The Child Psychotherapy Treatment Planner / Edition 3

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Overview

The Child Psychotherapy Treatment Planner, Third Edition provides all the elements necessary to quickly and easily develop formal treatment plans that satisfy the demands of HMOs, managed care companies, third-party payors, and state and federal review agencies.

This book provides treatment planning guidelines and an array of pre-written treatment plan components for child behavioral and psychological problems. Problems addressed include blended family problems, children of divorce, communication disorder, attachment disorder, academic problems, stuttering,and underachievement, among others.

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Product Details

  • ISBN-13: 9780471270508
  • Publisher: Wiley, John & Sons, Incorporated
  • Publication date: 11/15/2002
  • Series: PracticePlanners Series , #146
  • Edition description: Third Edition
  • Edition number: 3
  • Pages: 378
  • Product dimensions: 6.98 (w) x 9.98 (h) x 0.90 (d)

Meet the Author

ARTHUR E. JONGSMA, Jr., PhD, is the founder and Director of Psychological Consultants, a group private practice in Grand Rapids, Michigan. He is the coauthor of the bestselling The Complete Adult Psychotherapy Treatment Planner.
L.MARK PETERSON, MSW, is the Clinical Supervisor of Substance Abuse Services for the Salvation Army of Grand Rapids and the coauthor of The Complete Adult Psychotherapy Treatment Planner.
WILLIAM P. McINNIS, PsyD, is in private practice with Psychological Consultants; he specializes in the treatment of children, adolescents, and families. He is coauthor of The Child and Adolescent Psychotherapy Treatment Planner.
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Table of Contents

PracticePlanners Series Preface xiii
Acknowledgments xv
Introduction 1
How to Develop a Treatment Plan 4
Academic Underachievement 17
Adoption 28
Anger Management 39
Anxiety 50
Attachment Disorder 59
Attention-Deficit/Hyperactivity Disorder (ADHD) 71
Autism/Pervasive Developmental Disorder 82
Blended Family 92
Bullying/Intimidation Perpetrator 103
Conduct Disorder/Delinquency 111
Depression 122
Disruptive/Attention-Seeking 130
Divorce Reaction 141
Enuresis/Encopresis 153
Fire Setting 163
Gender Identity Disorder 170
Grief/Loss Unresolved 176
Low Self-Esteem 186
Lying/Manipulative 196
Medical Condition 208
Mental Retardation 216
Oppositional Defiant 226
Parenting 238
Peer/Sibling Conflict 247
Physical/Emotional Abuse Victim 257
Posttraumatic Stress Disorder (PTSD) 266
School Refusal 274
Separation Anxiety 285
Sexual Abuse Victim 295
Sleep Disturbance 305
Social Phobia/Shyness 312
Specific Phobia 322
Speech/Language Disorders 332
Appendix A Sample Chapter with Quantified Language 343
Appendix B Bibliotherapy Suggestions 355
Appendix C Index of DSM-IV-TR Codes Associated with Presenting Problems 367
Appendix D Index of Therapeutic Games, Workbooks, Tool Kits, Videotapes, and Audiotapes 375
Appendix E Bibliography 377
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First Chapter

ACADEMIC UNDERACHIEVEMENT

BEHAVIORAL DEFINITIONS

  1. History of overall academic performance that is below the expected level according to the client's measured intelligence or performance on standardized achievement tests.
  2. Repeated failure to complete school or homework assignments and/or current assignments on time.
  3. Poor organization or study skills that contribute to academic underachievement.
  4. Frequent tendency to procrastinate or postpone doing school or homework assignments in favor of playing or engaging in recreational and leisure activities.
  5. Family history of members having academic problems, failures, or disinterests.
  6. Feelings of depression, insecurity, and low self-esteem that interfere with learning and academic progress.
  7. Recurrent pattern of engaging in acting out, disruptive, and negative attention-seeking behaviors when encountering difficulty or frustration in learning.
  8. Heightened anxiety that interferes with client's performance during tests or examinations.
  9. Excessive or unrealistic pressure placed on client by parents to degree that it negatively affects his/her academic performance.
  10. Decline in academic performance that occurs in response to environmental factors or stress (e.g., parents' divorce, death of loved one, relocation, or move).

LONG-TERM GOALS

  1. Demonstrate consistent interest, initiative, and motivation in academics and bring performance up to expected level of intellectual or academic functioning.
  2. Complete school and homework assignments on a regular and consistent basis.
  3. Achieve and maintain healthy balance between accomplishing academic goals and meeting his/her social, emotional, and self-esteem needs.
  4. Stabilize moods and build self-esteem so that client is able to cope effectively with the frustrations and stressors associated with academic pursuits and learning.
  5. Eliminate the pattern of engaging in acting out, disruptive, or negative attention-seeking behaviors when confronted with difficulty or frustration in learning.
  6. Reduce level of anxiety related to taking tests or examinations to a significant degree.
  7. Parents establish realistic expectations of the client's learning abilities and implement effective intervention strategies at home to help the client keep up with schoolwork and achieve academic goals.
  8. Remove emotional impediments or resolve family conflicts and environmental stressors that will allow for improved academic performance.

SHORT-TERM OBJECTIVES

  1. Complete a psychoeducational evaluation. (1, 3, 4)
  2. Complete psychological testing. (2, 3, 4, 46)
  3. The client and his/her parents provide psychosocial history information. (1, 2, 3, 4)
  4. Cooperate with a hearing, vision, or medical examination. (5, 48)
  5. Comply with the recommendations made by the multidisciplinary evaluation team at school regarding educational interventions. (1, 6, 7, 8)
  6. Move the client to appropriate classroom setting(s). (1, 6, 9)
  7. Parents and teachers implement educational strategies that maximize the child's learning strengths and compensate for learning weaknesses. (7, 8, 9, 18, 19)
  8. Participate in outside tutoring to increase knowledge and skills in the area of academic weakness. (8, 9, 10, 15)
  9. Cooperate with the recommendations offered by the private learning center. (9, 10, 11, 12, 14)
  10. Implement effective study skills to increase the frequency of completion of school assignments and improve academic performance. (10, 11, 12, 13, 33)
  11. Develop effective test-taking strategies to decrease anxiety and improve test performance. (12, 14, 22, 23)
  12. Parents maintain regular (i.e., daily to weekly) communication with teachers. (16, 17, 18, 19, 20)
  13. Use self-monitoring check-lists, planners, or calendars to remain organized and help complete school assignments. (11, 12, 13, 32)
  14. Complete large projects or long-term assignments consistently and on time. (12, 13, 16, 32)
  15. Establish a regular routine that allows time to engage in play, to spend quality time with the family, and to complete homework assignments. (17, 20, 21, 25)
  16. Increase praise and positive reinforcement by the parents toward the client in regard to school performance. (18, 19, 20, 21, 37)
  17. Parents and teachers identify and utilize a variety of reinforcers to reward client for completion of school and homework assignments. (18, 19, 34, 37)
  18. Identify and remove all emotional blocks or learning inhibitions that are within the client and/or the family system. (24, 25, 26, 27, 38)
  19. Increase the parents' time spent being involved with the client's homework. (17, 18, 30, 31)
  20. Parents verbally acknowledge their unrealistic expectations or excessive pressure on the client to perform. (26, 27, 28, 29)
  21. Decrease the frequency and intensity of arguments between client and parents over issues related to school performance and homework. (24, 25, 28, 29)
  22. Parents verbally recognize that their pattern of overprotectiveness interferes with the client's academic growth and responsibility. (25, 30, 31)
  23. Increase the frequency of on-task behavior at school, increasing the completion of school assignments without expressing frustration and the desire to give up. (22, 32, 34, 35)
  24. Increase the frequency of positive statements about school experiences and confidence in the ability to succeed academically. (34, 35, 36, 37)
  25. Decrease the frequency and severity of acting-out behaviors when encountering frustrations with school assignments. (38, 39, 47)
  26. Identify and verbalize how specific, responsible actions lead to improvements in academic performance. (41, 42, 43, 45)
  27. Develop a list of resource people within school setting to whom client can turn for support, assistance, or instruction for learning problems. (13, 43, 45)
  28. Increase time spent in independent reading. (45, 46, 47)
  29. Express feelings about school through artwork and mutual storytelling. (45, 46, 47)
  30. Take prescribed medication as directed by the physician. (2, 48)

THERAPEUTIC INTERVENTIONS

  1. Arrange for psychoeducational testing to evaluate the presence of a learning disability, and determine whether the client is eligible to receive special education services.
  2. Arrange for psychological testing to assess whether possible ADHD or emotional factors are interfering with the client's academic performance.
  3. Gather psychosocial history information that includes key developmental milestones and a family history of educational achievements and failures.
  4. Provide feedback to the client, his/her family, and school officials regarding psychoeducational and/or psychological evaluation.
  5. Refer the client for hearing, vision, or medical examination to rule out possible hearing, visual, or health problems that are interfering with school performance.
  6. Attend an Individualized Educational Planning Committee (IEPC) meeting with the parents, teachers, and school officials to determine the client's eligibility for special education services; design educational interventions; and establish educational goals.
  7. Consult with the client, parents, and school officials about designing effective learning programs or intervention strategies that build on the client's strengths and compensate for weaknesses.
  8. Recommend that parents seek outside tutoring after school to boost the client's skills in the area of his/her academic weakness (e.g., reading, mathematics, or written expression).
  9. Refer the client to a private learning center for extra tutoring in the areas of academic weakness and assistance in improving study and test-taking skills.
  10. Teach the client more effective study skills (e.g., remove distractions, study in quiet places, develop outlines, highlight important details, schedule breaks).
  11. Encourage the client to use self-monitoring checklists to increase completion of school assignments and improve academic performance.
  12. Direct client to use planners or calendars to record school or homework assignments and plan ahead for long-term projects.
  13. Utilize "Getting It Done" program in Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis) to help client complete school and homework assignments on a regular, consistent basis.
  14. Teach the client more effective test-taking strategies (e.g., study over an extended period of time, review material regularly, read directions twice, recheck work).
  15. Consult with teachers and parents about using a "study buddy" or peer tutor to assist client in area of academic weakness and improve study skills.
  16. Encourage parents to maintain regular (daily or weekly) communication with teachers to help the client remain organized and keep up with school assignments.
  17. Assist the client and his/her parents in developing a routine daily schedule at home that allows the client to achieve a healthy balance of completing school/homework assignments, engaging in independent play, and spending quality time with family and peers.
  18. Encourage the parents to give frequent praise and positive reinforcement for the client's effort and accomplishment on academic tasks.
  19. Assist the parents in resolving family conflicts that block or inhibit learning and establish new positive family patterns that reinforce the client's academic achievement.
  20. Encourage the parents to demonstrate and/or maintain regular interest and involvement in the client's homework (e.g., parents reading aloud to or alongside the client, using flash cards to improve math skills, rechecking the client's spelling words).
  21. Identify a variety of positive reinforcers or rewards to maintain the client's interest and motivation to complete school assignments.
  22. Teach the client positive coping mechanisms (e.g., relaxation techniques, positive self-talk, cognitive restructuring) to utilize when encountering anxiety, frustration, or difficulty with schoolwork.
  23. Train in relaxation techniques or guided imagery to reduce anxiety before or during the taking of tests.
  24. Conduct family sessions that probe the client's family system to identify any emotional blocks or inhibitions to learning.
  25. Assist the parents and teachers in the development of systematic rewards for progress and accomplishments (e.g., charts with stars for goal attainment, praise for each success, some material reward for achievement).
  26. Conduct family therapy sessions to assess whether the parents have developed unrealistic expectations or are placing excessive pressure on the client to perform.
  27. Confront and challenge the parents about placing excessive pressure on the client.
  28. Encourage parents to set firm, consistent limits and utilize natural, logical consequences for the client's noncompliance or refusal to do homework.
  29. Instruct the parents to avoid unhealthy power struggles or lengthy arguments over homework each night.
  30. Observe parent-child interactions to assess whether the parents' overprotectiveness or infantilization of the client contributes to his/her academic underachievement.
  31. Assist the parents in developing realistic expectations of the client's learning potential.
  32. Consult with school officials about ways to improve the client's on-task behaviors (e.g., keep the client close to the teacher, keep the client close to positive peer role models, call on the client often, provide frequent feedback to the client, structure the material into a series of small steps).
  33. Assign reading of 13 Steps to Better Grades (Silverman) to improve client's organizational and study skills; process reading with therapist.
  34. Reinforce the client's successful school experiences and positive statements about school.
  35. Confront the client's self-disparaging remarks and expressed desire to give up on school assignments.
  36. Assign the client the task of making one positive self-statement daily about school and his/her ability, and have him/her record it in a journal.
  37. Help the client identify what rewards would increase his/her motivation to improve academic performance, and then implement the suggestions into the academic program.
  38. Conduct individual play-therapy sessions to help client work through and resolve painful emotions, core conflicts, or stressors that impede academic performance.
  39. Help client realize connection between negative or painful emotions and decrease in academic performance.
  40. Teach the client positive coping and self-control strategies (e.g., cognitive restructuring, positive self-talk, "stop, look, listen, and think") to inhibit the impulse to act out or engage in negative attention-seeking behaviors when encountering frustration with schoolwork.
  41. Explore periods of time when client completed schoolwork regularly and/or achieved academic success. Identify and encourage client to use similar strategies to improve current academic performance.
  42. Examine coping strategies that client has used to solve other problems. Encourage client to use similar coping strategies to overcome problems associated with learning.
  43. Identify a list of individuals within the school to whom client can turn for support, assistance, or instruction when he/she encounters difficulty or frustration with learning.
  44. Encourage parents to use the "Reading Adventure" program in the Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis) to increase client's motivation to read. Utilize a reward system to reinforce client for engaging in independent reading.
  45. Utilize mutual storytelling techniques whereby therapist and client alternate telling stories through use of puppets, dolls, or stuffed animals; therapist first models appropriate ways to manage frustration related to learning problems, then client follows by creating a story with similar characters or themes.
  46. Have client create a variety of drawings on posterboard or large sheet of paper that reflect how his/her personal and family life would be different if he/she completed homework regularly; process content of drawings with therapist.
  47. Instruct client to draw picture of school building, then have client create story that tells what it is like to be a student at that school to assess possible stressors that may interfere with learning and academic progress.
  48. Arrange for medication evaluation of the client if it is determined that an emotional problem and/or ADHD are interfering with learning.

DIAGNOSTIC SUGGESTIONS

Axis I:
315.00 Reading Disorder
315.1 Mathematics Disorder
315.2 Disorder of Written Expression
V62.3 Academic Problem
314.01 Attention-Deficit/ Hyperactivity Disorder, Combined Type
314.00 Attention-Deficit/ Hyperactivity Disorder, Predominantly Inattentive Type
300.4 Dysthymic Disorder 313.81 Oppositional Defiant Disorder
312.9 Disruptive Behavior Disorder, NOS

Axis II:
317 Mild Mental Retardation V62.89 Borderline Intellectual Functioning
799.9 Diagnosis Deferred
V71.09 No Diagnosis on Axis II

ADOPTION

BEHAVIORAL DEFINITIONS

  1. The adoption of an older special-needs child or set of siblings into the family.
  2. Relates to significant others in a withdrawing, rejecting way, avoiding eye contact and keeping self at a distance from them.
  3. Exhibits a pattern of hoarding or gorging food.
  4. Displays numerous aggressive behaviors that are out of proportion for the presenting situations and seem to reflect a need to vent pent-up frustration.
  5. Lies and steals often when it is not necessary to do so.
  6. Displays an indiscriminate pattern of showing open affection to casual friends and strangers.
  7. Parents express frustration with adopted child's development and level of achievement.
  8. Parents are anxious and fearful of adopted child's questioning of background (" Where did I come from," "Who do I look like," etc.).

LONG-TERM GOALS

  1. Termination of self-defeating, acting-out behaviors and acceptance of self as loved and lovable within an adopted family.
  2. Resolution of key adoption issues of loss, abandonment, and rejection.
  3. The establishment and maintenance of healthy family connections.
  4. Removal of all barriers to enable the establishment of a healthy bond between parents and child(ren).
  5. Develop a nurturing relationship with parents.
  6. Build and maintain a healthy adoptive family.

SHORT-TERM OBJECTIVES

  1. Develop a trusting relationship with therapist that will allow the client, parents, and siblings to openly express their thoughts and feelings. (1)
  2. Cooperate with and complete psychosocial assessments. (1, 2)
  3. Complete psychological evaluation. (1, 3)
  4. Comply with all recommendations of the evaluations or assessments. (4)
  5. Parents acknowledge unresolved grief associated with infertility. (5)
  6. Family members attend family therapy sessions and report on their perception of the adjustment process. (6)
  7. Parents commit to improving communication and affection within the marriage relationship. (7)
  8. Attend and actively take part in play-therapy sessions. (8, 9, 10, 11, 12)
  9. Reduce acting-out behaviors connected to unresolved rage, loss, and fear of abandonment. (8, 9, 10, 11, 12)
  10. Verbalize the connection between anger and/or withdrawal and the underlying feelings of fear, abandonment, and rejection. (8, 9, 13)
  11. Identify feelings that are held inside and rarely expressed. (14, 15, 16)
  12. Identify and release feelings in socially acceptable, nondestructive ways. (17, 18, 19)
  13. Express feelings directly related to being an adopted child. (20, 21)
  14. Parents verbalize an increased ability to understand and handle acting-out behaviors. (22, 23, 24, 25)
  15. Parents affirm client's identity as based in self, bioparents, and adoptive family. (26, 27)
  16. Express and preserve own history and its contribution to identity. (28)
  17. Verbalize needs and wishes. (29)
  18. Verbalize a feeling of increased confidence and self-acceptance. (27, 28, 30)
  19. Parents verbalize reasonable expectations for client's behavior given client's developmental stage and the process of adjustment to adoption. (31)
  20. Parent spends one-on-one time with client in active play. (32)
  21. Parents increase the frequency of expressing affection verbally and physically toward client. (33)
  22. Parents speak only positively regarding client's bio-parents. (34)
  23. Parents feel free to ask questions regarding the details of adoption adjustment. (35)
  24. Parents verbalize reasonable discipline and nurturance guidelines. (36, 37, 38)
  25. Family members express an acceptance of and trust in each other. (39, 40)

THERAPEUTIC INTERVENTIONS

  1. Actively build the level of trust with client(s) and parents in sessions by consistent eye contact, active listening, unconditional positive regard, and empathic responses to help promote the open expressions of their thoughts and feelings about the adoption.
  2. Conduct or refer parents and child(ren) for a psychosocial assessment to assess parents' strength of marriage, parenting style, stress management/coping strengths, and resolution of infertility issue and to assess child's developmental level, attachment capacity, behavior issues, temperament, and strengths.
  3. Conduct or arrange for psychological evaluation to determine level of behavioral functioning, cognitive style, and intelligence.
  4. Summarize assessment data and present findings and recommendations to family.
  5. Assess parents' unresolved grief around the issue of their infertility; refer for further conjoint or individual treatment if necessary.
  6. Establish a wellness plan whereby family goes at three-month intervals for a checkup with therapist to evaluate how the assimilation and attachment process is proceeding. If all is well, checkups can be annual after the first year.
  7. Refer parents to a skills-based marital program such as Prep (e.g., Fighting For Your Marriage by Markman, Stanley, and Blumberg) to strengthen marital relationship by improving responsibility, communication, and conflict resolution.
  8. Conduct filial therapy (i.e., parent involvement in play-therapy sessions), in which client takes the lead in expressing anger and parent responds empathically to client's feelings (hurt, fear, sadness, helplessness) beneath the anger.
  9. Employ psychoanalytic play therapy (e.g., explore and gain understanding of the etiology of unconscious conflicts, fixations, or arrests; interpret resistance transference or core anxieties) to help client work through and resolve issues contributing to the acting-out behaviors.
  10. Employ A. C. T. model (Landreth) in play therapy sessions to acknowledge feelings, communicate limits, and target acceptable alternatives to acting-out or aggressive behaviors.
  11. Conduct individual play-therapy sessions to provide the opportunity for expression of feelings surrounding past loss, neglect, and/or abandonment.
  12. Utilize the Theraplay (Jernberg and Booth) attachment-based approach, in which the therapist takes charge by planning and structuring each session. Therapist uses his/her power to entice the client into relationship and to keep the focus of therapy on the relationship, not on intrapsychic conflicts. Also, parents are actively involved and are trained to be cotherapists.
  13. Assist the client in making connections between underlying painful emotions of loss, rejection, rage, abandonment, and acting-out and/or aggressive behaviors.
  14. Use puppets, dolls, or stuffed toys to tell a story to client about others who have experienced loss, rejection, or abandonment to show how they have resolved these issues. Then ask the client to create a similar story using the puppets, dolls or stuffed toys.
  15. Ask client to draw an outline of himself/herself on a sheet of paper, and then instruct him/her to fill the inside with pictures and objects that reflect what he/she has on the inside that fuels the acting-out behaviors.
  16. Use expressive art materials such as Play-Doh, clay, or finger paint to create pictures and sculptures that aid the client in expressing and resolving his/her feelings of rage, rejection, and loss.
  17. Read with client or have parents read A Volcano in My Tummy (Whithouse and Pudney) or Don't Rant and Rave on Wednesday (Moser) to help client recognize his/her anger and to present ways to handle angry feelings.
  18. Play with client, or have parents play, Talking, Feeling, Doing game (Gardner) or Anger Control game (Berg) to assist client in identifying and expressing feelings and thoughts.
  19. Use a feelings chart, felts, or cards to increase client's ability to identify, understand, and express feelings.
  20. Ask client to read How It Feels to Be Adopted (Krementz), and list two or three items from each age-appropriate vignette that he/she will process with therapist.
  21. Assign client to read I Feel Different (Stinson) and/or Adoption Is for Always (Welvoord-Girrard) to help him/her identify with issues and not feel alone.
  22. Affirm often with parents the health of their family while they are working with the disturbed client to avoid triangulation and undermining of parental authority by the client.
  23. Refer parents and/or client to an adoption support group.
  24. Have parents read Helping Children Cope with Separation and Loss (Jenett/Jarratt) and/or Adoption Wisdom (Russell) to increase their knowledge and understanding of adoption.
  25. Work with parents in conjoint sessions to frame client's acting-out behaviors as "opportunities to reparent the client." Then strategize with them to come up with specific ways to intervene in the problem behaviors.
  26. Ask parents to read The Whole Life Adoption Book (Schouler) and/or Making Sense of Adoption (Melina) to help them gain knowledge and understanding of adoption and to assist client in building a healthy, integrated identity.
  27. Educate parents on the importance of affirming the client's entire identity (i.e., self, bioparents, adoptive parents), and show them specific ways to reaffirm the client (e.g., verbally identify talents such as art or music that are similar to those of the biological parents, recognize positive tasks client does that are similar to those of adoptive mom or dad).
  28. Assign parents to help client create a "life book" that chronicles the client's life to this point in order to give him/her a visual perspective and knowledge of own history and identity. A form for "Create a Memory Album" can be found in Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis).
  29. Have client complete exercise "Three Wishes Game" from Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis) to help client express his/her needs and desires.
  30. Assign a self-esteem-building exercise from SEALS & Plus (Korb-Khara, Azok, and Leutenberg) to help develop self-knowledge, acceptance, and confidence.
  31. Process with parents the issue of expectations for client's behavior and adjustment; confront and modify unrealistic expectations and foster realistic expectations considering the client's developmental stage and adjustment to the adoption process.
  32. Work with parents to have each spend specific time in daily one-on-one active play with client.
  33. Encourage parents to provide large, genuine, daily doses of positive verbal reinforcement and physical affection. Monitor and encourage parents to continue this behavior and to identify positive attachment signs when they appear.
  34. Encourage parents to refrain from negative references about bioparents.
  35. Conduct sessions with parents to give them opportunities to raise adoption-specific issues of concern to them (e.g., how to handle an open adoption, how much to share with client about bioparents) in order to give them direction and support.
  36. Provide parents with education about keeping discipline related to the offense reasonable and always respectful to reduce resentment and rebellion. Recommend How to Raise Responsible Children (Glen and Nelson).
  37. Ask parents to read The Seven Habits of Highly Effective Families (Covey) for suggestions on how to increase their family's health and connections.
  38. Have parents spend individual one-on-one time with children who were part of the family prior to the adoption.
  39. Refer family to an initiatives weekend (e.g., high and low ropes-course tasks and various group-oriented physical problem-solving activities) to increase trust, cooperation, and connections with each other.
  40. In a family session, construct a genogram that includes all family members and shows how everyone is connected to demonstrate client's origins and what he/she has become a part of.

DIAGNOSTIC SUGGESTIONS

Axis I:
309.0 Adjustment Disorder With Depressed Mood
309.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct
300.4 Dysthymic Disorder
314.01 Attention Deficit/ Hyperactivity Disorder
309.81 Posttraumatic Stress Disorder
313.89 Reactive Attachment Disorder of Infancy or Early Childhood

Axis II:
799.9 Diagnosis Deferred
V71.09 No Diagnosis on Axis II

ANGER MANAGEMENT

BEHAVIORAL DEFINITIONS

  1. Repeated angry outbursts that are out of proportion to the precipitating event.
  2. Excessive yelling, swearing, crying, or use of verbally abusive language when efforts to meet desires are frustrated or limits are placed on behavior.
  3. Frequent fighting, intimidation of others, and acts of cruelty or violence toward people or animals.
  4. Verbal threats of harm to parents, adult authority figures, siblings, or peers.
  5. Persistent pattern of destroying property or throwing objects when angry.
  6. Consistent failure to accept responsibility for angercontrol problems accompanied by repeated pattern of blaming others for poor control of anger.
  7. Repeated history of engaging in passive-aggressive behaviors (e.g., forgetting, pretending not to listen, dawdling, procrastinating) to frustrate or annoy other adults or peers.
  8. Strained interpersonal relationships with peers due to aggressiveness and anger-control problems.
  9. Underlying feelings of depression, anxiety, or insecurity that contribute to angry outbursts and aggressive behaviors.

LONG-TERM GOALS

  1. Express anger through appropriate verbalizations and healthy physical outlets on a consistent basis.
  2. Significantly reduce the frequency and intensity of temper outbursts.
  3. Terminate all destruction of property, physical aggression, and acts of violence or cruelty toward people or animals.
  4. Interact consistently with adults and peers in a mutually respectful manner.
  5. Markedly reduce frequency of passive-aggressive behaviors by expressing anger and frustration through controlled, respectful, and direct verbalizations.
  6. Resolve the core conflicts that contribute to the emergence of anger-control problems.
  7. Parents establish and maintain appropriate parent-child boundaries, setting firm, consistent limits when the client reacts in a verbally or physically aggressive or passive-aggressive manner.
  8. Demonstrate marked improvement in the ability to listen and respond empathetically to the thoughts, feelings, and needs of other people.

SHORT-TERM OBJECTIVES

  1. 1. Complete psychological testing. (1, 3)
  2. Complete a psychoeducational evaluation. (2, 3)
  3. Cooperate with the mandates of the criminal justice system. (3, 4, 5)
  4. Parents establish appropriate boundaries and follow through consistently with consequences for anger-control problems. (6, 7, 8, 9)
  5. Increase compliance with rules at home and school without protesting or venting strong feelings of anger. (7, 8, 9, 23, 24)
  6. Acknowledge instances when anger has not been controlled. (10, 23)
  7. Verbalize how feelings of fear, hurt, sadness, or anxiety are connected to anger-control problems. (11, 27, 36)
  8. Decrease the frequency and intensity of destructive behaviors and throwing of objects. (12, 14, 19, 20)
  9. Reduce the frequency and intensity of angry outbursts and aggressive behaviors. (13, 17, 19, 20, 21)
  10. Reduce the frequency of passive-aggressive behaviors. (7, 15, 18, 44)
  11. Express anger through controlled, respectful verbalizations and healthy physical outlets. (12, 15, 20, 50, 51)
  12. Decrease the frequency of arguments with authority figures. (15, 46, 47, 49)
  13. Directly communicate thoughts, feelings, and needs to adults and peers in an assertive, controlled, and mutually respectful manner. (7, 17, 40, 47)
  14. Parents agree to and follow through with the implementation of a reward system or contingency contract to reinforce controlled expression of anger. (18, 19, 20)
  15. Increase the number of statements that reflect acceptance of responsibility for angry outbursts and aggressive behaviors. (10, 22, 23, 24)
  16. Parents increase the frequency of praise and positive reinforcement to the client for showing controlled expression of anger. (16, 18, 19, 20)
  17. Decrease the frequency of verbalizations that project the blame for angry outbursts or aggressive behaviors onto other people. (22, 23, 24)
  18. Uninvolved or detached parent(s) increase the time spent with client in recreational, school, or work activities around the house. (26, 27, 28, 29)
  19. Verbalize an understanding of how angry outbursts or aggressive behaviors are associated with past neglect, abuse, separation, or abandonment. (30, 34, 35)
  20. Identify and verbally express feelings associated with past neglect, abuse, separation, or abandonment. (33, 34, 35, 36)
  21. Parents verbalize appropriate boundaries for discipline to prevent further occurrences of abuse and ensure the safety of the client and his/her siblings. (25, 30, 31, 32, 33)
  22. Increase the frequency of positive interactions with parents, adult authority figures, siblings, and peers. (16, 20, 28, 29)
  23. Identify and verbalize unmet emotional needs. (37, 39, 41)
  24. Identify and verbalize how poor control of anger negatively affects others. (22, 38, 53, 54)
  25. Increase verbalizations of empathy and concern for other people. (40, 52, 53)
  26. Parents acknowledge conflict within the marital relationship. (25, 26, 57)
  27. Increase participation in extracurricular activities or positive peer group activities. (52, 53, 54)
  28. Express feelings of anger through art and music. (42, 43, 44, 45)
  29. Increase verbalizations of positive self-statements to help improve anger control. (16, 55, 56)
  30. Take medication as prescribed by physician. (1, 58)

THERAPEUTIC INTERVENTIONS

  1. Arrange for psychological testing to assess whether emotional factors or ADHD are contributing to anger-control problems.
  2. Arrange for a psychoeducational evaluation to rule out the presence of a learning disability that may be contributing to anger-control problems in the school setting.
  3. Provide feedback to the client, his/her parents, school officials, or criminal justice officials regarding psychological and/or psychoeducational testing.
  4. Consult with criminal justice officials about the appropriate consequences for the client's destructive and aggressive behaviors (e.g., probation, community service, pay restitution).
  5. Encourage the parents not to protect the client from the natural or legal consequences of his/her destructive or aggressive behaviors.
  6. Assist the parents in establishing clearly defined rules, boundaries, and consequences for client's angry outbursts and acts of aggression or destruction.
  7. Establish clear rules for behavior at home or in school; ask client to repeat the rules to demonstrate an understanding of the expectations so that anger does not escalate when he/she receives consequences for any rule violations.
  8. Teach parents effective disciplinary techniques (e.g., time-outs, removal of privileges, response cost) to help manage client's anger-control problems.
  9. Assign parents to read 1-2-3 Magic: Training Your Preschoolers and Preteens to Do What You Want (Phelan), Family Rules: Raising Responsible Children (Kaye), and Assertive Discipline for Parents (Canter and Canter); process readings in sessions.
  10. Actively build the level of trust with the client through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/her ability to identify and express times when angry feelings have not been controlled.
  11. Assist the client in making a connection between underlying, painful emotions (e.g., fear, hurt, sadness, anxiety) and angry outbursts or aggressive behaviors.
  12. Teach mediational self-control strategies (e.g., relaxation, "stop, look, listen, and think") to help express anger through appropriate verbalizations and healthy physical outlets.
  13. Train client to use progressive relaxation or guided imagery techniques to induce calm and decrease the intensity of angry feelings.
  14. Identify and confront irrational thoughts that contribute to the emergence of anger-control problems; replace irrational thoughts with more adaptive ways of thinking to help control anger.
  15. Teach client effective communication and assertiveness skills to express anger in a controlled fashion and to meet his/her needs through more constructive actions.
  16. Encourage the use of self-monitoring checklists at home or school to develop more effective anger control.
  17. Assist the client in identifying successful strategies that have been used on days when he/she controls temper and does not hit sibling(s), peers, or others; process client's responses and reinforce any positive coping mechanisms that he/she uses to manage anger.
  18. Encourage the parents to provide frequent praise and positive reinforcement for the client's positive social behaviors and good anger control.
  19. Design a reward system and/or contingency contract to reinforce anger control and deter aggressive or destructive behaviors.
  20. Design and implement a token economy to increase positive social behaviors and deter destructive or aggressive behaviors.
  21. Utilize "Anger Control" exercise in Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis) to reinforce good control of anger and help identify core issues that contribute to emergence of angry outbursts or aggressive behaviors.
  22. Firmly confront client's destructive and aggressive behaviors, pointing out consequences for himself/herself and others.
  23. Confront statements in which the client blames others for his/her anger-control problems and fails to accept responsibility for the consequences of his/her destructive or aggressive behaviors.
  24. Explore and process the factors that contribute to the pattern of blaming others.
  25. Conduct family therapy sessions to explore the dynamics that contribute to the emergence of anger-control problems.
  26. Assess the family dynamics by employing the family-sculpting technique, in which the client defines the roles and behaviors of each family member in a scene of his/her choosing.
  27. Conduct filial therapy (i.e., parental involvement in play sessions) whereby client takes the lead in expressing anger and parent responds empathetically to other feelings (e.g., hurt, sadness, helplessness) beneath the anger.
  28. Hold a family therapy session in which family members are given a task or problem to solve together (e.g., building a craft, producing a drawing); observe family interactions, and process the experience with them afterward.
  29. Give a directive to uninvolved or disengaged parent(s) to spend more time with the client in leisure, school, or work activities.
  30. Explore family background for a history of physical, sexual, or substance abuse that may contribute to his/her anger-control problems.
  31. Insist that parents cease physically abusive or overly punitive methods of discipline.
  32. Implement the steps necessary to protect the client or siblings from further abuse (e.g., report abuse to appropriate agencies; remove the client or perpetrator from the home).
  33. Encourage and support expression of feelings associated with neglect, abuse, separation, or abandonment.
  34. Use the empty-chair technique to assist the client in expressing and working through feelings of anger and hurt about past separation or abandonment.
  35. Conduct individual play-therapy sessions to provide the opportunity for expression of feelings surrounding past neglect, abuse, separation, or abandonment.
  36. Interpret the feelings expressed in play therapy and relate them to anger and aggressive behaviors.
  37. Use child-centered play-therapy approaches to increase mastery of anger control (e.g., provide unconditional positive regard, reflect feelings in nonjudgmental manner, display trust in child's capacity to act responsibly).
  38. Employ A. C. T. model (Landreth) in play-therapy sessions to acknowledge feelings, communicate limits, and identify acceptable alternatives to destructive or aggressive behaviors.
  39. Employ psychoanalytic play-therapy approach (e.g., explore and gain understanding of the etiology of unconscious conflicts, fixations, or arrests; interpret resistance, transference, or core anxieties) to help client work through and resolve issues contributing to anger control problems.
  40. Use puppets, dolls, or stuffed animals to create a story that models appropriate ways to manage anger and resolve conflict; then ask client to create story with similar characters or themes.
  41. Direct client to create stories that can be acted out with puppets, dolls, or stuffed animals to assess unmet needs, family dynamics, or core issues that contribute to anger-control problems.
  42. Instruct client to draw a picture of a house, then pretend that he/she lives in the house and describe what it is like to live in that home; process feelings and content of responses to help assess family dynamics.
  43. Assign the task of drawing three events or situations that commonly evoke feelings of anger; process thoughts and feelings after drawings are completed.
  44. Assign client to draw an outline of human body on large piece of paper or poster board; then instruct client to draw or fill the body with objects, symbols, or pictures indicative of people, actions, or issues that evoke feelings of anger.
  45. Instruct client to sing a song or play a musical instrument that reflects feelings of anger; then talk about a time when client felt angry about a particular issue.
  46. Assign homework from the therapeutic workbooks The Angry Monster (Shore) and How I Learned to Control My Temper (Shapiro) to help the client develop more effective ways to control anger.
  47. Play the therapeutic game The Angry Monster Machine (Shapiro) to help client express his/her anger through more constructive channels.
  48. Assign reading of Sometimes I Like to Fight, But I Don't Do It Much Anymore (Shapiro) or The Very Angry Day That Amy Didn't Have (Shapiro); process the reading with therapist.
  49. Assign techniques from Anger Control Toolkit (Shapiro, et al.) to help client learn to control anger more effectively.
  50. Assign the use of Coping with Anger Target game (Shapiro) at home when strong feelings of anger begin to emerge so that client can remind himself/herself of constructive ways to control anger.
  51. Use the Angry Tower technique (Saxe) to help client identify and express feelings of anger: Build tower out of plastic containers; place small item (representing object of anger) on top of tower; then instruct client to throw small fabric ball at tower while verbalizing anger.
  52. Encourage participation in extracurricular or positive peer group activities to provide a healthy outlet for anger and to increase self-esteem.
  53. Assign the task of showing empathy, kindness, or sensitivity to the needs of others (e.g., assisting sibling with chore, verbalizing compassion for peer's emotional pain).
  54. Refer client for group therapy to improve anger control, social judgment, and interpersonal skills.
  55. Identify and list the client's positive characteristics to improve self-esteem and frustration tolerance.
  56. Assign the client to make one positive self-statement daily and record that in a journal to improve self-esteem and frustration tolerance.
  57. Assess the marital dyad for possible conflict and triangulation, in which the focus is deflected away from marital issues and toward client's aggressive behaviors; refer for marital counseling if indicated.
  58. Have client evaluated for medication to improve anger control and stabilize moods.

DIAGNOSTIC SUGGESTIONS

Axis I:
313.81 Oppositional Defiant Disorder
312.34 Intermittent Explosive Disorder
312.30 Impulse-Control Disorder NOS
312.8 Conduct Disorder/ Childhood-Onset Type
312.9 Disruptive Behavior Disorder NOS
314.01 Attention-Deficit Disorder, Predominantly Hyperactive-Impulsive Type
314.9 Attention-Deficit Hyperactivity Disorder NOS
V71.02 Child Antisocial Behavior
V61.20 Parent-Child Relational Problem

Axis II:
799.9 Diagnosis Deferred
V71.09 No Diagnosis on Axis II

ANXIETY

BEHAVIORAL DEFINITIONS

  1. Excessive anxiety, worry, or fear that markedly exceeds the level for the client's stage of development.
  2. High level of motor tension, such as restlessness, tiredness, shakiness, or muscle tension.
  3. Autonomic hyperactivity, such as rapid heartbeat, shortness of breath, dizziness, dry mouth, nausea, or diarrhea.
  4. Hypervigilance, such as feeling constantly on edge, concentration difficulties, trouble falling or staying asleep, and a general state of irritability.
  5. A specific fear that has become generalized to cover a wide area and has reached the point where it significantly interferes with the client's and the family's daily life.
  6. Excessive anxiety or worry due to parent's threat of abandonment, overuse of guilt, denial of autonomy and status, friction between parents, or interference with physical activity.

LONG-TERM GOALS

  1. Reduce the overall frequency and intensity of the anxiety response so that daily functioning is not impaired.
  2. Stabilize the anxiety level while increasing the ability to function on a daily basis.
  3. Resolve the key issue that is the source of the anxiety or fear.
  4. Interact with the world without excessive fear, worry, or anxiety.

SHORT-TERM OBJECTIVES

  1. Openly share anxious thoughts and feelings with therapist. (1, 2)
  2. Verbally identify specific fears, worries, and anxieties. (1, 2, 3, 4)
  3. Verbalize an increased understanding of anxious feelings and their causes. (5, 6, 7, 8)
  4. Report a decrease in frequency of experiencing anxiety. (3, 4, 8)
  5. Implement positive self-talk to reduce or eliminate the anxiety. (9, 10)
  6. Develop and implement appropriate relaxation and cognitive diversion activities to decrease the level of anxiety. (11)
  7. Identify areas of conflict that precipitate anxiety. (12, 13, 14, 15, 16)
  8. State a connection between anxiety and underlying, previously unexpressed wishes or thoughts. (17)
  9. Identify and utilize specific coping strategies for anxiety reduction. (18, 19, 20, 21)
  10. Increase participation in daily social and academic activities. (22, 24) Increase physical exercise as a means of reducing anxious feelings. (23) Participate in a camp that focuses on confidence building. (24)
  11. Set aside time for overthinking about anxieties. (25)
  12. Parents verbalize an understanding of the client's anxieties and fears. (26, 27, 28)
  13. Parents verbalize constructive ways to respond to client's anxiety. (29)
  14. Participate in family therapy sessions that identify and resolve conflicts between family members. (30, 31)
  15. Parents reduce their attempts to control the child. (32, 33)
  16. Express confidence and hope that anxiety can be overcome. (34, 35, 36)

THERAPEUTIC INTERVENTIONS

  1. Actively build the level of trust with the client through consistent eye contact, active listening, unconditional positive regard, and warm acceptance to help increase his/her ability to identify and express anxious feelings.
  2. Use a therapeutic game (Talking, Feeling, Doing, available from Creative Therapeutics, or The Ungame available from The Ungame Company) to expand client's awareness of feelings, self, and others.
  3. Conduct play-therapy sessions in which the client's anxieties, fears, and worries are explored, expressed, and resolved.
  4. Ask client to complete and process the exercise "Finding and Losing Your Anxiety" from Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis).
  5. Assess the client's anxiety by using the Squiggle Wiggle game (Winnicott), in which therapist or parent makes a squiggly line and then the client is asked to make a picture out of the squiggle and tell a story about that picture to help reveal to the therapist and parent what is going on internally with the client.
  6. Assign client the task of drawing two or three situations that generally bring on anxious feelings.
  7. Conduct psychoanalytical play-therapy sessions (e.g., explore and gain understanding of etiology of unconscious conflicts, fixations, or arrests; interpret resistance or core anxieties) to help client work through to resolution the issues that are the source of his/her anxiety.
  8. Utilize child-centered play-therapy approaches (e.g., provide unconditional positive regard, reflect feelings in nonjudgmental manner, display trust in child's capacity to work through issues) to increase client's ability to cope with anxious feelings.
  9. Explore distorted cognitive messages that mediate the anxiety response.
  10. Help the client develop reality-based, positive cognitive messages that will increase self-confidence in coping with fears and anxieties.
  11. Train client to use progressive relaxation or guided imagery techniques to induce calm and decrease the intensity and frequency of feelings of anxiety.
  12. Use puppets, felts, or sand tray to enact situations that provoke anxiety in the client. Involve the client in creating such scenarios, and model positive cognitive responses to the situations that bring on anxiety.
  13. Play the therapeutic game My Home and Places (Flood) with the client to help identify and talk about divorce, peers, alcohol abuse, or other situations that make client anxious.
  14. Instruct client to sing a song or play a musical instrument that reflects his/her anxious feelings; then discuss a time when client felt that anxiety.
  15. Ask the client to develop a list of key past and present conflicts within the family and with peers. Process this list with the therapist.
  16. Assist client in working toward resolution (using problem solving, assertiveness, acceptance, cognitive restructuring, etc.) of key past and present conflicts.
  17. Use an interpretive interview method in which the therapist interviews the client to help express motivation and feelings. Then assist the client in making a connection between fears or anxieties and unexpressed or unacceptable wishes or "bad" thoughts.
  18. Use a narrative approach (White) in which the client writes out the story of his/her anxiety or fear and then acts out the story with the therapist to externalize the issues. Then work with the client to reach a resolution or develop an effective way to cope with the anxiety or fear. See "An Anxious Story" from Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis).
  19. Assign client to complete exercises from My Own Thoughts and Feelings: A Growth & Recovery Workbook for Children (Deatin). Process each exercise with therapist to increase client's understanding of and ability to cope with and handle anxious feelings.
  20. Conduct sessions with a focus on anxiety-producing situations in which techniques of storytelling, drawing pictures, and viewing photographs are used to assist client in talking about and reducing the level of anxiety or fear.
  21. Use a mutual storytelling technique (Gardner) in which the client tells a story about a central character who becomes anxious. The therapist then interprets the story for its underlying meaning and retells the client's story while weaving in healthier adaptations to fear or anxiety and resolution of conflicts.
  22. Assist client in identifying behavioral anxiety-coping strategies (e.g., increased social involvement, participation in school-related activities); contract for implementations.
  23. Assist client in developing a schedule of physical activity that reduces anxiety.
  24. Encourage the parents to seek an experiential camp or weekend experience for the client that will focus on the issues of fears, taking risks, and building confidence. Process the experience with the client and his/her parents.
  25. Advocate and encourage overthinking (e.g., help client explore and prepare for every conceivable thing that could possibly happen to him/her in facing a new or anxiety-producing situation). Monitor weekly results and redirect as needed.
  26. Educate the client's parents to increase their awareness and understanding of which fears and anxieties are normal for various stages of child development.
  27. Assign the client's parents to read books related to child development and parenting, such as Between Parent and Child (Ginott) or How to Talk So Kids Will Talk (Faber and Mazlish).
  28. Refer the client's parents to a parenting class or support group.
  29. Work with the parents in family sessions to develop their skills in effectively responding to the client's fears and anxieties with calm confidence rather than fearful reactivity (e.g., parents remind client of a time he/she effectively handled a fearful situation or express confidence in client's ability to face the fearful situation).
  30. Conduct family session in which the system is probed to determine the level of fear or anxiety that is present or to bring to the surface underlying conflicts.
  31. Work in family sessions to resolve conflicts and to increase the family's level of healthy functioning.
  32. Use a structural approach in the family session, adjusting roles to encourage the parents to work less on controlling children and more on allowing kids to be kids.
  33. Conduct family sessions to develop and offer strategic directions designed to increase the physical freedom of the children and to adjust the parental control of the system.
  34. Use a metaphor, fairy tale, or parable to get the client's attention, to evoke possibilities or abilities, to intersperse suggestions, and to implant hope of a good outcome. (See 101 Play Therapy Techniques by Maruasti.)
  35. Assist the client in developing internal structures for self-regulation and the ability to tolerate his/her anxiety by evoking the memory of the therapist as a soothing, encouraging, internal object to help when he/she confronts an anxiety-producing situation/issue. (See The Therapist on the Inside by Grigoryen.)
  36. Prescribe a Prediction Task (Shuzer) for anxiety management. (Client predicts the night before whether the anxiety will bother him/her the next day. Therapist directs client to be a good detective and bring back key elements that contributed to it being a "good" day so therapist then can reinforce or construct a solution to increasing the frequency of good days.)

DIAGNOSTIC SUGGESTIONS

Axis I:
300.02 Generalized Anxiety Disorder
300.00 Anxiety Disorder NOS
309.24 Attention-Deficit/ Hyperactivity Disorder, Combined Type
309.21 Separation Anxiety Disorder

Axis II:
799.9 Diagnosis Deferred
V71.09 No Diagnosis on Axis II

ATTACHMENT DISORDER

BEHAVIORAL DEFINITIONS

  1. Brought into family through adoption after coming from an abusive, neglectful biological family.
  2. Consistent pattern of failing to initiate or respond to social interactions in an age-appropriate way (e.g., withdrawing and rejecting behavior toward primary caregivers, a general detached manner toward everyone).
  3. Pattern of becoming friendly too quickly and/or showing indiscriminate affection to strangers.
  4. Three years old or older and has no significant bond with any caregiver.
  5. Resists accepting care from others, usually being very insistent he/she does not need help from anyone.
  6. Hoarding or gorging food.
  7. Aggressive behaviors toward peers, siblings, and caregivers.
  8. Frequent lying without remorse.
  9. Stealing petty items without a need for them.
  10. By age seven, little or no sign of conscience development is evident (e.g., shows no guilt or remorse when confronted with his/her misbehavior).
  11. Excessive clinginess to primary caregiver, becoming emotionally distraught when out of caregiver's immediate presence.
  12. Has experienced persistent disregard for his/her emotional and/or physical needs.
  13. Has been subjected to frequent changes in primary caregiver.

LONG-TERM GOALS

  1. Establishment and maintenance of a bond with primary caregivers.
  2. Resolution of all barriers to forming healthy connections with others.
  3. Capable of forming warm physical and emotional bonds with parents.
  4. Has a desire for and initiates connections with others.
  5. Keeps appropriate distance from strangers.
  6. Tolerates reasonable absence from presence of parent or primary caregiver without panic.

SHORT-TERM OBJECTIVES

  1. Openly express thoughts and feelings. (1, 2, 3)
  2. Cooperate with and complete all assessments and testing. (4, 5)
  3. Comply with all recommendations of assessments and evaluations. (6)
  4. Parents commit to improving the communication and affection within the marriage relationship. (7)
  5. Parents acknowledge unresolved grief associated with infertility. (8)
  6. Parents verbalize reasonable expectations regarding client's attachment progress. (9, 10)
  7. Parent(s) make a verbal commitment to take an active role in client's treatment and in developing skills to work with client and his/her issues. (11, 12, 13)
  8. Attend and actively take part in play-therapy sessions. (14, 15, 16)
  9. Client and parents verbalize an understanding of the dynamics of attachment and trauma. (17, 18)
  10. Parents acknowledge their frustrations regarding living with a detached child and state their commitment to keep trying. (19, 20, 38)
  11. Share fears attached to new situations. (21)
  12. Identify specific positive talents, traits, and accomplishments about self. (22)
  13. Verbalize memories of the past that have shaped current identity and emotional reactions. (23)
  14. Parents acknowledge client's history and affirm him/her as an individual. (24)
  15. Parent(s) spend one-on-one time with client in active play. (25)
  16. Parents increase the frequency of expressing affection verbally and physically toward client. (26, 35)
  17. Report an increased ability to trust, giving examples of trust. (27, 28)
  18. Recognize and express angry feelings without becoming emotionally out of control. (29, 30)
  19. Parents demonstrate firm boundaries on client's anger expression. (31, 32, 33)
  20. Family engages in social/recreational activities together. (34, 35)
  21. Accept physical contact with family members without withdrawal. (35)
  22. Parents use respite care to protect self from burnout. (36, 37, 38)
  23. Parents respond calmly but firmly to client's detachment behavior. (39, 40)
  24. Parents give client choices and allow him/her to make own decisions. (41)
  25. Complete a psychotropic medication evaluation and comply with all recommendations. (42)
  26. Take medication as prescribed and report all side effects. (43) Report a completion to the process of mourning losses in life. (44, 45)

THERAPEUTIC INTERVENTIONS

  1. Actively build the level of trust with client through consistent eye contact, active listening, unconditional positive regard, and empathic responses to help promote the open expres-sions of his/her thoughts and feelings.
  2. Conduct a celebrity-style interview with client to elicit information (school likes/dislikes, favorite food, music, best birthday, hopes, wishes, dreams, "if I had a million dollars," etc.) in order to build relationship and help client learn more about himself/herself.
  3. Conduct all sessions in a consistent and predictable manner so that all is clear for the client and he/she can start to take a risk and trust therapist.
  4. Conduct or refer parents and client for a psychosocial evaluation to assess strength of parents' marriage, parenting style, stress management/coping strengths, and resolution of infertility issue and to assess client's developmental level, attachment capacity, behavior issues, temperament, and strengths.
  5. Conduct or arrange for psychological evaluation to determine level of behavioral functioning, cognitive style, and intelligence.
  6. Summarize assessment data and present findings and recommendations to family.
  7. Refer parents to a skills-based marital program such as Prep (e.g., Fighting For Your Marriage by Markman, Stanley, and Blumberg) to strengthen marital relationship by improving personal responsibility, communication, and conflict resolution.
  8. Assess parents' unresolved grief around the issue of their infertility; refer for further conjoint or individual treatment if necessary.
  9. Process with parents the issue of expectations for client's behavior and adjustment; confront and modify unrealistic expectations regarding their child's emotional attachment progress and foster more realistic expectations considering the client's history.
  10. Explore with parents the reality that "strong relationships involve love, understanding, trust, time, money, sharing, giving, stimulating, and inspiring; they seldom come automatically, and love may be last thing on the list rather than the first." (See Anxiously Awaiting Attachment by Paddock.)
  11. Elicit from parents a firm commitment to be an active part of client's treatment by participating in sessions and being cotherapist in the home.
  12. Work with parents in conjoint sessions to frame client's acting-out behaviors as "opportunities to reparent the client." Then strategize with them to come up with specific ways to intervene in the problem behaviors.
  13. Train and empower the parents as "cotherapists" (e.g., being patient, showing unconditional positive regard, setting limits firmly but without hostility, verbalizing love and expectations clearly, seeking to understand messages of pain and fear beneath the acting-out behavior) in the process of developing the client's capacity to form healthy bonds/connections.
  14. Utilize the Theraplay (Jernberg and Booth) attachment-based approach, in which the therapist takes charge by planning and structuring each session. Therapist uses his/her power to entice the client into relationship and to keep the focus of therapy on the relationship, not on intrapsychic conflicts. Also, parents are actively involved and are trained to be cotherapists.
  15. Employ A. C. T. model (Landreth) in play-therapy sessions to acknowledge feelings, communicate limits, and target acceptable alternatives to acting-out or aggressive behaviors.
  16. Conduct filial therapy (i.e., parent involvement in play-therapy sessions), whereby client takes the lead in expressing anger and parent responds empathically to client's feelings (hurt, fear, sadness, helplessness) beneath the anger.
  17. Provide education to parents and client on the nature of attachment and the overall affect of trauma on children and families.
  18. Teach client that his/her detachment is a normal reaction to painful experiences of rejection, disappointment, broken implied and explicit promises, abandonment, and/or abuse; emphasize client's need to separate current family from past abuse.
  19. Suggest parents read The Difficult Child (Turecki) or The Challenging Child (Greenspan) to provide understanding, ideas, and encouragement in continuing to work with their child.
  20. Empathize with parents' frus trations regarding living with a detached child; allow them to share their pain and disappointment while reinforcing their commitment to keep trying.
  21. Have client complete "Dixie Overcomes Her Fears" from Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis) to help client share fears and gain self-acceptance.
  22. Assign a self-esteem-building exercise from SEALS & Plus (Korb-Khara, Azok, and Leutenberg) to help develop self-knowledge, acceptance, and confidence.
  23. Assign parents to help client create a "life book" that chronicles the client's life to this point in order to give a visual perspective and knowledge of his/her history and identity. A form for "Create a Memory Album" can be found in Brief Child Therapy Homework Planner (Jongsma, Peterson, and McInnis).
  24. Educate parents on the importance of affirming the client's entire identity (i.e., self, bioparents, adoptive parents), and show them specific ways to reaffirm him/her.
  25. Work with parents to have each spend specific time in daily one-on-one active play with client.
  26. Encourage parents to provide large, genuine, daily doses of positive verbal reinforcement and physical affection. Monitor and encourage parents to continue this behavior and to identify positive attachment signs when they appear.
  27. Have client attend an initiative or adventure-based summer camp to build his/her self-esteem, trust in self and others, conflict-resolution skills, and relationship skills.
  28. Conduct a family session in which parents, client, and therapist take part in a trust walk. (One person is blindfolded and led around by a guide through a number of tasks. Then roles are reversed and process is repeated.) The object is to increase client's awareness of his/her trust issues and to expand his/her sense of trust. Process and repeat at intervals over course of treatment as a way to measure client's progress in building trust.
  29. Train client in meditation and focused breathing as self-calming techniques to use when tension, anger, or frustration is building.
  30. Read and process with client Don't Rant and Rave on Wednesday (Moser) to assist him/her in finding ways to handle angry feelings in a controlled, effective way.
  31. Support and encourage parents to maintain firm control, anticipate and stop manipulative behaviors, avoid power struggles, and stick with behavior management techniques.
  32. Help parents design preventive safety measures (i.e., supervision and environmental controls) if client's behavior becomes dangerous or frightening.
  33. Direct parents to give constant feedback, structure, and repeated emphasis of expectations to client in order to reassure him/her that parents are firmly in control and that they will not allow client's intense feelings to get out of hand.
  34. Encourage parents to engage client and family in many "cohesive shared experiences" (James), such as attending church, singing together at home, attending sports events, building and work projects, and helping others.
  35. Assign family the homework exercise of 10 minutes of physical touching twice daily for two weeks (see James in Handbook for Treatment of Attachment-Trauma Problems in Children) to decrease client's barriers to others. (This can take the form of snuggling with parent while watching television, feet or shoulder massage, being held in a rocking chair, or physical recreation games.) Process the experience with therapist at the end of two weeks.
  36. Assist parents in developing a list of potential respite care providers.
  37. Encourage and monitor parents' use of respite care on a scheduled basis to avoid burnout and to keep their energy level high, as well as to build trust with client through the natural process of leaving and returning.
  38. Meet with parents conjointly on a regular basis to allow them to vent their concerns and frustrations in dealing day in and day out with client. Also, provide parents with specific suggestions to handle difficult situations when they feel stuck.
  39. Educate parents to understand the psychological meaning and purpose for the client's detachment, and train them to implement appropriate interventions to deal day to day with the behavior in a therapeutic way (e.g., calmly reflecting on client's feelings, ignoring negative behavior as much as is reasonably possible, rewarding any approximation of prosocial behavior, and practicing unconditional positive regard).
  40. Monitor parents' implementation of interventions for detachment behavior and evaluate the effectiveness of their interventions. Assist in making adjustments to interventions so that client's intense feelings do not get out of hand.
  41. Ask parents to give the client as many choices as is reasonable and possible to impart a sense of control and empowerment to him/her.
  42. Arrange for client to have a psychiatric evaluation for medication. Monitor client for compliance, side effects, and overall effectiveness of the medications.
  43. Play The Good Mourning Game (Bisenius and Norris) to introduce the idea of loss and the process of mourning to client.
  44. Assist, guide, and support the client in working through each stage of the grief process. (See Grief/Loss Unresolved in this Planner.)

DIAGNOSTIC SUGGESTIONS

Axis I:
313.89 Reactive Attachment Disorder of Infancy and Early Childhood
314.9 Attention Deficit/ Hyperactivity Disorder NOS
296.3x Major Depressive Disorder, Recurrent
300.4 Dysthymic Disorder
309.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct
309.81 Posttraumatic Stress Disorder
300.3 Obsessive-Compulsive Disorder
313.81 Oppositional Defiant Disorder

Axis II:
799.9 Diagnosis Deferred
V71.09 No Diagnosis on Axis II

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Interviews & Essays

An Interview with Arthur E. Jongsma Jr.

Question: How did the original Adult Psychotherapy Treatment Planner come about?

Arthur E. Jongsma Jr.: In 1993, I consulted for the Salvation Army Turning Point chemical dependence treatment program. JCAHO reviewers had been critical of the treatment plan documents being produced. They flagged lack of uniform quality, deficits in problem definitions, low measurability of objectives, and ambiguous interventions as issues.

I worked with the clinical director of the program, Mark Peterson, MSW, to develop a menu of treatment plan components for common presenting problems in that client population. The clinical and quality assurance staff eagerly embraced this lexicon and organization, finding that it dramatically cut the time they had to invest groping for words, yet enabled them to create high-quality, customized treatment plans. This guidebook was expanded to include general mental health issues and was published as The Complete Psychotherapy Treatment Planner. Little did I know then that this single guidebook to help mental health professionals would turn into a series of over 45 books as well as software!

Q.: What have you enjoyed most about working on the PracticePlanners® series?

AEJ: It is satisfying to hear both graduate students and seasoned therapists praise the contribution these books have made to their training and practice. Also, as the series has evolved, I've had the honor of collaborating with very knowledgeable experts in specialized fields such as addictions, couples and family therapy, group therapy, and gerontology. Working with these specialists has helped me broaden my own clinical skills.

Q: The bestselling status of the series certainly points to it being an unusually useful tool for therapists. Why do you think that is?

AEJ: The breadth and depth of the Treatment Planners content is unparalleled in the professional marketplace. We have tapped the resources of experts with many different treatment populations and treatment approaches. And when Treatment Planners are integrated with Progress Notes Planners, Homework Planners, and Documentation Sourcebooks, it gives mental health professionals a complete package of timesaving tools for comprehensive treatment planning and clinical record management.

Q: What is ahead for you and the series?

AEJ: We recently launched a new line of books, Progress Notes Planners, that are a natural extension of the Treatment Planners: helping mental health professionals continue to save time while not compromising patient or client care.

When I'm not collaborating on the books, I'm continuing in my private practice, and putting together a wish list of new projects for the series! Which reminds me, the chance to exchange ideas with colleagues is another thing I've greatly enjoyed about working on the series. I'd love to get more feedback and suggestions from mental health professionals.

Dr. Arthur E. Jongsma Jr. heads an independent group practice in Grand Rapids, Michigan. He serves as coauthor of most of the books in the PracticePlanners® series.

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