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developmental practice

Matching therapeutic style with developmental level

Thomas P. Oles

For quite some time child care workers in residential programs have used developmental perspectives, principally those of Erikson and Piaget, and more recently Kohlberg, to define their expectations concerning residents and their behavior. However, the relative paucity of therapeutic principles and techniques specific to developmental stages, which could be applied by child care workers in their daily interactions with the youth in care, is a serious limitation of these perspectives. Consequently, child care workers are often good at recognizing behavior as developmentally appropriate or not, but they have only the most general of techniques to apply in the service of promoting development. Indeed, most of the intervention techniques available to and used by child care workers, while supportive of development, are not specifically referenced to promoting developmental progress. Recent work by Ivey (1986) remedies this problem by offering specific guidelines for using a cognitive developmental assessment in clinical interventions. This paper will discuss these guidelines and build upon them to improve cottage-based interventions with youth in residential care.

Background
The importance of recognizing cognitive capability in our work with children cannot be overstated. We routinely expect the children in care to cope with the demands of a completely new social system. In addition, we expect them to be in therapy to resolve any characterological problems that have developed and further, to participate in profound changes in their family's function: sophisticated challenges for anyone! How youth make sense of these experiences, how they gain perspective and proceed in the face of overwhelming anxiety and challenge is of critical importance to anyone who wishes to help. Recognizing how the youth in care construct and understand the world allows child care workers to modify the interventions used so that they are complementary to the youth's ability, Rosen (1985) discusses the lack of clinical prescription in Piaget's theory and offers three ways in which Piagetian psychology may be clinically relevant and helpful: 1) as a way of expanding our use of other Current approaches; 2) as a perspective for matching what we do to a client's developmental level; and 3) as a set of goals for psychotherapy. His points are well argued, they articulate more clearly what many child care workers already do intuitively, and they are worth thinking about more. His discussion, when applied to child care workers, suggests that residential treatment centers have not fully exploited the usefulness of cognitive developmental approaches for treatment planning.

To maximize the utility of developmental perspectives child care workers would need to: 1) describe programs or interventions in ways that are complementary to the resident's means of understanding (even when this means that the same program may be framed differently to different youth who are in the program simultaneously); 2) use cognitive-developmental perspectives to inform routine interventions and discussions with the youth in care; and 3) make the promotion of age-appropriate cognitive functioning an explicit goal of child care programs. Before illustrating the use of a cognitive-developmental perspective in these ways a brief discussion of Piaget seems sensible.

Piaget identified four principal stages of cognitive development in youth: 1) sensorimotor, 2) pre-operational, 3) concrete-operational, and 4) formal-operational (Phillips, 1969, p. 63). In his view, each stage was characterized by a type of reasoning or a way of knowing the world which both defined and limited the coping strategies and capacities of the child. In addition to the skills acquired in each stage, a sense of perspective on those skills was crucial to further development; that is, higher order thinking is dependent upon the abilities developed in any stage as well as a sense of the implications of those abilities.

This latter point is particularly important to the notion of using cognitive-developmental perspectives for goal-setting, I cannot count the times that a resident in care has told me how she used to think about a problem and how her former way of thinking had limited her capacity to handle that problem. It is this sense of the limits of previous modes of thought that provides a context and incentive for working with adolescents around a goal of further development. Teens have a sense of themselves as growing and developing; they find the suggestion that they will think differently in the future sensible, and they resist a focus on how they approach problems much less than they resist a focus on the problems themselves. Developing goals along developmental lines is easy, and because it is “normal” (even reassuring) to develop, youth are far less resistant to it. Briefly, in the sensorimotor stage children are submerged in, and reliant on, sensory stimuli and bodily expression; in the pre-operational stage children begin to use language and symbols, they begin to understand past and present, simple causality, and to develop moral judgments; in the concrete-operational stage they are interested in how things work and they are capable of consistent and logical thought; and in the abstract, or formal-operational stage, adolescents can use hypothetical and deductive thought, are capable of considering the effects of different courses of action, and are concerned with symbolic issues such as identity and justice.

To Piaget, this developmental sequence was a predictable outcome of four basic processes: heredity and physical maturation; interaction with the environment; social transmission and equilibration; and, the process of moving from stage to stage. In the most general sense residential treatment centers already provide programs consistent with promoting development. All centers value good nutrition, recognize each child's unique genetic endowment, provide an appropriately stimulating and challenging environment, and put considerable effort into providing good information and formal skills training. Few, however, have been able to individualize a focus on promoting development. Rather, child care workers have had to take it as a matter of faith that through the consistent provision of the above the child would grow and develop. They often do. The demands for shorter stays, however, require more intensive and individualized cottage treatment programs.

Contemporary child care work requires the ability to recognize a child's cognitive-developmental level and the ability to think comfortably about and talk with the youth in care using whatever mode of thinking is most consonant with the youth's ability, While the notion of matching the mode of transmission to a child's level has been recognized for over 20 years, too little attention has been given to the lifespace implications of a child's modes of structuring knowledge. Jerome Bruner (1966) articulated the importance of the mode of presentation in education and identified the enactive, iconic and symbolic modes as the principal means of structuring knowledge. Since then, curriculum and formal skills training programs have stressed the importance of requiring students to use all the learning modes, and to some extent, a differential emphasis on mode depending upon student characteristics has been advocated. Too often, however, child care training programs have tended to treat the concept of mode as a static and technical concern. That is, child care workers are trained to structure formal programs with an eye towards a balance with respect to the learning modes required and to be alert to a youth's preference, but they have not been trained to see a child's mode of structuring knowledge as a key ingredient in how the child experiences and uses the invisible curriculum of the program's daily structure. Moreover, no attention is given to the cognitive demands which a cottage program's therapeutic style presents to the child.

In Developmental Therapy, Ivey (1986) articulates a concrete system for making a cognitive-developmental assessment and then using that assessment to set goals and decide upon an appropriate therapeutic style. His work is extensive and rich in detail. The approach he describes for therapists provides a powerful model for use in developing life space interventions.

From Ivey's perspective, personal problems result when the youth is “stuck” with understandings and, perhaps more importantly, means of understanding that simply do not work. What he suggests is that people work on and present their concerns utilizing, with various degrees of effectiveness, several kinds of cognitive approaches at any time cognitive approaches that may be regressive or progressive, rigid only in this one context or representative of the youth generally. In any case, the core of the approach he has developed asks the counselor to make an assessment of the particular mix of cognitive strategies the youth is utilizing and to use that assessment to decide upon the goals and method of helping. Interventions can be organized to challenge the youth to think in new ways or organized to support the youth's present strategy for coping.

Assessment
The advantage of a cognitive-developmental assessment is the efficiency with which it captures essential characteristics of the child and the child's difficulty while usefully guiding intervention along a predictable path. What Ivey has done that is so very helpful is to match therapeutic styles with Piaget's stages of development. Figure 1, developed from Ivey's work, lists behavior that is indicative of cognitive functioning at a particular level and then suggests what therapeutic style is appropriate for youth at that level. Child care workers can use the chart to reflect upon the behavioral presentation children make and. then use the suggested style to enact the cottage program or develop individualized interventions.

The chart can be adapted for use as an in-house assessment tool. It is brief and concrete, relies on the child care worker's own observations, and it is complementary to intervention styles already in common use among experienced child care workers. It is also an excellent way to structure discussion in staff meetings and supervision. Indeed, I have used the chart as a way to help workers think about the children whom they are most adept at helping and those who they are not. It is always interesting and frequently helpful. Below I will illustrate how to use a cognitive-developmental perspective in this way through the description of two case applications taken from personal experience. Both involve recent admissions struggling with issues of separation and loss.

Sue
This is the first time Sue has been in placement. Both of her parents, who are of limited intelligence and have lived in an urban area for less than ten years, are suspicious and hostile. Neither seems to comprehend why Sue was removed from their home and they cooperate only minimally with the agency at the time of referral and placement. Sue is the youngest child and the second girl in the family. Her brothers and father are well known to the police, and although they have done time in local jails, none has ever been imprisoned for longer than 30 days. Sue is ambivalent and confused and presents as vulnerable to frequent emotional outbursts and severe tantrums. She does not respond to discussions about when she will be able to visit home or what the consequences of misbehavior might be. Her behavioral difficulties, particularly her aggressive acting out, become increasingly evident as bedtime approaches. She is potent enough to have the whole cottage on edge as the evening wears on and at bedtime she cams down and sleeps only after provoking a restraint and sobbing uncontrollably in her worker's arms.

Figure 1

Patti
Patti is as upset and vulnerable as Sue. She copes with her concerns through a careful investigation of all the rules and roles in the cottage. She wants to know, preferably in writing, exactly what she has to do to get out and she seems to be taking her placement in stride. Indeed, her behavior is exemplary and she earns a substantial allowance and privileged status her first week in the program. Her behavior is so contrary to that described in her records that everyone is wondering why she was placed.

Ostensibly, these two young women are in the same situation. In both examples we would be inclined to see each of their needs as resulting from loss and separation. Our goals would be to help the child grieve over the loss, adapt to placement, and to help her resolve to use the program well. Because each of these teens make sense of the world in completely different ways, they will require very different kinds of support, even though the goals of the grief work will be the same in each situation. The inclination to develop a consistency of approach to similar types of problems, in this case those associated with separation and loss, needs to be resisted if child care workers are to individualize their approaches to different youth.

One insight that has been helpful to me in this regard is the work of family therapists and psychologists who have laid aside the assumption that emotional systems constitute a single reality for all members. Indeed, Plomin and Daniels (1987) and Daniels, Dunn, Furstenberg, and Plomin (1985) demonstrate that families are in fact “unshared environments” with respect to many crucial dimensions of social life. While most of this work focuses on well- known family composition variables such as sibling position and gender, the examples above suggest that cognitive developmental level may be another basis for seeing members of the same system as having substantially different subjective realities. Recognizing that children in the same program experience very different realities is an important pre-condition to genuinely individualized interventions.

The two brief behavioral descriptions are sufficient for making gross assessments of a child's predominant cognitive style and for making tentative plans for intervention. It would be sensible to conclude that Sue was coping in, or through a sensorimotor mode. The skills associated with an operational or abstract level of functioning are clearly lacking. At the same time the use of sensorimotor modes is evident. This does not suggest that Sue cannot utilize operational or even abstract modes (indeed, she does junior high level-work in school); it only indicates that at this time with this problem she cannot. We can also recognize that Patti is functioning through a concrete operations mode. She is making sense of the world in a way that is more effective than Sue's approach, but at the same time there are inadequacies in her approach. We wonder about her lack of emotion and are concerned that feelings denied will result in her being vulnerable when stressed. We speculate about what will happen when she fails at being perfect and what will happen if (when?) her peers reject her for being a “junior house parent.” Will her feelings be available only then and will she regress and act out destructively? Or will she be a kid that skates through largely untouched by our very real concerns?

Intervention
After establishing a sense of where the child is developmentally, the next step is to assess whether the goal should be to consolidate the functioning at the level presented or to challenge the resident to utilize functions associated with the next stage. In this regard Ivey's Developmental Therapy is an advantage over the focus on mode that many child care workers have adapted from Bruner. The closer attention to Piaget provides a sense of what is (or should be) next and provides a basis for thinking about whether to challenge or sustain.

Given how often new behavior is enacted almost by chance, and how often the best a child care worker can do is reinforce behavior after it has occurred, a sense of what is developmentally progressive and how to support that progress is very helpful. Given the sense of crisis and the very basic level at which the first girl is functioning, the best approach is organized around the theme of consolidating her functioning at the sensorimotor stage. This would take the form of interventions designed to care for her proactively at the physical level, tuning into and responding to her nonverbal cues and supporting the development of relationships that do not require discussion and acceptance of therapeutic terms and conditions (each of these approaches would require higher order cognitive functions).

With this type of plan, change is likely to come when it is not expected “perhaps with the request for something to be done exactly the way it had been done before “and the child care worker's task is to develop consistent and reliable routines of caring for the youth. With the teen upon which this exemplar is based the serendipitous application of skin lotion following bath one evening led to the development of a nightly ritual of applying skin lotion to her back. After a couple of evenings of this ritual, the child care worker was sensible enough to note to Sue that having skin lotion put on seemed to result in bedtimes with far less upset. She speculated that perhaps Sue now knew a new way to handle her feelings of sadness about being away from home. Sue agreed and in a very short time was saying that she would not need restraints if she got skin lotion after her bath. It is clear that getting lotion put on after bath is soothing on the sensorimotor level and it is the kind of intervention that child care workers do all the time. It is also sensible to see beginning pre-operational modes in the perspective Sue has taken on her experience and, as she settles into the cottage, we can anticipate planning for her to take over the application of the ritual.

This exemplar also illustrates how tying intervention to developmental level, rather than learning mode (recall Bruner), increases the child care worker's sensitivity. The developmental perspective suggests the next step in the process, recognizes that several modes may be operating at once, and offers the child care worker a sustaining perspective on her work.

There is no sense challenging this almost magical faith in the lotion ritual and demanding that Sue adopt more age-appropriate strategies at this point. The conservative position is sensible: a ritual that is sensorimotor though functional in many of its essentials does no harm and we are prepared to respond when she signals she is ready. The child care worker can look for opportunities to anticipate and reinforce increased self responsibility for the lotion ritual and/ or experiments with functioning without an immediate effort to transfer responsibility for the behavioral improvement from the ritual to Sue. With Patti our approach would be best organized around challenging her to adopt a more sophisticated approach. Her reliance on a concrete operations level mode is in many respects successful: it is intentional and directed, it diminishes the sense of crisis, and it concretely resolves her problem as she sees it “do what it takes to get out. At the same time the approach also gives her the means to consider and modify her own efforts if they are not adequate. By using the intervention style of teacher and coach, the style that complements this stage, we can challenge her to try new modes of approach and to grow.

The first step is to assure ourselves that she is getting all that she can from the concrete operations approach. This stage of the work took the form of developing with her a “problem-solving chart” with one column being problems and another being solutions. Her idea of the problem was “being placed” and her goal was to get discharged fast. Her idea of a strategy was to do whatever she was told. We added being “bummed out” to her problem list and while reinforcing her to approach placement as sensible (we like obedience) and effective (it does indeed work) we challenged her view that being good was sufficient to take care of being bummed out.

The challenge took three specific forms: 1) we asked her to consider some if/then questions in regard to what she would do if this behavioral strategy didn't work with respect to managing feelings: 2) we asked her to consider ways in which her current approach was representative or patterned: and 3) we asked her to evaluate the pattern. The plan challenged her to think more abstractly: if/then questions required her to manage two variables at once, and we organized child care workers and teachers to be on the look-out for situations in which she avoided or denied her feelings in routine problem solving. They would then feed back to her their observations on the efficacy of the pattern. They were also prepared to recognize and reinforce those situations in which Patti had integrated a strategy for managing her feelings in a problematic situation and to make sure when that occurred that Patti would get a sense of perspective on having done that.

The plan accomplished our goals. By providing demands for more mature thought, we were able to move on our concern about her lack of attention to the affective domain and we introduced some flexibility into her coping approach. Interestingly, by focusing our observation and feedback efforts on her attending to feelings we were able to help her discover that she was already doing it some of the time – principally in the school program. She would ask for time out when she was too frustrated to work and she would return to task when she was ready. She knew that she would do a poor job if she continued her school work when upset so she took care of her feelings first. The process of managing feelings as a separate problem in school was presented to her as analogous to having to do grief work as part of adapting to placement and putting together a better discharge strategy. The approach was very helpful. Patti made better use of her time with the social worker, was less vulnerable when she received negative feedback, and began to focus negotiating on the terms of placement rather than simply “being good.” In both of the situations discussed above a cognitive-developmental schema was used to assess the resident's developmental level and to organize a coherent response to a problematic situation. By matching therapeutic style to developmental level. the child care worker's therapeutic power is enhanced and the resident's treatment is more proactive and individualized. Moreover, the focus becomes nonnative and progressive rather than problem focused.

Discussion
This paper has provided guidelines for matching a child care worker's intervention style with a resident's developmental level. The guidelines improve the child care worker's ability to use developmental assessments in treatment planning and routine lifespace intervention. The discussion focused upon Piagetian perspectives on development, partly because of their continued relevance and partly because of their widespread use. However, the approach advocated here (identifying styles of intervention most helpful to youth of particular developmental levels) is applicable for use with other theoretical orientations to development “Kohlberg's (1969), for example. Since developmental perspectives are well established in residential treatment programs, experimentation with matching therapeutic style to developmental level offers the promise of making child care workers more effective in an environment demanding ever briefer lengths of stay in residence.

References

Bruner, J. (1966). Toward a theory of instruction. Cambridge, MA: Harvard University Press.

Daniels, D., Dunn, J., Furstenberg, F., & Plomin, R (1985). Environmental differences within pairs of adolescent siblings. Child Development, 56, 764-774.

Ivey, A. (1986). Developmental therapy: Theory into practice. San Francisco, CA: Jossey-Bass.

Kohlberg, L. (1969). Stages in the development of moral. thought and action. New York, NY: Holt, Rinehart and Winston.
Phillips. J.L. Jr, (1969). The origins of intellect Piaget's theory. San Francisco, CA: Freeman and Co.

Plomin, R, & Daniels, D, (1987). Why are children in the same family so different from one another? Behavioral and Brain Sciences, 10(1), 1-60.

Rosen, H. (1980). The development of sociomoral. knowledge: A cognitive structural approach. New York, NY: Columbia University Press.

Rosen. H. (1985). Piagetian dimensions of clinical relevance. New York, NY: Columbia University Press.

This feature: Oles, T. (1991). Matching therapeutic style with developmental level: A guide for child care workers. Journal of Child and Youth Care. Vol.6 No.3. pp.63-72