edc_treatment_teamWe are continuing our series on training exercises. The following exercises are to provide practice in formulating a case and using that formulation to guide our treatment. There is an exercise to use when creating a response to a behavior that hurt others. The final exercise provides practice in using that exercise with the cases previously used for formulation, in order to respond to specific hurtful behaviors. 

 

Formulation: Jeffrey and Alexandra 

Jeffrey

Jeffrey is an 11-year-old-boy who has a history of witnessing domestic violence and multiple separations from his grandmother who raised him. Child protective services finally removed him from his grandmother’s care when they found for the 3rd time that Jeffrey was left alone at home over night. He was referred to your facility for his explosive anger and defiant behavior. Staff has noticed that Jeffrey becomes especially defiant during the evening routine – he often refuses to eat his evening snack, will not get into his pajamas, or brush his teeth. Battles with Jeffrey that often include him pushing staff, spitting at staff, and restraints will often go on for over an hour. Even when staff allow him to sleep in his clothes, he finds other ways to engage staff like banging his head in his room or playing his radio so loud it is disruptive to other kids. Staff worked on a sticker chart to motivate Jeffrey to complete his evening routine. It worked briefly, but soon staff were having long arguments with him over the details of the sticker chart.

Leader: Emphasize:

How do we understand Jeffrey’s behavior? Why was the sticker chart ineffective? Jeffrey’s fear of being alone and how actions keep staff engaged; mention how in old system we would give Jeffrey and early bed- how would that help?

Alexandra

Alexandra is a 14-year-old-girl who has a history of trauma and several foster placements. She has a history of self-injury and suicidality. Staff has noted that in the last month she’s been opening up to a few of them in a new way that she has not before. Last week, it was announced that one of the unit therapists (not hers) was being transferred to work in another program. This morning staff observed that she was wearing long sleeves even though it was 90 degrees out. When a staff asked why, she told her to “f__off.” She eventually revealed that she had been scratching herself with a paperclip.

Leader: Emphasize:

How do we understand Alexandra’s behavior? Why didn’t she just tell someone that the therapist leaving made her scared? Understanding the meaning and function of the symptoms gives you many more options for intervention.

Creating Restorative Tasks

Use these questions to lead your team to your response:

  1. What was the problem behavior?
  2. What led up to the behavior?
  3. What was he or she feeling? What need was the child trying to meet?
  4. What would we want the child to do when he or she feels this way or has these experiences?
  5. What skills and/or beliefs would the child need in order to be able to do this alternative behavior?
  6. What tasks can we create (preferably with the child) that will help him strengthen the positive beliefs and learn and/or practice the needed skills?

Creating Learning Tasks Exercise

Jeffrey

Jeffrey is an 11-year-old-boy who has a history of witnessing domestic violence and multiple separations from his grandmother who raised him. Child protective services finally removed him from his grandmother’s care when they found for the 3rd time that Jeffrey was left alone at home over night. He was referred to your facility for his explosive anger and defiant behavior.

Last night, when he was upset about going to bed, Jeffrey started smashing furniture to the ground. He broke two chairs and the TV remote. Accidentally he hit Mark, a staff member with a chair when he pushed it hard into Mark. The noise and commotion kept the unit up for quite a while, and several other clients had trouble sleeping and were uneasy.

Using the formulation you previously developed:

  1. How do you understand this behavior? What was Jeffrey feeling?
  2. What do we want Jeffrey to do when he is feeling this way?
  3. Based on your understanding of the behavior, what learning task could you give Jeffrey to help him learn or practice the skills he would need in order to react differently?
  4. How could Jeffrey make amends to Mark and to the other boys on the unit?

Alexandra

Alexandra is a 14-year-old-girl who has a history of trauma and several foster placements. She has a history of self-injury and suicidality. Staff has noted that in the last month she’s been opening up to a few of them in a new way that she has not before. Last week, it was announced that one of the unit therapists (not hers) was being transferred to work in another program.

Yesterday, the unit had planned a goodbye party for the departing therapist. Alexandra became rude and starting yelling at the therapist, saying she was no good, a whore, and just in it for the money. When staff tried to calm her down, she threw a glass (which broke) and ran off the unit. She was gone an hour and a half, but probably stayed on grounds. The party was disrupted because staff had to tag Alexandra, who was on suicide precautions. They finally found her and she came back in.

 Using the formulation you previously developed:

  1. How do you understand this behavior? What was Alexandra feeling?
  2. What do we want Alexandra to do when she is feeling this way?
  3. Based on your understanding of the behavior, what learning task could you give Alexandra to help her learn or practice the skills she would need in order to react differently?
  4. How could Alexandra make amends to the unit and the therapist for disrupting the party?

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