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.
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.
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.
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