On The Theoretics

My first professional role model was one Mary Rygg, MSW, among other roles in her life a volunteer counselor at Karma Clinic. The service arm of Everett, Washington’s non-profit Drug Abuse Council in the early 70’s, Karma was a takeoff on the Haight-Ashbury Free Clinic, providing help aimed primarily at “street youth”. In reality, the NPO was a subsidized community service that provided counseling, medical services, an off-hours crisis phone, and the occasional “flying squads” of young volunteers that went to a home situation screened by the clinic’s 24 hour  phone service. I went on occasional flying squads. As assistant director but like most everybody else working and volunteering in the place, I was in on-the-job training.  Later in my career, I came to understand the flying squad service to be borderline crazy, given a couple of really sketchy situations encountered. But we were young during an expansive era, and we were a part of the broader ‘movement’, so to speak. On the whole, we did good work.

Mary, on the other hand, was as straight as could be. At that time in her late 50’s, she was a faculty member of the UW Hospital’s Division of Child Psychiatry field training unit, Clinic 10. Beginning in the late 50’s, she was an early student of Satir’s, and became a field instructor for her, becoming one of Satir’s so-called ‘Beautiful People’. Mary was also particularly concerned about the drug abuse problem at the time, something that had struck her family, hence her involvement at Karma. We as staff were particularly fortunate.

In one of those impromptu, free-hour lessons, Mary talked about the different way Satir viewed the etiology of mental health problems. Now referred to as circular reasoning (see Wikipedia entry on Family Therapy), the belief was that dysfunctional patterns of family interactions were pedominantly responsible for the creation of most mental health problems, this in contrast to the professional standard then and now that problems were the result of individual psychology and experience, a.k.a. linear causation. To the circular causation way of thinking, family therapy was the most logical approach to mental health treatment – change the dynamics of family interactions in a guided setting, facilitate healthier interactions, improve the mental health, and diminish the “problem” behavior, mood, and/or thoughts.

For us boomers, the era of the sixties through the mid-seventies was the pursuit of a social reformation on a grand scale, now viewed by many if not most as quixotic, but at the time we were dealing with a thoroughly ghastly war in addition to wide discriminations and gaps in social well being, so something deep must have been amiss nationally. Many of us working in mental health were drawn to the alternative. 

As an extreme example, popular Scottish psychiatrist R.D. Laing, who at some point touted the healing properties of LSD and thus evolved into something of an icon to the counter-culturalists, postulated that an individual’s schizophrenia resulted from seven consecutive generations of double-binding within a family tree. At Karma, we doubted this based on our experience with a couple of local schizophrenic kids who hung around the clinic’s living room. So did Mary, but the more general notion of family communication issues as the major contributor to mental health problems struck a chord and we absorbed to be better at what we did.

Mary conducted a few planned in-house trainings on Satir’s methods and her own extrapolations. We took on Mary’s beliefs. I began to dabble. In her role as a UW faculty member, Mary also conducted trainings for child psychiatry fellows and residents but included us MSW practicum students placed at Clinic 10 as well. I began to incorporate family work into my regular caseload maintained at Counterpoint Clinic (a staff break-off from Karma more dedicated to counseling per se). Like for most practitioners, an individualized method started to grow. 

In fact, clinical thinking based on linear causation theory remained the mainstay. The symptoms get identified, the diagnosis comes next, followed by a clinical formulation about what went wrong in the past, what might go wrong in the future, and a skeletal intervention plan. Then the interventions begin. Given that formulations are essentially hypotheses, re-formulation and adjustments naturally occur as more information emerges and more treatment has its impacts. Take the case as far as possible, learn, finish, and move on. 

Mary taught that the circular-type therapist gathers the family together and is “treating” at the very outset. Communication problems become evident and get addressed by mostly using experiential techniques. Change and Improvements are processed between the family members with the clinician’s assistance and guidance. The family stops or phases out when ready. 

I didn’t use that model in its full scope. Most every other training, supervision, consultation, and class taken were rooted more in linear methods of problem formulation and resolution. My own work used a family format to the degree possible and feasible, exhibited both linear and circular concepts approaches. Formulate, calibrate, treat the symptoms, address the diagnosis, facilitate more functional and closer relationships, recalibrate, and so on to what hopefully is a healing end. The circular reasoning approach is clearly evident in the on-going therapy.

Orientation To The Content

After leaving Children’s Hospital, the creation of a therapy process for private practice began. Without any specific intent other than continuing to do what I knew how to do from a half dozen years earlier, the task was to create something that worked for the clients and make a living. Maybe 90 – 95% was in place by ten years. The process was essentially organic – “a systematic arrangement of parts; organized; elements fitting together into a unifiedwhole” (dictionary.com).

To reiterate, all outpatient mental health therapy processes get individualized by the practitioner to one degree or another, particularly important because of the assumption that the clinical relationship is an intrinsic element of clinical work. The presumption is that a clinician functions best with techniques that have a demonstrable effectiveness, and perhaps just as importantly, something in which they have an abiding belief, something that feels good. The reader will hopefully take away information and techniques that can be incorporated into their own work.

As discussed a bit in the last post, repetition can be seen as a clinical aid or tool itself. If a clinician uses one tool or ploy often enough, how people react to the use becomes an evaluative element in and of itself. If the tool is used repetitively over time, the clinician can observe how the client changes their responses over time. Simply noticing that improvement to the client is providing random, unanticipated reinforcement, which itself is the most impactful type of reinforcement. And if a decline is noticed, the therapist can explore that in one way or another and help turn the direction around.  

This repetition quality is also a facet of a personalized approach. Not everyone is so inclined, The experience here has been one of appreciable effectiveness, not universal by any stretch but that’s for the geniuses in the field amongst us, and that I’m not.

First Phase Process Outline

The purpose here is to offer ideas and tools that have worked effectively, and not a comprehensive template of treatment process. Pick and choose.

The first four sessions evolved into a structured problem formulation process itself, along the lines of the linear model. In the first conjoint sessions, which include the fourth session, themes out of the circular model begin to emerge. Most of the intervention techniques came out of the behavioral school, as differentiated from dynamic insight or experiential models.

In this practice, the initial contact with someone seeking help was always by phone. Rarely would someone email or text about availability and other questions, although that may have changed substantially just in the past five years. Those who did so were asked to phone. Whether they did or not is an unknown since the situation hardly ever arose.  That first contact establishes the need and confirms that the problem(s) are within the range of my casework.

The first meeting is with the parent(s), and provides a global view of the family composition and history, the current problems, reckoning with administrative and logistical matters, and discussion of the overall process that would be anticipated. With the rare exception, the result is a verbal agreement to continue the work. The exception is when the parent decides not to continue, either based on the experience, a coverage issue, or some other clinical expectation that could not be met. 

The second meeting is with the youth individually, age 4 to 18+, for an assessment. What emerges is a picture of symptoms, a tentative diagnostic hypothesis, their perspectives, evident strengths, and an initial reaction to relational skills. The meeting establishes the problem baseline, and aims to facilitate a sense of calm and confidence for the new client who was usually nervous or wary at the outset.  

The third meeting is a summary and recommendations session with the parents. This meeting completes the initial problem formulation and establishes a consensual treatment plan. Some elements of treatment are quietly implemented during the discussions.

The fourth meeting is with the client, the parents, and other children in the family who will be participating, and is broken into two sections. The first elicits what each person wants to see “get better”. This activity provides the initial clinical baseline. In the second half, the family plays a game. I observe, may ask unrelated questions, get to know them a bit less formally, and perhaps coach a bit vis-a-vis the game itself. Based on the in vivo observations, the game activity also helps establish a direction in terms of relational work to be incorporated into my clinical baseline.

Except in the broadest of terms, the formulaic session structure ends at this point. The fifth (or occasionally the sixth) session begins the regular family therapy process. 

Helpful Prerequisites

In my opinion, four basic clinical skills and one educational experience are prerequisites to doing family therapy. First is the ability to establish a clinical relationship. The second is doing an individual assessment and formulating the problem for treatment. The third is comfortably managing a clinical session from beginning to end. The fourth is recognizing the need for consultive help. The educational experience would be sufficient training and/or observational opportunities to develop an assuring conception of one’s own case process.

Once comfortable in the family therapy setting, one will likely find that the format is easier and less taxing than individual work. In one-to-one, the therapist is ‘on’ all the time. Marital therapy involves a threesome, and any triangle has its own encompassing dynamic. There the therapist is also ‘on’, although to a lesser degree than in individual work. With families of three or more, the therapist eventually can sit back and just watch while the others interact, coming in when necessary to share observations, suggestions, or reinforcement. As the process develops, they often do so for longer and longer periods in session. That’s easier work, certainly less taxing. The side benefit of the conjoint approach is that kids will randomly laugh during the family time, and that can be infectious to everyone else in the room. Nothing else in therapy has quite the same effect, especially if the therapist somehow gets drawn in.

On The Initial Contact

Responding to a prospective client’s request for an appointment may seems like a routine and even mundane task. To those clinicians who have done so hundreds of times, that is most certainly the case. But no one really offers a script. So, this section is largely oriented toward the new practitioner in the world of private practice. Doing well from the beginning helps. Two considerations arise. 

Most new cases for licensed practitioners come from referral sources, a practitioner’s most valued assets beyond their own skills and attributes. Particularly for professionals, referents in general have their own clientele or audience to consider. One of their expectations is that something as routine as a phone call with a prospective client would be handled flawlessly, or at least beyond generating negative feedback from the referred.

The second consideration is the evolution of a clinical relationship. The first interaction, however brief and elemental, is the beginning of an orientation for the prospective client to your own way of working and who you may be. A new caller usually does so with uncertainty to one degree or another as they ring you up. Beneath the brief greetings and movement toward an agreement, the clinician is introducing her or himself. In doing so, they hopefully provide a sense of confidence and security that registers in some way with the client. How were they feeling at call’s end? If a person is calling a therapist for the first time, one can presume they do so with anxiety. 

After a comfortable and confirmative call, however brief, the prospective client’s attitude likely changes from uncertain to a genuine curiosity about who this new person may be, in a way sewing a seed of a trust. Trust itself sometimes arrives quickly, sometimes not for a while, for a small handful of adult clients not for years, but they can at least enter the office less anxious than had been the case when they rang up the number. 

Some aspects of private practice appreciate with on-the-job training. I was somewhat unprepared from the outset, not aware that the initial five years or so of part-time agency clinical work was insufficient in the way of orientation. Add to that under-experience an interim six years of medical social work that did not involve much in the way of on-going counseling at all and one could anticipate early on that an initial call would occasionally go awry. I hadn’t even thought about this, felt a bit humbled when the problem emerged, eventually chastened and then sat down to work something out. During that first year, a basic framework or routine emerged. After another year or so, as I recall, with more honing, a settled process  was in place. I don’t think any problem occurred again. The call may not necessarily have ended in an appointment made, but for reasons that were more functional rather than reactive. Understanding the pitfalls helps.

Offered here is how I handled first calls, in level of detail that would likely be of little interest to those who have their own way established. For anybody though, if in going through this relatively short text, some thing or things – anything, really – could be found useful – then the time spent may be of worth.

Returning calls to potential clients within 24 hours or by the end of the next business day is a preferable habit for two reasons, those being as a demonstration of commitment,  and supporting your referent. Unless factors of fame make this diligence impractical, expeditiousness is courteous and earns credit. Do so even with a full caseload, or have your phone message indicate that you’re not taking new cases. If you do return a call and full, have a name or two in mind to give the client, should they ask. This can be seen as professional courtesy. Try not to leave someone hanging. Particularly in the spring when child and adolescent practices are most likely to be full, I would field the occasional  complaint from inquiring parents that “no one’s returning calls”. If nothing else, returning calls not as a matter of business but rather as one of courtesy is good karma. The referent also does not appreciate “ X didn’t (or wouldn’t) return my call.”

After the caller’s opening “I’d like to make an appointment for my child”, a certain set of questions followed. In order, they included: 

“Could I ask where you got my name from?”  –   Knowing the referent may make a difference in accepting or scheduling a new case, and the tack with the new caller is a nice, neutral way of starting the conversation. 

“Could you tell me a little bit (or a bit more) about the problem?”  –   Basic information about the presenting problem obviously determines whether the case is within your scope. An adroit couple of clarifying questions may be necessary to make certain. A brief confirmation that what the caller described is within your scope may be given. I avoided the practice of getting into substantive clinical discussion that verged into the clinical assessment itself, and even into treatment interventions during these calls. This is only a screening.

“And is this covered by insurance?”  –   The insurance question opens the topic of charges and payment, and panel status if insurance in involved. The caller may be advised to double-check their coverage, co-pays, service limitations, etc. I didn’t make that call myself unless some broader question or concern existed about the insurance company, and then get back to the caller. That was rare.

Once those three questions are addressed, and so far this would take a couple of minutes at most, a description of the assessment process is shared, to wit:  “So what I usually do is see the parent(s) first to do the intake, then see the child in the second session to do an assessment and get their point of view about things, and then see the parents again to share impressions and recommendations. And then see where we go from there.” 

Infrequently, a caller would have questions about that three session process, most commonly  wanting an individual format for a latter adolescent. While that would certainly be possibility, the practice policy for a minor client was to see the parent(s)or guardian first. I could see an insistent parent pushing back with “why?”, but can’t recall any parent actually stopping at that point for that reason. I wonder, though, that in these past five years since retirement a reality has changed – that with the more individualized latter adolescents in combination with more stressed parents, pushback on that first session may occur. That being the case and discretion being the better part of valor, I likely would have adapted.

When the parent has accepted the general process, e.g. ’that sounds OK…” , etc., the next step was scheduling. While the process of scheduling is mostly a non-issue, the problem can be  when the practice is close to full. Most practitioners leave a couple of slots open for returning clients – the return rate in my practice was around 8 – 10% – that could be used for an intake in a crunch, but sooner or later most practitioners face the dilemma of no more room on the calendar.

The practitioner either lets callers know their practice to be full, uses a waiting list, or, with some frequency, won’t answer the call at all. That’s a problem, and you never know what you’re missing. 

During a typically cloudy November afternoon three years before retiring, I returned a call to a mother looking for a therapist concerning her depressed 12 year old son. I was full at the time, but inquiring calls were nevertheless returned. Before I could move beyond “Hi, I’m returning your call…’, the mom went into a two minute outline of the boy’s problem, which was of moderate concern, and a family situation of Gordian dimensions, all said with a certain degree of irony and drama that might inwardly crack a tiny fissure of humor within the most stalwart. When my turn came, I told her “I’m sorry, but I’m not taking any new cases. Her frustration erupted, not directly toward me but more upward toward fate, and with pique, “No one’s returning any calls! No one!! I’ve called a lot, and they don’t get back!!! None of them!!!! And then the first one who calls back isn’t taking any new cases???? (shrilly) W… t.. f…!!!!!!!.”  And she heard my futile effort to stifle a laugh at the routine, I couldn’t help it, just couldn’t. But now I was stuck.You can’t laugh at a client you’re turning away. She was listening, quietly. She knew it. She was smiling. I knew it.”OK, OK, I’ll get you in.” I came in an hour early a couple of days afterward. Three years later, she was one of the last clients I saw before retiring. The bright kid was more socially active and getting much better grades her husband/step-parent got worse and moved out but by no means left the picture, the high achieving younger sister, who had a mouth, demonstrated more self-control and gained more friends, her long-ailing dependent 85 year-old mother living 90 miles away still somehow survived with attention by her only daughter, and the family members were all still living on the edge financially, like broke, a challenging morass and the reader can’t be told the half of it. There was more. She herself wasn’t much different from beginning to end. All in all, one of my very favorite cases/people. That was one way to get in.

Once the practice recovered some ten years after the massive influx of newly licensed providers into the area beginning in 1990, my practice remained near full from mid-October through June of each year. Periods did occur where I had no spaces available for child and adolescent work. Complicating matters were school districts that became increasingly reluctant-then-forbidding to let students out early for regular appointments, this as curriculum management became increasingly structured and expectations of student learning attainments that dominated teacher’s annual reviews were more rigorous. Thus, therapy appointments had to be at 3PM and later. I could make time for 18 slots, working until 9PM two nights a week. During the busy nine month period,  appointment times were all taken maybe 50% of the time, new cases averaging about 1.3 new cases a week. Hence, a couple of times a month I’d get a call and all was full.

I tried using a waiting list during the late 80’s, Aside from being one more administrative function to track, managing the list created as many problems as it solved. The lack of closures was disconcerting, what with people not returning calls when something opened, etc.  Keeping a waiting list for a large group practice or institution is less problematic, if for no other reason than someone other than the practitioner manages the list and deals with their inherent dilemmas, disappearances, and discontents of the seekers. I did come up with an approach that worked, thanks to the overall regularity of the practice’s business cycles.

In this scheduling part of the initial call, I would first find out what would suit the parent best. With nothing available within that parameter, I suggested that they take the earlier or less convenient time for the first two or three weeks with the assurance that something more convenient would show up. While the average numbers of sessions per case was 29.3, the mean was around 15. Turnover was reliably close to one per week during the heavy nine month period, meaning that something was likely to turn up for the new caller, and I said as much. The unshared fact was that If something did not clear, I would extend one of the two shorter days in the office to 7PM, and accommodate them until something in the regular schedule did appear. I would also keep track of who on the regular calendar had the latitude in scheduling to switch themselves to a different time slot if I asked. This system worked well for the purpose, and did not take much time to manage. Plus I had the flexibility and my own family’s support, for which I have a certain indebtedness. 

The last element is dealing with any remaining administrative matters, in those few instances mostly clarifying billing and payment processes. Increasingly toward the time when the practice closed, sending forms, histories, and clinical inventories for the prospective client to complete or fill out prior to the first appointment inched toward becoming the standard of practice. I was never so inclined, for reasons that can be addressed in the next post on the initial parent intake.

The last question was “Do you have any questions you’d like to ask me now?” This was clinical foreshadowing, always encouraging their questions. For the most part, the caller said ‘no’. Occasionally, someone might ask a simple question about experience, particularly in the area of the child’s presenting problems, or clarifying some other administrative concern. The guiding light here was to be both gracious and brief. The important purpose was to establish an openness and my interest in their thoughts.

And then closed with “I’ll look forward to seeing you.” More often than not, the response was along the lines of “Thank you, me (or us) too.”

Two additional points.. …

If issues of safety become apparent during the portion about the client’s problem. The large majority of those situations involved suicidal ideation. The assurance of safety became the central concern at the moment. A discussion about resources, i.e. emergency rooms and crisis line numbers, needed to occur whether an appointment with me was made or not. Almost all those cases did not require those services, both then and during their time in therapy.

A distinction can be made between the caller wanting to make an appointment and one who wants to interview the clinician about their services, histories, and clinical orientations as part of a decisional process of their own. I can’t remember the latter occurring, so this may be rare. My inclination would have been to inquire if they were considering me to help them, and if so, ask for a bit of information about what kind of problem the potential client’s may have. That may help the therapist to decide whether to be interviewed at that moment or at some other more convenient time to be set. I suppose the clinician could decline altogether, but doing so helps one hone their own line at the least.

Attributes, Purposes, and Intents

I usually returned these calls between sessions. Virtually all of them took less than those 10 minutes, maybe averaging 5 – 6. Brevity was a benefit.

Being friendly and focused in sessions carried over to these calls. Parents and even clients notice. As postulated earlier, the interaction is the seed of the clinical relationship. My belief is that the parent(s) is are likely to be a bit more relaxed to talk about what is precious and intimate, those being of the family and progeny, as the intake session begins having already had a favorable experience. The therapist being comfortable in doing the work, in all its minutia-to-sublimity, is a model for conjoint work toward resolutions.

Thinking again about the value of repetition, going through the necessary questions, fielding the answers, knowing what to do with the material, and coming to a mutual understanding, all in a manner of competence, helps develop meaningful confidence.

Staying on point, in this instance creating an initial agreement about proceeding, serves two functions. The first is the economic use of time, which is in the clinician’s interest, and in 2021’s world, ever more likely for the inquirer as well. The second is staying clear of doing clinical work, per se. Three reason exists for that stance. 

First, the therapist does not have a clinical agreement until the disclosure statement or similar document is signed. Some therapists certainly view this as a trifling, and that may be so. The concern in this limited arena of the initial call is not so much legal as giving the new client pause about who they are planning on seeing. The therapist knows nothing substantive about them until they meet face to face (in reality or virtually, as covid-19 has taught). The third is that delving further into the problems the family is experiencing and suggesting what might or could be done about the issues can end up with one of three outcomes: the caller could be impressed; the caller could be unimpressed, make an appointment and never show, or be more forthright and say they have ‘a couple of ‘other calls to make’ and never be seen; or they could take all the information they have collected during the discussion for free, and proceed with their own treatment. One out of three is not great odds.

So, what about just chatting? The only concern here is that the prospective relationship is about a professional helping a client, so the orientation is always toward the client and not toward the self. Might doing so be a temptation of fate? They are evaluating everything you say and do, with intent.

Stay on point. Watching change is the entertainment.