of origin history
- Academic & Work History: A description of the child’s school behavior and academic performance, and the work history of the parents
- Additional Relevant History: A description of additional relevant information, such as possible trauma history within the family (including in the childhood of the parents or with the grandparents), histories of alcoholism and substance abuse within the family (including in the parent’s childhood or with the grandparents), and histories of psychiatric diagnoses within the family (including the extended family). Additional relevant social, legal, and medical histories should be documented.
Jones, K. D. (2010). The unstructured clinical interview. Journal of Counseling and Development, 88, 220-226.
- Case Conceptualization: The symptoms to be addressed by therapy should be specified and a theoretically substantiated clinical determination should be made regarding the apparent origins of these symptoms.
The theoretical framework that organizes the case conceptualization can be from any of the six primary schools of psychotherapy; psychodynamic, humanistic-existential, cognitive-behavioral, family systems, post-modern social constructionism, neuro-social developmental, or can draw from and integrate several theoretical models (the anticipated length of this case conceptualization would be 1-2 pages and would assume the reader has a professional level knowledge of the theoretical foundations).
Content Domains of the Treatment Plan
The written treatment plan should specify a set of theoretically substantiated treatment interventions that are directly linked to the clinical case conceptualization regarding the origins of the symptoms.
The written treatment plan should specify an estimated timeframe for accomplishing the resolution of the identified symptoms, with due consideration given to the variability of treatment related influences that may arise and alter this estimated timeframe. The written treatment plan should also offer an estimated prognosis for recovery of normal-range development and relationships.
If the estimated timeframe for resolving the symptoms exceeds six months, then a six month benchmark of anticipated gains should be identified and the reasons for the longer than six month estimate of therapy should be documented.
Treatment Progress Updates
At six-month intervals during the course of therapy, the therapist should provide written treatment progress updates specifying the treatment gains to date and the estimated timeframe for achieving a resolution of the symptoms.
If treatment progress has not been substantial in six months of therapy, then an explanation of the barriers to treatment should be documented, and adjusted interventions should be identified to address these barriers.
There are a variety of possible reasons for the failure to achieve substantial treatment progress in six months,
Neuro-biological limitations. These include factors such issues as autism-spectrum limitations, prenatal child exposure to drugs or alcohol that affects cognitive and behavioral development, parental psychiatric disturbances such as bipolar disorder or schizophrenia, etc. These types of issues present an inherent limitation to the treatment gains that can be expected, and realistic treatment expectations need to be established.
Therapist failure. The therapist may lack adequate knowledge and expertise to enact the therapy, or the client-therapist fit may not promote treatment success. A change in therapists may be indicated.
Inaccurate case conceptualization. The initial case conceptualization may have been in error leading to treatment interventions that were off-target to the origins of the symptoms. A revision in the case conceptualization and the treatment plan may be necessary.
Note: Research in psychotherapy efficacy finds that all theoretical orientations are effective (Wampold, 2001). According to the empirical research, the key determinative feature in psychotherapy efficacy is that the therapist has a model of psychotherapy for case conceptualization and that the client accepts this model as an explanation for the problem.
Client factors. A client within the family system may be resistant to the goals of treatment, resulting in slowed treatment progress. The nature of the client factors affecting therapeutic progress should be identified and revised treatment interventions to address and adjust to client factors should be specified.
Inadequate time. Treatment progress is being made, but the prior issues creating the symptoms are complex and deeply embedded and require a longer period of time to resolve. The underlying issues slowing treatment progress should be documented along with an estimated time frame and prognosis, and the factors affecting prognosis should be identified.
Treatment expectations:
- In most cases of parent-child conflict, substantial treatment progress should be expected from six months of therapy.
- Treatment should be expected to resolve the symptoms in no longer than one year of therapy.
- Failure to meet these expectations should generate documentation as to the reasons for the failure of therapy to meet these expectations.
Note on Child Development:
The developmental phases of childhood are relatively brief and each phase is associated with important child experiences and emerging developmental capacities that build sequentially and cumulatively upon earlier developmental maturation.
Child developmental phases occur at approximately three-month intervals during the first year, six-month intervals during the second year, and then express a roughly two-year interval pattern between subsequent developmental phases:
Ages
0-1 infancy development, early emergence of foundational brain systems
1-2 toddler development, socio-language integration and exploratory locomotion
2-4 preschool socio-emotional-behavioral integration
4-6 early school entry and more elaborated socio-cognitive development
6-8 increasing stability in self-regulation and enhanced maturation in family bonding
8-10 elaborated personal and peer (social) achievement motivations
10-12 enhanced social awareness and modeling of same-gender parent, enhanced early proto-adult cognitive reasoning
12-14 increasing independence in self-identity, physio-social puberty changes
14-16 stabilization of adult-like cognitive reasoning and enhanced adult-like self-independence, gender-bonding motivations emerge
16-18 emergence of adult-level cognitive and social maturation
18-20 transition into young adult responsibilities and self-reliance
A six month time period reflects fully ¼ of the timeframe for a developmental phase. Disruptions to normal-range development lasting longer than six months will have increasingly deleterious effects on healthy child development, as the phased sequencing of later developmental experiences become increasingly desychronized with developental readiness.
When treating children, therapy should have as its goal, and should make significant efforts toward achieving, a substantial resolution of treatment-related issues within six months, and no longer than one year.
Failure to achieve this goal, important to maintaining the healthy developmental trajectory of the child, should receive examined scrutiny to identify the reasons why therapy was unable to achieve this goal, leading to appropriate treatment modifications to address and resolve the limitations to the extent possible and in the least amount of time feasible.
Therapy lasting one year is fully ½ of a developmental phase. Therapy should achieve substantial resolution of developmental child symptomatology within a year. Given the critical importance of time-related factors in child development, failure to achieve this standard should receive review and require specific documentation of the factors limiting therapeutic progress. Substantial alteration of the treatment context and organization of therapy may be indicated.
Clinical Review of Treatment
In any initial review of the case conceptualization and treatment plan, broad latitude should be granted to the therapist’s identification of the theoretical framework for case conceptualization and treatment planing. Later reviews should expect moderate to substantial treatment progress with due consideration for legitimate barriers to treatment progress identified in the update report and within the context of the therapist’s responsibilities to resolve the family conflicts.
Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857
References
Professional Practice Guidelines
Specialty guidelines for forensic psychology. (2013). American Psychologist, 68(1), 7-19
Patel, S.H. & Choate, L.H. (2014). Conducting child custody evaluations: Best practices for mental health counselors who are court-appointed as child custody evaluators. Journal of Mental Health Counseling, 36, 18-30
Jones, K. D. (2010). The unstructured clinical interview. Journal of Counseling and Development, 88, 220-226.
Psychotherapy Research
Wampold, Bruce E. (2001). The Great Psychotherapy Debate: Models, Methods and Findings. Routledge.
Dr. Craig Childress: Attachment Based "Parental Alienation" (AB-PA) 