On a personal note, mine was a solo practice with all the trappings, what with the responsibilities for the clinical welfare of the clients, developing and maintaining a referral base, paying the bills, meeting legal and professional requirements, using consultation, self-educating, establishing a network of other professionals such as a child psychiatrist, lawyer, and  neuropsychologist as adjunctive referents, and so on. Regardless of the particular circumstances driving the day, those among a wide range of possibility, a certain degree of pleasure was almost always taken in coming out of the office and into the waiting room to greet and escort the next family into the office, maybe taking a few moments to look and comment on what the kids may have drawn on the dry erase board, or by crayon on construction paper with the work left on the small pre-school table with its tiny chairs and maybe get taped with the others already on the wall behind, or a construction of some kind on the floor made out of a decades-old set of some eighty small blocks coming in different sizes and shapes. These little moments of attention and recognition is one of the distinct advantages that working with adolescents and particularly children offers, where the younger the child, the generally busier and more delighted they get.The waiting room was alive. And then there’s that innocuous bit of gratification, maybe obscured, maybe not, that the parent(s) have come to seek aid in the office and the kids are generally all in. 

The opener toward the assembled for this first family therapy meeting focused mostly on the parent(s). 

“So, what can I do for you today, and I’m also interested in what’s been better since the last meeting?” 

The first phrase is self-evident. Since the fourth, family game session generally did not end with any recommendations, the question really referred to changes that may have occurred simply as a function of family members talking about them. The reasonable clinical presumption is that talking in and of itself foments positive change. With uncommon exception, families readily disclosed one or more. If they were encountering difficulty doing so, we’d continue the discussion and search. This did work.

These two questions introduce basic session conformations for the work thereafter. The first is to have each session content initiated by the family as much as possible, rather than the content of the day being more or less determined by the therapist. The second is to emphasize the most basic purpose of the process, that being the fostering of positive change. The third is to reinforce the importance of bilateral feedback, me to them and vice versa. The creation of this collegial approach is done with intent. 

While almost always appearing at the beginning of this fifth session, asking about ‘what’s been better?’ only surfaced occasionally thereafter. Doing so was for tactical purposes such as exploring the effects of a previous session’s recommendations, or in the midst of a tough stretch during treatment as a reminder of earlier gains, or specifically toward a child or adolescent in a way to encourage their participation and enhance their confidence as an appreciated member of the session group. If s/he had difficulty coming up with something, the therapeutic work would gently continue until the client or sib identified something meaningful that could be verified by the parent or was otherwise reasonably evident. The parents seemed to intrinsically understand the meaning of the exercise, lightening the atmosphere and providing a certain kind of role model for relating to their children. Be patient.

The flow of this first therapy session is conventional. Usually, one of the parents responds to the opening overture by providing a description of a family issue or need of one sort or another.The  following questions and family responses tend to focus more or less sequentially on: understanding the history, evolution, and current depth and breadth of the presented problem; how individual family members and relationships have been impacted and evolved over time; and the steps already taken in attempts to modulate or correct the situation. In doing so, other issues will inevitably be introduced by members of the family. That same sequence may occur again as the problem list and clinical focus expands. So too does the case’s clinical baseline. 

The young client and siblings tended to be listeners during the first couple or few sessions. Questions from me tended to focus on the parent(s) at the beginning. On occasion, the client youth will independently enter the give-and-take. They tended to be latter adolescents but every once in a while some 8 or 9 year old would chime in, as I recall almost invariably girls. At some point midway through this first conjoint family session, I would usually ask each child who had remained quiet if they had something “to add”. Some would, some wouldn’t. Toward those who had remained watchers would be told that whenever they wanted to talk or contribute or add or whatever word seemed to suffice at the moment, their input would be welcomed.

I knew the child or adolescent client from the assessment session, and the siblings from the family game session, so the session began with at least some subjective notion about their individual comfort levels in this format session, and wanted to avoid creating any level of discomfort at this point. Other family clinicians from other persuasions may want to involve the kids right away. To me, the development of a more collegial atmosphere meant a comfortable, self-initiated involvement by the child. Inferentially, the message was that the therapy was not going to be directive. A reinforcing nod or comment about their offerings would definitely be conveyed at some adroit point during the session, particularly at my summary of the session toward the end of the hour, giving a kind of send-off. Specific supportive observations seemed to enrich the content and help create this collaborative environment.

The 50 minutes did end with a short summary of what has been said and learned this day. Most every time, the sessions concluded with a suggestion or recommendation regarding the problem presented at the opening of this first therapy. So, the session began with a family problem presentation and ended with a clinical response regarding that particular issue. Everything in between was gathering information and doing the indicated therapy, including comments, suggestions, and/or recommendations at the moment. One of the clinical tasks was creating a segue to the family’s stated concerns at the beginning of the session. Addressing the presenting concern was almost always at least a part of the wrap-up. 

As a side note, I cannot recall any client noticing this pattern of the family identifying problems or issue at the beginning of the session and then getting advice in regards to whatever they identified at the end. This is a purely subjective point, but I think that approach enhanced the confidence with which they walked back out the door. At least, no one ran.

Lastly, the suggestions made were not constructed as a prescription, “this is what I’d like you to do….”, that implied a clinician-driven review or check-up concerning the recommendations in the next session. The suggestions and recommendations were left open-ended, and that seemed to work reasonably well. This approach was also part of the introduction to the overarching session structure. When I specifically wanted to know more about reactions and progress, out would come the line, “I’m interested in what’s been getting better….”

Operating as a qualified, trained, sufficiently experienced clinician guided by some recognized school of therapeutic thought and behavior to independently conduct processes, the journey now is one’s own to create, effect, and manage. And middle work begins.