When mental health professionals such as play therapists and family therapists are presented with new cases, there is much to be learned in a short period of time. Working together with the family, therapists typically review the family’s history and relationships along with the parents’ or family’s reasons for coming. Regardless of the theoretical orientation that guides therapists’ treatment work, most practitioners first work with the family to establish treatment goals and an overall plan for moving forward. This can be an overwhelming task for relatively new therapists, and even for experienced therapists when confronted with complex and/or multiple traumas, attachment disruptions, and a multitude of other challenging situations. Where does one start to tease apart the situation to determine which goals represent a starting place? There are no easy answers to this question.
I firsts developed the following guide during the years that I worked in community mental health (1978-1993). We used it in a community mental health center where I served as vice president of clinical operations, and applied it in most of the programs that were contained therein, such as outpatient therapy, day treatment, residential programs, substance abuse programs, and case management for children and adults. The guide was influenced by multiple sources at the time and earned the approval and praise of our state reviewers. In subsequent years, I have used it in my work in a medical center with chronically ill children and their families, in my many years of private practice with children and families providing play therapy and Filial Therapy for a wide range of difficulties, and as an exercise during professional workshops I have conducted on the topic as well as with many small supervision groups of mental health professionals, school counselors, and numerous play therapists. Most have found it useful, and I made revisions over time based on their feedback. It now is part of two online supervision courses that I have developed: A Collaborative Model of Supervisory Case Consultation for Use with Play Therapists and Family Therapists (to be available for purchase as a CE distance course here by the end of 2022) and Supervisory Case Consultation in Animal Assisted Play Therapy™ and Other Animal Assisted Interventions (2018; currently available for purchase as a distance learning course by contacting me here). It seems to have withstood the test of time, and now that I also work with animal professionals working with families and their companion animals, with some revision it likely has applicability there, too.
This article does not include all the information of my own or others’ “how to be a supervisor” courses. The focus is solely on the case formulation guide that might be helpful to clinicians and supervisors as well as other professionals who work with children and families. As written here, it mentions trauma, but it can be applied to most other problem areas. For more information about how this fits into the larger supervision picture, please see the links in the prior paragraph. To get an idea of how this guide walks you through the case formulation process, think of one of your clients/families and take your time working through the various questions.
Strengths and Needs
Consider the following guiding questions in as much detail as possible. Think as broadly as you can.
- What are the child’s developmental needs? At what age did the trauma occur? Where does the child seem to be developmentally? How is this different from what you would expect of children of this chronological age? Think of the many aspects of development (physical, cognitive, social, moral, etc.), and determine where there might be strengths and needs.
- What are the child’s physical and sensory needs? How does the child do with mobility, independence, general health, coordination, and immune system functioning? How does the child interact with the environment in terms of sensory functioning? Are there challenges with vision, touch, olfaction, hearing, taste, or perception? Are there sensitivities with any of these? How well does the child handle complex environments? Does the child have medical needs?
- What are the child’s clinical needs? What has been the impact of the trauma on the child’s emotions, behaviors, attitudes/cognitions? Remember to consider both strengths in this area as well as needs.
- What are the child’s relational needs? What has been the impact on the child’s attachment, security, identity, boundaries, and overall relationships (with parents/caregivers, siblings, peers, teachers, authority figures, etc.)?
- What are the child’s overall strengths? Include as many as you can. Think broadly. What coping mechanisms does the child have? What current maladaptive behaviors now might have been adaptive in the past? Could some problem areas, if they were less intense, be considered strengths?
- What are the strengths in the child’s environment/support system/family? Has there been someone constant and reliable in the child’s life? Are parents a support? Are siblings a support? Someone else? Has the child had a secure attachment relationship or several? With whom? Have extended family, neighborhood, community, school, religious organizations, community support organizations, etc. offered some form of social support?
- What are the environmental stressors for the child and the family? Do caregivers have unresolved trauma of their own? Could this interfere with the child’s trauma issues? How well is the child accepted and respected within the extended family, school, neighborhood? Does the child experience unkind behavior from others (obvious and subtle), or is the child subject to others’ negative biases and messages? (This can include racial, religious, gender, identity, and other forms of social prejudice, injustice, or cruelty). What aspects of the environment might have held the child back?
- What resources does the child’s family/caregivers have? What coping mechanisms do they have? How cohesive are they? How committed are they? Do they, as caregivers, have sufficient support?
Treatment Possibilities and Priorities
Next, consider the following points to hone in on intervention options and where to start:
- What are the most fundamental and/or most urgent needs of the child/family system? Safety? Trust? Crisis management? Night terrors? Secure attachment figure? (Consideration here includes the family’s perceptions of what is most needed as well as the therapist’s.) Consider the responses to the Strengths and Needs questions to help identify these. What areas seem to hold the child back the most right now?
- What are possible ways of helping the child/family move forward in a positive direction? Think of actual types of interventions, including nondirective/directive forms of play therapy, behavioral, educational, family, systems education/involvement, and other treatment methods. WHY do you think these interventions might be important for this situation?
- What are your (the therapist’s) skills, experiences, orientation(s), assumptions? Do you know HOW to conduct the intervention that might be best? Is more training needed? Is regular supervision needed? Scope of practice and amount of training in a particular intervention factors into this area. For example, it might seem that EMDR or Filial Therapy or Theraplay might be a good approach, but if the therapist does not have sufficient training in the area, they should not attempt to use that particular approach with the client. There are usually other options.
- Tentatively prioritize the interventions. Is crisis intervention needed? Could filial/family therapy be used right away? What are the least “intrusive” interventions? What interventions will stabilize the situation? What interventions have the greatest chance of success? Might it be useful to start with an easily attainable goal to help build client/family confidence and hope before tackling more challenging interventions?
- Draft an approximate “sequential order” for the interventions. Several interventions can occur simultaneously. What factors might influence your decisions? What factors might interfere with your decisions? How do the possible interventions fit with the client’s/family’s strengths and needs? What would be needed before you would move to the next interventions on the list? Be careful to avoid overloading the family with so many changes that they are overwhelmed and less likely to follow through.
- If in doubt about the course of action, obtaining supervision for the case might be the best route to follow. Otherwise, share the possible places to start with the family and determine if they see the value in it to meet their needs.
Complex interventions are often needed for complex challenges. It is important that therapists have sufficient training and competence in those interventions when considering them. (Shown here: preparation of a dog for Animal Assisted Play Therapy™, a far more complex intervention than many realize.)
Please remember that this is only a guide. It provides a way of thinking about cases, but child and family situations are all different, and even within the same family, things can change over time. We also can’t predict how children/families will respond to our intervention choices. Mutually developed goals are important, but there are often several routes to achieve goals. Rigid adherence to a treatment sequence without family buy-in can be detrimental. Therapy should be driven by the goals, not the specific techniques or methods. Most of all, therapy should be an interactive process between the therapist and the client parties involved, and stakeholders should play as active a role as possible in their own treatment process. Empathy and empowerment need to start with the very first interactions, operate throughout the treatment planning phase, and then during all the treatment. When questions arise about treatment efficacy or relevance, case consultation can be very valuable.
© 1978 (original), 2014 (revised), 2022, Play Therapy Press. All rights reserved.
VanFleet, R. (1978, 2014, 2022). Case Formulation Guide for Professionals Working with Children and Families. [Indiana, PA: Transitional Living Program (1978)]; Boiling Springs, PA: Play Therapy Press.
Dr. Risë VanFleet is a Licensed Psychologist (PA), Registered Play Therapist-Supervisor, Certified Filial Therapy Instructor, Certified Dog Behavior Consultant, and Certified Animal Ethology and Behavior Instructor with 48 years of experience in a variety of mental health, medical, and educational settings. She is the founder and President of the Family Enhancement & Play Therapy Center, Inc., in Boiling Springs, Pennsylvania USA. She has trained and supervised thousands of professionals throughout the world, and her dozens of books, chapters, and articles have been translated into numerous languages. She is perhaps best known for her work in disseminating information and training in Filial Therapy, which she learned from its co-creators, Drs. Bernard and Louise Guerney, as well as the creation of Animal Assisted Play Therapy™ with Tracie Faa-Thompson of the UK, which is a multidisciplinary approach to involve animals in play therapy, family therapy, and psychotherapy in a relationship-based manner that fully attends to the needs and preferences of the animals as well as clients. She is the recipient of 18 distinguished national and international awards for her training programs and writing. Her websites are found at www.iiaapt.org and www.risevanfleet.com.