KateWhat are the ideal skills and actions for a therapist in a congregate care setting?

Clinical Thinking

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 therapists 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.

Fixing Interferes with Change

In a congregate care treatment program there is considerable pressure for a therapist to turn away from clinical thinking and become a “fixer”. Some times it seems that therapists’ job is to take away a screaming child and bring her back calm.

The therapist 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 children would be much better already because this has been done a thousand times before.

What should the Therapist Do?

The job of the therapist 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 therapist is not present, and learn emotion management skills.

The therapist should have a complex and ever increasing understanding of the child, what their experiences have been, and how those experiences have shaped them.

The therapist 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.

What About the Family?

In family therapy the therapist 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.

The Importance of Formulation

Therapists should formulate the case. A formulation makes explicit 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 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 therapist’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.

Using the Formulation

Then, the therapist 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 therapist’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?

Support for the Therapist

For this to be a viable and vibrant process the therapists need administrative support.

They need excellent clinical supervision.

They need access to ongoing training of many sorts.

They need opportunities to replenish themselves and their work.

They need reasonable caseloads which allow time to think about their clients.

Results of a Strong Clinical Team

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.

Would you like a guide to integrating the therapist and the team?
Read this guide for therapists and teams

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