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 of pattern. The documentation needs to describe the clinical psychology features of note; in this case the turn-taking rhythm. The second level is 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
Dr. Craig Childress: Attachment Based "Parental Alienation" (AB-PA) 