#44 – Parent Intake Session
Out of the 58 parent intakes in the study group, 56 continued to the child assessment session. The two cases that dropped out called to let me know. Both were doing so for administrative reasons, one due to an insurance coverage issue and the other due to job loss. The fact they took the time to call would suggest the problem was not the quality of their first meeting.
Calls of that sort did have a certain awkwardness. A reduced self-pay rate could have been offered. With space available on their calendar, many private clinicians would so so. The problem arises when the clinician also bills insurances for payments. Charging private pay clients at rates lower than those charged to insurances is technically committing fraud.
The issue arose in a meeting of the state’s NASW Private Practice Commission in the early 90’s where a representative of Regence Blue Shield came to talk with us about insurance billing in general. All dozen or so clinicians present were relatively new to the business of independent practices. The session was going along smoothly until the topic of private pay charges being less than insurance billings arose. He said that doing so could result in required reimbursement to the company involved and possible dis-paneling. Social workers viewed the right to charge less to those in need bordered on the religious.
As one might imagine, a hue and cry arose, but the Regence rep was adamant. To his credit, he went back to check the policy at his office, and later wrote us to say that under limited circumstances a reduced fee could be overlooked. Taking that to heart, one reduced case at time was my practice. A year or two later, I did hear of one clinician whose billing practices were part of an audit due to an unrelated consumer complaint. The outcome was not favorable, and he was required to reimburse well into the four figures, quite a sum in 1992.
Please consider the following list of therapist qualities that serve to aid and assure parents who are coming into the office to meet for the first time. Presume they are feeling both eager and nervous.
Tempered excitement: about meeting someone new to your practice and introducing them to your own version of this therapeutic world in which you have certain faith.
Likes people, relates well: Why someone who doesn’t like or relate well chooses this field is difficult to comprehend, but they are out there.
Enjoys stories: Obviously, every family is authoring a life story. As a clinician comes to know a family’s particular narrative or drama and becomes a contributor to help toward some happier, foretelling shift in direction.
Curiosity: knowing more, digging deeper into the who, what, when, where, how, and why of the child-and-family’s dynamics, following both educated and intuitive leads, in doing so reflecting the clients back to themselves in ways that aid their growths.
Humility: If being invited into the intimacies of a family is not humbling, you might be in the wrong field. Compassion is every bit as important as knowledge. The first is validating and the second is instructive. Both are therapeutic.
Patience: Clients react more favorably toward recommendations when ready to do so. Tosome degree, change has its own schedule. Knowing what to do is important; knowing when to do is key.
Equanimity: Evenness of reactivity toward the almost impossibly wide range of potential client thoughts, behaviors, and emotions is an ideal. Very few can universally handle anything and everything with calm presence and thoughtful response. How many times, particularly early in one’s career, do we re-think and re-think more some stressful situation to come up with an ideal perfect response. We do learn that way. Sometimes silence is best, even necessary, until the effective response comes to mind. In prolonged moments of head-down concentration, more often than not the client will fill the void. At first, taking and waiting that time takes courage. Then that becomes equanimity.
Boundaries: Keeping the relationship professional, meeting professional obligations, and avoiding making judgements about others.
Seek self-Improvement: through the last day….
Some proportion of the latter group send forms pertaining the presenting problem and history including past treatment, with whom, how successful, other outstanding problems and their treatment if any, etc. And yet some proportion of those, no doubt a distinct minority of therapists but equally no doubt getting larger, will send additional diagnostic inventories of symptoms and other clinically evaluative forms of their liking, everything to to be completed by the soon-to-be client, some returned in advance of he first session, and some all to be reviewed during the first meeting.
As with most any other American business type of the past few decades, mental health practitioners too have been seeking efficiencies. The utility of having the information prepared in advance and in hand as the new client takes a seat seems obvious. However, the solution to a problem. Take that axion as an article of faith. To wit, the following is a rough analogy and thoroughly grandiose in scope, but nevertheless makes a point:
Nicole Perlroth, the cybersecurity and digital espionage reporter for the New York Times, recently related a story she investigated in an MSNBC interview. An engineer for a small American city’s water department was sitting at the computer screen one morning, as per usual monitoring the town’s water flow. Suddenly, the cursor started roaming on its own. The engineer quickly discovered he had no control over the movement. The cursor moved to the site that controls additives to the water supply, and he watched in quite some horror as the release of lye into the system was increased from 11 parts per million to 111 parts, essentially making poisonous what was meant to be enhanced water quality. The engineer quickly took manual control of the system and reversed the command. Had he not been watching, a disaster could have easily occurred.
The culprit had not yet been firmly identified at the time of Perlroh’s interview, but was clearly a hostile force. Her most pertinent observation, though, was that in the midst of the overall national economic push toward digitization, most all water supplies had become managed on-line. Through that particular modernization, though, the water supply industry as a whole had not taken the necessary steps to secure the systems from digital assaults. This important safety feature had received little attention. The corollary here is that the solution to the problem of clinical time consumed while gathering core client information in session by having the client fill out forms beforehand does not take into account the underside of doing so, however incidental that may seem.
How clients, including the parents in this instance, relate with others is an integral part of the treatment process in child and adolescent work, almost regardless of the particular therapeutic modality employed. Some would say improving and repairing one’s relatedness is the most important component.The tenet being offered here is that the clinical relationship is enhanced when the clinician and the client are finding out about each other at the same time while together. Because relatedness itself is part of the treatment, the outpatient mental health clinician-client relationship is somewhat unique in the broad field of medical care.
At the start of the initial session in a traditional format, neither client nor clinician know much about the other. Regardless of how preternaturally composed the client may be, anxiety is present. The session starts easily enough with name, address, and so forth. The story then begins, sometimes detailing the uncomfortable, even the wrenching as the client watches the information being received while relating. You, as the therapist, like meeting new people, getting absorbed in the story, curious, and respecting the humanity involved as professional and client are each doing their part and learning about each other at the same time, all these elements being seeds of trust.
What the client did not have was an additional worry – in a few cases frank suspicion – about what the therapist’s incontrovertibly preconceived impression of them had been. In most circumstances with these pre-intake forms, the sense of “I can work with this person” unfolds unabated. For an estimated 80% – 90% of new cases, all the form completion and document signing is innocuous and the different paces in which therapist and client come to know each other resolve in favor of trust.
The other 10% to 20% would be the concern, those who have lower degrees of basic trust toward others with higher degrees of underlying insecurities, defensiveness, or even manipulativeness that shapes answers and thereby commits to a degree of false narrative, right from the beginning. Generically, these would be the Axis II – type troubles or their difficult-to-discern equivalents of the potentially difficult client. The start may be in trouble before the monitor is active, even before the inner office door is opened. Watching the therapist react in the here-an-now is more convincing that reliance on imagination.
Just a suggestion – you might try doing this both ways, having some complete the clinically oriented form first, and then others complete them after the first interview. See what differences become notable down the road.
First Part – Basic Information
As indicated above, the only information about the child and family came from the initial phone contact, and that was generally limited to the nature of the problem. Relative to knowing each other – usually not much – the parent(s) may have had more information had they researched this referral to me.
Whether one or both parents came to the intake was left up to the parents. Seeing how the family managed the first appointment was good information in and of itself. Also, I generally followed the notion that being directive when not really necessary could create more problems than not.
I had the parent(s) read the disclosure statement and privacy policies in the waiting room. The session itself began with asking if they had any questions about either form, and addressing any that arose.
All the family’s demographic information was covered in the first few minutes of the initial session, some times a bit longer in complicated family situations. The nature and content of the presenting problem and history usually took 30 – 35 minutes. The summary and business end of the session took the last few minutes. Once experienced at doing so, all could be done with relative ease over the course of that first 45 – 50 minutes.
What followed was gathering basic information, including names, address, jobs, referral source, and insurance coverage, which included the Pleistocene photocopying of the card. That was followed by information about the child of concern including, birthday, school, and grade. If a disparity between age and grade existed, that would be queried as to how and why. Next was about whoever else lived in the home, usually just sibs, if any.
Unless already established, the final basic information question was “And s/he is your natural child”? If the answer was yes, the interview would move on to what was bringing them here.
Different family configurations generated their own specific inquiries at this point. They included families with step-parents, mostly step-fathers but occasionally step-mothers; single parents, almost always mothers; adoptive parents; the infrequent occasion of a family members as guardian/caretakers (a few including grandparents, aunts, or uncles, i.e. not many. Foster parents would have been interesting, but they tended to be funneled to agencies with state service contracts.
With a history of marital separation or divorce, right after the basic family and child information collections were completed, the question was posed to the natural parent present, again almost always mothers, “Could you tell me briefly what led to the divorce”? This is a pregnant question, happening in the first few minutes of interaction, likely unanticipated in the moment, and not to be underestimated.
The answer most commonly involved one or more of adultery, alcohol, addiction, abuse, or abandonment. As irrational as the feeling may have been in the moment, a sense of shame anywhere from minutely and quickly passing to an unresolved omnipresence commonly seemed to get activated. Hence, the next interchange can generate something of value.
The surface purpose of this interviewing at that particular junction was to get information about the ex’s formal and informal relationship with the child. The break-up itself could well take the rest of the session if becoming the focus, but this is simply the intake. Assuming the difficulty of the disclosure, the parent often paused before answering, poignantly always true if the precipitating events included physical abuse, only a small few over the years, but each gripping each in their own way.
When violent or particularly atrocious behavior was involved, the interview at the moment became unavoidably more complicated. The next question was how much the child witnessed directly, was within earshot, or afterward viewed the physical and/or emotional damage, and the impacts. One reason for doing so was an initial exploration of possible PTSD, still knowing little about the child. The second purpose was to engage with the abused, because the topic could be so hard.
The next series of questions were more neutral, and one that was used for all cases involving separation or divorce. The focus was on the current relationship between child and the”ex”, including: where he lived; what he did for work; what his own relational status was at the time; what the custody or visitation arrangement was; how often he saw the child(ren); how often the child and father contacted each other; who initiated these calls or on-line communications; the general nature of the father – child(ren) relationship; and the current relationship between the two parents, at least from the participating parent’s perspective.
When the mother’s initial reactions to the question of “what led to…” had been palpably distressed, particularly with a history of being physically abused, at the end of the discussion an acknowledgement, something along the lines of “that must have been a very difficult situation” was offered, and invariably got an assertive nod in return. For a small few occasions, that particular interchange often became a “moment”, an eye-to-eye, unspoken appreciation by the client of their own strength in the moment, the acknowledgement, and the relieving brevity of the interchange; and an almost visceral appreciation on my behalf of the client’s honesty, sincerity, extension of trust, and at the same time doing so without making overt and negative pronouncements about the abuser, as tempting as that might be, keeping his nature out of the interchange. To do so would a boundary problem, in this instance placing judgements onto someone about whom I know next to nothing about, a toxic breach of equanimity in and of itself.
‘I can work with this person’ can quietly go both ways.
After exploring the aftermath of the original family’s split, the attention switched to the step-parent, if present. A relevant notion, either an aphorism or the result of a study, was introduced: a child’s attachment to the step-father develops when they have been together as many years as the child was old when the step-parent entered the family. In this case, the term ‘attachment’ refers is a child’s sense of security that the step-parent will remain in their life.
The concept gained immediate attention, offering a new perspective from which the couple could view their particular situation, whatever it may be. In the instance of physical abuse, the step-father is immediately drawn back into the discussion in a specific, positive light, reducing the tension, something which he may have been doing all along. The subsequent examination of this step-parent – child relationship had the two adults interacting in a way that was usually helpful to their co-parenting, to my clinical understanding, and to the counseling’s viability itself. As well as providing good clinical information, the shift away from the disclosures of “what led to…” was a relief often approached with some relish.
The only questions during the intake were in regards to the circumstances of the adoption. They would generally include: what led to the decision to adopt, from where the child came; how old at adoption; to the best of anyone’s knowledge, what that led to the child being adopted; and any contact with either or both of the birth parents. Cases of adopted children were not that common. They represented 10% of this study group, or 6 of 56 cases, but that seemed abnormally high for a two year period. While the average number of adopted cases over time was never calculated,1 – 1.5 per year, or say, maybe 35 cases out of 900 – 1000 over the years seems more probable, maybe less.
Without a concerted effort over time to track outcomes for adopted children, recognizing specific difficulties with case management for the group as a whole could be seen as difficult. Anecdotally, I had no particular impressions going into this study, i.e. they must have been like the general others. To add to the impression void, after licensed masters level clinicians were mandated to attend 18 hours of continuing education per annum following 1989’s licensing law, very few, if any courses concerning outpatient mental health treatment for adopted children were advertised by the major continuing education outlets. I have a certain faith that at least one such workshop would have been attended had they been advertised.
The problem here is that the work with this particular group of six turned out to be less than acceptable. For certain, three of the six cases were difficult from the outset. The outcome results of this group compared to the four other parenting configurations of the study as designed (Post 14), were unexpectedly low. Single mother cases were similarly low, but those were affected by a lower degrees of resources available to sustain a treatment process and a much higher number of Axis II – related issues among the ten fathers. Such was less the case with the adoption group. At least these parents had plus-adequate resources. The new thought about the work with adopted youth-and-family is that some core element was missing in the conception of treatments processes. Issues with attachment and detachment, or idealization and devaluation, or some other impactful shift or development within the basic mother-father-child triangle come to mind as possibilities.
The overall writing plan is to discuss a few sub-groups following the publication of the therapy process as a whole, one of which would be this group. The current intent is to enlist one or two outpatient therapists who are adoption specialists to help create the post. Hopefully the comments will be more salient than could be the case now.
One last group to mention, of which only one was in the study group, are those youth who are in the custody of family members other than the biological parents, again a very small but distinct group. The one in the study was a latter adolescent male in the custody of the grandmother. The father himself was deceased and the mother in prison. Most all of these cases involved significant parental disturbances and sometimes chaotic relationships between the caretakers and biological parent(s), a couple of which included extraordinarily bitter custody disputes. Therapy can definitely be of at least supportive help, but the external circumstances can make the sanctity of the treatment process tenuous, even in spite of good clinical relationships and demonstrable progresses with the client.
During the assessment summary and recommendations session where the treatment contract would be developed, the one stipulation regarding these sometimes legally complicate custody disputes was that I would do everything possible to would avoid becoming directly involved in any legal process. My input could be funneled through the guardian ad litem. The rationale was that becoming directly involved ran the risk of damaging the therapy process itself. The cases did not stop because of that stance, nor do I think played a factor in termination. Suffice to say, getting ensnared in messy or vituperative legal processes did not occur.
Part 2 – Problem Evaluation
Two types of content simultaneously unfold in this portion of the interview. One is gathering information about the child and family issues, notably the symptoms, problem areas, and relational conflicts and abandonments. The second is the family narrative. While the formal function of diagnosing is generally done in a question-and-answer format, the story is more listening and providing prompting questions that would have the narrative continue. A third type of interaction would be doing clinical work itself, but in this intake session with this particular style that would occur only if driven by issues of safety.
Because time would run out long before both evaluative and narrative streams would run their course, given a choice between the clinical and narrative streams, my own inclination was to support the narrative. Covering a few areas of diagnostic information is enough to create a rudimentary intervention plan at session’s end, which is the central goal of the meeting. The narrative tends to get the family members involved into the flow, and helps establish a desired clinical environment for the on-going process that follows. One could argue with wide concurrence that the interview itself is therapeutic, but the deliberate pursuit of change except regarding issues of safety can be seen as premature and even disengaging if the client is not sanguine with the “help”.
Not necessarily in order, the clinical information sought could include any few of the following:
The precipitating event leading to the search for help
Current symptoms of depression, anxiety, behavior, and other less common diagnostic categories
Current problem areas of the client, including family relationships, school performance and behavior, social relationships, and community issues such as patterns of misbehavior, mischief, disturbance, police/legal attentions, etc.
Past client history of clinical and other personal problems
Previous treatment(s), results, reasons for termination
The youth’s reaction to this new attempt to obtain help
Other problems, stresses within the home including sib relationships
Impact on marriage or, for the single parent, impact on mental health
A necessary addition to this list developed over the past few years is specifically asking about possible trauma in the client’s history that might help explain their current status. If any benefit came out of the post-9/11 mideast wars, that might be the transfiguring increase in our cultural awareness and professional understanding of trauma and the difficulties of recovery.
Most importantly, deal with anything dangerous or critical and beyond the scope of clinical advice at the moment. This situation hardly ever appeared in my practice, which itself was likely tame compared to others in less resourced communities. In that event of an on-going crisis, the immediate goal is to suggest or refer to the appropriate community service for more immediate attention.
Given the task at hand is to assess, part of the intake process was observing the parents as well. My tendency was to simply follow their customary way of managing a situation, in this instance with an inquiring third party, and not attempt to manage their mutual communication process or style
Every once in a while, the parent who responded to “what can I do for you” would continue to answer everything and continue to do so until the imbalance had become almost dreadfully apparent. With uncommon exceptions, the other parent included themselves within a short time after the opening. But with the monologically-inclined, at some point after maybe 5 or 7 minutes that feels like 20 – and I can think of one that took more than 10 minutes that felt like 40 – I’d give a friendly look toward the quiet one and say something like “would you care to comment?” At that point they would start, maybe a bit abashed, maybe smiling at the mild effrontery.
Exactly why the precipitating pattern existed remain an unknown at the time, and under these circumstances one can assume the in-office behavior was not unique. The imbalance was certainly noted and at some point in a later therapy session would likely get addressed. By then, the silent partner was usually talking and initiating more normally. The pattern had been noted, underscored thrice on the note sheet. Why the difference between the quiet beginning and being more involved later would become the topic of inquiry that I would inject. The question initiated a look at an evident positive change that would likely serve as a reinforcement. In essence, this became a CBT-like approach – wait for the opposite behavior to manifest, examine the before and after, and reinforce the emergent behavior.
This is going into too much detail, but the notes were patterned as well. The clinical notations took center page, which made the dictation easier and more fluid. The relational and other narrative aspects of the interview tended to be kept on the side margins, and usually formed the outline of the treatment plan above and beyond the clinical objectives.
Part 3 of Intake Session
The transitional question from the problem description phase to this conclusion time was “Is there anything else you think I need to know”? Usually, that receives a shake of the head, but occasionally that ”one more thing” is expressed following a few seconds of deliberative consideration. Whatever the question may be, some kind of clinical meaning that may surface later in the process may make a sideline note worthwhile.
“OK, so what kinds of questions do you have at this point?”
In a sense, the question foreshadows the regular session routine. At the beginning of a therapy session, the opening question was “What can I do for you today?” and the signal to wrap up was “Are there any other questions you have today?” This was true for at least the first few sessions. Processes often transmuted into their own form, as each has differences or uniquenesses, but this is how they began.
One good reason most disclosure forms include a 5 minute elastic clause to the length of sessions, e.g. 45 – 50 minutes, is that how many questions the parent(s) may have toward the end is almost impossible to predict, and the least desirable type of conclusion is hastening a new client out the door. After a while, the therapist has a clock in their head, intuitively knowing when to move from section to section, whether to anticipate a couple or a litany of questions, and how to expediently wrap up.
A fair proportion of new cases don’t have any particular questions at this point, and ask or in some way indicate the question “what’s next”? The short answer is confirming the assessment session with the youth, answering what questions or concerns they may have about that, and then move on to remaining administrative details.
Among the frequent questions at this juncture are the following, in no particular order as to frequency:
The occasional boomerang was “What do you think?”, almost always the father when the question infrequently appeared. The real question is whether their particular situation belongs in this practice, and was answered in that vein, i.e. along the lines of, ‘these kinds of problems have been seen here before (or are common here), but I’d need to see your (child, adolescent, boy, girl) to confirm that.’ I don’t recall anyone asking about success rates. At least in my practice, the assessment session usually demonstrated some kind of effectiveness in and of itself that made the question moot.
“How do we prepare Joey for his session next week?”, mostly raised by the mother when it, also infrequently, came up. The response was to ‘share with him/her what your own experience was here, field any concerns or worries he or she may have, and assure that you’ll be in the waiting room while they’re in the office’. If the youth is a balky adolescent, what I said was “I can’t do anything to get him into the waiting room, and it doesn’t matter what his demeanor is, but once here, things will be fine”, and that was true. For a younger child, “you might want to bring him in a few minutes early to play with things here or draw”.
Particularly for children but generally applicable to adolescents, if they build with the blocks or draw on the dry erase board, I ask them to leave their work, and ask parents to do the same while leaving the office. Sometimes others add to their little work of art, which is kind of fun fo all concerned.
The most frequent question was probably “what do we do about X problem.”As stated earlier, my tendency was to avoid clinical work per se until after a treatment agreement was reached toward the end of the third, summary and recommendations session with the parents, meaning that clinical work per se would begin more formally in the fourth session. However, they are asking and the clinician has to respond, so I would start with “What would you normally do?”, and riff off of that, making suggestions that would alter here or there their own tendencies. That approach included cases where suicidal ideation was extant.
With that particular issue, this broad brush approach may not longer be professionally feasible. When a particular mental health disorder gains attention as an epidemic or national hardship generating intensive psychological research and treatment development, clinical approaches can evolve into community standards of care that unofficially need be met by the practitioner. Such may be the developing case with S.I. As a clinical professional, staying up to date on these community standards through on-gong collegial relationships, consultations, continuing education, and independent reading is helpful.
“What if medications are needed”? That question rarely came up during the intake, and in those uncommon circumstances when it did, the answer was deferred to the third session, after the youth had been seen. I will say that the question of medications in the first session almost
never came up 35 years ago, but was surfacing, say, 1out of 20 or 30 new cases by 2010. That kind of percentage has likely increased since.
Lastly on this list is “How do you treat this kind of problem”. This was almost always answered in terms of format rather than school of therapy or detailing a process. The question was whether to pursue a therapy with parents and client together, parents and all children together, split sessions seeing client and parents separately during the same hour, or seeing the youth individually with occasional parent meetings That response sufficed.
Administrative issues such as fee payment and releases were usually held off until the end of he summary session.
Scheduling was reviewed and altered if necessary and possible.
The parents were also alerted that a second assessment session with the youth may be requested before the summary session in the event that the full assessment could not be completed, and that this was not an indicator of severity or difficulty. In fact, that happened maybe once a year, but did occur.
Does the parent(s) feel comfortable managing their youth between now and the next session? If not, are they aware of community resources that they can rely upon in case of emergency? Do they know you may not be available on a 24/7 basis, might not be able to field a call for hours or even one business day? Personally, my disclosure statement indicated where to get emergency help, and that return calls may take up to business day. I got maybe 3 or 4 emergency calls in those 30 years, and the practice was none the worse for the wear.
“Are there any other questions you have for today”. If any are asked, they get answered and then:
“I’m looking forward to meeting your boy/girl.”