A Strategic and Therapeutic Protocol for Adjustment Disorder in Custody Cases
Most clinical counselors have had children with adjustment disorder as a result of their parent’s separation or divorce come through their counseling room. It is truly ubiquitous that most kids live in at least two homes if not more. Many clinicians avoid these kinds of cases like the plague, because they are difficult to avoid being triangulated into. But these kids do need help, and if we decide to take such cases, we would do well to have a clear plan for ourselves as helpers and change agents.
The primary reason for the use of a protocol and strategy in such cases is to help the child(ren) to be relieved of their stressful symptoms; adjustment disorder symptoms can increase to levels that spill out from the family context into school and community, and left unaddressed, have the potential to become more severe disorders such as oppositional defiant disorder, anxiety, depression, and even conduct disorder.
Another important consideration for using a protocol for approaching cases such as this is for the clinician to avoid being triangulated into the custody battle that is inevitably going on. Many parents, bringing in their child ‘to talk about the divorce’ with the counselor, will eventually begin to pressure the clinician to come to court and testify. When a clinician does this, they have been triangulated into the discord, have become a tool for an attorney to get a ‘win’, and have become useless in the therapeutic effort.
It is noted that some parents seek out counseling ‘for the child’ to see if the child’s symptoms can be reduced so that the parents can continue their contentious relationship guilt-free. Other parents seek out counseling ‘for the child’ in order to seek a professional ally against the other parent in court. Effective clinical counseling refuses both motivations for children who need their parents to stop the behaviors that cause the child’s symptoms. Some parents engage briefly in counseling, and then reject the effort as not suiting their needs or desires, or realize that the clinician is not going to ally with them the way they anticipated.
Calming the damaged family system is a key strategy. Reactivity between ex’s in such situations is rampant, and is the genuine toxic reason for the child’s adjustment issues, not living in two different houses and having two different tooth brushes (if only). Until the reactivity is lowered, neither parent will be able to listen well enough to learn the proper boundaries and limits on their communications with their ex, and begin to honestly and effectively co-parent their child.
Another key is to begin to educate clients, attorneys, and judges about how such a therapeutic protocol works, and the value it may represent to their prospective functions. Most judges would agree that clogging up dockets with frivolous family court issues is a waste of time, money, and people’s serenity and joy in life. Attorneys may not have such a positive view of the protocol, as they are habituated by their profession to see their process as essentially confrontational and ‘win’ oriented. Some lawyers have no real economic investment in calming people to reason, because if the parties do this, there are fewer court actions for the lawyer to earn income. Wise attorneys, though, may discern that they can still earn a living by helping folks go through needed legal processes (like custody orders) with as little conflict as possible. They can make up their income by becoming known for a relatively painless custody process.
Any strategy and protocol must anticipate difficulties. As hinted at in the previous paragraph, some attorneys are seeking ‘wins’ a means to enhance their reputations, and may press to subpoena the clinician to court. Clinicians should know that this can be very tricky, as in some courts, they will be essentially asked to testify as an expert, and not just the treating clinician. Most codes of ethics clearly state that clinicians are breaking the rules by entering a ‘dual role’, and can be disciplined by their board for so doing. If forced to testify, the clinician has an ethical responsibility to remove themselves from the clinical case.
Additionally, when a child's legitimate anger resulting in estrangement presents, direct repair needs to be made between that parent and child in session surrounding the child's anger at the parent. If a situation arises where there is suspected active alienation going on, the court needs to be open to the clinician contacting the judge directly to advise the judge that an independent (not the treating clinician) qualified professional assess the situation and then advise the court if there is active alienation going on. it is imperative for the court to understand that the treating counselor cannot ethically perform in a dual role and advise as a neutral expert on the alienation possibility.
People usually divorce for reasons, and one important reason to recognize for the clinician is that there are parents involved in such cases that can be described as ‘difficult personalities’ in the least, and ‘Personality Disorders’ at the worst. When a parent is hostile to a therapeutic engagement and process, there is clear danger of making things more difficult for the child than if counseling never started. The hallmark of personality disorder is the ability to ‘poison’ positive efforts and people via a plethora of subterfuge, manipulations, and alienation tactics. In such cases, the protocol must be carried out with iron-clad resolve and to the letter. Done in this way, the outcomes (or lack positive outcomes on the side of the difficult personality) should be obvious to the judge.
It is very useful to establish an important basic of the working contract for treatment: the clinican's clear verbal and written position on not being involved in court actions regarding custody of the child(ren). This waiver and discussion should include the rationale for the clinician not going into court, as well as the stated consequence of being forced to do so (releasing work on the case, and associated fees and who will paying for appearing).
In most cases, one of the parents bring the child(ren) in at the first session on the premise that the child ‘needs to talk to someone’ about the divorce (as if any child under age ten can articulate or gain insight into what is going on that is creating their symptoms!) Gentle, initial assessment of the child can take place in this session, but more effort should go into beginning the education process for the parent present, followed by another session just for the other parent. Subsequent sessions should focus on the reduction of the mutual reactivity between the two parents, instead of excessive entertainment of their complaints against each other. Each parent should also be seen intermittently with the child(ren) to coach the parent in how to talk (or more accurately, NOT to talk) about the other parent and the other home. If possible, the child should be seen alone intermittently to check on their experienced symptoms and help the child with any confusions, emotions, or difficult behaviors.
Judges may in fact need to be apprised of important facts of the counseling process in relation to the custody issues of the case, and these can be provided via a ‘Course of Treatment Report’. This report should include the basic biographical data of the child, the dates of treatment sessions and attended by whom, the goals of treatment, and progress on the goals. It is important to keep the report brief, and not turn it into a multiple page history. Just the basic facts will do. An addition of a ‘projected course of treatment’ is advisable. The point of the COT report is not to include anything that could violate confidentiality of session material, provide any ‘expert’ or ‘opinion’ material, or present any material that is not genuinely needed to inform the judge of the status of the treatment. The data presented in this report should be able to clearly assist the attorneys and judge to discern if each parent is engaging in and cooperating with the treatment effort for their child (see ‘Assessment of Progress on Goals’ below).
Primary Goals of Treatment
The primary goals in cases of adjustment disorder as a result of parental separation or divorce is to calm the family system from a state of mutual reactivity so that parents can learn to communicate and co-parent effectively. This usually results in positive returns for the child in a reduction of symptoms.
Parental reactivity (‘ex’s’) often have a difficult time in easing their reactivity towards each other, despite counseling efforts to do so. Some accept learning the skills taught in treatment, and begin to use them to ease the reactive process, while others either reject the teaching or decide not to use the skills. In many cases, only one parent is willing to engage in treatment and/or follow through with skill use.
Because the child is under excessive stress, the child is not worked with directly, or very little, as pressing the child in therapy conveys to the child that they are the problem, when in fact it is the parents that are the cause of symptoms in the child, and it is they that need the counseling.
The child, of course, needs to be directly assessed for level of difficulty, as the presenting parent(s) may be exaggerating the behavioral signs and symptoms of the child for the purposes of gaining ammunition for court against their ex. The assessment and direct therapeutic process with the child need not be detailed here, as it is beyond the scope of this article, and the clinician should be well versed in such work.
Assessment of Progress on Goals
A review of the sessions completed should give indication of each parent’s investment in the counseling process.
The outcomes of the treatment effort can be assessed easily by the court by noting the parent’s engagement in the counseling process (data in the COT), use of learned skills from counseling (self-report to judge), a marked reduction of the child’s symptoms (parent reports to judge), and the slowing down and even cessation of court actions and counter-court actions in regards to custody. Generally, it can take six months or more of counseling effort to help contentious parents settle their reactive stances where they are co-parenting effectively and the child’s symptoms are reduced, if both parents are genuinely engaged and buy into the premise of counseling. At times, only one parent ‘buys in’ to the counseling process, and progress can still be made, albeit slower.
Projected Course of Treatment
If both parents have engaged honestly and with good faith in the treatment process, the projected course of treatment can progress quite rapidly, even concluding within six or eight sessions, and possibly eliminating further litigation. While custody orders are still a very good idea to keep all parties following an agreed upon plan, it is the court’s responsibility to follow up and see that individuals are doing what was ordered and what they agreed to, not the clinical counselor’s.
Clinical counselors can encourage parents to be patient and engage in treatment that can ease adjustment disorder in their child(ren), but they cannot pursue them or force them into such efforts. As long as one parent engages honestly and faithfully in treatment, a child’s symptoms can be reduced.
When any parent sees the counseling process as either a tool to exact revenge on an ex, or an unnecessary annoyance, this will at least slow down progress and at worse, completely stall treatment and begin to unfairly triangulate the clinical process into the parental contentions.
If the treatment protocol is used, and a parent with a difficult personality decides not to be cooperative, or subverts the process, this should be readily evident to the attorneys and judge, and relieve the clinician from having to go into the courtroom, possibly damaging the therapeutic process that is still going on with the more reasonable and positively working parent and child
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