#49 – SUMMARY AND RECOMMENDATIONS SESSION

Where the parent intake and child assessment were almost entirely information gathering, the more direct clinical work begins here. The nature of relationships and individuals roles within the family begin to take shape as the previous two weeks are reviewed. The discussion of problems focuses more on what happened within the family since the parents were seen rather than a continued exploration of prior history. In doing so, a more dynamic picture of the child and family emerges, and opportunities to be more directly helpful to the parents tends to arise.

The basic objectives of the session are twofold. First and foremost is developing a mutual understanding of the basic problems bringing the client and family into the office. The second is an agreement about the format to be used, or at least defer that decision until the best arrangement becomes apparent. In the latter instance, an interim process is usually a family format including as many of the family as feasible and possible, and then shift at an opportune time.

The structure of this appointment is fairly simple. First is a review of events pertaining to the child from the time he or she first entered the waiting room through the next week or two to this summary session. That segues into the second portion, a review of pertinent information gathered and observations noted as the child went through the assessment process. The discussion with the parents then gradually expands to include other information they have to share, adding to the intake session information. This third phase establishes a mutually understood baseline of problems to be addressed, followed by a format recommendation, and then an agreement about how to proceed in terms of session scheduling and frequency. 

The last phase of the summary session tends to administrative matters. Often just routine, matters like scheduling, obtaining releases of information, co-payments, and late cancellation policies are addressed, some of which were in the disclosure statement read before the session began and covered as a reminder. This time is also used to address issues like complicated or contentious issues between divorced parents and how they may effect the therapy itself, other legal matters including CPS involvement, coordination with other professionals involved with the child and parents, etc. etc.

Getting To Work

The session begins with “I’m interested in what questions you have, and I’m interested in how Tommy reacted to being here, and whether there have been any sort of changes you’ve noticed, for better or for worse, whether they seem to be related to coming here or not.” 

Parents generally began their response with the question about changes. In roughly half of the cases, the parents reported no particular change, and the interview went on to the assessment review.

The other half noted improvements to one degree or another. The direct clinical work begins here, largely because the changes being discussed are in the here-and-now. In particular, the review of change included a summary of events, thoughts about why the changes occurred, what role the parents may have played, and what their responses to the changes may have been. Underlying the interview here are the emphases on relationships, observation, and the use of reinforcement. As an aside, and one of those fleeting satisfactions for the clinician, the parents reporting improvements detailed what they had experienced in a way that was noticeably more animated than they had been during the intake.

Those instances where the child seemed to worsen after the assessment session were few and far between, but they did occur. A worsening following the assessment session is not a death knell to the process, but does require attention. In reviewing the week with the parents, some unrelated negative event or stressor was usually identified. Still, though, since the reaction to that something else may have been in some part exacerbated by the session, the situation was likely to be covered in depth. The downturn offers an opportunity to create a discussion about responses that occurred, and exploring possible alternatives. To the degree possible, the intent is helping the parents come to their own solutions, or at least to a recommendation through discussion rather than a therapist analysis-and-pronouncement. 

The clinical interest was in essence a series of questions. How did the child report the session to the accompanying parent, and was that similar or different than my impression; what was the child like driving home; what happened at home and elsewhere between then and now; what worked, what didn’t; anything the parents had tried that was different? 

As they spoke, portions which may have raised concerns about the parenting itself were usually just noted. Their actions on the child’s behalf that were effective, particularly those that were the result of a creative effort on their part, were reinforced. Looking for the opportunity to do just that was part of the clinical work. Generally and unless matters of safety and security are involved, the events of the previous week are part of an emerging picture. Important to remember is that a baseline is still being created. To the degree feasible, corrective measures could wait.

Even with a practice that was 90+% boys over the last ten or fifteen years, the level of overt resistance to their assessment session was surprisingly uncommon. As inferred in the Assessment post, once through the door and the interview begins, that attitude generally began to dissipate and the relevant information begins to flow. In and of itself, that transformation c bean medicinal. The parent is out there wondering. In the best of circumstance, and this did happen with some frequency, the boy would walk out of the session into the waiting room, open the suite door as the mother rose to accompany him, turn toward me and say “Thank you.” The mother’s head would snap straight, she looked at him and then toward me with a querying expression, and then break into a smile as they disappeared. I liked that one, and in an act of pure indulgence, brought it up at some point soon after the summary session began.During the course of the reviews, theirs and mine, discussions in and of themselves have a capacity to generate change, however small they may be. Organic change may be the most potent and lasting.

For that large majority of the youth who came cooperatively and for whom the session went reasonably well, the approach with the parents was less rigorous. The types of questions included: what the child reported on the way home; noticeable changes in behavior or mood; differences in how the client related to family members or others; how their particular situation evolved over the days; and what the parents did differently that may have enhanced the improvements were commonly used. A reinforcing observation or two would likely still be made. 

Patterns of the child’s mood and behavior are now based on up-to-date experience. Such was also the case with parenting. The impacts that the parents are having, both positive and otherwise, become more demonstrable. The discussions can generate at least some insight on their part about their respective roles and effects. Potential changes are taking shape. While clinical goals themselves get more concretely established during the next two sessions, the possibilities begin to take shape. The development of clinical trust is a fruitful byproduct.

Much remained to learn about the new case, particularly the inner dynamics of the parental relationship. Secondly, and this may seem picayune, a treatment contract per se had yet to be made. Presumably, that would occur at the end of the session, maybe just minutes away, but a certain reticence about unsolicited advice remained until that agreement was made. Modeling and gentle shaping are reasonable recourses.

Overview

After debriefing the period following the assessment, the parents’ questions were fielded. They were almost always versions of “What do you think?”

Ultimately, this section of the session helps to develop overviews of: individual problems of state within child, including physical, medical, and/or developmental problems; relational concerns within family, including problematic role issues; historical forecasters, including traumas; problematic environmental, social, academic, and/or extracurricular activity; and residential, legal, and/or financial issues.  

Gently guided by the clinician, the section begins with specifics, evolves into a joint exploration of observations, experiences, and other relevant thoughts, and then begins to hone what will become the initial baseline of problems to be addressed.

Assessment Review

Rather than some kind of semi-formal or otherwise prepared summary of the assessment session, the approach here was a narrative that essentially followed the informal notes taken during the session.The client is summarized and for the most part not directly quoted. The results of evaluative portion, including the depression/anxiety inventory, self-esteem questionnaire, ego-development evaluation, and the socio-moral dilemma response were more directly portrayed, these being test results rather than self disclosure. The artwork of the younger clients were similarly reviewed.

First covered was the ease with which their child engaged by using the 5-tiered format of opening questions, i.e. ‘What can I do for you?’, ‘What brings you here?’,etc. Comments were about their comfort level, where they fit into the norms for their age, and their particular responses. Then field any parent questions.

Similarly, the history of the “problem” from the client’s viewpoint (generally for children age 8 and up) universally drew some kind of comment, be it either affirming, correcting, or elaborating. That would lead to questions or comments on my part.The parent(s) now are more active participants as the “review” moves into discussion mode. Continuing through the notes, any set of problems and events within the family and other problems personal, social, academic, etc., could be encapsulated and presented. 

A body of mutual knowledge about the child is being constructed. The parents are commonly becoming more actively involved through the discussion, sharing their own perspectives and thoughts. The contours of a clinical relationship are emerging. Parental questions, observations, and anecdotes are encouraged, so the process of detailing experiences with their child is interactive, both theirs and mine.They are essentially being acculturated into the collaborative therapy process itself, and accumulating their own perceptions and judgments about the person to whom they turned for help. One’s own comfort helps. 

At the same time, concerns about the presentation of assessment information itself were omnipresent. Thinking about Johari’s Window, the two panes representing what I know that the parent doesn’t, and what they know that I don’t as of yet are still large. The migration of the two knowledge bases to that area representing the knowledge we share is best done on a smooth path, but one that for some can get easily rutted. How privileged information gets conveyed is everything. Making the client somehow vulnerable or leading the parent to question the clinician’s judgement is clearly a problem. 

That the parent could share with the client that which was shared with them is a given not to be overlooked. Whether these particular parents in front of me are susceptible to misunderstanding or poor judgement themselves is still something of an unknown. Ultimately, the clinician has to rely on their own judgement. Being tight with the breadth of information is probably a good governing dictate, but at the same time, passing on relevant and educative information that is instrumental. ‘Protect the process’ is the first rule, if for no other reason than doing so is protecting the client.

Parents leaning forward on the couch is almost always a good sign, and this routinely occurred when the review got to the evaluative and artwork portion. What kids produce is obviously fascinating to the parents, much being positive but some can generate concern. The parents become instrumental in making the interpretations.

The last element of the review was a summary of how the session ended. A question that sometimes arose was whether that particular ending was typical or atypical of the child or   something that they had anticipated or not. The oppositional boy saying thank you at session’s end is an example.

Problem Summation

Then, “So, what questions might you have at this point?” 

If the parents had questions, they sought to clarify something about a particular assessment result or comment, but usually their question amounted to “Where do we go from here?” The underlying thrust of the posed question is a part of the acculturation to the therapy process, in this instance the encouragement to ask.

“Is there anything else you’d like to add?” And field the response.

“Anything else?”, if they in fact added something more, ibid.

The appropriate segue here would be outlining an encompassing, routinized system of problem summary, but that’s not the case. The presentation of the problem formulation was more a reflection of how the clients and parents see the problems, and at least inferentially, what they would like to see get better. The language was not necessarily theirs, but their substances guided the result. If the parents gravitated toward symptom relief and at least inferentially resolution of a diagnosis, which was actually rare, the summary would be so guided. The discussion can be essentially instrumental, targeting what the parents would like to see their child attain in a developmental sense of maturity, including areas such as sociability, confidence, empathy, compliance, industry, the list could go on. If adjustment, normalcy, and achievement were important, then those can be described as goals.  

Somewhat surprisingly even those parents who are more symptomatically oriented seldom asked for a diagnosis, satisfied with the more concrete problem orientation. Presuming that the institutional regimentation of mental health care provision that gained traction in the early 90’s will continue to expand, that question “What’s your diagnosis?” will be heard by practitioners more frequently. When asked, the response was usually “for the time being an adjustment disorder with (one of the options), but we’ll see – I do think you’re in the right place.” The exception would be those kids who have been diagnosed with ADHD since challenging a medical opinion, at least at this point, is folly. The drawback to offering a diagnosis is that the parents may be inclined to ask around, and the chance of losing the case for no good reason rises. As stated though, very few parents ever asked. And as stated, that may not be the case anymore. The one advice is to keep the response simple and and more suggestive than definitive. Clever has drawbacks.

Choice of Format

The predilection in this practice was to begin with the family approach as much as possible. At the same time, the family orientation to child and adolescent therapy spanned most all the format options.

The three basic formats were family, split sessions of roughly equivalent individual time for both client and parent(s), and individual therapy with the client, usually with less frequent parent check-ins. Shifts from one format to another regularly occurred. On occasion, a case could go through all three, from conjoint to split to individual, although these were always cases that were seen for longer periods up time, like a couple of years or more involving fifty sessions or more. Most cases stayed with the family format throughout their time in therapy, but the other formats served their purposes, to wit:

Format Type                   Type 1*          Type 2*              Total #

Conjoint           27 9 36

Conj. to Indiv.               4 1 5

Conj. to Split to Indiv           1 0 1 

Split Session             4  1 5

Split to Indiv.             2 0 2

Individual             3 1  4

Total Type           41           12           53

  • Ending Type 1 were those cases that satisfactorily ended with modest to comprehensive results. 
  • Type 2 covers two categories, including: Those who left therapy early due to administrative imperatives, typically loss of employment and coverage, changes of insurance coverage or companies, or moving away; and those terminating due to lack of progress or wanting a change in therapeutic approach, i.e. moving to a specialist. In the case of the latter, three of the obsessive cases in the family therapy group moved to a specialist. 

Note: Three cases did not progress beyond the fourth session 

To be fair, the distinctions between columns #1 and #2 do lack empirical precision, but they are at least close to a reality. The high number of Type 2’s in the conjoint line of the table – 25% – did come as a surprise. The first question is whether that difference is statistically significant, unknowable with that kind of N. Except for ‘super therapists’, and one can reasonably assume their numbers to be small but they do exist, lost cases are a hazard of the trade. So is making the occasional clinical mistake in case acceptance, choice of format, in execution, or use of basic judgement. Stuff happens, keep an open heart.

The one exception to the practice’s family therapy preference were cases involving 16 – 18+ year-old clients who wanted to be in counseling and whose personal problems according to the client and with the support of parents warranted straight individual work. Those cases went straight to individual work after the summary session with the parents. Mostly the parent came infrequently, as little as maybe twice during a process of months, for five to fifteen minutes to add their perspectives about progress and changes. The clients themselves usually knew of the meeting beforehand, and got a brief summary afterward. These were generally mature young people struggling with early phases of emancipation, losses, traumas, and peer relationships.

The split session format from the outset of therapy was used when prevailing issues required some kind of privacy on the part of either client or parent(s). More than half of the cases involved single mothers, some with and some without the father involved in childcare. For the former, the most common problem presentation was the triad of parenting, the working with the ex, and personal stress, and for the latter the triad of parenting, personal stress, and economic struggles.

Adolescents could insist on being seen alone on a split session basis, the parent wanting to be seen regardless of format. Such was the case for a small few clients who seemed to be suffering an identity crisis. A very small few were instances of early to mid-adolescent boys whose presentations both personally and symptomatically suggested the possibility of an incipient and fearsome anxiety about sexual identity, and who were adamant about being seen alone. These were ticklish situations, where the main clinical feature was the underground nature of the possibility. The teen had said nothing to anyone while living with the fear, was not going to do so in therapy, would not be referred to the “appropriate” resource, and the parents were similarly not going to raise the concern they themselves likely harbored. 

The clinical management of this particular identity crisis may well be changing by now. Circa 2015, the pertinent research quoted in the Seattle area by a local suicide prevention NPO was that suicidal behavior increased fourfold when a young person was brought out early, or when someone comes out late, i.e. in their 40’s or older. How to handle this specific and poignant issue in the office was just not part of continuing education’s commonly presented repertoire, nor advertised workshops, graduate school curriculum, or public presentations. One certainty is that we kept up to date on community standards of practice.

At that time, the clinical management was helping the young person identify those behaviors that needed attention and change, as defined by client and clinician together and be they related to anxiety, depression, and/or self-defeating and self-denigrating patterns. Improvements and resolutions did occur in therapy, just not necessarily toward the presumed source of existential distress. Keeping the door open for returns is a given, and that can act against the impulse to edge into guarded territory, something that would likely scotch any thought of coming back.

Similarly, the process with parents of these young ones was helping them through their own list of presented of problems that similarly did not include “…do you think….?”.

The limited experience in this practice was that this particular casework would continue for several months, at first in the split session format, then a period of individual work once the parents felt sufficiently oriented. The termination was initiated by the clients. Overcoming situational anxiety in social and academic settings appeared to be the improvement that led to finishing. The parting declaration of the last session – these clients did not just disappear – was  “If there’s anything else with which I can be of help, give me a call, and I’d be glad to see you.” At the very least, the young person is offered an unqualified, genuine acceptance that could serve as one tonic for their being and one balm for their soul.

The split session is a necessary accommodation to some circumstances that makes the family session itself unfeasible. However, some of family therapy’s advantages itself are still present. The raison d’etre remains to be the well being of the child or adolescent. The well being of the child is the underlying focus, and, at least from my perspective, the recommendations at the end of the parent session have the child in mind. The therapist continues to learn about the individuals and relationships within the family, continues to monitor the processes of change, including the impacts of the given guidance and recommendations. While the child is the object, the triangle is the force. The triad relationships of parent(s)-child, parent-therapist, and therapist-child-therapist is functioning in some kind of unison, all aimed toward the improvement in the child’s well-being. A good process can have the secondary impact of improving the parent’s relationship. Helping to enhance and sustain a functional triangle can evoke unique strengths.  

Contracting

The last component begins with an agreement about the format, then attends to relevant administrative matters, and for a few cases, finishes with addressing potential complications and hindrances.

For the majority the cases, the format best fitting the client and family was fairly obvious. Most of them were recommendations for a family therapy, and the parents routinely concurred. 

For the older adolescents wanting individual therapy, the only question was how to schedule the parent’s short meetings. What could not occur was a separate weekly or bi-weekly therapy with them. The experience here, somewhat painful, is that the client could develope (unfounded) worries about boundaries and quit.

For about 15 – 20%, conjoint treatment or split sessions were presented to the parents as options. When asking the older children and adolescents at the end of the assessment what their preference of format may be, quite a few would have opted for individual had the choice been solely up to them. Thinking more about family therapy for the particular case, I’d ask them that if the decision when meeting with their parents was for family, how would they feel about that. Most said fine. A few balked, rarely a refusal, but said “OK”. If the case were of mild-moderate severity and the parents had parenting issues with relational tones, and/or this unusual apprehension within the client, that case could go either way, and a discussion led to a decision that could go either way. While not in this cohort, a case going from split to family did occur.

Maybe two or three times a year, the choice of format was deferred, mostly at my suggestion. The dynamics were varied. For example, those parents with oppositional adolescent boys prone to angry outbursts could be leery about a family format, and the boy may very well be a candidate for that approach. Based on experience with that population, the clinical inclination was still toward family. I’d explain the nature of the fourth session, in which vocal adolescents were generally effective contributors, and the parents agreed to bring their child plus other sibs if appropriate and available. We’d see how that went, work out how the next session would be arranged, and go from there until the format question was settled. 

Some parents may have wanted more in the way of assurance that the family format was conducive and not provocative. Some clients were leery of being seen with their parents. Some parents simply wanted a session or to more to evaluate and then decide. More discussion was needed, and that was fine.

To reiterate a point made in the assessment session description, carried into this summary meeting with the parents was the discussion with the client at the end of their assessment session about their format preferences. My role was to represent that point of view.  What the clients preferred, if anything, certainly played a role here.

Scheduling, payment process, cancellation policy, and emergencies were covered during the intake. Just FYI, my particular emergency policy was that the parents could try to reach me through the answering service, but I might not be available. The alternative was to go to the emergency room or call 911. To the best of my knowledge, that did not create problems in and of itself. With maybe three or four exceptions over the year, I did not get emergency calls. I’m convinced that if a service is offered, it will get used.

The last area of focus was on potential complicating factors or hindrances that could pose problems to the process itself. Most of these discussions were about the involved ”ex”, in this instance virtually always contentious fathers. The nature of the parental relationship was explored during the intake session, and a starred note was made for those situations where the post-divorce or separation remained to be contentious. They would have to be addressed, cannot be ignored with the hope they will simply never surface. In most of the divorce families, a functional to good working relationship between the couple had been developed. The concerns were where mutual distrust remained, and the presenting parent’s experience with the ‘ex’  was tainted with issues of implacable anger, obsessiveness, blame, and/or splitting. The results certainly contributed to the youngster’s presence in the office, and the emotional ramifications were part of the baseline. The problem was protecting the process.

About a year into the practice, a particular strategy was developed to use with any biological or parenting ex of the parent seeking help. The approach remained to be effective throughout. I never had a tussle in the midst of the casework, the antagonistic phone call  “I understand you’re seeing my son/daughter, and I want to know what’s going on, and I want get a copy of the records!” More importantly, the procedure offered and encouraged a limited contact for the ex with me to help allay their concerns. Be advised, this was before any widespread use on zoom, which certainly increases the levels of option, and this all precedes the metaverse.

To the parent in the office: “So, what I’d like you to tell your ex is that I’m willing to see him once. It would have to be in the office –  I don’t do this by phone. He would be responsible for payment of that session or the co-pay if the service is covered by insurance. He can ask me about how I see (the child), what I’m doing, or what I’m thinking, and I’d be glad to  to help him understand what’s happening here. Whether I see him or not, your job is to keep him informed as needed. If he does come, I’ll review the gist of the meeting with you one-on-one the next time I see you.” The occasional bemused, instinctive response of  pursed lips, tolling eyes, and slow shake of the head by the parent listening to this did not deter the sobriety of the moment, and they carried through.

3% – 5% of the fathers who received this message responded. On the whole, they did come to share their experiences and learn. For some, the discussions produced helpful perspectives about their child and notions about parenting. None came to challenge, from any stance of objection to their child’s therapy. By the same token, entreaties from them to become involved in one way or another did not occur, none of the fathers asked to be directly included. One mother in this position did so, although that proved short lived. The more hard core objectors who tended to harbor hurts and grudges seemed uninterested to take advantage of the offer to meet.The interpretation of the sum experience is that these were generally fathers who had come to terms with the new family reality, and while several wanted more time with their children, as per the case with many in their position, they were more accepting of the family realities. 

Periodically for most cases, I would occasionally arrange for a few minutes with the mother alone and ask how things are going with the ex, just to monitor. Some reported improvements,  most indicated no particular change. And that small few who were difficult from the outset were more inclined to be yet more irritated, not inclined toward the helping profession. The child is usually getting better to one degree or another, some of the parenting relationships are getting better, but much remains unchanged, and the 2% less hinged can get worse. 

In and of itself, the fact that the child was in therapy seemed to have escalated a couple of cases that can be recalled. The clinical impression the fathers left from afar were that of a threatened personality disorder of the immature group on a splitting mission that was under the legal bar, essentially double binding all three in the mother-child-therapist triad. These were truly difficult situations without a reliable remedy. The therapy plan was: support the dyad; maintain an insightful, reinforcing clinical relationship with the boy with the hope that if their processes were cut short, and they both were, that they would consider returning later;  get as much done as possible in what could be a short period of time; and be available to the mother in the aftermath if she wished. One did and one didn’t.

In terms of working with the ex, the offer of that one orienting session suited the purpose, which was to tamp down paternal resistances to the child’s therapeutic involvement. With the mother keeping the father informed, in some instances as a result of the subtle push of periodically checking with her on how things are going with him, the level of tension is likely to decrease, psychopathy aside. If the father emerges more objectively confident in their parenting skills, the client is bound to be benefitted. As the participating parent gains confidence with the child, they tend to do so vis a vis the ex, as well. Some of the relational work in session lends to effect communication with the ex for the mothers. These developments in turn help the child out of the uncomfortable and anxiety provoking position of taking sides in those cases where the conflicts remain overt. The problem is that remaining tensions become a force that drags on the client’s progress.

In hindsight, the paucity of divorcees and seperatees not involved with the therapy is somewhat surprising. Part of the intake with the involved parent was a quick question about whether the ex knew of the plan to seek help. Most all did. Most of the divorces had settled into a routine where at least some of the dust had settled, and insofar as childcare was concerned, some having visitation, some having every other weekend, some having every other week. These factors did not seem to have any effect on their urge to participate, and that was extremely few. And Seattle’s north Eastside is rife with child-centric communities.

Again almost always operating in that lean forward mode, I frankly did not give the situation that much thought beyond having the involved parent relay the message to the ex about a one time meeting. The impact of a marriage dissolution on children is well documented, where increases in anxiousness, depressed mood, and/or acting out to one degree or another are endemic. I think the data also indicates that the more contentious the marital relationship was prior to separation, particularly during the divorce process itself when the loss becomes extant, and in the aftermath, the greater the disturbance. To deal directly with the parental relationship is to work with both. And that’s a problem.

I view family therapy as a one-household activity. My first mentor and original Satirian family therapist Mary Rygg once said that talking represents 10% of communication. The other 90% in all its permutations is non-verbal, and many of those permutations come to life in the context of family therapy. What is said describes only a portion of meaning. The non-verbal behaviors within the  household that emerge in therapy add so much more about their realities of day-to-day life, and that’s important toward understanding the relationships, and that’s important to treatment. Over time, the real scene at home emerges, and then shapes the therapeutic responses and recommendations. The unit functions better and the child gets better, again to one degree or another and dependent on the non-relational issues brought into treatment, ie. personality, trauma, medical conditions, etc. The foundation is mutual experience, intimacy, the security of four walls, and a trust that undercutting will not occur.

All this was as of 2015, which in this arena differs in two important ways. One is that this one time meeting with the ex could feasibly be done by zoom. Likely a higher percentage of fathers would participate, but whether the is 3% or 20% would be unclear until someone tries. The father’s receptiveness and acceptance of the clinical messaging by will be more difficult to discern, but in this instance the act of reaching out itself and being who you are may is likely to be more important as anything said. Re the other side and to state the obvious, the second difference is that overtly aggressive behavior is far more common now than a mere six years ago, and showing no signs of abatement. The 21st century is not likely to ease up. Hobbs may very well trump Locke. Some predictions are that internecine struggles will be increasing in intensity and, sadly, ferocity. One can only hope that frequency is not included.

Out of that lean forward mode clinicians employ, the use of zoom as an adjunct to the in-person office mode would necessarily occur, if for no other reason than its omnipresence. From that one virtual meeting with the father, what cold arise are periodic, relatively brief three way zoom check-ins with both parents about the client’s progress, share observations, and put forth suggestions. Particularly because of complicated issues involving histories of violated trusts and so on, this would specifically not be a concurrent therapy process. From experience, two concurrent therapy processes run the risk of premature terminations. Referring the divorcees to their own therapy with be the better alternative, but even there, best to be cautious. Protect the process.

Be all that as it may, the metaverse will foster helpful innovation in talk therapy, not in necessarily in clinical terms, if at all, but rather as the expedience it is in times when time itself is a precious commodity for many if not most. The 21sr century will  be….

Etcetera 

Dictation: Make notes as if the client and any or all other family members are looking over your shoulder. Assume the wincing stuff will be filed in your memory. 

Do be careful about unilaterally referring parents out for their own therapy, divorced or not. At their explicit request for a referral is another matter and easy to accommodate. Protect the process.

The split session format does see both child and parent to help both individually.

Two Randoms: Foregoing a no show charge is an option – I often if not usually did so. Call me spineless, it’s OK; Demands to review kept records never happened to me, luckily – unhappy clients are a hazard of the business, and this will happen to an unlucky few clinicians.

Unsolicited Advice:   BE ON TIME – it’s easier for everyone.