Sunday, September 21, 2008

The Role of the Clinician and of Formulation

Trauma informed care depends on clinical thinking. What is clinical thinking? It is looking beneath the behavior of the moment, and asking why? What’s going on? It is understanding that symptoms are adaptations that behavior has reasons, that people are doing the best they can, and that their behavior is solving a problem for them. The job of the clinicians in a treatment program is to be the standard bearers for clinical thinking, to teach and train the team until this sort of inquiry is second nature to all members of the team.

So when a child care worker reports that Monique ran away last night, and wants to know what her consequence should be, the clinician should divert the discussion to the question of “why”. What was going on last night? What was the provoking incident? What is going on in Monique’s life? What are her sources of stress, her worries, her fears? What are her strengths, what good things are happening for her that could be brought into the equation? What internal and external resources does she have?

In a congregate care treatment program there is considerable pressure for a clinician to turn away from clinical thinking and become a “fixer”. Some times it seems that clinicians’ job is to take away a screaming child and bring her back calm. The clinician may be drawn into thinking that what she is supposed to do with the child is talk to him about what he has done wrong and how if he stopped doing it his life would be much better.

The problem with this approach is that it doesn’t work. If it did, the kids would be much better already because this has been done a thousand times before. The job of the clinician is first of all to form a healing relationship with the child, then to use this relationship to help the child learn their own worth, develop connections that can be accessed even when the clinician is not present, and learn emotion management skills.

The clinician should have a complex and ever increasing understanding of the child, what their experiences have been, and how those experiences have shaped them. The clinician should hold in his mind a clear picture of the healed child- of who this child can become. He holds the hope for the child, even when the child can see no hope.

Similarly, in family therapy the clinician can get trapped into endless discussions of behavior and consequences. Instead, she must understand and honor the rich complexities of the family’s life. What is their history, their trauma, their pain, their strengths? What are the dynamics between family members, including extended family? What are their resources? What are their fears, what paralyzes them? The healing relationship, connection, developing self-worth and emotion management skills are equally important with the family.

Clinicians should be taught the art of formulating a case. A formulation makes explicit the clinician’s best understanding of the child’s history, their current circumstances, the effects these have on the child, how we understand their current behavior in light of their situation, and what we think will be the path for growth and change necessary to develop healthier methods for meeting needs.

The formulation should be one to two paragraphs which provide a clear road map for understanding and for treatment. Of course it is ever changing and evolving as we come to understand the child and family better.

In one program I heard described (Germaine Lawrence in Boston, they have a practice that every time they talk about a child, they start with a quick repetition of the formulation by the clinician, just to remind them of their road map and where they are on it. I thought this was a great idea.

Here are some examples of formulations:

1. Sarah suffered early neglect and abuse followed by repeated moves. Her siblings were adopted but she failed the placement. She struggles to maintain safety by keeping her fears hidden in oppositionality. She sees danger every where and over reacts with physical and verbal aggression. Her processing difficulties contribute to this misapprehension of events. She responds to care givers with suspicion but does react to limits. She will need to develop safety and trust in order to be able to relax, to explore her past and decrease her conviction that what has happened to her is her fault.

2. Thomas is a young man whose genetic heritage suggests that he might be vulnerable to a mood disorder. Multiple stressors have apparently exacerbated this biological predisposition. These stressors have included inconsistent parenting, being a witness to domestic violence, physical and emotional abuse, emotional, medical and educational neglect, and the death of his mother. Thomas’ most likely felt overwhelmed by these stressors and developed a negative coping style that resulted in his trying to “shut down” or avoid painful thoughts and experiences. When he was forced to be reminded of these painful experiences and when he had to incur more stress during times when adults were not able to limit his exposure to it, Thomas would rapidly become disorganized and resort to primitive defenses as evidenced by his becoming aggressive, suicidal, and even by his reporting psychotic symptoms.

Based upon reports of his progress in previous programs, Thomas seems to be able to utilize the structure of residential treatment to afford him the predictability and safety he needs in order to organize his thoughts and demonstrate his desire to behave in a socially acceptable way. His treatment goals should focus on increasing his ability to identify and practice positive coping skills to manage overwhelming affect, and on developing age-appropriate social skills.

3. Vanessa had early experiences with severe neglect and observing domestic violence because of her mother’s drug addiction. She learned to take care of herself. The loss of several family members combined with mom’s addiction and unavailability sent Vanessa and her sister into a crisis culminating in their removal from the home. The family seems to now be on a positive track as the mother is in recovery and the girl’s have made improvements. However Vanessa understandably still has difficulty trusting her mother and other adults, and does not let adults help or guide her.

4. Latasha’s symptoms and level of functioning seem consistent with her admission diagnosis of Reactive Attachment Disorder, Posttraumatic Stress Disorder, and Oppositional Defiant Disorder. She experiences chronic and pervasive shame as a result of her past abuse, separation from family, disruptions from foster care, and multiple placements. These feelings of shame are overwhelming and cause her to react with a well-established pattern of oppositionality and defiance. In addition, considering that her developmental stages were disrupted by her trauma, she may be struggling with issues of competency and trust leading her question her own safety and sense of belonging as well as her ability and to learn new skills and grow in her functioning.

Latasha will benefit from the routines and structure of daily living in residential treatment. Latasha will benefit from a restorative approach in treatment to help her gain confidence and trust in her caretakers and to allow her to develop her strengths, which include good verbal skills, a sense of humor, and an ability to engage positively others, in the context of healthy relationships.

5. Stephanie is a bright and insightful child who has suffered immense abuse and neglect in her formative years. She was witness to horrendous domestic violence, substance abuse and sexual activity. Stephanie was often the caretaker of her brother and biological mother while her own needs went unmet. As a result, she learned that it was not safe to trust adults to care for her. Upon her adoption to the Anderson family, Stephanie struggled to adjust to this environment. Her adoptive parents appeared to accept her need to be in control and for a while went along with her behavior. However, over the years, Ms. Anderson grew increasingly worried and angry. As she became more vigilant in monitoring her daughter, Stephanie grew increasingly oppositional and detached. Ms. Anderson felt Stephanie was deteriorating and influencing her other children whom she felt were connected and settled. As a result, Ms. Anderson gradually began to disconnect from her daughter. Stephanie impacted by fears of abandonment responded accordingly and became increasingly withdrawn and detached from the family.

Ms. Anderson raises her foster and adoptive children primarily on her own without much spousal support and is looking to meet her needs through her children. Her husband is largely unavailable and detached. She expects her children to “love back” considering how much effort she puts into caring for them. Stephanie’s lack of attachment to her, therefore, is intolerable. It is also complicated by the fact Stephanie is entering adolescence. Ms. Anderson has limited experience with this stage of development and since her own childhood was unremarkable, she expects the same from her children. Ms. Anderson is also angry at Stephanie due to the conflict it has raised with her own parents, who criticize her parenting skills and lack of nurturing with Stephanie. Her perception of their withdrawal of support has been extremely painful, which she blames on her daughter. Ms. Anderson feels that she needs a break from this child and treatment will focus on whether the relationship can be restored in order to support Stephanie’s return home.

The formulation articulates our theories, our understanding of what causes problem behaviors and what helps to heal them. The formulation leads directly to the treatment plan. In the treatment plan we describe the problem behaviors, we describe their positive opposites, the behaviors we would like to see, and we describe the steps to get there. The treatment plan, again, is a theory: it makes concrete our understanding of the steps that would help a child heal. Thus if Latasha is feeling shame, what will help her? Experiences of competency, positive relationships, identifying strengths, developing skills to master her own emotions. These should be clear in her treatment plan.

If Vanessa cannot trust adults and use their help, what will change that? Small experiments in trust. Using her leadership and self care skill to accomplish things. Positive trustworthy relationships. An understanding of her past and it’s effect on her. Developing emotion management skills to withstand the fear she experiences when she beings to trust.

If Stephanie and her foster mother are locked in a painful cycle of unmet needs, what will help? The relationship between the therapist and Ms. Anderson may begin to meet some of her needs, allowing her to relax with Stephanie. Perhaps her mother will be part of the family work. Helping mother and daughter share their experience and listen to each other may be part of the healing. Structuring positive experiences between them may begin to rebuild their connection. These interventions would be clear in the treatment plan.

So the clinician’s job is to gather information respectfully and understand the experience of the child and family, then to use that to develop a formulation. The formulation articulates what has happened, what is going on now, how these factors produce these behaviors, and what steps may help move towards more effective meeting of needs. Then, the clinician must convey this formulation to the entire treatment team, including the child and family (in understandable and respectful language).

Then, and perhaps even harder, the clinician’s job is to keep the formulation alive. Whenever a new behavior happens, or the four hundredth repetition of the old behavior, or an accomplishment, or something bewildering, return to the formulation. Is this still how we understand this child and family? Do we need to adjust our thinking? How do the new events fit into our theories? Where does this understanding lead us- what new interventions are suggested?

For this to be a viable and vibrant process the clinicians need administrative support. They need excellent clinical supervision. They need access to on going training of many sorts. They need opportunities to replenish them selves and their work. They need reasonable caseloads which allow time to think about their kids.

This clinical leadership will gradually develop a more knowledgeable and sophisticated team, in which all the staff will assume the child is doing the best they can, routinely wonder what is behind a behavior, and seek ways to help the child develop new skills. This thinking will produce more creative and caring intervention possibilities. And this will lead to more deep and lasting healing for the children and their families.

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