herewesayf&@#k!!!

Mutherfucking Process Recordings

What in the actual fuck is a process recording you may ask?

Well aside from being the absolute, most, obnoxious, biggest, pain in the dick for any a student intern just trying to survive their required hours, required readings, and weekly assignments for any of their classes….it is simply put a detailed document ment to aid in the theraputic process.

A process recording is a written record of a therapy session or theraputic interaction. It is used to track the therapeutic process and progress and is a detailed, verbatim account of what happened during the session.

This includes a verbatim reflection of every word a client said as well as their non-verbal contributions. This includes pitch, tone, facial expressions and physical reactions.

There is also a reflection of the therapists verbatim responses. This is more than just a written dialog, but a labeling of intervention, technique and tools used for the questions, statements and possible activities tbe clinican is performing.

A segment is included for the clinician to make note of any nonverbal cues, body language and any other notable behaviors as well as the therapists thoughts, hypotheses and observations about the case. This can include reflection in pre-engagement activities, goals and agenda setting,observations and reflections of the client’s progress.

Lastly, there can also be a segment for a professor or supervisor to offer feedback to help the clinician develop new skills, sharpen their abilities and consider other perspectives or possible interventions they may have overlooked for many reasons. It may also cause the clinician to reflect on any possible biases or blindspots that caused them to overlook something.

Obviously these are a bucket of fun and a great way for anyone to spend their time…but despite this part on a computer screen there are other purposes a process recording serves.

Process recordings help the therapist evaluate their own performance, identify where they need to improve and develop their skills further.

They can also be used as a training tool for supervisors to help untreated techniques ,enhance theraputic skills and discuss challenging situations. Despite my absolute hatred for these fucking pieces of paper they have proven time and time again to help disect complicated situations and multiple layers in complicated cases….especially when dealing with an individual, diagnosis and complicated family dynamic that can easily overlap and blur the lines.

These bits of paper can also be used to help track the growth and progress of your clients ,identify patterns of behaviors, reoccurring themes (especially ones clients are trying to deflect or avoid) and provide detailed information that can aid on informing the treatment plan.

A final aspect for students handing in their assigned load of these fucking recordings is that the contribute to the research compiled to determine the theraputic effectiveness and the outcomes across multiple studies in the field.

So, despite the tedious drone of these fucking documents their simple review ca. Help us refine our approach ,define our style, enhance client engagement and improve treatment outcomes

…..I fucking hate when things I despise doing are actually fucking useful 🤦‍♀️

Until next week

Fucking Treatment Plans

Treatment plans are a fucking mood that are essentially a detailed, individualized plan developed in collaboration with a patient. It outlines the goals, objectives, and strategies for managing a patient’s specific health condition or issue. A treatment plan typically includes: Diagnosis and problem statement, short and long term goals and objectives, interventions & therapies,how progress will be monitored & outcomes will be tracked, how the end of treatment will be recognized and will be revisited to make any needed modifications and adjustments.

Treatment plans help ensure that care is coordinated, effective, and patient-centered.To do so there are many intensive steps for the client and clinician to work through together.

First there must be a thorough assessment done where the clinicam gathers information about the client’s situation, including their history, strengths, and challenges. Then they work together to identify the client’s goals. This entails establishing specific, measurable, achievable, relevant, and time-bound (SMART) goals. Then the clinician will Formulate a diagnosis to identify any mental health conditions

Developing a treatment plan outline considers the following components:
    – Client information
    – Presenting problem
    – Goals and objectives
    – Interventions and strategies
    – Timeline
    – Evaluation criteria

   Evidence-based interventions are choosen and are based on the client’s needs and goals, and can include modalities such as cognitive-behavioral therapy (CBT), psychodynamic therapy, or family therapy. Interventions are prioritized and their order and importance are based on the client’s needs.

   Then an action plan is created. This is an outline specific steps, responsibilities, and timelines for each intervention. A crisis plan is also creates. This is a plan for emergency situations, including contact information and coping strategies.

   Once created the plan will be regularly reviewed and updated through regular corporation with the client to assess progress, make adjustments, and celebrate successes.Documention will be seen in the maintenance of accurate and up-to-date records, including the treatment plan, progress notes, and any changes.

It’s important to be mindful and consistent in maintaining cultural sensitivity, and address any systemic or environmental factors impacting the client’s well-being.

Lastly it’s important to remember that treatment plans differ for children, adolescents, and adults due to developmental considerations, unique needs, and varying presentation of issues.

For children (ages 4-12)
The biggest factor is family involvement. Parents or caregivers are actively involved in the treatment process.
Play-based interventions are necessary for effective treatment. Play therapy, art, and games are used to engage children.
The clinickan must keep developmental factors in mind when constructing the TP. Be sure to consider developmental milestones, social skills, and emotional regulation.Simple language should be maintained to explain concepts and goals.With a focus on Short-term goals to address immediate needs and behaviors.

For Adolescents (ages 13-18)

Focus should be on increasing autonomy while gradually involving adolescents in decision-making and goal-setting. When considering developmental factors attention should be on identity formation, peer relationships, and emotional regulation. While focus is on evidence-based therapies such as CBT, DBT, or psychodynamic therapy ypu can utilize art and movement therapies as well. When implementing family involvement the goal is to balance adolescent autonomy with family support and involvement. While short-term goals are important its ok to emphasize long-term goals with focus on future-oriented goals, like education and career development.

For Adults

The focua is on autonomy and self-direction with the client taking an active role in setting goals and making decisions. It’s important to address complex issues, like relationships. trauma, or chronic conditions.While using approaches such as CBT, psychodynamic therapy, DBT or other mindfulness-based therapies. As the clinician there should be an Emphasis on self-sufficiency and accountability. Both the client and clinician can consider a more holistic approach when considering physical, emotional, and social aspects of well-being.

And that my friends is a very detailed ,if not fucking exhaustive description of Treatment Plans.

….until next week

TF-CBT

Trauma Focused Cognitive Behavioral Therepay is a conjoined child and caregiver model used for children and teens experiencing clinically significant emotional and behavioral difficulties related to past traumatic events.

This treatment is designed to brief , at around 12 to 20 sessions and has specific goals. They include : learning effective coping skills for the emotions and behaviors connected to trauma, facing and resolving those issues in a safe and effective way, helping children & families effectively integrate their trauma to help them move on in a safe and healthy manner, reduces symptoms of PTSD and improve support, communication and parenting skills of the caregiver.

This treatment is designed coffee children 3 to 18 years old with a history of trauma. That trauma can include : experiencing or witnessing violence in home, school or community, an unexpected or traumatic death of a loved one, car accident, animal attack , sexual/physical abuse or violence, experiencing a natural or man made disaster such as a flood or building collapse and exposure to war, combat or torture.

The child does not need a diagnosis of Post Traumatic Stress Dosorder or any other trauma disorder for this treatment to be effective, but they do need 4 or more trauma symptoms or other trauma related problems. It is also effective if there is a co-morbid diagnosis of a trauma disorder and ADHD, Oppositional Defient Disorder (ODD) or Conduct Disorder (OD). There also needs to be consistent involvement from either a parent or caregiver.

This treatment is NOT for children with no history if trauma, no trauma related problems or severe cognitive challenges. Problems such as active suicidal ideation,significant substance abuse, severe aggressive beha for and danger to imminent safety must all be managed before starting treatment if they are present.

In principle TF-CBT is a components based practice where each component had a specific purpose that builds on the previous. It can be adapted to many different clinical settings, situations or families. Pacing is flexible and techniques are adaptable. Procedures and techniques should be adapted as necessary to accommodate cultural norms and values of each individual family. This is critical as treatment js family focused with nearly half of treatment involving a supportive caregiver. Treatment relies in a strong rheraputic alliance to develop skills and help the patient develop a strong sense of self-efficacy to help them move past their trauma so they are no longer overwhelmed by it.

There are 9 components to treatment. They include psychoeducation, parenting skills,relaxation techniques, affect identification and regulation , cognitive coping, trauma narration and processing, in vivo mastery and enhancing safety and future development.

These components are delivered through caregiver involvement and gradual exposure during consistent weekly sessions lasting 60 to 90 minutes.

TF-CBT has 3 stages. STABILIZATION includes psychoeducation, relaxation, affective expression and regulation, parenting skills and gradual exposure. TRAUMA NARRATIVE includes creating the trauma narrative and processing it. The final stage INTEGRATION/CONSOLIDATION includes In Vivo mastory,and conjoint child-carrgiver enhancing future safety and development

Each phase should take up 1/3 of the treatment time with parenting skills and gradual exposure happening throught treatment.

Lastly there are 2 components to treatment fidelity and they are adherence and competence. Adherence-treatment must be conducted as developed ,appropriate for clients and caregivers with the session rare and components followed. Competence-entails the process of the procedures, techniques and skills are completed correctly and overseen by a clinical both knowledgeable and trained in the treatment.

What in the Actual Fuck….part II

So last week I discussed the 1st experience that helped create my worst day in field….allow me to illuminate you with what clinched the shit day title.

My family of demons had left my office and I had just finished cleaning up the path of destruction left in their wake when I heard the arrival of my next client.

This client is 13 years old who lives with Grandma after running away from her father’s house. Client, AKA ,Mrs. Clause survived neglect, physical and sexual abuse and a sexual assault. Grandma has taken her in after discovering the issues at home. The biggest issue in the house is the adjustment and communication while Mrs. Clause addresses her trauma and is treated for her other diagnosis. Which include suicidality, with multiple attempts , major depressive disorder and PTSD.

Grandma and Mrs. Clause have the same fight. Grandma gets angry at the lack of respect she is given and Ms. Ho Ho Ho gets angry that she has rules.

I let them into the office and they are fighting, because Grandma won’t let her spend the weekend with her boyfriend. I try to de-escalate the situation and bring them back into the office. Grandma says she wants to make next weeks appointment and let us speak, but they continue to go back and forth.

I intervene and make both of them sit down and do a quick breathing exercise to relax and refocus. Then I use empathy, active listening and reflection to try to facilitate their argument in the hopes they can address what the issue is and stop yelling at each other.

After grandma stated she just wanted to be treated with respect Mrs. Clause mumbled under her breathe an insult that I didn’t catch, but made grandma leave the room. I asked her what respect looked like for her and when she couldn’t answer I pointed out it may be difficult for her to describe because she’s never felt respected before.

I’d like to point out that this is a client I’ve had great rapport with since day 1. She opened up to me easily , shares her concerns and has said it’s nice to have an adult I can trust…despite this established theraputic alliance it was obvious I hit a nerve and obvious she wasn’t in the right mood to have that nerve hit.

Her response was to sneer at me at tell me that she has been lying this whole time and she actually hates me. She hates therapy, doesn’t need it ,won’t be coming back and can’t believe I was dumb enough to believe she trusted me because all I was , was just a fat bitch.

I wish I could say I had some great zinger or line in response to this, but alas I did not. I laughed. It started as a chuckle and grew to a giggle and I looked at her and said , that’s the best you can do? She looked at me confused and I said…well I am fat and am indeed a bitch…so, ya got me there.

I almost feel bad at her lost look, as she wondered if perhaps her therapist was becoming unhinged. But I finished my giggling and asked her if she wanted to discuss what respect felt like or insult me more..she choose neither and stopped speaking & picked at the wall until I yelled at her to stop when she tried to pull out the outlet.

Oh well….until next week

What in the Actual Fuck

Not to brag, but when I do things, I do them big. So it should come as no surprise that my first bad day was 1 that outdid even itself, leaving me to wonder what client do I even talk about.

I’ve been treating two sisters for about 4 months and they are adorable and sweet girls at 7 & 9. Their problem really is behavioral and the end result of simple bad parenting. Mom has no rules, no consequences, no boundaries and few parenting skills. Essentially, Mom ignores all the problems and chaos until there’s sheer chaos and then she begins to scream at and insult her daughters. Mom also has a 2 year old son who is absolute demon energy that she makes zero attempt to intervene or discipline.

I have my session with the older daughter and everything goes well, despite the occasional high pitched screams coming from the waiting room. This is where baby brother ran around throwing toys and screaming across the room.

I finish the session and go to get lil sister, Mom tells me she’s had a horrible day and has been unable to regulate her emotions which has resulted in multiple tantrums. I told Mom that I was going to have to take the toys away from the baby as a natural consequence of her intervention to help modify his behavior. That other people are in the waiting room and it’s unfair to them before heading in for our session.

Despite Moms warning she is in a fantastic mood and we gave 1 of our best sessions. I use art therapy and ask her to draw her emotions, where we make them as big or small as she’s feeling them.

The end arrives and I need to get mom to sign a form and schedule next weeks session. Mom asks if we talked about her behavior and why she can’t behave. I explained that I don’t tell them what to talk about, but that it’s their time to address what they want to. This doesn’t sit well with Mom who sits staring out the window not signing paperwork or noticing her child.

Said child as grabbed, tossed and dumped out every toy in my office. I ask Mom to get him but she doesn’t even acknowledge I’ve spoken. He begins to climb my bookcase and despite not being allowed to touch my clients I have to grab him before he falls. I put him in the furthest corner with crayons and again ask Mom to sign. To which she tells me she’s bothered I didn’t address why he daughter can’t behave.

Through gritted teeth I explain again that therapy doesn’t work that way. At which point the baby runs across the room like a mini linebacker and body slams into his sister and the mini table they’re playing at. They are now all screaming as every piece of every toy in his path is midair. Mom immediately begins to scream at her daughters to “Watch their fucking brother” and “Why can’t you girls help, are you fucking stupid” Her daughter begins to cry so hard she almost vomits and the baby runs out the door.

I tell Mom that her language is unacceptable and unhelpful and we aren’t going to accomplish anything so she needs to go. She gets up to leave and her son throws himself down in a fit and she screams you live here now and power walks to the door. I scramble to get him out of the office, pick him up and unceremoniously dump him into his mother’s arms as I usher them out of the office.

The prevailing assumption is that I went back to my office and cried, but that’s not the case. I went back to my office and raged. I raged as I envisioned hitting Mom with her son. I raged at the damage being done to those kids and my inability to stop it, I raged as I imagined what that house must be like and I raged at the ruined progress finally made.

I’ll have to wait till next week to describe the second shitty client of the night

The lawyer & The Therapist

Protecting the best interest of a child can include so many, but sometimes people who don’t want to have anything to fucking do with each other must unite for the betterment of someone else. Sometimes those are forces that are historicaly oppositional ,sometimes they personally don’t like each other and other times it’s all about personal fucking perspectives.

I have my own unique history that has fostered my own opinions and outlooks and up there is I don’t like fucking cops, fucking lawyers and fucking jocks. While I’m adult enough to understand there are probably many who fill those roles that are entirely delightful humans….I’m not sold. I will always feel unsafe and uncomfortable around them.

My judgements are my judgments and my reasons and experiences belong entirely to me, and for that my instincts are always to tread lightly ,do what I came to do and get as far away as humanly possible as fast as fucking possible.

I am always 1,000% prepared to meet the arrogant, condescending, self-important fuckface that will give his best “you poor lil lady, how’d you get here” tone the second he speaks to me. If is overly polite condescension is not rewarded with immediate supplication he will turn on a dime from bemused entitlement to aggressive arrogance in a heartbeat. Again, I’m sure there are many great men filling these roles, but all I’m saying is….I haven’t fucking met em.

This week my voicemail held the message of, “Hey your Scooby’s therapist & I’m here legal representative so call me back so we can make sense of this diagnostic thing.”

I did not want to call back.

For some context Scooby is a 13 year old girl living with her Maternal Grandparents, who have temporary custody. Mom handed over rights before she feld the country to escape from “Dad” who has attempted to murder her 4 seperate times. Dad has not seen Scooby in 8 years when Mom was awarded full custody due to his documented history of violence and abuse. Not only did Scooby witness her Mother’s failed murder attempt, she witnessed her multiple rapes at the hands of Dad. Dad also physical and sexually abused Scooby. Dad is trying to stop Grandparents attempt to terminate his parental rights and get supervised visitation. Dad does not know where Scooby & family live and family plans to leave country if awarded full legal custody.

In my 30 minute call with this lawyer it became very clear that his view of mental health was limited to say the least. How serious is this selective Mutism thing ? Because he saw it on big bang ,but didn’t think it was real. Doesn’t Scooby know this isn’t normal? So Scooby didn’t speak to me either? Like even though she doesn’t speak, she can if she wanted to right? Like nothing was keeping her from speaking ? How do we have therapy is she won’t talk? Why doesn’t she trust me yet? How long until she will? But, perhaps my favorite question was….if you have to speak to other people in regards to Scooby how do you ensure you don’t break HIPAA?

It should come as no surprise that he would talk over me, dismiss my answer as wrong or that I wasn’t answering it the right way for 90% of my responses. He lectured a lot and would interrupt me to “think out loud” about many different things. The only thing that gave him pause was my very loud “under my breathe” of are you serious when asked how I don’t break HIPAA. He was unprepared for my tossing out bitch sprinkles when I asked “How do you not break ethical violations?” In his silence I pressed further with , “Like how do you stop yourself from telling me the details going in in cases with other clients?”

Not gonna lie it got pretty awkward as we stared at each other in silence

I fucking hate lawyers

Healing

So, with almost a year in the field doing clinical work I have noticed some things about people in the healing process. Bare in mind they are of different backgrounds, demographics and managing different illnesses or disorders and overcoming different traumas or set backs. They also have different aspects to their process that is as unique as them. But, below is some universal things I’ve noticed with my clients:

1) The more you heal the more comfortable you become with being the villian in other people’s story….many clients have expressed being comfortable having people unhappy with them when they stand up for themselves or protect their own peace and mental well-being.

2) Setting boundaries can feel weird, especially when you are a people pleaser….clients have vocalized the debate they have wondering if they are being mean or respecting their own feelings and limits. Mant clients also find themselves able to examine the role their self esteem (or lack thereof) contributes to their desire to please others. Recognizing the desire from validation and it’s connection to self worth can have a significant impact on people’s efforts to please others.

3) A reminder ,or almost an affirmation, that I like to tell clients is that if trauma can be inherited so can love, wisdom and emotional intelligence…..this simple affirmation can help when clients are in need of a reminder to their own strengths as well as the support systems they have.

4) A history of trauma can give someone a high tolerance for pain and clients need to learn that just because they can take it doesn’t mean they should. This involves some DBT practices to help clients to relearn their triggers and boundaries.

5) Many never get the apology they deserve ,and it is sorely needed. It is important to either reaffirm that apology as the clinician or to allow for a role playing discussion where they are told some version of, “I’m sorry they had the courage to hurt you and the cowardice to ignore it’s impact. “

Cry a Fucking River

Today I had my first appointment with a 6 year old girl. She is quiet, curious and sickly. She is sickly from the medications she’s on to treat the STD she got when her mother’s boyfriend raped her. By the end of the session I was rewarded with a smile.

She walked out the door and I put my head on my desk and sobbed. I cried a small torrent of fast and furious tears before fixing my face and greeting my next client.

If you are safe, if you are fed, if you are loved, accepted and supported …you are blessed.

….until next week.

The fuck

It has finally happened and the fuckery has reared it’s oblong shaped head.

Everyone fucks up, everyone has an off day and everyone rests comfortably knowing they will indeed make a mistake.

It wasn’t a colossal mistake, it wasn’t one that had dire consequences. Nobody was limping off the field or suffering a monumental breakdown. Nope, this was a wounding of the ego, a blow to the pride, where I was the only injured party.

While my night at the clinic ends at 8 pm, I usually wrap up anywhere between 7:15 and 7:45, leaving me enough time to write my session notes and do my charting. So , I should have tried to better prepare myself for a squeezed in session at 7:30.

This gave me no breathing room as a had a family session from 6:30 until 7:30 with a family of 5. The session was going well, I was observing how the children interacted while they played a game and was checking in with Mom and Dad about events since our last session. I had taken some notes, asked some questions and had just assigned some homework that I wanted them to work on during the upcoming month between sessions.

When I looked over and saw that it was indeed 7:30 and I had to do my best to get them out of the office without making them feel thrown out. Especially because I had to give my next client every one of the 30 minutes before the day ended. Which started a small mental brush fire as I already felt rushed knowing that I would have to finish every aspect of my notes during the session as I didn’t want to be the reason anyone was staying past 8.

So they kids were almost out the door and Mom and Dad were being gracefully rushed out when I looked at the hallway clock & noted that it was 7:03 and not 7:30. I practically exhaled the fuck as my face planted into my palm and I ushered the family back in with apologies and a feebly attempted explanation. With all the confidence I could manage I sat them back down and said with a chuckle, “Now that you’re confident in my superior abilities I’d like to ask you about….”

…..until next week .

Respite

The past few weeks have been constant motion of fast decisions, errands, work and feeling like I’ve been on call with no breaks. So much so, that when every demand met and responsibility taken care of the follow week seemed like it would be a cake walk.

How wrong I was. The slower pacer just made all my responsibilities and obligations feel as obnoxious and needling as a whiney toddler. On top of that the mental ,physical and emotional demands had taken their toll and I personally feel like a dumpster firing during in the middle of a shit show.

I also realized that all methods, moments and meaningful self care resulted in meeting the single goal of remaining present and grounded in what was happening. To keep me from letting my daughter’s moments and her deserved attention being lost and seeming like an obligation rather than the celebration it was.

So, now I sit here with the realization that it is I in need of some tender care, appreciation and relaxation. I needed the respite to allow me to refocus rest and heal , and I needed to pull out the big guns of a self-care routine put into overdrive.

If you’re anything like me, it’s hard to give freely and completely to yourself. Guilt will instantly remind you exactly who is counting on you and how they need you the second you consider lightening your load. To counter that I started my week using every minute of my waking hours to see to my obligations and responsibilities.

In those 1st two weekdays I got every chore and errand done. The shopping, the laundry, etc. That 1st day I meal prepped for the work week to make my life a little easier. I finished my homework and school obligations.

The next step in my self care arsenal was painfully boring. I ate well, got 8 hours of sleep each night, did a 30 minute workout every morning, and did not use my cell phone for at least 1 hour after waking up.

The next big gun was putting things down and leaving them there. When I finished work I didn’t bring anything home with me, when I finished clinical I didn’t think or check anything until I went back. I effectively kept home, work and school seprated in their entirety. Then on I took a mental health day on Friday.

I sat in my backyard and drank my coffee slowly, played with my dogs, weeded my garden, read a book and watched a movie. I ate what I wanted and didn’t feel guilty for having chocolate fir dinner.

The weekend saw more of the same, I went on a date with my partner ,spent time with my kids, had an adventure and went wherever the day took me with a friend. I had brunch, a massage, laughs and a nap. I listened to myself and my body about what it needed and I can already say I feel ready to start a new week.

……until next week.