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.
Yes, by using cognitions to help change behavior in a therapeutic setting…were it so simple….
Part of my introductory training in mental health work, way back when, involved watching the Gloria Tapes three times along with a half dozen other young staffers of the Everett (Wa.) Drug Abuse Council’s clinical arm, named Karma Clinic. That name itself was about five years out of date, but in ways so was the small timber and industrial port city, one that was comfortable within itself.
Gloria’s problems were conventional issues of anxiety, depression, relationships, and none with behavior. A pleasant and earnest woman in her 30’s, she would have been rated somewhere in the moderate to mild, 51 – 70 range on the CGAS scale. She had consented to be interviewed by three psychotherapy titans of the time, including Carl Rogers, Fritz Perls, and Albert Ellis.
Rogers was a manifestly kind and gentle man who represented the humanistic, “client-centered” approach that itself came to be known as Rogerian Therapy. That school’s clinical focus was on self-actualization, the realization toward fulfillment of one’s potentials. Perls was the somewhat theatric and more widely known proponent of GestaltTherapy, a school that focuses on one’s experience and insights as they emerge in the here-and-now, enhancing self-and-other awareness. Ellis was the founder of Rational Emotive Therapy. That school’s clinical focus is on self-defeating thoughts and feelings, challenging their rationality, and helping the client replace them with healthier, more productive beliefs and behaviors. As a representation of the growing, coalescing clinical world at the time, the Gloria Tapes would have been more complete had they included Virginia Satir, both as a representative female therapist and as an advocate for the family approach to mental health, one that promotes mutually supportive and enhancing relationships for their clientele, in some part as a conduit toward behavior change.
The three professionals had very different approaches and left plenty of discussion material for us beginners. In her summary exit interview, Gloria said she felt most comfortable with Rogers, but would have chosen Perls. She got less from Ellis, but then again, his approach was less gravitational than those of his two magnetic peers (albeit those two were vastly different from each other) and would likely need more time to become fully engaged. Of the three, Ellis was the one toward whom I instinctively gravitated, not so much concerning his focus but for his more centrist approach to problem definition, clinical formulation, and creative solutions.
All through the 40 + years following those ‘Gloria’ staff sessions, et. al., identifying my work by a specific school of therapy never really occurred to me. What got done is what got done, all along reasonably effective, the process grew and was best at the end, et.al.
Two years before retiring and in need of a few CEU credits before what turned out to be a last recertification, a flyer advertised a six-hour Friday workshop by Don Michenbaum on CBT. The topic itself was not of particular interest. At that time, my incorrect belief was that CBT entailed a collection of specific behavioral treatments from which clinician could choose. I didn’t do that. The attraction was Michenbaum himself, a forerunning clinician and researcher in the field of behavioral therapies since the late 60’s, a cut below the more iconic three above. This would be like seeing Tony Bennet on a farewell tour.
Arriving at the hospital conference hall about 15 minutes late, I took a copy of the program manuscript and sat in one of the back seats. Michenbaum was well into his introductory remarks, walking back and forth across the stage. His delivery was an almost reverent overview of his specialty, then interspersed by a raspy, acerbic patter that for all the world sounded like a 1950’s Catskills comic, an odd, amusing, maybe even endearing combo that also raised questions about just what this day might possibly bring. A disappointing CEU conference could feel like an eternity, and then Friday evening travel out of the city could be long and jangly. But then, this would be the six credits needed. Maybe with a quizzical look, I continued to read through the manuscript.
Some fifteen absorbing minutes later, I laid the document down, a bit stunned. What he outlined was what I did. I’d had virtually no idea. This 75-ish character, expertly knowledgable, maybe eccentric, out there roaming the stage, presenting his information and periodically veering into this vernacular was my role model…really? But then his show went into a live, Gloria-type interview. Buddy Hackett disappeared, and his inner therapist led his client, coincidently or not a 35-ish single female, through a beautifully done, compacted initial session replete with engagement, problem identification, tentative clinical formulation, conceptually broad suggestions, and a clear mutual appreciation to conclude. I walked out at the end with a clinical identity, supposing better late than never.
An excellent synopsis of CBT that closely resembles what Michenbaum presented is an article published by the American Psychiatric Association’s Psychological Tools section pertaining to PTSD treatment entitled “What Is Cognitive Behavior Therapy”, available via google.
Continuation on Language Shaping in Session
As stated in the last post, language shaping as a clinical tool involves two functional dynamics. The first is the intent to directly aid the client, in this instance here by facilitating clinical comfort, maintaining a clarity of roles, and preserving trust. The second function is to provide a model of interaction that can be experienced as more engaging, running less risk of being off-putting or disengaging, and probably more of benefit to the parents.
In a way, psychotherapeutic style can be seen as being bipolar (the graphic type), one pole being directive and the other collegial. The directive style relies on unilateral expertise to develop a truth and apply their authority on remedy. The collegial style works more toward mutual discovery to understand, and include trial and error among recommended treatments. Typically, the inquiring style of the ‘expert’ is structured by the ‘who, what, when, where, why, or how’ questioning paradigm to uncover what one thinks, feels, and or does. The collegial approach is essentially “let’s explore this together”. While never much for extorting authority (despite having been a lieutenant in the army), the gravitation toward the peak of the collegial pole took time. Conduciveness to family therapy, if for no other reason than that the collegial style lends itself as a model for more effective resolution skills and solution processes within the family itself.
The following short compilation of phrases were accumulated over the first ten years or so of the practice. My first private practice clinical consultant, a conventional clinical psychiatrist and consultant with forty years experience, had an unusual combination of a personal austerity and a heightened sensitivity to other’s struggles. He modeled this humanist tone outlined here by using the first three phrases on this list as regular part of his repertoire. The rest were either adopted from hearing someone else or occurred spontaneously. Noticing a positive impact within a client, the new line was field tested, generally using the dictum ‘if something worked once, take note; if something worked twice, there’s a pattern; and if three times, the item is probably a keeper’… until proven otherwise.
Also take into account that the interpretation of spoken words can be seen as a combination of given meanings and the personality of the conveyor. Particularly in the first half dozen sessions, clients young and old alike can find the atmosphere intrinsically intimidating to one degree or another. Beginning therapy can generate vulnerability when the delving person is essentially an unknown, even if highly recommended. Knowing the words to use is important. Knowing how you as the therapist come across using those words is equally as important if not more so. Particularly if being an unknown entity to the ‘other’, modulating some kinds of probes or critiques by a beckoning preface can reduce self-protective resistance on the part of the client, even dissipate it altogether, and help foster a growth of trust, both of the therapist and within oneself.
Cultivating The Clinician Role
“I’m interested in understanding…..” rather than just “what…” or “how…” or the more potentially more vexing “why…”.
“I’m interested in learning more about (your feelings, thoughts, behavior, etc)” rather than ‘tell me why” or “…what”, or “…how”
“You did the work”, in response to ‘you’ve helped me so much’ when reviewing changes that have occurred
Clarifying Role Boundaries
“I work for you…”
“My job is to work myself out of a job.”
“I may have helped, but you did the work”.
When time allows toward the end of a session, on occasion randomly ask “Do you have any (other) questions you’d like to ask me?”
“How are you feeling about this process so far?.” Some speaker years ago said that ‘super-clinicians’ are in part defined by the willingness to encourage honest feedback from clients about themselves. This line was used effectively, again on occasion, after the first few sessions of a case settling into the process and a certain comfort established in the room, particularly with complicated or evidently difficult cases.
Wading Into Difficult Waters
“I might be wrong here, but I think what’s happening here is….”
“There may be no answer to my question here, but…….”
“This will be a difficult question, but I’ll help you with it”. Infrequent, but used particularly in a family setting, providing both direct clinical help and, in a way, parental modeling.
“Unsolicited advice is usually worse than no advice at all, so, this may be pushing things, but I’d like to suggest that…” or something along those lines. Parents in particular might remember this one, and thereafter perhaps be more judicious with their feedback to the children.
“I’m having a hard time making sense out of this, so please help me…”
Acknowledging differing opinions
“…but you understand what I’m saying – you may not agree, but you get my point of view, right?” Again used infrequently, this was usually employed with adolescents
“Right or wrong, good or bad….” When offering an arguable point of view….
Second Half of Session 4 – Family Game
Following the individual inputs and around-the-room discussions about what each participating family member wanted to see improved, the second half of the session was having the family play a game together. The game of choice was Jenga, chosen for its simplicity, being well under under thirty minutes to play, and options of approach.
For the uninitiated, Jenga is a block construction activity that uses 54 wooden pieces,
all 3” x 1” x 1/2”. The classic game is to build a 3” x 3” tower as tall as possible. A level is usually made of either one or two pieces, starting with two, then crossed in the middle by one, then another two, etc. The skill is to maintain balance as the tower grows. Imbalance leads the tower to crash, a cute paradigm in this clinical setting that remained unspoken.
An interesting facet of Jenga is that playing the game can be either a competition or a collaboration. As a competition, everyone is on their own. Each player works to avoid being the one who causes the stack to fall. A handful of times among the few families that chose this approach, one of the children, usually an elementary aged boy, may try to set up the following player, often a parent, to be the ‘loser’ with an odd placement that poses a balancing problem. If the parent then crashes the tower, the joy can be truly funny.
As a cooperative enterprise, the group’s interest is to see how high the stack can be built. The goal of this particular game is to use all the blocks and still have a standing tower. What I would tell all families at the beginning is that building a tower of thirty-six levels can theoretically be done but is very difficult to do. Most families gravitated toward that route and cooperated with suggestions and rooting for others.
Aside from that implicit nudge toward the cooperative approach, I remained a neutral observer insofar as the game was concerned. The clinical purpose of the family game was to gather more information about the individuals, their individual relationships, roles, habits, and demonstrated values. As the final part of the formal assessment, I also viewed the family game as an opportunity to interact more informally with them. The byproduct would hopefully be enhancing the engagement process by joining them a bit. While clinical suggestions based on evident problems could have been done, to me the rubric of ‘unsolicited advice being worse than no advice at all’ prevailed. The next session, which starts with “what can I do for you today” would begin the treatment per se and all suggestions thereafter in the session could be deemed as overtly solicited.
This family game exercise was done some 350 – 400 times over the years. Very early on, one family of four did accomplish the goal of a 36-level stack. The pride they had in doing so was palpable. The ten year old client himself laid down that final stick, ever so carefully because of the slight but potentially deadly teetering up top. Knowing this sounds like saccharine theatrics, the father had his arm around the kid’s shoulder on the way out. Given the family’s presenting issues, that father’s gesture was meaningful in and of itself.
At the time, I didn’t give credit due to this exercise. As a result, almost nothing in the way of descriptions or notes were written afterwards. And I have no record of who that family was, what were their presetting problems their family structure, or the clinical outcome. Only the accomplishment and the distinct memory remained.The difficulty of finishing with a standing tower is demonstrated by the fact that this success would never be replicated in the office by anyone. Thirty-six is a tough make.
With very few excerptions, the families left the office relaxed, so this somewhat lengthy assessment process finished on a fitter note.
Only one out of the 55 cases experiencing this fourth session dropped out at that point afterward. Going into session five, 54 of 58 continued.
One of the regrets in hindsight was not collecting data about how families chose to approach the game, family make-up, pre and post CGAS status, other characteristics, etc.
Lastly, the value of repetition is that norms get established over time. The positive abnormals can be confidently reinforced based on data, and the troubled abnormals can be addressed on a similar basis.
The first family meeting is the last of the structured variety. The number of participants ranged from three to six, mostly of two parents and one to four children. More than four children would have certainly been welcomed, but in fact that only happened two or three times over the years. Oftentimes when the participants were a single mother and one child or adolescent, the process moved directly from the summary and recommendations session into straight clinical sessions, the two having been long accustomed to working together.
Roughly a third of the families bypassed this session and moved directly into clinical work. In addition to the few mother-child dyads, cases involving multiple family-wide issues that required immediate attention and recommendations was the primary reason for skipping the routines of the fourth session. These could include manifest conduct disorder types of aggression, delinquencies, suspensions, and resistances; self destructive behaviors; threats to safety and security; and lingering post-divorce issues that pull the child(ren) back and forth, creating a prevailing atmosphere of inhibiting anxiety and dread.
Nietzsche once wrote that “out of chaos comes a dancing star”. These situations cited above were usually among the most difficult, with a higher percentage of early withdrawal. But those that stayed the course and really got somewhere new and healthier could be seen as the dancing stars. If the clinician can work them, meaningful degrees of peace and even beauty can emerge.
The purpose of the fourth overall session is threefold. The first is to accustom the group involved family members to working as a group in the office, for the most part an entirely new endeavor. The second is to establish a family-determined baseline of desired changes. The session is split into two separate sections, and one function of the second half is to observe the family playing a neutral and entertaining activity that also provides an opportunity to engage with the participants more informally.
After the induction of family members attending for the first time, the session begins with: “Is there anything of immediate importance that you need to discuss today?”
An affirmative was uncommon, and most of those situations were deferred to the last few minutes of the session.
The follow-up was “What I’d like to do is to hear from each of you what it is that you’d like to see get better in your family, so whoever wants to start, go ahead.” After a few seconds of looking around at each other, nine times out of ten that person would be the mother. Staying in the role of interviewer rather than director, who came next was left up to them.
The first process consideration concerned time. Minimally, twenty of the fifty minutes were going to be used for the session’s second half game, and preferably twenty-five. One intent was to use the same amount of time interviewing each family member present during this first section, so these mini-interviews had to be structured accordingly. If the group in the office numbered three, that would leave eight minutes or so for each; for six that would be five.
Before shifting to the game they were to play, a quick summary of what the group had identified as targets for improvement was given. I ask if anyone has anything they want to add or elaborate of change.
The list forms the family baseline, different from the clinical. Together, they make an outline of reference points that will help shape the termination session review, whenever that occurs.
For an experienced interviewer, this work is fairly easy, enlightening, and as so often with kids, sometimes pretty fun.
In addition to establishing baselines, much of the clinical work during these early sessions involved two kinds of language shaping. The first is a small body of suggestions for the participants as they related thoughts and pursued changes, all toward facilitating manners that are more descriptive, specific, and positive in nature. The other involves interviewer phraseology, modeling what can be viewed as a collegial style as differentiated from a directive one.
Shaping Vis-a-vis The Participants
All of these following examples recurred over time, enough that a standard response was developed to intercede for most. Any of the first four could and would surface in this fourth session or early thereafter, and the others would arise more randomly.
“You should…” or “should not”
‘Shoulds’ were actually not used very often during session, almost surprisingly so. Shoulds were usually used by a father reproving a son during this first family meeting. Before the youngster could answer, I would interject, “There are no shoulds” (highlighting the ‘are’ as a mild emphasis)”, so what I’d like you to do is restate your point without using the ‘should’.
Almost all the rephrasing parents created a better and less challenging restatement. That they did so unquestioningly was a kind of revelation. More importantly, the restatement itself could be highlighted as being more to the point and effective, thus providing some unanticipated, random reinforcement, always the most potent kind.
Only two fathers that I recall challenged the assertion. Both were lawyers, and they both used an example, like “Of course there are… ‘you should pay your taxes!’’
And I replied “A should is really just an opinion presented as an imperative.”
And both shrugged, accepted this proposition, and went ahead with their revisions. With an exception or two, the use of ‘should’ by the adult being addressed fully stopped. The important part was that these parents, particularly the fathers, were likely putting more thought into their messages rather than bering reflexive. In the office, anyway, the children were more attentive at that moment of revision. In and of itself, the last point could be randomly reinforced as well.
Defining objectives in positive terms
To a parent who has just told the child he needed to, say, cut down on computer game time: “Now, could you phrase that in terms of what you want to see happen rather than what you want to see stop happening?”
For some parents the transition here is challenging, affording an early opportunity to be of straight clinical help in shaping their new message. Possibly that work might include how the parent could aid or facilitate what they’d like the child to be doing. Would the child like the parent to be of a bit more help with homework, that usually being what the parent wanted the kid to do in lieu of gaming at the outset. Basic CBT.
Beneath most anger is fear
This approach can be particularly effective in the office. From a clinician’s standpoint, switching the focus is a shortcut around what can be the laborious and time consuming task of unwinding the anger itself, and the parents now have a new and easy tool to use at home.
“What might you be worrying about here?”
“Can you say that in a quieter way? You’ll be heard better”
An alternative to the approach above. If the occurrence of anger was frequent, one could also use a family narrative approach, asking the parents if either of them or other family members of theirs had the same kind of anger pattern.
In response to the parent talking about themselves in the third person, e.g. “Mommy’s is disappointed about (what you did)”.
I interjected, “Use ‘I’.“ The belief here is that third person-ing induces more in the way of guilt, and produces less in the way of thought.
“I’m just lazy”
This statement appeared maybe only a half-dozen times over the years. The use is essentially a dodge of responsibility. Every one was by boys.
The response was: “I don’t believe in ‘lazy’. There’s no “lazy” gene. You may have problems with motivation or focus and concentration, but those are problems of mood and/or anxiety, not of who you are, and I can help with those.”
The following discussion was about which of these symptoms applied to the client, what might they be worried about, what actually happened when they tried to focus or concentrate, what could be done by the parents and even sibs to help an improvement along. Follow up in the next session is important to consolidate the gain, presuming one occurred.
Complaints by client of boredom
This sentiment usually took a bit of time to emerge and not to be ignored. As parents of apathetic, listless, or overwhelmed children would testify, tackling this problem with guidance, persuasion, or pure pleading, structure, reinforcers and consequences, tight reins on the one hand or ’s/he’ll grow up’ on the other, etc. etc. etc. can be draining.
Eventually pieced together, the approach used here was reality-based, sharing a set of observations about other youth who complained or asserted this state of mind, to wit:
“I spent some time thinking about the kids I’ve seen here who say they’re bored, and found they have some things in common. So, I’m going to share them with you. Some seemed to to be kind of young for their age: some may worry about how they’re being seen by others; some may have trouble initiating activities and interests; some may feel lonely; and some sometimes just feel sad, almost for no reason.”
Because this is a lot of information to absorb, the delivery is slow. The question is whether the client experiences any of these themselves. The list was given mostly as information simply for them to consider. I avoided pushing any narrative about the pertinence of the list to the child, but rather just asked if any did pertain. If so, the discussion went toward that area, carefully, and in turn could lead into conversations about the young person’s realities in one or more the of cited areas and maybe others.
The particular emotional and behavioral problems the young person had been experiencing have already been defined during the assessment phase. The work had started and likely began to generate observable improvements in other areas like school performance or social activity. Some adroit reinforcement for effort is always in order. Gently exploring once again feelings of worry and sadness can marshal a sense of support for the client, and while not quite the same as acquiring a friend or getting an A on an assignment, the experience in the office can help reduce that sense of isolation. Seeking joy comes next. Least important but notable is that with these clients, the phrase “I’m bored” usually didn’t surface again.
The use of “I don’t know”
Not knowing an established fact is one thing. Being unable to a have a semblance of how one feels, what one thinks, or what one did is quite another.
The response would be one of two:
“You know, ’I don’t know’ in this office usually means ‘I do know but I don’t want to tell you’. So, assuming that’s not true, let’s try this again.”
“ ‘I don’t know’ just doesn’t work in here, so, let’s try this again.”
With either, the important part of the response is to actively help the client reformulate, then praise, For most of these cases, “I don’t know” has long been reinforced, so reinforcing the opposite behavior, one of knowing and responding, and making something positive out of the challenge through the subsequent exploration is constructive.
Clarifying feelings from thoughts
Raising awareness about a client’s own feelings and and recognizing those within others is an intrinsic part of child and family therapy work. As part of that mission, a majority of the children and adolescents who went through the assessment were given the feeling identification exercise (see Post 47 – Assessment). Those who did not would frequently be given this test during this session as part of his or her interview.
The use of that tool continued into this first family meeting. As part of that 5 – 10 minute time interviewing the client youth, many of those who were not asked to go through the exercise did so here, i.e. “OK, there are five different basic feelings that everyone has. I’m going to ask you to name the five. Very few people can name all five, but I’ll help you. So, what are they?”
Part of the purpose in doing so in the family session was to introduce the rest of the family to the concept of feelings as differentiated from thoughts.
The fun part was when one of the parents, again usually the mother but occasionally a dad, do the exercise themselves. These would be for instances where the child has already done it in the assessment. The first step was to carefully pick out the parent. The last thing needed was to embarrass one of them. Some were not that conformable yet, some still not persuaded about therapy itself, some naturally more introverted, inhibited, or inherently anxious. A parent who demonstrated equanimity, forbearance, and humor was ideal. Finding a prompt during their short interview was simple, and from there, “OK, there are five different feelings….”
Since the client child had already gone through this process during their assessment session, they always sat forward, usually with this big smile because they knew the answers. The younger the client, the more animated they would become just sitting there, they can’t was, and the parent knew their jig was up. Watching a child occupying the proverbial catbird seat is a real treat. Interestingly, the parents struggled in the same way as their child in identifying all five. They’d name three, a few four, and I don’t recall anyone getting all five. Every once in a while, I’d have the child help the parent identify the last one or two, and that was satisfying to watch. Fun helps.
Through all this attention on behavior, an accurate awareness of what others feel may be paramount.
“But, I’m ADHD.”
In the first thirty years of doing child and family therapy, this line did not arise. Beginning around 2010 and for reasons I can’t explain, this utterance started appearing.
An old axiom is: ‘If something happens once, take note; if something happens twice, you have a pattern; and if something happens three times, you have a problem.”
“But I’m ADHD” appeared more than three times. Like with the declarations of being lazy or bored, the use of the particular diagnosis was usually a dodge.
Interestingly, all of the maybe four or five of these clients during those last five years of practice were adolescent girls. With the same basic intent, boys used “lazy”or “bored”. Also, the male use of being lazy or being bored always occurred in the context of conjoint work, as if to lay out a challenge to the parents. The ADHD declaration, on the other hand, usually occurred while the young women were being seen individually during split session processes. That point is significant because they likely never would have used the diagnosis as an explanation for deficits in front of their mothers and/or fathers. In this instance, one has to appreciate female discretion re: the family as a whole.
Charles Mann’s 500 page book “1491”, described by the NY Times as a “sweeping portrait of human life in the Americas before Columbus”, looked into the social structure of the Haudenosaunee nation of the U.S. northeast. He summarized that the leadership of the tribes were divided into two discreet roles. Women ran the politics and men provided the defense. And then one thinks about the contemporary U.S. Republican Party….
Creating a generic response to particular client avoidances and resistances requires a few episodes to develop, and four or five is probably not enough. Eventually, I used the following approach with the last one or possibly two of them, not enough to be validated, and in this instance certainly not to be recommended due to being a little over the bar. But for these two, this worked in the sense that the need for the excuse seemed to dissipate and the discussion matured. They stayed with the program, so to speak, by adjusting.The other difference was that with the lazy and bored declarations, the interviewing demeanor was definitely sober because of the feedback’s serious nature. This approach used an affable exaggeration, to wit:.
“Is there anyone else with whom you used that one…and it worked…it kind of got them off the trail…like they just throw up their hands… and turn away…and you say to yourself… in a surprised tone… ‘It worked?!….’
The discussions then tended to move toward what the experience with ADHD was like, what some of the problems were, how they coped, what worked to pass or even pass-plus, how they felt about themselves before and after, where they got their A’s and B’s and how did they do that?
I think this approach to adolescent males would run the risk of generating a more smoldering sort of reaction that diminishes the clinical relationship. These millennial females seemed more responsible.
Abiding the notion that behaviors speak as well, two types occurred in the office that warrant some kind of attention, if for no other reason than they are distracting, they being yawning and fidgeting.
Again not particularly common, but a pattern of yawning by the client was noticeable and presumed to be meaningful in the office. Going through the relevant articles online about yawning, the cause and meaning has yet to be firmly identified, making the action one of the more mysterious human behaviors. Many associated yawning with the state of boredom, or lack of brain activity. The large intake of oxygen is proven to be energizing. Others postulate is that yawning “cools” an overheated brain, one that’s undergoing stress. From this perspective, the latter hypothesis is more to the point under the circumstance of a therapy session. The experience for a client and other family members working together in the office together is anything but “boring”.
A pattern of yawning was presumed to be an indictor of a client’s specific anxiety related to the overall topic or tenor of the session, and likely needed some attention.The incident(s) were generally not cited at the time, but rather noted to be addressed later. That would usually be during the next session or two.
Yawning did dissipate, and probably would have over time without attention. The behavior offers an entry point into work with anxiety and other discontents.
By one published study (not noted), fidgeting increases the amount of serotonin in the system, so the behavior pattern becomes a biological way of improving mood.
Fidgeting can be either random and fleeting, or a significant condition. Instances of restlessness, nervousness, and/or impatience at the beginning of a therapy process can be expected for some plurality of children and adolescents, particularly so when in the presence of parents. When being seen individually, they refrain and tend to be more focused. Those early manifestations of situational anxiety would be overlooked as they evanesce fairly quickly.
On the other hand, fidgeting as a condition, meaning the afflicted just cannot refrain, is another matter altogether. The longest case in the 58 case study – 162 sessions over 6 1/2 years lasting from sixth thru twelfth grade – was also the epitome of persistent movement and fiddling with whatever nearby caught his attention. He’d be redirected, and within a few short minutes, he’s back at it, then redirected, then back….
Nate presented with multiple behavioral problems at home and school that amounted to an oppositional disorder, a depression with anxious features, social isolation and victimization, and obsessiveness beyond mere fidgeting. Perhaps superseding all was a socio-cognitive deficit that did not fall well into spectrum criteria, nor of a low IQ, nor any aspect of reality testing. Three diagnostic specialists in the area of socio-cognitive disorders who had evaluated the boy had differing opinions, but none that led either to a cogent understanding or an effective treatment. That included multiple attempts at medicating. The last medication was prescribed by referral of mine to a regarded child psychiatrist specializing in this general child and adolescent area. In a follow-up conversation, he agreed that the boy had a deficit, but one that defied categorization. He added that these more vague problems were not all that rare.
Fortunately for the client, his parents were Ohioans replete with midwestern values such as family-orientation, honesty, competence, belief in hard work, and persistence. Both were mid-level administrators, one in the private sector and the other in local government. The older daughter by three years was a high achieving student and athlete with an active social life, eventually getting accepted to a top-tier West Coast university. She participated during early sessions and was helpful filling in details about the younger brother’s strengths and difficulties.
From the very outset in my office, Nate was easily distracted by the minutia around him. He sought to examine and manipulate anything from the clock to a small potted plant to the couch buttons and even more than once to a dust bunny. Such behavior occurred even when being seen alone in the assessment session, and would require redirection more than once or twice during a session.
This process was the first and only psychotherapy process the family used. The mental health work done prior was mostly evaluations and programmatic recommendations that could lead to modest improvements which then waned. Medications hadn’t seemed to help. The psychiatrist to whom I referred him prescribed an SSRI during his fourth year in treatment. Within three weeks he became suicidal, was taken off, returned to his old state, all providing us with a sharp startle.
The therapy here was a standard combination of behavioral, relational, affect management, and personal growth or insight techniques. The fidgeting was not a central focus. Rather, the attention focused on re-direction, praise for maintaining attention, random unsolicited praise for his propriety during sessions, etc. The overall problem list was long and concerning, and the fiddling became a secondary concern. Making the fiddling a central feature of the work felt like fiddling itself, given the extant of other issues.,
As the process proceeded into years length and he had presumably become accustomed and less anxious about being in the office, the fidgeting did decrease, but very slowly with considerable and sometimes steep ups and downs. That matched his school performance over time, where he would have periods of reasonably good work and then flag, and a social experience that would also wax and wane. All those areas of unstable life activities did not necessarily rise and fall in conjunction with each other, in a way demonstrating a modest but profound lack of integration. Particularly during junior high, his schoolmate experience could be emotionally brutal. But the overall plane of functioning as seen over months and ultimately years did rise, however slowly. The fidgeting per se was not tracked, but the sense here is that the activity lessened more quickly and more linearly, likely gone by his junior year in high school, if not sooner.
Reinforcing the opposite behavior was probably the most frequently employed tactic, certainly during sessions both conjoint and individual. Various home supervision and programmatic ideas were floated during sessions. A few were employed by the parents with success for a while and then waned. Being in therapy, the parents were less isolated in their parenting struggle. Never particularly punitive, their irritation levels could nevertheless rise and hang over the home atmosphere, a major incentive to try therapy again at the elementary school counselor’s recommendation. The clinical work itself helped reduce the isolation. The mother in particular was a relentless advocate, with the father’s allegiant support.
I worked with the three school counselors involved with Nate from elementary through high school, mostly during junior high. His eighth grade was probably the worst year of his life up to the time he terminated as the social machine ground up the litter. During that time, though, Nate developed an interest in origami, of all things and a perfect outlet for a fidgeter. He showed a skill level that probably eclipsed any of his other endeavors, excerpt online gaming. The idea of him doing an origami project for class credit came up in a family session, and he was unusually animated. The school counselor thought that a display of his work in the school’s rotunda was feasible and was similarly enthused. So Jenny and I agreed to approach the school’s up-and-coming vice principal, by reputation a ‘tough guy’, but the class credit idea just seemed so innocuous and potentially spiriting. She set up a meeting.
He took a seat behind a large circular lunchroom table by the entryway, setting himself about nine or ten feet apart from where we sat. Jenny and I were both experienced, generally known and respected professionals, comfortably and ably involved with the student and family both. With thanks for meeting with us, I outlined the problems. She explained the proposed plan.
Homework was only one of several problems in school, not the least of which was hallway bullying. On the other hand, his ability to produce something artistic had emerged, the first appearance of a tangible, abiding interest that could be relevant to school and community. Showing the work might help reduce the denigration and occasional victimization. The credits would matter and may encourage a better academic effort via the greater degree of confidence.
The taciturn VP took all of this in with a question or two, sometimes with eye contact, mostly looking down at his pad on which he had made couple of notes, maybe fiddling, hard to say. When Jenny finished our input, he paused as if to think for a bit, then as he was rising and with a hint of disdain he declared “If my eight year old daughter can do her homework, he can do his too.”, got up, turned around, and strode out the door, clearly put out. Jenny and I had a wordless few seconds of eye contact, shaking the heads, and got up ourselves. Both of us realized on the way out to the parking lot that the meeting needed to be between the principal and the parents rather than the VP and two mental health people. That was a mistake, and in this business, clinical mistakes are not that easily countenanced.
This story is shared because the experience with this human intransigence was something of a metaphor for the therapy process itself. Nate had serious problems. He also had unflagging support from his parents and reasonably competent, diligent, and creative professional help. He’d been climbing a hilly road with steep inclines, declines, and patches of bumpy traveling surfaces to tread. He would make some progress, for example academically, recognize his efforts, and then tailspin like some cold, implacable, internal force inside thrusted a “Nope”, only later to bring himself up just a bit further up that hill, again into new territory, and then “Nope”, only again later to.…
Some of his problems he created for himself but those such as a cognitive deficit were created to endure. Declines followed inclines, but successes could also follow setbacks. Finding that one key, know for a fact what he really thought and felt why he did what he did seemed to be the task of Sisyphus, but nevertheless he was getting better at interchange. The team of parents/therapist employed what felt like everything. Nate was slowly clueing in to the experience of others, slowly over six years, and the directions that the therapy had been taking seemed reasonable, providing direction, avoiding the punitive, and reinforcing the gains. He could acknowledge disappointment, recognize what needed to be done, but that too could quickly wane. The parents were struggling to find the narrow space between too much and too little involvement because that line’s placement in life readily shifted within Nate. As for behavioral action, his stimuluses and effects were quixotic, and not in the glamorous sense at all. Stuff happens, but still, growth can prevail, emphasize the word ‘can’ as opposed to ‘will’. Just as the VP’s response, the ‘stuff’’ this kid endured was not common, at all. That was just one more.
Our professional charge apparently shrugged about the result of the meeting, perhaps relieved in some way, kept up with the origami for a short while, then turned toward some other interest. His one advantage was the more enlightened version of fidgeting. He was always into something.
Nate carried on into 12th grade. He was now passing most everything, had a small coterie of friends, but still a distance from the normal social experience of latter teens. He had a part-time afternoon job at a farming supply store where he was doing reasonably well. And then he decided to quit high school and go to the school district’s award-winning voc tech. He also independently decided to conclude therapy.
The termination session was more perfunctory than most long terms. His social relationships had developed some warmth for him, so the coolish demeanor didn’t really indicate a lack of capacity to care for those who value him. His parents were not particularly effusive all along, but always friendly, and appreciative when intervention successes and progress occurred. Right or wrong, I associated the reserve with their strain of midwestern personality.
I felt warmer during the termination session than he, the work having been reasonably effective and one always wanted to root for the kid. The mindless fidgeting had not appeared for a long while. I reminded him about that. He looked a bit puzzled, and then shrugged, underwhelmed. As per the custom, I told him any time he wanted met be of some help, I’d be glad to do so. This generated his more affirmative nod and smile. He left with a good, firm handshake.
Via my own scoring using the CGAS scale, he had gone from being in the upper side of the severely disturbed decile, estimated to have been a 38, changed and grew through the serious decile, then through the moderate, and finally operating in the mildly disturbed area, estimated at a 62. He still had a level of disturbance, but momentum itself in a case like this can push the progress forward. At the same time, were it not for his parents, the therapy would never have gotten this far, so ultimately, he has also been lucky.
More broadly, the process could also be seen as plodding. From certain contemporary perspectives emphasizing efficiency and cost minimization, that may be hard to dispute. Granted, the complex of problems was somewhat daunting, particularly driven by the cognitive deficit. A small congress of third parties with differing vested interests charged to evaluate a therapy for that length of time over that many sessions involving that many people would minimally have a contentious time. But the critiques that become valuable are those that are couched by the realities of early 21st century mental health practice in real life, out there in the community, away from brilliant lights.
Indulging in my own musings with an eye on both history and the concept of developmental growth by stages, the science of mental health treatment can arguably be in the prepubescent stage of development. We know enough to concretely understand the basics, but remain far from an overarching, formally, and scientifically reasoned understanding of the brain, the person, the community, the environment, life itself as an operative aggregation of all these variables. We’re what, 150 years old as a profession? That leaves a far and long way to grow. Talk therapy may become relatively primitive when thinking about just how far technology has yet to take the effective treatment implementation, likely will remain a mainstay because we are social at heart…most of us, anyway.
Maybe where the profession is now? If all extant outpatient treatment types were divided into, say, five discreet categories, talk therapy bring one, and a comparative outcome study including, say, 2500 cases all treated by chosen community-based practitioners that create an equal distribution among the five expertises, my guess is that the differences between four of the five would be empirically insignificant and the fifth would a bit fall short, and that none would empirically stand out from the others in standard deviation terms. One may turn out to be significantly lower, and that would not include this talk therapy. That’s an estimation of where we are.
So, we choose how to work among the contemporary options, get the training, stay up to date, and do the best we can, and for the time being, that’s more than acceptable until we as a species know a lot more and something emerges as categorically better by some significant measure to resolve the problems that come through our doors.
If there’s a message here, hard cases are certainly out there and you can get them anytime, and they will challenge in many ways, some that might be insuperable but many that provide an almost unique human satisfaction as did Nate and his folks.. So…. Stay the course. Be diligent. Trust your skills. Be Kind.
Note: The following post will address in order: interviewing language; the family game; and the fifth session that essentially presents the basic structure of regular family and individual sessions.
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.
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.
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.
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.
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….
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.
The last section of the previous post discussed several clinically notable elements of childhood family drawings, to include: who of the family are included; who’s left out; extra characters included; the presence of a yellow sun; the streaking of the yellow sun with orange; the usage of red and black; baselining; and the relative size of the characters i.e. who is portrayed significantly bigger or smaller that real life relative to others. Not discussed there but obviously of central importance is the nature of the family activity and the affects portrayed by the drawing client.
This next area involves pieces of the drawn picture that are missing. These include drawing everyone in the family drawing with no faces, hands, or feet, or having drawn no people at all. The constriction of colors to the use of only one for the drawings turned out to be clinically associated with these missing pieces as well.
As mentioned in the previous post, for evaluative purposes I went back four years prior the study and pulled out all the 5 – 8 year olds, producing an N of eighteen 5 – 8 year olds. All these cases save one produced the three drawings requested. The family drawings as a whole produced previously unregarded and completely unanticipated results.
Out of the eighteen, they included:
Four who drew characters with no faces, hands, or feet
Four who drew those with no hands or feet
One who drew no people at all
Four who used only one color (three of them included among the three types above)
Note: Using only one color is associated with perfectionism (look up on Google). At the time these cases were being seen, the significance of one-color usage was not recognized, but neither did the broader problem of obsessiveness and its various sub-categories receive fair due either. The data above was the result of research for this post, and not particularly noticed at the time of services.
The question then became what distinguished these ten cases clinically from the other eight. What follows are brief case summaries, as might appear in a chart of the ten.
No faces, hands, or feet
#1. 7 year old 1st grader; parents divorced 2 years; mo. in custody; father ? depression, acted out; client is dysthymic, occasions of aggression, ?ODD; 2 older bros. w/Aspergers; mostly conjoint process with later split sessions, initially mother and all three boys, later just with client; father never involved; 72 sessions, over 2 1/2 years; mutual term, much better, normal functioning
#2. 7 year old 2d grader; fa.?bi-polar w/ family history, aggressive, suicide gesture w/ gun; mo. situationally depressed, marriage in trouble; pt. ? OCD/ODD or RAD, but no family history suggesting the latter; poor social skills, rocking, hard time with directions, obsessive, easily agitated and reactively aggressive; IEP at school; also drew with one color; 8 sessions, split session format; did not respond well to tx, difficult to have him focus; unilateral termination; likely getting psychiatric eval.
#3. 8 yr.old 3d grader: both parents professionally successful, Ivy League bright, depressed; fa. w/ culturally-based belief that depression is moral failure; mo. situationally depr.; pt. non-compliant, easily irritated, situationally aggressive, soc. probs, ODD(?); drew w/ one color, playful but no faces, hands or feet; two processes a year apart, seven conjoint and six split sessions each; doing much better at term., significant gains; pars pulled out, unanticipated unilateral term, but kid picked up soc. skills, more extroverted, prognosis good
#4. 6 yr old 1st grader, adoptee from eastern Europe; obsessive, perseverates, falling behind in school, OCD-type, can’t stay on task at school, takes up “80%” of mo’s time; adoptive father tech exec, mother homemaker, both OK; Picture of self included two sisters and “another kid” hanging on a playground jungle-gym type apparatus, no face, hands, or feet; ten sessions, conjoint process; showed good progress during #s 4, 5, 6 and 7, then mother’s mother suddenly died at home in Northwestern Europe, process interrupted for a month, came back, client regressed, started to pick up again; the tenth session ended the school year, mother and children returned to Europe; cancelled Sept session; unilateral termination, got the sense they were pursuing an OCD eval.
No hands, no feet
7 yr. old 2 grader; Pars separated, going through divorce, both OK mental health, fa. may have had OCD in family history; child reported perfectionistic, hyper focused; since 6 1/2, has rapid escalation of OCD-like symptoms, irritability, uncommon aggressiveness, i.e. throwing rocks a classmate in a pique, and adamant non-compliance at home; in assessment, he was nervous, fidgety, but made an effort; drawing picture of family was almost tortuous, all in black, dividing page into four squares, the X-ing out each, flipped paper and did the same thing on other side, except drawing his father in the last, bottom right box with vaguely angry look, no hands, no feet, all evidencing seriously contradicting self-directives beyond the youngster’s ability to manage; conjoint process w/both parents, client active and involved, showed nice improvements over sessions 4, 5, 6, increasing and sustaining; went for psychology group OCD eval resulting in dx. of PANDAS and Lyme Disease, and they took over treatment; mother later wrote re: finishing co-payments, said progress was slow, up and down but overall getting better.
2. 8 yr.old 3d grader; marital conflicts; fa’s parents divorced when young, hasn’t seen father or 25 years, OCD in his mo’s family; evidencing OCD-type behaviors, ritualistic, hyper-focused, considerable anticipatory anxiety, easily irritated, memorizing license plates, recognizing and naming people by their plate numbers, as a toddler could roll toy train wheels on his palm for long periods of time, etc; family pictures bright, big yellow sun, colorful, no hands, no feet; conjoint including older brother; 30 sessions over a year, mutual termination; modest gains, improved in areas w/some cycling back and forth; more social, stabilized school performance; probably heading for OCD eval.
3. 8 yr. old 3d grader; father OCD, off-on-off meds, depressed, caustic, agitated w/son when fa. was off meds, not recognizing own behavior at the time; mother stressed, marital probs; client defiant, aggressive, interruptive, controlling, bit perfectionistic, ?ODD; fam pic. characters indistinct, no hands, no feet; 21 sessions, modest gain w/ compliance, fa. stayed on meds, social, school perf. better, case looking long term; headed for ADHD eval.
4. 7 yr.old 1st grader; ? RAD/PTSD; parents divorced when two years old, live in rural area, mother in a commune, father re-married with two step-children about clients age; client mostly with father but parents basically split care; huge child for age, more height than weight but has both; multiple concerns about boundaries, often casually acting like none exist, occasional bursts of anger the might include throwing rocks, pleasant when not limited, multiple behavior issues, “management problem everywhere” as per father; both parents report their own self-control issues as younger parents, fa depr., aggressive, mo. alcohol, boy lives with fa more; family drawing immature, no hands, no feet, all black, both parents smiling, he’s not in the picture; conjoint involving several family members over three generation; began living more with the mother by agreement of all three, mo. reduced alcohol; started getting better reports all the way around, including school via school counselor; had ten sessions, took off summer, cancelled just before school began.
No people at all in family picture:
8 years old, 3d grade; Family of three, father in business, mother at home and volunteers; client dx. w/Aspergers, no previous treatment; obsessive, perseverates, dropping school performance, only one friend, out of 3d grade social loop, does self harm, other symptoms of depression; mothers sister died suddenly a year before process began, client responded by carrying a large clock 24/7 for a week; OCD in mo’s family, probably depression in father’s who chose to not participate; picture of family was a bowling alley, ball scattering pins, family member’s names on an alley scoreboard, all in nice detail, yellow lanes, blue scoreboard, and black ball and pins, no people; picture of self was a pool game with numbered balls, a cue held by a hand on an odd, wavy non-table surface, almost like a small bay; 69 sessions, conjoint with mother over two years, significant progress all the way around, 5th grade started well.
Use of One Color
6 1/2 year old girl, 1st grade; father corp. exec; mother job shared in retail management; fa. no mental health history, mo. MDD as adolescent, two recurring episodes since, controlled with medication; family referred following traumatic event on playground w/ badgering autistic child; ?PTSD, initially seen as anxiety manifesting in a number of daily routines, phobic, obsessing, controlling, aggressive when distressed, could be early OCD (said now in hindsight); mother’s level of expectations, constancy, and persistence also suggests her own perfectionism; three drawings each one color, light purple, pink, then brown, drawing with no faces, family members sitting watching TV; conjoint process; 15 sessions; considerable settling at home yet still mixed results, some problems emerging after others subsided, worked on accommodation/assimilation, particularly with mother; +50% results; parents comfortable w/ direction; mutual termination.
1 Marital problems w/ ?OCD mother, ?depressed father
The disparity in parent’s marital status between the “obsessive” group of ten cases and the other eight is notable as well. Of the OCDish group, three set of parents had divorced, and the other seven marriages were intact. Five of seven marriages were reporting marital distress, but none appeared to be threaten the marriage itself. Within the other eight cases of the affective group of clients, though, two were divorced, four were separating and in the process of divorcing, and two marriages were intact. One of those last two were adoptive parents. Only one of the eight cases involved natural parents whose marriage appeared to be intact and functional.
The most obvious interpretation is the affective stress of marital dissolution on the child. That event is not necessarily the precipitant of the child’s mental health issues, but rather a driver into treatment that serves to bolster the child’s coping mechanisms. The question left is whether the existence of cognitive disfunction of a child acts as a relational binder for the parents. Of course, the differential findings within this small sample may not be statistically significant, but they are intriguing. For the parents of the cognitive group, the child therapy process implications lean toward parental learning and experimenting rather than correcting. With the affective group, the parents may get a recommendation to seek marital counseling – I did not do that very often – but again, the process focuses on growth and coping with considerable reinforcements, particularly those that are random. The marriages that heal may be those who take sincere random reinforcement to heart.
Heart v. Brain
Note: The following information is largely taken from the article “Yes: The Symptoms of OCD and Depression Are Discreet and Not Exclusively Negative Affectivity”, by Katherine A. Moore and Jacqui Howell, published in the Frontiers Of Psychology, 5/2017.
In their review of the research comparing depression with OCD, Moore and Howell made several points about the similarities and differences between these two major clinical categories that are germane to these particular findings concerning the 5 – 8 year old clinical population. While the differences between the two are clear and clinically relevant, ultimately in treatment some of the core interventions effectively used with the depressed can be equally effective with the “obsessive” of OCD-type client.
Citing earlier research by Steketee (1993) and others, the authors concluded that OCD is fundamentally a disorder of disturbed cognitive processing, and not a mood disorder. Several streams of thought are used to make the point. For example, Moore, et.al. state that while “OCD positively predicted depression within the OCD population, depression was a negative predictor of OCD…These results support the hypothesis that OCD and depression are discreet disorders. (Moore and Howell)” In other words, OCD individuals often get depressed, but the depressed seldom develop OCD-type symptoms, all creating a significant etiological separation.
While “disturbed cognitive processing” is a clear descriptor, an overarching descriptor for all those disorders that involve emotions and behavior does not seem so readily available. Assuming human affect management difficulties manifest into behavior problems as well, perhaps ‘affective management’
Quoting the authors again, “High negative affect is composed of a wide range of factors, including fear, nervousness, anger, guilt, hostility, sadness, loneliness, self criticism, and self-dissatisfaction”. Negative affectivity is found in both OCD and depression; both generate mental health and coping problems as a result of mounting negative feelings about oneself. The difference is in how these emotions are processed.
The authors cited research that found depression was linked to inward but not outward aggression, presumably allowing for the uncommon outward aggression under extreme circumstance, i.e. “blowing up”. Depression is linked with “intro-punitiveness”, or inner directed hostility. On the other hand, they cite theory and supportive research that asserts OCD generates external aggressions when the levels of negative affect about oneself are high and one perceives external threats to their being, usually off-based.
Among other applications to casework, this manner of OCD reactivity also explains the often bewildering aggressiveness of an upset youth who fits the diagnostic criteria for Oppositional Defiant Disorder. Which leads to the question of what characteristics and diagnoses fits into this area of ‘disturbed cognitive processing’. The term OCD is not an umbrella.
Paradigm of Obsession
In going through the chart notes of these ten young clients, several behavioral descriptors appeared multiple times. In emotional terms, they were feeling the negative affectivity of anxiety, insecurity, tenseness, and/or helplessness. Those are almost taken for granted in a children’s mental health office. Each one also exhibited obsessiveness, perfectionism, ritualism, and/or perseverating. As a group, they included likely diagnoses of OCD, ODD, Aspergers, and RAD. Are these four broadly linked in some disorderly cognitive processing way?
Treating ODD was a specialty in my practice. The parents’ presenting problems were generally affective in nature, plus behavior management, more the former than latter. The work was more successful than most, hence the referrals, but probably still 10 – 15% less effective than the rest of my practice. OCD did not enter the clinical equations, and obsessiveness in general was seen as a behavior issue.
The treatment was conjoint as much as possible. In that setting, a considerable amount of clinical energy toward the client was focused on the understanding of others’ thoughts, feelings, actions, and the client’s own reactions to life, the latter of which obviously included ODD patterns and outbursts. Self-understanding was seen as the byproduct, and not the central theme. Outside of reinforcing the opposite behavior, which was rife for these cases, behavioral work was done only on an as-needed basis.
That a young client had negative affectivity was presumed. A desired baseline outcome always involved lowering the negativity, both toward self and others. When evident, aggressive outbursts in response to losses, limit setting, and senses of deprivation were included. That the externalized aggressiveness generated by self-negativity was an OCD characteristic is new to me. Thinking of ODD as a cousin to OCD is also new, but the notion satisfactorily explains a whole lot. These kids do get obsessed, hyper-focused, some probably perseverate could on one or another activity of life, in the next instance become purely chaotic, and in the aftermath with little cognizance of that paradox dwelling within. Paradox is not their forte; black and white can be more descriptive. ODD belongs in this broad category of disturbed cognitive processing.
The Asperger’s boy in the study had rituals and obsessions, not many, but enough that their disruption could cause a stir. Two other Asperger clients, a boy and a girl and both sixth graders, were seen for 30+ session treatment processes over the last few years of the practice. The boy clearly had obsessions that could pose serious social trouble, and the girl had interests in nature’s phenomena that were often preoccupying to the point of disappearing. As with the client in the study, both did well. Some kind of connection with obsessiveness exists with the Asperger’s cases I saw, but not to the point of being subsumed into OCD. Still, they do have cognitive processing issues and may belong in this paradigm.
Comparing basic outcome data between the ODC-like group of ten to the emotionally troubled group of eight, both groups averaged close to 20 sessions. Most cases were done prior to the study, hence not rated for gains made. My guesstimate is that the cognitive group’s overall outcomes were about 15% lower. The corresponding fact is that I was less knowledgable about their treatment needs compared to the more common ‘depressed’ group.
RAD’s diffusion of maladaptive personal, familial, scholastic, and social behaviors that include externalized aggressions of one sort or another an can be dangerous to one degree or another seem obsessive in their persistence in spite of the meaningful attempts to connect of others. The diagnostic label suggests the affective etiologies of PTSD and major loss, but I do now wonder about an underlying kind of obsession for connection with little skill to do so?
To the degree that this correlation between a child’s obsessions and the dearth of detail on their drawn human figures is significant, some kind of explanation that could lead to enhanced clinical treatment would be helpful. One is offered here, fairly concrete but at least a place to start. The fact that this age group operates on a cognitively concrete basis may lend some support.
The basic idea is that as the child’s preoccupations with rituals, hyper focusing, and rigid ordering absorb their small worlds, they lose sight of the broader social world.
Concretely, they can’t envision the important details of what constitutes another person. The portion of meaningful inter-personal engagement that leaves impressions is bereft. Two kinds of therapeutic actions come to mind. One is a slight alteration to the child assessment process, and the other is to incorporate a bit more drawing into the individual therapy process with the child, starting in this assessment itself.
Virtually always, the presence of obsessiveness behaviors among a child’s pattern will be disclosed during the intake with the parents. In anticipation, I could have changed the sequence of drawing and have the child draw a picture of themselves first, the picture of anything they wanted to draw second, and saved the family picture for last. If the child leaves out features, then guide them to do fill in, starting with themselves. Then perhaps help the client pick out affects for each family member, and if needed, help them with their depictions. Then they could even develop a story about a family experience or adventure, and draw in a background. If the child is OCD-like, is accepting of me, and is invested in the drawing, this clinical intervention will begin to expand their sense-of-other, and set a precedent for doing so later in the therapy process. The problem is that the parents won’t see the unadulterated family drawing, but that’s a trifling matter.
The second approach is to incorporate drawing into arranged individual time with the client during one or more sessions. The process could also include some kind of gently guided story-telling done by the client, including the creation of facial expressions, activity, and movement. That may distract from the conjoint process, but again, if other-awareness is enhanced, missing some conjoint time is a worthy sacrifice. Or perhaps his or her drawing and story-telling could be incorporated into the conjoint process itself.
Other Points About Family Drawings:
These are common observations that were usually of interest to the parents.
Size distortions – I think these are usually the product of children under 5, and not seen much in 5 and up. They do have significance, but the clinician almost necessarily has to have parental input to determine what might be driving the new client to do so, personality or experience. The clinician’s role is to help determine if anything needs to be addressed, or if whatever the meaning to the child may be will simply dissipate with age and maturity.
Missing family members – Separated parents, one or both of whom are in another relationship, can complicate this drawing for the children, particularly true if either or both parents have homes with children of the parent’s new partner. In my experience, the kids didn’t ask me something like ‘which family to draw’, so they went ahead and drew what they felt was their family, as per the instruction. If concerns arose on my part, again this would be addressed with the parent(s).
Extra characters beyond extended family members – uncommonly occurring altho that did arise here. The boy who drew an additional ten characters was the child previously diagnosed as RAD. He was certainly acting out, could be violent, scattered in his verbal interactions, impulsive, and socially inept, but the family history was negative for disturbed, chaotic, neglectful and/or abusive parenting. The identified problem behaviors did suggest an RAD-type picture, so his family drawing was intriguing, again in hindsight.
“No friends” came up three times in this cohort, not really surprising given the self-absorptions involved. That social state is often poignantly painful for the parents, and can bring out a depth to their individual and sometimes relational pain. Working toward an improvement to that parental sense of responsibility, feelings of guilt, or, sadly, blame on the spouse. The parents are apprised of that. “That must be difficult for you” is an easy entry point.
Picture of Oneself Doing Something
Again, the function of these drawings in the context of their assessment is threefold. First is to gather evaluative information in the anticipation of the following summary-and-recommendations session with the parents. The second is help create an atmosphere of familiarity and hence comfort for the new client. and the third is to facilitate the clinical relationship with the child by being there observing and interested, asking the occasional question, and remarking positively on what they have accomplished.
Because drawing is a major communication medium for a child, almost all these new clients are comfortable and even excited at the prospect. That helps with the development of trust and a clinical relationship, and the drawings add to clinically relevant information. The vast majority of these young clients were unhesitant as they began these drawings. At least in theory, their ease could be attributed to a normal child’s use of drawing at an early age to communicate with others. The child usually discloses to the parents about their drawings on the way home with some vigor, which helps the parents’ trust grow. The artwork is also a medium of reporting to the parents in the summary-and-recommendations session. Because of the latter point, I maintained an observer’s posture during the drawings.
The particular tendency to have missing bodily features continued into the self drawing, and thematically the second was usually a continuation of the family depiction. Coloration tended to be brighter and the pictures a bit more playful, their expansions presumably because they were getting more comfortable.
Picture of Anything
These drawings of the client’s choice were usually the most animated. By this time in the exercise, the youngsters are more comfortable and willing to spread their wings, so to speak. The contents run the gamut from space battles to gliding underwater. Unfortunately, as per the demographics of the practice in general during the last few years, the drawings are almost all by boys. With a couple of exceptions including the 6 year old who struggled to get much of anything drawn in the family drawing and couldn’t/wouldn’t continue, the artists were eager to narrate their stories. The reactions, explanations, and color commentary by the parents in the next session helped lead into discussions which in turn led to treatment plans.
Please remember these are almost all OCD-type clients. Examples of their work are as follows:
A 6 1/2 year old boy narrated his ‘anything’ picture as he drew, describing the volcano that was spitting out volcano balls (red fireballs) with two characters below, one of whom was doing flips because he liked volcanos and the other who tried to get into the volcano and “was spat out on fire.”
A family having dinner at an outside table with father cooking nearby at an elaborate grill that he made himself.
A space battle between good guy ‘Lightening’ and bad guy ‘Storm’ , shooting lightening bolts at each other as the good guy smiles and the bad guy frowns
A high school football field with bleachers by a boy who watches his older brother play in real life and he wants to play football too when he gets older
A space monster eating a spaceship
Swimming low beneath the surface with hair flowing and a big smile
A long squarish building with windows, an outside table, and a chair as smoke came out of chimney, no people, a picture with which I associated an Eastern European barracks out of which the boy was adopted. That attuned most precisely to the parents’ spoken concerns about loss and possible trauma.
The last one is example of the clinical material that can be generated by any one of these pictures. The drawings of ‘anything’ probably generated the most discussion with the parents in the next session.
Observation About The Drawing Exercise…In Hindsight
The pattern of the clients moving from a relative conservatism in the family drawing to a lighter, more artistically expressive picture of themselves, and then on to a more elaborative and sometimes narrative picture of whatever they wanted to draw was intriguing. This tiny bit of growth as they swept through these drawings could be seen as evidence of a burgeoning competence and independence, in a way a normal evolution through a new situation. Half of the ten in the obsessive group demonstrated this progression, as did five of the affective eight.
Whether this represented a pattern or was a random novelty remains to be seen, and then the problem of meaning would need to be addressed.
Recognizing and understanding patterns of clinically relevant change, particularly those involving clinical gains, is a core element of developing and continually improving a therapeutic process. To recognize a pattern, obviously one has to notice, and this I did not until reviewing the charts of these eighteen 6 – 8 year old clients. As inferred earlier, I didn’t notice the relationship between missing identifying bodily features and the use of constricted coloration with obsessive young clients until now. Would that have made a difference in their treatment had this been known? I think absolutely. To spare myself, the number of times 5 – 8 year old children with obsessive concerns were seen for an assessment over the thirty year course of the practice may have been as few as 3% – 4% of the thousand children seen. An N that large would likely be needed to validate a significance. To be honest, though, I’ve used patterns to notable effect with lesser N’s.
Other Evaluative Tools
The analysis of this OCD-ish group leads to the notion or hypothesis that a young child’s obsessiveness detracts from the development of other-awareness, something that can be addressed systematically in either individual or family therapy. Understanding of the ‘other’ was an intrinsic element of this therapy process, and did help with increasing a sociability that would have – almost surely did – reduced obsessiveness. If the clinical work facilitated the sociability of a client, i.e. having friends, the total obsessiveness would decrease if for no other reason than less time alone. Six of the ten in the obsessive group show social improvement, and two others began to evidence a progress in that direction before terminations in less than ten sessions. The following evaluative tools leant to that kind of process.
Note: Most commonly, three of these four evaluative aids were commonly used per child, two if the depression-anxiety inventory was used. Which ones were a matter of choice at the time. The feeling identification was used more often during a family session. The Talking, Feeling, Doing game was occasionally used asa regular activity during an individual therapy.
The Depression-Anxiety Inventory, Etc.
The depression-anxiety inventory, self concept scale, and ego development scale were occasionally employed with clients under 9 if need existed and the child’s capacity to do so having been demonstrated. The socio-moral was used very sparingly with this age group, and even then much later in the process. Perhaps this was underestimating the child’s objectivity and the parent’s faithful tolerance, but the Heinz Dilemma’s content of cancer, penurious insensitivity, and subsequent stealing seemed a bit much.
The Feeling Identification Exercise:
“OK, so there are five basic feelings that everybody has. It’s what makes us human. I’m going to ask you to name them, and what I’ll tell you is that you’ll be able to name three of them, you might be able to name four, you’re not be able to get all five, but I’ll help you.”
(Arguably) the feelings are happy, sad, angry, scared and guilty. Through the entire age range of the clientele, a large majority would identify happy, sad, and angry without difficulty. A handful of the thousand child and adolescent clients could not identify anger either. Maybe 7% – 8% would list “scared”. A very small number were able to identify “guilty” as well.
More often than not, this exercise was saved for some fitting moment in the first three therapy sessions (fourth, fifth, and sixth overall), but for younger clients I sometimes to do this with them in the assessment. When we got into doing this in the first or second family session, I’d tell the youngster to let the others guess. Knowing something that the others didn’t would set them off into smiles and sometimes laughter as the others in the family struggled…and the others did so, just like all the kids.
The exercise also prepared the client for one aspect of being interviewed. If I asked a client how they felt about something that happened, and they answered “Well, that just wasn’t fair”, I would say “Well, I understand, but that’s not a feeling, so try it again and think about those five feelings.” Kids would catch on quickly, and that helped with both the maintenance of focus and pace of discussion.
Toward the topic at hand, this exercise may have a clinical value beyond facilitating the therapy process in and of itself. Developmentally, the basic personality is in place by age 5. Some standards say age 2, others later, but a general consensus is certainly by 5. They have moved beyond parallel play and are now engaging in friendship play in all its joys and struggles. Certainly by age 8, their social thrust is toward fitting in. The obsessive sub-population of 5 – 8 year olds is clearly struggling with this developmental task.
Where the statement “everybody has these five feelings…it’s what makes us human” is already presumed by most kids this age, for obsessive-type kids this may be an entirely new concept, i.e. “I have these feelings (they now know this as a result of going through the exercise) and everybody else does too, so, I’m kind of like them (and we know “…kind of…” is true), but this education is step by step. Plus, the exercise emphasizes an undeniable universality; this is being human, and wedges that door of other-awareness just that bit more.
Story Telling Using Blocks
A local Starbucks was selling small boxes of eight randomly shaped blocks, presumably for caffeinated table entertainment, quite a few years ago. I bought one for office to use with younger clients, and found they were intriguing to kids. In short order, this became the basis for another evaluative tool.
“So, what I’d like you to do now is to make something out of these blocks, anything you want, and then make up a story that uses what you created, or use the blocks in some way to tell the story”.
A Rather Notable Example
This is the first time I’ve met with Joe, a young 7 year old brought in by parents with concerns about ADHD, anxiety, compliance, and a tendency towards obsessiveness. Joe came in quite willingly, very chatty, very friendly. He asked a lot of questions initially, lot of facial expressions. He seems to grasp concepts reasonably well. He also seems to take off in any direction from one particular topic and can get very tangential. He may have difficulty picking up on conversational inference. Eventually he acknowledged that he was here to “chat about school and how it’s going”, and then went on to say that school is good. In doing so, he went through an entire day’s schedule. I asked him if he had problems at school, and he replied “Can I think about it” and then talked about a reinforcement system they offer at school and then said “No, I don’t have any problems at school”. He has the ability to come back after excursions elsewhere. I explained what I did here and he then immediately started talking about a poorly behaved kid in school, so he seemed again to understand basically what was going on here, but had a hard time making reference to himself.
He does acknowledge the problem at home as far as bedtime is concerned and claimed he has a hard time falling asleep and is afraid of bad dreams. That would fit in with the overall picture.
I had him do the standard series of drawings. The picture of the family doing something was of a restaurant that was complete with tables, chairs, plates, wine bottles, windows, chimney, smoke, clouds, a sun, but no people. He used brown, blue, orange, and some yellow.
In the picture of himself doing something, he drew a picture of a playground with his two sisters on a piece of playground equipment and another unidentified kid beneath a slide, along with clouds and trees. He used gray, green, red, and brown. There are no facial expressions, no hands, and no feet. It was a nice picture with the exception of lacking of any sort of facial expressions and a somewhat young stick figure presentation.
Lastly, I had asked him to draw a picture of anything he wanted, and he drew a picture of a house with beds, a window, table, chair, smoke coming out of a chimney, and no people. It seemed mote like a barracks and it did make me wonder if this was some version of the place he lived while waiting for adoption in eastern Europe.
I then had him do the blocks and story telling. He initially made a path. He said the paths are for walking on. If there are no paths, you will fall down and not get a present. And then he went into a functional description of paths which was very good itself, but didn’t tell a story. He then reconfigured the blocks and said it was a dragon in a faraway land, and inside the dragon was an egg and it popped out and then there were apples and then “it grewed up” and then the mother dragon said “You will have to find another dragon” and he found a girl dragon and “there was lots of fire in her tummy” and then there were more sentences about the experience of having a baby, and then there “was a big fire” and then “The End”.” The picture suggests some attachment kinds of issues, in addition to the apparent obsessiveness problems the parents had described that may be worth talking over with them the following week. And ask about the dragon.
The activity is another way to acculturate the young client toward an expressiveness that aids our understanding of them during treatment. Ongoing issues can be highlighted and marked for clinical attention. As importantly, more elaborative material becomes available for the summary-and-recommendations session with the parents.
Again beyond an aid to the budding therapy process, this activity is also a lesson in parenting, one that emphasizes the interest that their child can generate with their own (probably special) creativity, and in doing so support and reinforce this perhaps developing ability.
Matching Affects with Situations
Sometime in the early 00’s, I ordered two therapeutic games for young children on the spectrum from ChildsWork/ChildsPlay Inc. “The Understanding Faces Game” offered forty pictures of different children’s looks representing the gamut of feelings and circumstance. The child client’s task was to interpret the look. In the second game, “What Did You Say?”, sixty situations that a child might encounter were posed, and the child’s task was to act out how they would react if they were in the situation. For example: “It’s pouring outside – what do you look like?”; “Your family is going on a great vacation – what do you look like?”;“You went to ride your bike but it has a flat tire – etc.”; “You are going to a new school and you don’t know anyone – etc.”; “You are staring but you don’t like what’s for dinner – et.”; You are worried about what to get your mother for her birthday – etc?”.
Neither game would be particularly helpful with my clientele, but when combined, they created a great game. I would distribute ten “Understanding Faces…” cards to each of us. Then one by one, I read ten of the situation cards. We would each present the Faces card that would best fit the situation, and decide between us whose card closest fit the presented situation. That card was then collected, as were all the rest, leaving us with nine cards left. Usually, the Faces cards between us would offer some reasonable facsimile of an appropriate response to the situations, and I would make sure both of us were in the game, the client ahead by one or two. The game ended with absolutely ludicrous faces for the last situations, and between the two of us we found these instances really funny.
After talking about the presenting problems, what they thought and felt, how they impacted the client and family members, etc., just to establish the purpose and baseline of the process, the assessment sessions were really not particularly “heavy”. By this time the young ones were usually pretty comfortable. Having a game experience that offered the ridiculous humor kids this age generally adore is like icing.
This exercise very directly works to expand other-directedness.
The Talking, Feeling, Doing Game
This is a board game designed by Richard Gardner, a well-known child psychiatrist in the 70’s and 80’s. Each participant moves their along a track with a roll of the dice. Most of the squares along the way are marked Talking, Feeling, or Doing. The player gets a chip if they answer the to the question posed by a card corresponding to where they land. The player who has the most chips when the game ends “wins”.
Examples of Talking cards: If you could make yourself invisible, what would you do?; Suppose two people were talking about you and they didn’t know you were listening – what would they say?; If you had to be changed into someone else, who would you be?
Feeling cards: What’s something you could say that could help a person feel good?; Tell about
a time when your feelings were hurt”; Name a person you love very much. What does that person do that cause you to love her or him so much?
Doing cards: Act like a grown-up; Act out what you could do if you had magic powers; Do you believe there really is such a thing as magic?; Make believe you’re playing a musical instrument. What instrument are you playing. Why is it important to practice?
For the most part, the game was used during individual therapy sessions. One option was to have the family play during a session, but that was infrequent. rare occasion. This exercise was done if time remained in the assessment session. For this age group and regardless of their tech skills, the game does have a kind of timelessness, the questions are universal and non-controversial to most anyone, are educative, and can provide another source of assessment data to use with the parents.
Having some option of this nature is helpful a child therapy setting, if for no other reason than the kids are interested in the clinician talking about themselves. For these particular clients with obsessive and isolationist tendencies, the give-and-take of interactive exercises like this directly promote other-directedness.
One other factor to point out is that most of these young ones were not apathetic, displeased, negativistic, or in other ways avoidant in doing these evaluative tasks. With the occasional exception like the “RAD” child among this group of ten, a diagnosis that was to me dubious but nevertheless descriptive, they were active, reactive, interesting, interested, and capable smiles and the occasional laugh. All but two of these ten clients did show improvements in their behaviors and sociability, some just beginning on that track, but also some who showed improvements to the demonstrable point that therapy was not needed, the parents wold manage. For OCD, this process may not have been everything, but clearly contributed.
Finishing the session was fairly simple when compared to the 9-and-up population.
The first question is “OK, so do you have any questions that you’d like to ask me?”
For the most part, the youngsters would shake their heads. “Am I coming back here?” was most common. Occasionally they might have a personal question which would be answered with a friendly dispatch. Rarely would they have clinically oriented question. Part of the reason for asking the question in the first place is to encourage asking questions.
The second question was: “So, I”m seeing your parents next week. Do you have any questions or concerns about that? “
Usually they would shake their heads again. The most common response, itself not very frequent, was: “What are you going to say?” The question about what I’d say led directly to the last point.
The review that might take from two to four minutes began with a quick summation of the presenting problems and anything else in that regard that the client brought to my attention. Scanning the session notes while talking, something about the impacts of the problem upon the client would be covered. At least a couple of points about the clients strengths that were evident during the session itself, those that they could or would recognize as being a positive, were standard, necessary elements. Lastly, a reassurance, something like “I think I can be of help with the problems, and I’ll be talking with you parents about that, too.” And that would be it.
Harkening back to data mentioned in the previous post, two of the original 58 cases in this study dropped out after only that initial meeting with the parent(s). No cases dropped out after the client assessment appointment.
From the opening paragraph of Wikipedia page on “Magical Thinking:
Magical thinking is the belief that unrelated events are causally connected despited the absence of any plausible link between them, particularly as a result of supernatural effects. Examples can include the idea that personal thoughts can influence the external world without acting upon them, or that objects must be causally related if they resemble each other or came in contact with each other in the past. Magical thinking is a type of fallacious thinking and is a common source of invalid causal inferences. Unlike the confusion of correlation with causation, magical thinking dos not require the events to be correlated. In psychology, magical thinking is the belief that thoughts by themselves can bring about effects in the world or that thinking about something corresponds with doing it. These beliefs can cause a person to experience an irrational fear of performing certain acts or having certain thoughts because of an assumed correlation between doing so and threatening calamities. (Note: this entire Wikipedia page is a good introductory to the topic of magical thinking as a whole)
Using Piaget’s stage model of cognitive development, the 2 – 7 year old is commonly in the Pre-operational Stage, characterized by wha Piaget defines as symbolic thought. Magical thinking is a component. With what appears to be considerable overlap, the 7 – 11 year old usually operates in the Concrete Operational Stage, characterized by operational thought. The subsequent stage covering adolescence and adulthood is termed Formal Operations and is characterized by the use of abstract concepts. Some children aged 10 and 11 years olds are capable of thinking in these terms.
Piaget writes about the psychological impacts of loss, trauma, and other upsetting events on this Pre-operational bracket and how they differ from those reactions of people who are older children, adolescents, and adults. Again from the Wikipedia page, citing Piaget:
Due to examinations of grieving children, children of this age (2 – 7) strongly believe that their thoughts have an impact on the rest of the world. It is posited that their minds will create a reason to feel responsible if they experience something tragic that they do not understand, i.e. a death. During this age, children often feel they are responsible for events occurring or are capable of reversing an event simply by thinking about it and wishing for a change…Magical thinking is found particularly in children’s explanations of experiences about death, whether the death of a family member or pet…These experiences are often new for a young child, who at that point has no experience to provide an understanding of the event’s ramifications. A child may feel responsible for what has happened simply because they were upset with the person who died, or played too roughly with the pet. There may also be the idea that if they wished hard enough, or performs just the right act, the person or pet could choose to come back to life, snd not be dead any longer.
The vulnerabilities a young child may experience include a sense of responsibility when negative events occur to themselves or family members or friends. They may harbor personal remorse for the misfortunes of family members and friends that in reality have little or nothing to do with the child. They can assume that others certainly feel the same way that they do. Magic creates memorably beautiful experiences for the young child, but also produce an equally forceful dark side that can portend emotional struggles in the future, both near and far off in time. A good therapy can help.
The CBT-oriented family therapy approach to child and adolescent mental health assessment processes is usually a delineation of existing client problems, history, other previous and current therapies, other mental health or relational problems among family members, and other individual or family life factors that may be impacting this new client. To the degree possible, the presenting problems are defined by the end of the assessment process in behavioral terms that can understood by the family participants and be measured in one way or another. Unless compromised by problems with cognitive development, the child provides important, objective assessment information for the therapist.
One could argue, with merit, that a secondary role for the therapist is to help facilitate the 5 – 7 year old child’s movement away from magical thinking and into a more realistic frame of reference. That objective could be sought in individual therapy, but family therapy is a viable alternative.The outcome data of this study suggests that 5 – 7 years olds improving to the same general degree as did the older youth. The family approach where the parent(s) are actively involved in one way or another to meet the client’s therapeutic needs was effective. Some kids were presumably still engaged with magical thinking at the outset of clinical work, and by the end of an effective treatment, they are thinking more objectively about the problems, the others, and most importantly about themselves. Even in modest gain, trust is enhanced. It takes a village, so to speak.
Beginning at age 5 and possibly as late as 8, the child attains the ability to objectively view themselves, describe their own thoughts, feelings, and behaviors, share their experiences and points of view, with degrees of accuracy develop opinions about the motivations of others and why sequences occurred as they may have. They may not be fully disclosing, or are shy, or fearful of new situations, or be initially distrustful, but what they can do in sincerity is participate in a reality-based assessment process by contributing information and experiences, given with a ring of truth to them.
The 8 – and – older child may also acknowledge some responsibility for their problems, which they may or may not disclose, and can come to understand that others may have a different point of view to be considered. Human problems are almost necessarily overdetermined, a concept within which these concrete operational stage children can cope and avoid wholly blaming themselves. Magical thinking makes clinical approaches used for older children and adolescents assessments less feasible for many of these 5 – 7 year old clients. A different approach is likely needed for those who fall in the latter group.
In deference to the maxim “first do no harm”, the least desired impact of an assessment session for a youth still engaged with magical thinking, s to reinforce their sense of perpetration or unworthiness. Lacking the objectivity needed to engage in frank and thoughtful discussions about self-and-others, they can answer probing questions about themselves and their families with some level of forthrightness and still end up feeling internally worse because their guilt or flaws have somehow been reinforced.
About the Assessment
The two basic purposes of the child assessment are to inaugurate a therapeutic relationship with the new client, and to develop a cogent clinical understanding of the client to review and discuss with the parent(s) in the subsequent summary and recommendations session. With the older children and adolescents, coming to at least a rudimentary understanding of the new client during the initial meeting is primarily a result of the verbal information received from the young person over the course of interview. Secondarily, the subjective impressions formed through observing and experiencing the young person relate and act become part of the presentation to the parent in the following summary and recommendations session.
Think of the assessment as having vertical and horizontal components. The vertical represents that portion of the interview dealing with the problems that the client is experiencing personally, including possible exploration areas of: the symptoms; length of duress; efforts to solve or resolve; adjustments or accommodations that impacts daily life; emotional, social, and scholastic impacts; various coping mechanisms they may be using; etc. The horizontal dimension could include a few elements of client’s environment: including: parents and how they impact both positively and negatively the problems the client is experiencing and the same for siblings and other family members; how the other family members relate to each other, including mother and father; interactions with schoolmates; expectations of teachers; and possibly even extra-curricular experiences. The interviewing is not formulaic. The questions are driven intuitively, based on the sufficient clinical training, supervision, consultation, and experience needed to conduct a therapy process independently.
The clinical intent of the younger child’s assessment session’s outset is to use the same approach as used with the older children and adolescents as far as possible.
For the older child, In Piagetian terms, the ‘concrete operational’ thinking typical for ages 7 – 11, responding to this kind of interview takes the capability of taking at least a basic objective perspective in which they can view themselves in the context of their larger environment. The session, at this point usually 25 – 30 minutes total, then moves from the interviewing into the evaluative phase preceding the conclusion.
Some of the 6, 7, and 8 year old clients could meaningfully engage with the necessary objectivity to portray their realities accurately. The four 6 and 7 year old youngsters mentioned in the previous post who began talking with that first “So, what can I do for you? question could do so. Most clients this age, though, seemed less able to maintain that objectivity toward themselves as they answered basic questions, i.e. unsure, straying, timorous, hesitant, more inclined toward the uncomfortable ‘I don’t know’ response.
Their transition from the more formal interview just described to the observational mode about to be outlined was usually comfortable.They generally enjoyed the tasks and play that ensued and began to offer more unsolicited, “chatter” during a game. The suggestion here is that their presumed difficulties with the usual objective interview was less due to discomfort and more toward inability.
For the client age 7 and under, the relative degree of information coming from verbal information compared to observation and experience are effectively switched. With those under age 8, and the occasional 8 year old as well, the assessment is based much more on how the new client handles given tasks and the skill with which they interact. The particular tasks and activities used were chosen for their ease of implementation, the quality of responses received, and the interest they generated during an experience that could easily be anxiety-provoking.
The assessment for the younger ones began with the same greeting, often kneeling in front of them for eye contact as they often remained seated while being introduced by their parent, and offer a short explanation of what was to occur while their parent remained in the waiting room. Once the child was seated on the office couch, that same opener of “what can I do for you” was used, which may sound bit ridiculous for a 5 or 6 year old save for two reasons.
First, these younger ones did begin talking after that first question more frequently than their older counterparts. Four memorable young clients, two boys and two girls among the eight 5 – 8 years olds during the last three years of the practice did so. Secondly, among the benefits afforded by these first reactions was an opportunity to point out their precocity both to them and to the parent(s). Still, though, many were not sufficiently mature in their thinking capacities to help sustain a fruitful discussion about problems and issues, to wit and copied from the chart notes of the assessment session:
This is the first time I’ve met with Quentin, a 6 1/2 year-old first grader brought in by father and step-mother with concerns about oppositional defiant behaviors. Quentin was talking by the second question. He said he was here for “behavior issues” and “tantrums”. He says he gets mad and when he gets mad he starts throwing things, and then he gets in more trouble. He said that his family refers to him as “The Hulk” and “Godzilla” because he gets so angry. He says that at his mother’s house he has better behavior because they get to go more places. I’m not sure that’s the case. He said he gets angry when he gets in trouble because his brothers are “annoying” him, or when one brother is “bullying him”, and when people call him names. He talked about breaking a closet door. Punishments include going to the corner, going to his room, no video games, not being allowed to go to his brother’s room, toys taken away, and to sleep in the hallway because his bed is broken. He broke the bed by jumping on it after being told not to by his step-mother. He will also get punished for “lying”. He said he missed Christmas one year because he was in trouble and had been “bad at Mom’s”. I asked him how come he gets in trouble at his Mom’s and at his Dad’s but nowhere else? He said “Because my sibs bother me”. Then I pushed him a bit harder and he said he gets into trouble at home because he has “fun everywhere else”.
This very bright handful and youngest of four children in the family had a turmoiled couple of years following a split between his parents when he was a year old. Custody was initially shared with the children, going back and forth between his parents’ homes for a week at a time. His father became the residential parent when he became engaged to the current step mother, the mother then having every other weekend. Quentin’s adjustment was by far the most difficult. In hindsight, he was very likely engaged in magical thinking at the time of the therapy interview, still working out evident feelings of anger, but also presumptively from guilt and fear, neither of which were indiscernible day to day. By the end of a two year, full family therapy involving the six family members and covering multiple issues beyond those of the client, he had roundly improved.
The vignette is presented as an example of a cognitively pre-operational child in an assessment session. The initial part of the interview, which lasted maybe ten minutes, could have continued, but the result would likely be somewhat barren of detailed terms for the following summary and recommendations session with the father and step-mother. Hence the early shift into the next phase of the assessment interview.
Into The Evaluative Portion
As a result of experimenting with younger clients over time, the evaluative portions of the older children’s session that included the depression and anxiety inventory, the self-confidence self rating, the ego development sentence completion, and the socio-moral response to the Heinz Dilemma were not particularly helpful. The tools could be used in select instances with the pre-operative children, but not very often.
For the 5 – 8 group, the depression-anxiety inventory was already collected from the parents during the intake, and the terminologies and inferences were often difficult to grasp. Again, one purpose of this interview was to begin establishing a clinical relationship, and going through the symptoms with kids this young was as likely to create more anxiety as not. The self-concept rating scale, most younger ones were confused by the ten-point self-rating scale for each of the six categories (behavior, intellectual and school status, physical appearance and attributes, etc.). Interestingly, I did give the self-concept evaluation to 6 1/2 year old Quentin, and while he rudimentarily understood the concept of the 1 – 10 scale, he rated himself a 1 in three categories and a 10 in the other three. That result would not be considered valid. As for the socio-moral evaluation, my tendency was to use the Heinz Dilemma for kids 9 or 10 and above. Those young people could adequately separate themselves from the Dilemma’s circumstance of possible death by cancer, where the younger kids ran the risk of internalizing.
The ego development sentence completion was regularly more frequently used with the youngest group. Answers ranged from the ego-development stages one to three, with one and two typical for kids in K and 1st Grade students, and two – three typical for grades two – three students. Occasionally a level 4 answer came from an 8 year old, but none in this cohort. Responses with special qualities would generate a bit of unanticipated praise. The parents were also apprised during the next session, this time with an explanation of why and how the answer stood out.
Five other activities were commonly included during the evaluative portion with the pre-operational, which would typically take 30 – 35 minutes. They included: a set of three drawings, one of the family, one of the client themselves, and one of anything they wanted to draw; a brief feeling identification exercise; story telling; and one of two interactive games. Most child therapists have their own preferences, but for those who are beginning or considering this kind of work, these particular activities are presented as an example of an array.
The family drawings in and of themselves could easily take up much of the remaining time, particularly with more perfectionistic kids. Getting to the interactive games occurred probably half of the time, but on occasion with particularly anxious, wary youngsters, the interactive playing was inserted at the beginning of the evaluation or after the drawings.
The most tangible source of information for the parents came from the three drawings the child completed. To them, their child at that moment is alive and talking as they imagine him or her at work. First and foremost, they could see for themselves the results. Virtually all the other information they receive is by word. The drawings provided a focus for observations about the child and family for all two or three of us, a conduit for an exchange of interpretations, insights, revelations, concerns, satisfactions, the uplifting and the sobering, and emerging, new thoughts about their child and their situation.
On Children’s Drawings in Therapy
During the same era as when Erikson and Piaget were developing their stage models concerning human growth in differing areas, Victor Lowenfeld published his initial findings in 1947 on the childhood stages of artistic growth. They are as follows:
Stage 1 – Scribbling, Age 1 – 2: Children at this age are engaged in the physical activity of drawing. There is no connection between marks and representation at this stage. However, toward the end of this stage, children begin to give marks names. This stage is mostly the enjoyment of purely making marks.
Stage 2 – Preschematic Stage, Age 3 – 4: Children are beginning to see the connections between the shapes they draw and the physical world around them. Circles and lines may be described as people and objects that are physically present in the child’s life. It is in this stage that children first make the connection to communicating through their drawings.
Stage 3 – Schematic Stage: Age 5 – 6, where children have clearly assigned shapes to objects they are trying to communicate. There is a defined order in the development of drawing. Drawings at this stage have a clear separation between the sky and the ground. Often the sky is a strip of blue at the top and is a strip of green on the ground, and a strip of brown at the bottom. Objects are often placed on the ground instead of floating in space. Objects of importance are more often drawn larger than those that are of lesser importance.
Stage 4 – Dawning Realism – Age 7 – 9, at this age children are beginning to be more critical of their own work. It has become evident that a structured order to drawing objects is no longer sufficient. While a schema is still used to create drawings, it is more complex than in earlier stages. Overlapping can be seen, and a sense of spatial relationships is more evident.
Stage 5 – The Pseudorealistic Stage, Age 9 – 11: In previous stages, the process in making the visual art was great importance. In this stage, the product becomes most important to the child. This stage is marked by two psychological differences. In the first, called Visual, the individual’s artwork has the appearance of a looking at stage presentation. The work is inspired by visual stimuli. The second is based on subjective experience. This type of an individual’s Nonvisual artwork is based on subjective interpretations emphasizing emotional relationships to the external world as it relates to them.
Two parents came in with concerns about their two older boys, at that time aged 9 and 6. With them they brought their 2 week old baby girl, who laid quietly in her Moses basket at the Mom’s feet through out the first session. The family had moved from Europe a year earlier, and was now newly arrived in Seattle. The father was a working artist for a large tech firm and the mother remained the homemaker. The boys were both having social adjustment and academic performance problems at school as well as behavior issues at home. In particular, the mother was feeling overwhelmed.
The process was 5 years long, entailing about 170 sessions all told. By the end, both boys were excelling in school in their particular areas of expertise, making friends, contributing to their classes, less defiant and disruptive at home, still with challenges, but their problems were now in the area of more ordinary. The baby-turned young girl was brought to most every meeting, She never sat in on sessions, per se. Once mobil and over time, she contentedly and imaginatively availed herself of most everything the waiting room play area had to offer. To her, coming to the office was just part of family life, and to her I must have been a family-like character of sorts.
Around the age of 2 1/2, the girl began organized imaginary play, in this instance taking the few stuffed animals from the waiting room, bringing them to an office stuffed chair by a window away from the meeting area. The office itself was about 300 sq. ft., so she could play quietly and not be a distraction. But as a background, we could hear her talking to her little gathering, rearranging them on the chair, and continue talking just sweet, cute, sweet. She later began to draw on the dry erase board in the waiting room, and would make a point of showing us her work as the family left. I was impressed. She clearly had the father’s genes. And she was the nicest kid.
She shifted from mothering her little clan to the building blocks on the waiting room carpet, fashioning a circular perimeter housing two and three block-high structures, presumably houses in her little world. We could hear her talk to imaginary family or neighbors or whoever they might be in her world, and she went through the same routine of showing us her work, this time as her family was leaving, session after session. Best background ever.
Some time during the last year of the family’s therapy and now about 4 1/2, she came into the office from the waiting room where she had been busily drawing, and for the first time I could recall, she interrupted the session. She came up to my chair and proudly handed me a crayon drawing on a white page she had just finished, and with this lilting accent of her homeland said, ”This is for you!”, accenting the ‘you” with a rising intonation.
I looked at her work and was stunned, then looked at the father. He obviously didn’t know exactly what she’d drawn, or maybe he did but never gave on. He faintly smiled with raised eyebrows and a barely discernible nod, inferring a “See?” She had drawn the basics of a smiling girl with long yellow hair in a short dress, all with a degree of form and accuracy that could have come from an artistic 9 or10 year, but with her own indelible stamp. The legs were charicatured to more than twice the length of upper body, perfectly straight and parallel within shoes identically turned to the left. This was not drawing. This was art. She could tell I was impressed as I thanked her, and went back to the open-doored waiting room.
For the next maybe 10 sessions, over four or five months, she repeated the routine like theater. “This is for you!” Her picture continued to improve though, the legs even longer, the clothing now colored, the facial expression a bit more detailed, the hair tied with a big red bow toward the end. If you re-read the descriptions of the 3 – 4 year old preschematic and the 5 – 6 year old schematic, she was so far beyond.
In ways, understanding meaning in a child’s art is a melding of several factors, to include:
their particular developmental stage of art skills relative to their age; their own self-perception; their experiences, particularly as they relate to their being in a therapy office; their family history; the environment in which they are nurtured and live; when in the course of their therapy the art is being done; and, more broadly, what was going on in their world at the time. Events matter.
While all these points are largely abstractions, aided by an expertise, some things reasonably close to truths about the child can be learned and translated into the helping process.
Particular aspects of the child’s work come under scrutiny, for example the use of a color, facial expressions, who is or is not in the family picture, their portrayed sizes relative to each other, completeness of the body, the activity being depicted, and the composition of the surrounding environment. Particular mental health issues are said to be associated with specific aspects of a child’s drawing, ranging from depression, anxiety, and relational disturbances to what are contemporarily considered more brain-related disorders like PTSD and OCD. One unbeknownst and fascinating, to me anyway, correlation of drawing by those involved with the latter class of disorder cropped up in the context of research in preparing for this post, and will appear in Part 2.
In going through some of the on-line literature about assessing children’s drawing for the clinical purposes, a gleaning tendency toward conclusive certainty emerges, which taken literally can be troublesome. Like the global components of art appreciation listed above, clinical correlations with aspects of drawings are broadly based on observation, knowledge, and experience, and narrowly applied to the case itself. They are opinions, and not the result of empirically-based research, at least insofar as I’ve seen over the years of perusing articles where the meaning of drawings is the topic. This does make a difference in how the information gained from the drawings is conveyed to the parents and subsequently processed by them.
Taking the vignette above and applying some of the assertions about the meaning as seen in a child’s work, the drawn character’s yellow hair, by one account read, represents the girl’s anxiousness, the red bow a representation of anger, and the exaggerated legs a fear of impending disaster and the ability to get away quick. None of those remotely apply to this child that I learned about from the parents and watched as she developed.
Understanding the child’s drawings or specific aspects of the work like color, composition, likeness, or activity is a matter of the suggestive rather than the assertive.The correlation can be reasonably linked, but quite possibly overwrought if fused. More importantly, sharing thoughts about possibilities based on experience and knowledge with both the child and the parents leads to interactive discussions and disclosures, which hopefully and eventually lead toward a mutual understanding and purpose. That process that stands in contrast to a professional declarative with diagnostic and treatment implications. To understand the child, particularly one who is troubled in some way or another, ’it takes a village’.
Managing The Drawing
The directive was simply, “I’d like you to make three drawings, one of your family together, one of yourself doing something, and last a picture of whatever you’d like draw. Here are the crayons, and you can use the table here (small rectangular coffee table between client couch and the ancient stuffed rocker; crayon marks would come off the table with a little work, occasionally needed).
I was generally quiet as they worked, may make a comment about something interesting or different that had been drawn, more along the lines of relationship building than gaining clinical knowledge. After they completed each picture, I would have them identify the characters and what was happening. Any further questions were casual rather than done with an intent to confer insight. At this point, the clinical relationship was more the forethought. Before they finished the assignment, I looked for something that stood out in an interesting way that could be brought out to bear and praised.
As I understand their role, art therapists will start doing overt clinical work with the individual from the beginning. They know what they’re doing, and usually in great depth. For me, doing overt clinical work during the drawing exercise was out of the question, which for many art therapists would likely be a planned part of their process. In some part, my interest was what kind of impact the experience of this first sit-down had with the client in and of itself, that being the most conservative kind of treatment. Suggesting a different way to feel about a particular situation, get along better with a sib, do something active to deal with anxiety, seek companionship when depressed, go to a safe place when angered, and so on with a thousand possibilities of suggestion could come after the next session with the parents and a treatment agreement reached.
The child had known me now for all of maybe 10 -12 minutes, and I wanted to know more, facilitate the clinical relationship, and gain the parents’ confidence first. The support of that approach is that no case terminated after the child and adolescent interview, 56/56. What I did do during the drawing was keep notes on elements of the particular drawing that may have clinical significance as per the body of knowledge I had, done to review later, dictate notes, and prepare for the summary and recommendation session with the parents.
Noted Elements Of Client Drawings
Perhaps the major value of child drawings is in the discussions they can generate between the clinician and the parents in the subsequent session and thereafter. Diagnostic or interpretive declarations by the clinician of what one thing or another means in a child’s drawing can scuttle what could be an educative moment for both therapist and parents. The language used in this particular aspect of the overall assessment and treatment plan development is one of couching, i.e.: this often means…; this could possibly say…; what’s your take on this; have you seen this before; and in general working off each others thoughts.
Over time and with sufficient sampling, the following points are likely to arise in the drawing and become a note of mention:
Who is in the family drawing: For the most part, the drawings included the client, parents and other children. In cases of divorced or separated parents, the choice of the child is something of a dilemma, and several variations occur, including: the original family, as if nothing happened or if the parenting arrangement is evenly split; the home of the primary parent without the step parent, if one exists, or with the step-parent with their children, or at the other parent’s home and with their new partner and children to boot, etc. etc. etc.: I hesitated to explore with the child why they chose what they did during this particular question during the introduction session. The tendency was to accept the depiction as face value, and ask the involved parent what significance they may see.
Who is left out: One can assume some kind of tension with the missing factor that could theoretically be explored with about why age the 8-and-under, brand new client left that person or people out, but again in this first session with the child, now perhaps fifteen to twenty minutes in, the strong inclination was to explore this with the parent(s). Some kind of history exists that is worth understanding, bu the parent is most probably in the better position to initially discuss. The therapist could aways get back to the child at a later time.
Extra, non-family people in the family picture – This result was not common, and I believe often a manifestation of an already known cognitive issue, i.e. spectrum or other boundary-laden mental health issue, and reasonable to ask the client about the presences as well as addressing the question with the parent(s).
Presence of a yellow sun – Over time, I became more and more impressed with high-90% frequency that a yellow sun would appear somewhere in the child’s drawing, usually in the drawing of themselves, but sometimes in the family picture. One not appearing at all was worth noting and leading to some kind of plan to explore the significance directly. In terms of the child I viewed the sun as an expression of being nurtured. I usually made note of the sun’s presence in the meeting with parents, providing that little bit of unanticipated reinforcement that doesn’t hurt.
Yellow streaked with orange – As per Lowenfeld, the presence of the sun is a personal extension of the child. Based on the uncommon happenstance, I believe a correlation between an orange streaked sun and a prevailing tension between mother and child existed. The tensions were likely already covered during the intake with the parents, and may or may not be needing mention. Discretion is a fixture on the therapist’s shoulder during these initial sessions.
Red and black – Predominant or significant use of red is widely considered to represent anger. Similarly, black is seen as representing depression. These two assertions seem have the most concurrence within the field of understanding children’s drawings, or at least the most commonly cited. When either or both of these appear in drawings, I did point them out during the following parents session. If anger and/or depression was part of the presenting problems, the parents would basically just nod, and we went ahead. If not, though, the question for them was what were their thoughts were about the suggested correlations, or were there other ways to view their child, and follow that track to some kind of working hypothesis between us. In other words, red being anger and black being depression were not presented as statements of fact, but rather an observation worth exploring and see where the discussion leads.
Baselining: A word for using the entire page, top to bottom and side to side. I heard or read somewhere long ago that baselining was an indicator of a clinically significant anxiety, and found the correlation usually fit. Whether and how to address this with the parents is basically the same as that with dominating use of red and black above.
Relative size of characters: The pre-schematic 5 – 6 year old group are those most likely to have relative distortions of size. They did not occur often at all. When done at that age these were usually overlooked as far as the discussions the parents was concerned, unless one of the parents wanted to talk about their child’s perceptions, or when the distortion was gross. I can’t remember a specific example, that having occurred some time ago. The reaction was more likely one of mild humor toward age normalcy than a knotted concern. The discussions that did occur must have had to do with fairly relationships, particularly as they impacted the client child.
Noted Elements – Missing Pieces and Constricted Coloring – to be continued on next post…
Heinz Dilemma story as presented in this practice:
Once upon a time, a long time ago, there was an old couple, a man and a woman who had been married for many, many years and lived in a small town in Europe – (to the younger kids “you know where that is, right?). One morning they got up and the woman was feeling sick, which was unusual because she was always a pretty healthy lady. So, she and her husband went to see the town doctor. The doctor took her back into his office for a long time, examined her and ran a lot of tests.
Some time later, he came out to talk with the husband. He said “I’m very sorry, but your wife has a rare form of cancer”. The old man was shocked, and he said “Well, is there anything we can do?”
The doctor said, “Well, there’s only one cure for the cancer, and that’s a drug that’s been developed by the pharmacist in the town next door, so I’d suggest you go there and get the drug from him.” The old man said “OK, I’ll do that as soon as I can.”
The next morning he got in his horse-and-buggy and took the long drive down the mountainside to the next town. When he got there, he located the pharmacy and went in, introduced himself to the pharmacist, and explained to him that his wife had just been diagnosed with this rare form of cancer and the doctor told him that the pharmacist had a drug that could cure her and was that true?
The pharmacist said “Yes, that’s true. I do.”
And the old man said, “Well then, I’d like to buy it from you.”
And the pharmacist said “Alright. I sell it for $2000 dollars.”
The old man was surprised and he said “Gee, that’s a lot of money.”
The pharmacist said, “Well, I know it is, but the drug was expensive to develop, and I’m entitled to get some kind of profit out of it, so I only sell it for $2000.”
So, the old man said “Well, I don’t have anywhere near that much money. Can I pay you as much as I can now and pay the rest as I can?”
The pharmacist said “No, I’m sorry, I only sell it for the $2000.”
The old man said “Well, I guess there’s nothing I can do.”
And the pharmacist said “Well, I’m really very sorry.”
And with that, the old man walked out, got in his horse and buggy and took the long drive back up the mountainside to his home, thinking all the way about what to do. That night, he drove back down to the town, and he broke into the pharmacy and stole the drug.
Now, the question is, should he or should he not have stolen the drug, and why?
Boy, 13 – “No, he could have done it another way” Stage 4
Boy, 12 – “Yes, it was wrong, so he should have stolen the drug because his wife might die” Stage 2/3
Boy 10 – “He should have because I wouldn’t let her die”. Stage 2/3
Girl, 9 – “No, the police would be arresting him and then he would go to jail and his wife would be alone.” Stage 3
Boy, 12 – “Yes, he really cares for his wife and wanted to save her and didn’t care what was right or wrong.” Stage 4
Girl, 15 – “No, he shouldn’t because he’ll get arrested and he’s not going to win in the end” – Stage 2
Boy, 14 – “Yes, it was OK to take the medicine because he cared more for what would happen to his wife than what would happen to him.” Stage 4
Girl, 16 – “He probably shouldn’t steal it because if he gets caught it won’t do his wife any good and then she wouldn’t have him around, but if it’s the only way to get the drug, then it was OK”. Stage 4
And the winner is: Boy, 11 – “He should have stolen the drug because his wife had cancer and he wants to show that he really loves her and cares for her and that it was OK to steal even though others may have the cancer. He thought he had to because he doesn’t want his wife to die and he loved her. He may have a high price to pay for the theft because he may have to go to jail, but jail is only temporary.” Scoring is 3 + 4 = 5++
Assigning a level value to Heinz Dilemma responses was often less than straight forward. With the child and young adolescent population, distinguishing between level 2 and 3 could be difficult, introducing a degree of subjectivity if the rater was required to score a specific number. Older adolescents were less problematic. As far as adults and higher functioning adolescents are concerned, one common type of answer is that ‘stealing the drug was appropriate because life is more valuable than property (or profit), a response that could fit either stage 4 or 6, but not really 5. That is something of a trifle when compared to the benefits of the exercise.
Kohlberg’s system paired the six stages into three broader groups, the first two stages being Pre-Conventional, the second two Conventional, and the last two Post-Conventional. My own interpretation coming from a developmental framework for the three groups is that: stages 1 and 2 focus on the needs of the individual, the first being a very concrete choice of good or bad, and the second exclusively focusing on the individual’s own needs; the Conventional third and fourth stages focus on self-and-other relationships, or how to act in ways that at least considers the needs and rights others, and the importance of obeying the rules that lead toward social order; and the last two stages of the Post-Conventional refer to moral decision making that was based on broader principals that stressed the importance of societal needs and conventions, and universal principles of justice.
As with Erikson, Piaget, Hy, et.al., and other developmental theorists, Kohlberg’s view is that an individual’s moral development goes through an identifiable and sequential series of steps or stages that do not reverse, except as a result of cognitive diseases or disorders. The pertinent question here is whether effective mental health treatment, particularly of the young, can foster the growth of moral developmental.
The stages of psychosocial and cognitive growth as per Erikson and Piaget, resp., seem more biologically than experientially rooted, metaphorically being rivers that ‘can’t be pushed’. The effect of therapy is more one of enhancing one’s thoughts and behavior to make the experience of the particular stage in which the client is living more robust and satisfying to self and others. On the other hand, in doing post-testing on a small few long-term clients – three to six years in treatment – I did see concrete evidence of accelerated stage movement in Hy’s ego development, certainly in Piers, Harris’s self-esteem and self-concept, and at least a couple of memorable cases where re-test answers to the Heinz Dilemma had jumped two/three stages. These developmental areas can be impacted, not as a primary goal of treatment, which would have to be behaviorally and relationally rooted, but as a side benefit.
Using this overall Conventional construct, teaching and inculcating “useful principles of right conduct… and the distinction between right and wrong” (the definition of moral development via dictionary.com), can be seen in basic developmental terms. The individual first begins to develop increasingly sophisticated personal governors of conduct taught and shaped by parents, other family, teachers, and other caretakers. Then comes learning to recognize the needs of others and the ability to both accommodate and assimilate to solve differences, first through family and then out into the community, e.g neighbors, schools, social activities, teams, jobs, skill building, etc. Via education, experience, and general observance, the person comes to appreciate broader community needs and standards of conduct, and eventually develop a sense of universal principles of personal liberty, fairness, and standards of justice. At least in the abstract…as said earlier, some adults do not fully emerge from the pre-conventional state. A tarheted, programmatic intervention to improve or accelerate moral development, per se, is probably not necessary to achieve desired changes.
Family therapy has a certain place insofar as ego, self-concept, self-esteem, and moral development processes are concerned, being the setting of first impact and the primary recourse, along with marriage or adult life partnership, for most people through life when in doubt about being or handling other’s moralities. The therapist becomes a guide of sorts just by doing the work well.
At the least, a family therapy would likely facilitate discussions about client issues bearing on ego development, including self-concept and self-esteem, and moral development, as defined above, personal self-care, responsibility, initiative, effort, honesty, trust, and other aspects of being. Getting along with others, recognizing another’s perspective and needs, learning to give-and-take, respect boundaries, being a classmate or a member, etc., can and usually will appear as sub-themes in therapies for children and young adolescents. As a young client’s social world develops, discussions involving their own thinking about how they are being perceived by someone else, and then by a group of others, and then a community of others occur with some frequency. These are also fertile grounds for therapies of many kinds. Post-conventional Stage concerns such as the social contract and the greatest good for most people and the universal principles involving justice and the ethics of obeying were generally not a source of discussion in a child and family therapy, but every once in a while….
The most direct impact of the moral development construct and the Heinz Dilemma task was the reinforcement value that was bring offered. That appeared in three basic ways.
If the child is operating at a level that is two or more stages higher than their age would predict, that offered a great opportunity for me to praise and reinforce. Again, think of Johari’s Window. The parents get informed about the accomplishment in the next session, and they almost inevitably experience some kind or level of reinforcement themselves as parents. Presumably, the parents convey those feeling once again to the child when they get home. To be sure, this did not occur often, but could be powerful when evident.
If the child is operating at two stages below, that situation also gets reviewed with the parents in the following session. More likely than not, that information at least reinforces their perceptions of their child’s strengths and weaknesses, and lends credence to their decision to seek help. Shoring up that area of cognition can be incorporated into the treatment plan as developed during that session.
Possibly the best reinforcement to come out of the exercise is the parents’ awareness that their child took the Heinz Dilemma seriously. As parents, they are in the best position to read their child’s involvement just from the circumstance and quality of answer, and usually indicated so in one way or another. And they appreciated this entirely unanticipated display on their child’s part.
In hindsight, the Kohlberg’s Moral Development construct could have been used more frequently. Taking the specific elements of each stage as outlined in the paragraph above (beginning with “…using this overall Conventional….”), they could have been used as a template for a more detailed and comprehensive list covering the first five stages that could help focus discussion profitably and provide basis for suggestions and recommendations. An instrument like that may not have been used very often, but for a client that did seem to be struggling with socio-moral issues in age-appropriate manners, that could well have been a key for a few select cases that otherwise did not do as well as hoped.
The girl whose Heinz reply was “no, he shouldn’t steal the drug because he’ll get arrested, and he’s not going to win in the end”, was a 15 year-old going on 30 going on 3, driven by id and impulse, seen for a couple of session stretches in between which she managed to close down a mid-major airport for an hour after racing away from security guards. She was living with a sincere father beside himself, minimal contact with mother who by description sounded like an immature Axis II-type. But the girl would talk, as much a release as anything else, likable to me, could make sense, and could demonstrate some insights in the right circumstance. Seeing me, at least for the time being, was sort of one of those circumstances. And then she’d be gone.
What could have been done, and wasn’t, would be to take that Heinz answer, have her identify with the old man, share an equivalent experience of disappointment, or two, or three, that she had had, help her take the ‘assimilate and accommodate’ tack playing the old man toward the pharmacist, work with that until she arrives at a reasonable place, and then have her apply the same approach to the one, two, or three circumstances she had found similar. That would be an example of using a developmental skill that is useful for stage 3 answers, and maybe help her stage 3 growth just a bit.
Instead, I just took the information and relayed it to the father in the next session. Too bad about being in hindsight. I did see the father three or four times over the next few years as she struggled, but seemed to have tenacity at the right times.
The 11 year-old “winner” was entirely different. When relayed verbatim to the parents during the summary session, his ‘answer’ became pivotal in understanding the family and the particular impacts on the client. He was the youngest of four boys, the other three being 14 -18 years old. His retired father had day-to-day household responsibility as the mother was a high level corporate exec. She did attend the intake and the summary, as well as two regular sessions. The parents were somewhat floored by the their son’s elaborate response to the Dilemma, he being usually quiet at home. His presenting problems at school of poor focus and concentration, disruptiveness, and a couple of tic-like mannerisms brought him into the office, but what became apparent during the debriefing in this summary session was that the client was getting lost in the midst of this toxic triangle formed by his three brothers. Those three were at each other with a certain constancy just below the line of unbearable.The father was a serious consumer of erudite writers from Dostoyevski to William F. Buckley, from whom he could recite passages, so the turmoil could grow from three to four fairly quickly, leaving the client to his basement bedroom. At least the “problem” was identified. Discussing the format options and in his innately conservative nature, the father insisted that the treatment be brief.
I said “10 sessions, then stop”, which may sound like hubris, but during my MSW practicum I learned how to do a time-limited brief therapy technique developed by Otto Rank (an ex-valet of Freud’s) in the 30’s, and used the approach in some 30 cases while working at the NPO counseling clinic in Everett. The method was of uncanny effectiveness. Still, though, this limit was a reach.
The cathartic event in this time-limited process is a reenactment of the presenting problem after the sixth session – most commonly before the seventh session – by the client. Such occurred here, as per the norm. My role was commenting to the client that the end of the ten weeks is coming and how did they feel about that. The boy was going to miss it and felt kind of bad, and was then asked if anything else that’s making him feel the same way. I’d like to say he wanted more attention from his father but that would be a maudlin script. He did talk in essence of concerns about the mother’s stress and welfare, and the father enthusiastically involved himself in a serious discussion about all three of them, father, mother, and son, what each of them needed, wanted, etc. reassuring his son but also making a couple of suggestions. And the client, who had been improving, continued to do so until termination. I’d like to say they lived happily ever, but follow-ups are verboten in Rank’s view, and my practice was not to do so anyway without some specific purpose to concern. The Heinz dilemma did become the catapult, though. And the father was happy.
Again, the personal concentration and thought the young clients almost universally gave to the Heinz task was impressive in and of itself regardless of the answer’s particular quality or stage.
While first learning the basics about mental health practice during the 70’s, one concept used to understand therapy process at that time was Johari’s Window. My introduction was through a visiting speaker at the long-defunct Karma Clinic, who used a soft “a” in the introduction, and didn’t go any farther to cite its origins. For the longest time, I assumed the Window’s origin was Hindu, some kind of mystical thought-fruit. As discovered only now, the concept was developed by psychologists Joseph and Harrison (Luft and Ingham, resp.) known in contemporary research circles. More formally know as a “2 X 2 Design”, the concept has been used over time. Google ‘Johari Window Examples’ to gather the varieties of ways in which the tool has been applied. In this instance, the use is clinical.
During therapy, certain qualities and experiences about the client’s emotional, cognitive, and behavioral states are known by both therapist and client. That body of information occupies the top left box. Moving to the upper right, relevant information is known to the client, but not yet disclosed to the therapist, if ever. The lower left box represents what the therapist knows about the client but not yet shared to the client, if ever. Diagnostic hypotheses, dysfunctional relational patterns, and other explanatory would be the most obvious examples. The lower right box indicates that area of knowledge about the client of which neither is aware.
As taught at the time, the clinical belief was that the most important developments during a therapy came from that lower right box, when a significant aspect occurs or emerges about which neither therapist nor client had been aware. More broadly, of most importance to the therapy’s effectiveness was increasing the size of that upper left as much as possible, that which both knew about the client. The improvements gained in one’s mental health were assumed to be correlated. I don’t know of any published study that empirically verifies that, but just anecdotally, some kind of correlation does exist. Understanding takes time. So can healing.
All 56 youth in the study who went through the assessment process continued into the summary and recommendations session with the parents. Total cases remaining in treatment stayed at 56 out of the initial 58.
Like all other sessions, the youth assessment was also 45 – 50 minutes in length. Once a year or so, the process was extended to a second session in order to complete the basic work.
The client assessment was the usually the centerpiece of clinical engagement. Engagement was seen as the establishment of a client’s trust in the therapist’s basic competence and relate-ability, developed over a relatively short period of time. If the child is in need and willing to be involved, the parents and other members of the family are likely to be fully supportive. That development enhances family relationships to some modest degree right from the beginning. Also, though, clinical trust is presumed to be circumscribed, contractually based on the narrow need for help in the here-and-now rather than a relationship of potentially lifelong duration. For some, if not most, that trust can come easily and quickly. On the opposite end of the continuum, those who struggle mightily in some way or another with basic trust, the attainment of this particular type of trust in the clinician can be a longer evolution.
At least as I interpreted this sense of the term, a working clinical trust held by the client and parent(s) was generally in place by 10 weeks, most earlier than that. As an informal measurement, terminations thereafter were mostly a function of progress and change, and a few due to administrative roadblocks. To what degree these case endings were due to untreatable problems or to clinical skills simply not rising to the occasion was, to me, a riddle never solved. Getting the child or adolescent on board, though, was a central goal, hence the importance of the assessment.
Unlike the parent intake and the summary and recommendations sessions, this one involved bit of choreography. Doing therapy is far from an act, but here a little bit did seem to help the youth adjust to something they could have well experienced as anxiety-provoking or even forbidding. Balking could be a particular concern here, considering that 50% of the clientele were 12 – 14 year old boys. Where “freedom” is the raison d’ etre during this early phase of identity development, as per Erikson, most of these boys were moderately-to-seriously unhappy at the proposition of “counseling”. Little about them would be light-hearted if they remain distressed, so, why not introduce a bit of that?
The overall structure of the assessment session involved four sections.The first part of the interview followed a 5-tiered set of questions designed to enable the new client to talk about themselves and why they were in the office, usually taking just a few minutes or less, depending on their degrees of openness. The second part was focused on their own narrative and perspectives about the problems they and their families were experiencing, as well as identifying strengths. Generally, this would take 20 – 25 minutes. The third was the use of four diagnostic and developmental status testing instruments, an exercise that virtually all the kids found interesting and one that generated genuine effort.The last is the summarizing section focused on any specific questions they may have had, feedback from me, and talking about choices in the therapy to follow. All 56 remained involved, including a serious consideration of the format options for on-going therapy.
In a few ways, the assessment process for most 5 – 8 year olds is substantially different, and will be presented in the next post.
The first two steps here are essentially introductory. Over a few years, the simple matters of introduction and finding out what name the new client would prefer to be called developed into this little sequence that may seem contrived, but was one that categorically worked as a lead-in to the serious questions concerning their particular situations, whatever they may be.
With children under 10 and adolescents over 15, the initial greeting in the waiting room would appear to be normal and casual. The parent would usually introduce the youngster, I’d explain about the meeting, and then escort them into the office. With the middle group, the large majority being boys, a certain kind of pose would be assumed. The express purpose was to overcome any nascent resistances the new client had at the moment and be led into the office.
I’d walk into the waiting room, give a quick nod to the parent, walk over to the new client and extend for a handshake, all per the norm except a steady, serious countenance with total eye contact. Most kids stood up, a few sat, but that made no difference. I explained that we’d be meeting in the office for 40 or 45 minutes, that I may want to talk to the parent afterward, that she’d be waiting for him while we met, and ‘OK, let’s go’, and they go though the door I held open. Every once in a while, the boy would give the mother a beseeching glance for reprieve, but she’d simply point to the door, sometimes with a word of encouragement, a lot of times with relief.
I’d sometimes find out in the summary session with the parents that the client’s passive compliance to the quick introductory instruction belied a row in the house and/or in the car with the boy denouncing the appointment and threatening a refusal and worse, leading the parent to legitimately worry about getting the child to cooperate. What dawned on me years later was that my own faux demeanor was almost like a warden preparing the inmate for his walk to the chamber.They invariably preceded me through the door held open. And then that transient experience stood in somewhat stark contrast to the first interaction in the office.
They’d sit on the couch, and I’d ease into my overstuffed rocker, saying in a kind on monotone while lowering my head toward the writing pad “So, it’s John, right?”
They’d acknowledge the name, and continuing with head down in a deliberate monotone, I went on with “Parents call you John”, “Yes”, “Teachers call you John”, “Yes”, “Friends call you John?”, “Yes”, and then slowly raising my head to say with an identical “I’ll call you John?”, gaining eye contact but this time done with a bit of a grin. And usually, the new client would catch on to the parody, grin a bit back, and almost viscerally relax. Some didn’t notice, but they were no worse for the wear and may also have lightened up a bit.
Occasionally, the client did had two name versions parents, like John and Johnny, and we’d work out which I’d use.
Enough idiosyncrasy in these interchanges probably left many of them puzzled if not outright curious, which are steps up the ladder from the low rungs of defensiveness. That fit well into the next question.
Part 2 – The Clinical Intake
#1. The Opening: “OK, so…what can I do for you”?
This was how all initial sessions with a client were opened since early in the practice, which may sound strange for a 5 year old except a small few really young ones actually did begin talking, and some quite well. The rest had a variety of “I don’t know” responses from a simple shrug to a wrinkled smile. Maybe 1 out of 30 would actually respond with a meaningful answer with this first question, on a percentage basis girls more so than boys, and they did stand out. All others went on to the next question, and to them…
# 2 The Follow-up: “No problem, that’s OK. So, what brings you here?”
Being a little more specific and offering some kind of framework within which to respond, maybe 10% – 15% are talking relevantly following this question.The respondents here were more across the age spectrum, more verbal, probably more confident, still representing a greater percentage of female clients than was the case with males.
Aside from being easy and direct, one advantage to this somewhat unconventional two-step start has to do with Johari’s Window. The summary and assessment session with the parent(s) includes a review of how their child fared with the routine questions and tasks. In support of the clients who did answer positively and clearly to either of these first two questions – particularly the very few who began at Question 1 – I made a point of letting the parents know of their child’s advanced response, it’s coherence, and its rarity, ever more so as the child was younger. They learn of a new quality about the child, something neither they nor I could not have anticipated. This represents positive feedback coming from that lower right box, information neither of us knew, and brought into the upper left where we share the knowledge together, enhancing that incipient growth of trust. Furthermore, the feedback has an observational foundation, and not simply a subjective opinion. Random, unanticipated positive attributions are the strongest type of reinforcer, memorable for the parent, good for the child, good for the process, and maybe even under the circumstances, a kind of little peak experience for the family.
For the rest, on to the next.
#3: More Directly: “OK, no problem. So, who brings you here?”
“My mother!?”, from the 13 year-old boy with a little edge, but the question is so concrete as to be a jest, and I’m smiling.
“Right. And what’s your understanding about why your parents(s) wanted you to come here?
More than half of the youth begin to answer and start getting involved at this point. The interview then explored that particular interchange or discussion between parent and child in some depth. The content that followed would likely include problem history, differing opinions about the “problem”, parental actions taken, the impacts on the client, strengths, absorbing the family story, all toward gaining a situational understanding and generating a working relationship with this new young person. In other words just interviewing, following the narrative with open mind and interest, and always contributing at least a bit of valid, random, unanticipated, positive feedback at some point.
And then for those who would answer flatly, “I don’t know”, translated as ‘I do know, but I don’t want to tell you.’
#4 Onward: “Alright, no problem. How did you find out you were coming here?”
Usually answered, “From my mother”
“So, tell me about that conversation, if you would. What did she say to you?”
Sometimes, that question was all that was needed and the interview proceeded as per #3, but on the whole, this estimated 15% – 20% had more difficult parental relationships or life circumstances, hence more depression and/or anxiety and/or behavioral issues, and thus the recalcitrance. Being virtually all boys at this juncture, their resistance would naturally have taken the form of being oppositional.
To simply get a response to easy question of what was said to him could take as much as a few minutes work of trying this, that, and the other thing just to get the right angle in, but usually a working pathway was created. Patient, thoughtful, even-toned inquiry is a given.
The task was to first establish the difference that the new client saw between his perspective of the problem and what he believed as being the parent’s perspective. The fact that I’d already seen the parents was a usually non-thought at this point.The productive part started with the client’s view of the parent’s concerns, worries, complaints, whatever they identify. Once established, the focus shifts to client’s explanation of “the problem” and their view of themselves vis-a-vis the parental concerns
The youth at this point may actually be getting interested, if for no other reason than his stance was getting a competent, respectful, and non-judgmental hearing. Continued interviewing would likely get into the problem history, the nature of the parent-child relationships and those with other family members, then into other aspects of his life including both problems, strengths, and accomplishments, and then into what he would like to see changed or be different.
As straight-forward as the opening here may have been, Question #4’s simple request of what was said by parent to the son about going to counseling could still falter for the remaining, say, 2 – 3%, but by no means does the foray end.
#5 Gambit: “No problem. So I understand that you have no real idea about why you’re here. Right? They just brought you. So, knowing you don’t know for a fact why you’re here, why do you think they want you to be here.? All I want to do is understand your point of view and how you see all this.”
Or something else that might come to mind as a potentially productive way into a narrative about themselves and their experience. The circumstance presents the opportunity for creative experimenting, all in the effort to create the dialogue. More often than not, these efforts do enable the child to speak freely, identify clinical issues, give another view of family dynamics, establish the beginning of a narrative, and lay the groundwork for a functional therapeutic relationship.
All 56 clients here were communicating by Question 4.
At some point though, time left in the session can become a problem. While asking for a second session to finish the assessment could be done, discretion suggests to move on. Second assessment sessions were scheduled when the client had much more to say than could be finished in one meeting, and not due to avoidance.
If I was getting nowhere, we would seamlessly move on to the next section. They did cooperate with the new tasks that were not so personal at all. The task then was to, in some way, tie responses to the evaluative questions of Part 3 with what I knew about him or her based on the intake with the parents and what I’d just learned from interacting and observing him, and open up avenues to his clinical picture, history of the problems and relationships, and other relevant information. These were all boys.
Part 3 – Evaluative Testing
This section consisted of four diagnostic and evaluative instruments. They included: a 10-question depression inventory with an additional screening question concerning anxiety; a 6-question self-concept (or esteem) evaluation; a 4-question ego development assessment; and then a story-and-answer exercise measuring stages of moral development.
All youth aged 8 and up were led through the evaluative exercises. Younger children were more optional, some by their situation and others more out of my interest. If the youngster had blurted out a wish to die, that would trigger the depression evaluation. If their maturity level as evidenced by parental descriptions, the child’s verbal skills, and their non-verbal behavior or presence, then other parts of the list would be employed.
Depression Symptom List
The depression inventory used a combined version of the symptom lists from the DSM III-R and two DSM IVs, with a bit of adaption to accommodate the 5 – 18 year old population. The DSM V was not represented.
The DSM’s before the V were reasonably self-explanatory, clear, and convenient. Professionals and other interested parties bought their copy, familiarized themselves, and put the book to use. The more complicated DSM V necessitated a system of workshops and CEU presentations to teach its manifold systems of qualifiers and diagnostic options to users. I went to a workshop taught by a research psychologist who had worked on one of the V’s clinical section committees. By his own comments aside, clinicians were reportedly not enthused, but researchers in particular were complaining that with so many variables being created for specific diagnoses, doing field research was made much more difficult. To the degree that assertion was true, the new DSM posed a problem in one way or another for many.
1- Do you find yourself feeling sad and/or irritated more often than not, more days than not
2 – Do you have difficulty falling or staying asleep, or do you sleep more than 12 hours a day
3 – Do you have any problems with your appetite, like sometimes you’re not hungry for days, or sometimes you just can’t stop eating
4 – Do you find yourself feeling agitated, like you just can’t stop moving even though you really want to
5 – Do you find yourself feeling fatigued or tired often or have no energy for days
6 – Do you have a hard time focusing or unable to concentrate
7 – Do you find yourself feeling worthless
8 – Do you find yourself feeling guilty a lot, even though you may not be guilty at all
9 – Do you feel hopeless, like things just aren’t going to get better
10 – Do you have thoughts about not being alive or harming yourself
11 – Do you get headaches, stomach aches, or frequent anxiety
Mostly I just noted the answers and asked a couple of elaborative questions to assess severity here and there. Broader discussions about particular positive responses did not occur often. Much of this information would have been covered in the just-completed clinical intake. As was clear with the parents, this was simply an assessment. Attentions would come later.
The Self-Concept Evaluation
This scale was the first of these three assessment instruments to be employed in the practice. “Self-concept” is defined as “The idea or mental image one has of oneself and one’s strengths, weaknesses, status, etc” (dictionary.com). Research psychologists Ellen Piers, Dale Harris, and David Herzberg developed the original scale in the mid-60’s. Their 100 page monograph about self-concept that accompanies the test kit is an excellent work on the topic. Among other findings, the research concluded that one’s sense of self-concept, or esteem, is in place by age 5 and tends not to change thereafter. “Tends” is an important word here, because emotional events like a positively impacting corrective emotional experience or a damaging trauma, the do have impacts one way or the other on how one sees oneself. On the whole, therapy is very much on change’s positive side, and that was demonstrated in the few times I did a post-test.
The Piers-Harris evaluation begins with an 80-item questionnaire using a yes-or-no format to measure self-concept in six personal areas. The test was validated for the 8 – 18 year-old age range. Eventually, I stopped using the questionnaire itself and just asked the clients during the interview to rate themselves on a scale of 1 – 10 for each category. The range of responses seemed similar to the formal test results. At least the self-rating method sufficed for the intended purposes.
The six areas are: Behavior; Intellectual and School Status; Anxiety; Physical Appearance and Attributes; Peer Status and Social Skills; and Overall Happiness and Satisfaction.
The client hears:
1- On a scale of 1 to 10, how would you rate your behavior, with 1 being that you’re in trouble most all the time, and 10 is that you’re almost never a problem to any one?
2. How do you feel about your intelligence and your school performance, like combine the two and average out the scores?
3. How do you feel about your physical or athletic abilities and your appearance?
4. How do you feel about your anxiety; 1 is that you’re anxious most all the time, and 10 is that you’re almost never anxious or worried”?
5. How do you feel about your peer status and social skills. 10 is that you’re liked and get along with most everybody, and 1 is the opposite?
6. How do you feel about your overall happiness and satisfaction in life?
Moral Development Evaluation
Lawrence Kohlberg’s stage model of moral growth offers another plausible way to assess an important aspect of a child or adolescent’s cognitive state and maturity. The instrument is based on the concept that one’s sense of morality grows along a path of identifiable stages. Kohlberg developed the stage structure and then incorporated an evaluative system where moral dilemmas are posed to individuals, who are then asked what they would do were they in that situation. The answers were subsequently applied to a descriptive that characterized typical responses for each of the six identified stages.
The stages include:
1 – Obedience and punishment orientation – obey rules and avoid being punished
2 – Instrumental or Self-interest Orientation – what’s in my best interest
3 – Interpersonal Accord and Uniformity – want approval and avoid punishment
4 – Authority and Social Order – obeying rules is valuable and important
5 – Social contract orientation – What meets the greatest good for the most people
In the practice, the instrument was used as an assessment device, but seldom used to measure growth during a therapy. The exceptions were a few times with cases that went beyond three years. Moving from one stage to the next takes time.
The morality play Kohlberg commonly used is the Heinz Dilemma. The source of the basic story is not clear. Kohlberg’s rather harsh written version, clearly for adults, appears in the Wikipedia entry for ‘Lawrence Kohlberg’s Stages of Moral Development’. Briefly, the story involves a woman who develops a potentially fatal cancer. There exists only one cure for the cancer, stocked by only by one pharmacist who sells the remedy for an outrageous price. The husband cannot afford to pay the price, and the pharmacist refuses refuses to negotiate. Ultimately, the husband steals the drug, and the question is “Should or should he have not stolen the drug, and why?” I created my own verbal version, taking into account child and adolescent sensitivities. A transcript will be an addendum in the post following this one.
Answer examples to the Heinz Dilemma question for each stage:
Stage 1 – No – stealing is bad
Stage 2 – Yes – he doesn’t want to lose his wife
Stage 3 – Yes – he loves his wife and wants her to live a long time with him
Stage 4 – No – he could go to the mayor or a rich guy for help
Stage 5 – Yes – I couldn’t hold my head up if I let her die, we have to do what’s right
Stage 6 – Yes – Family is the most important part of life. I have to do everything I can to keep her alive for everyone’s sake; it’s the right thing to do, even if illegal. The pharmacist is wrong
Ego Development Scale
Hy and Loevinger’s measurement system of ego development was the last of these four instruments to be added into the assessment format. That the scale was used to measure outcomes in a clinical study published by the Journal of the American Academy of Child and Adolescent Psychiatry was intriguing enough to send away for the package and incorporated it into the assessment.
One definition of ego development is: “The nature of self-understanding, social relationships, and the mental processes that support connection between the person and his/her social world.” (Theories of Adolescent Development, Newman and Newman, 2020).
According to the authors, “One of the newborn’s earliest tasks is to construct for him or herself a stable world of objects, more specifically “constructing the world of objects and constructing the correlative (read ‘constructing the self’)”. This would be Stage 1.
A hierarchy of 8 subsequent stages of ego development, numbers 2 – 9, was devised by Hy, et.al. They included: Stage 2 – Impulsive; Stage 3 – Self-Protective; 4 – Conformist; 5 – Self-aware; 6 – Conscientious; 7 – Individualistic; 8 – Autonomous; and 9 – Integrated.
The team then created 36 phrases to open a sentence that would be completed by the subject. Based on their initial test runs, Hy and others developed representative answers for each of the 8 stages for all 36 phrases. All this information is published in “Measuring Ego Development – Second Edition” by Le Xuan Hy, et. al.” After getting the manual, I experimented with a few clients and subsequently incorporated the system into the assessment format.
Based on my experience with about 350 youth over a 10 year period that included a few of the 5 to 6 year olds seen: Stage 2 Impulsive was typical or average for children under 8; Stage 3 – Self-Protective was typical for 2 – 4th graders; 4 – Conformist was typical for 4 – 7th grade; 5 – Self-aware was attained with increasing frequency from 5th through adolescence; 6 – Conscientious, much less common but appearing in increasing frequency from mid-adolescence into adulthood; 7 – Individualistic appeared for a small few older adolescents; 8 – Autonomous may have appeared in one or two cases, and while nothing registers in my memory, with that many youth at least one would have probably appeared; and none for 9 – Integrated. I probably would not have been able to distinguish the last two from each other anyway. The issue never became germane, as 7 was the highest achieved among those tested here.
As a matter of reference, some significant proportion of adults themselves do not get beyond stage 4, with a few percentage points even lower. An interesting question is the degree to which the ego development is dependent on parenting, education, and similar experience vs. intrinsic drives. A research question could be whether the children of adults who answer in the lower levels could themselves attain higher degrees.
Examples from the practice using the four beginning phrases. This being a family therapy practice, the chosen four opening phrases were: 1- Raising a family….; 2 – A good father….; 3 – A mother should….; and 4 – I am….
8 yr. old boy:
1) is hard (Stage 3)
2) will always be good to his children (Stage 2/3)
3) always cook for the family (Stage 3)
4) respectful to others (Stage 3, and ironically one of the client’s main problems)
10 yr old girl
1) has hardships and fellowships, ups and downs (Stage 4/5)
2) should be there for his family and be a positive role model (Stage 4)
3) love her family and help set family goals and make kids desserts (Stage 4)
4) Whoever I want to be and will always be who I want to be (Stage 4)
14 yr. old boy
1) taking responsibility and working their best to help children be successful (Stage 5)
2) someone who cares about you, has fun with you, and takes care of his family (Stage 5)
3) Always looking out to take care of her family, raises them as best she can, and loves everyone (Stage 5/6)
4) wondering what is going to happen to me, what I’m going to do, like do ` something good (Stage 5/6)
The shift of focus or affect shown by the youth as the interview moved from the problem orientation to the second part’s testing format was notable.
In contrast to the unfolding of sometimes difficult descriptions, disclosures, stories, and uncertainties, the second half was more like an academic challenge which was usually taken seriously, often eagerly. Answering the posed questions in the evaluative section was more impersonal, concentrated, and touched their creative sides, like the client could and would step outside themselves, leave the drama behind to achieve the perspective necessary to answer the questions relative to depression, self-confidence, ego, and moral thinking. The appreciation from a nod to a comment to an explicit praise of their responses was appreciated by them in return.
The first part of the assessment interview focused mostly on the client’s narrative, that being their views about current problems history; relationships; disappointing, disturbing, or traumatic events events; losses; and doubts that linger. Virtually all clients had at least couple of these experiences; some had more. To one degree or another, most all re-experienced their downside of life once again, but by the end of the overall assessment interview most all had some sense of optimism, if not outright relief. Their transition out of whatever emotional state their narrative brought on during the first part of the interview was a useful data point. When that shift demonstrably occurred, a nice source of feedback was provided, both to the client and later to their parents during their next session.
Among other uses, the depression and self-confidence evaluations assess the client’s state of being, meaning how healthy and how content one is with one’s self. The moral and ego-development evaluations can assess aspects of intellectual growth. The first two can identify areas of emotional strength and symptoms of distress, while the other two can identify strengths of maturity and perspective, and those who have deficits.
When administering these devices, one track of the interview was the search for positive reinforcements. Think of Johari’s Window and the power of observations that come from the lower right box, where neither the client nor the therapist were aware of something important about the client. Giving positive reinforcement only for the sake of doing so runs the risk of lighting up the client’s phony detector – assume they know when words don’t match their reality -but in the midst of answering these various challenging questions, the spontaneity of a response to their answers adds to a sense of authenticity.
The addition of the ego development evaluation opened up a whole new mine of reinforcement opportunity. The stages are sufficiently proximate to each other that answers from higher-than-average stage for a child or adolescent were more common than those from the moral development system. Additionally, the opportunity for creative answers could be given four times during each evaluation compared to the one coming from the Heinz Dilemma.
Sometimes the best available praise was a recognition of the young client’s difficulties and in what way they were trying to do their best in their given situation. However, I could usually find something in what they portrayed either during the narrative half, or among their answers to all the questions provided during the evaluative half. The feedback was also conveyed to the parent(s) during the following summary and recommendations session.
Again, these are usually examples of the lower right box in the Window, where the child and parent and therapist are learning something of positive substance about which no one had particularly been aware, i. e. random, unanticipated positive reinforcement, the most impactful of its type.
Vis-a-vis the Depression Symptom List
This adapted construction of a depression inventory ended with a global indicator of child and adolescent anxiety. If they endorsed one of the three possible problems posed – headaches, stomach aches, or frequent or overwhelming anxiety, the assessment continued to the DSM III- R’s 15-symptom list for generalized anxiety. This particular list was the most helpful for generalized anxiety among any of the DSM’s. In addition to thoroughness, the list was divided into three sub-groups, the first of which seemed to be about the anxiety created by chronic stress, the second one about the anxiety of how one is seen, and the third about the anxiety that foretells danger of some kind or another, a convenient overall schematic.
The anxiety question ending the depression list also ‘buried’ the suicidal question, so that disquieting consideration wasn’t left like a dangling participle.
Understanding that the community standards of assessment and intervention processes for SI are in the midst of significant change as the problem of child and adolescent suicide in this country has been upgraded to epidemic status in the past few years, the following paragraphs are presented only as “this is the way it used to be done” and not as a contemporary model, per se. Whatever they be now and however vague, community standards are never to be ignored.
37% of the study, or 21/56 cases, involved suicidal ideation difficulties for clients from 8 to18 years old. Over the years, an average of 8 – 12 new SI cases were taken into the practice annually. Based on the study cases, their average length of treatment and average number of sessions were about 15% higher than that of the other 35 cases combined. These cases also had higher levels of problem resolutions and fewer premature terminations. The sense I had was that once satisfied with the therapist, these parents in particular were determined to stay the course. Perhaps counterintuitively, once the suicidal ideation began to abate, these cases on the whole were easier to manage, treat, and help create change, and the parental involvement was clearly an aid.
Suicidal ideation and behavior was the prompting problem that led the family into the office for all 21 SI cases in the study. The issue was usually disclosed during the initial phone contact by the parent, and if not, during the intake. Most of the 21 clients also disclosed the ideation during the assessment interview. If not, they would do so during the depression evaluation itself. Maybe once in this group I had to bring the topic up for verification.
The assessment work was to establish where on the continuum, from an isolated blurt to a manifesting plan the young person was functioning. Whatever the conclusion, initial severity would be part of the assessment debriefing with the parents during the following summary and recommendations session, a step about which the client understood.
If the SI was isolated or had been managed to the satisfaction of safety concerns by the parents at home, no specific action was necessary at that time. The therapy thereafter would tend to the underlying issues. As with the others, all SI cases did continue into treatment.
If the safety of the child was still in question at the end of the assessment session, the accompanying parent would be called in and included to make a management plan to everyone’s satisfaction, client, parent, and therapist alike. If the client was concerning and balking both, the ER was an option. That happened a couple of times years earlier than the study. One cooperative 13 year old girl was escorted to the psychiatric hospital intake next door. The most common intervention outside the office was to have an outpatient child psychiatric assessment which would normally include a medication evaluation. Psychiatrists’ admitting privileges were an important adjunct and consideration in the referral.
Parenthetically, I can tell you that having a child psychiatrist as a referral source who thought clinically before pharmacologically is a gift.
One particular interchange was choreographed if the thoughts had been persistent but had not advanced to imminent threats of attempts that required the efforts in the above paragraph. To the client, I’d say “So, if you got to your very worst, where everything just seemed sooo bad, and you were thinking about doing it, what would convince you not to do so?”
One of two types of answers came forth. By far the most common reaction was the client identifying the pain that family, friends, teachers, and/or others would feel. The concerning response was something like “because it’s stupid.” The first is appropriately other-directed, and the second is a concerning self-absorption, dearth of empathy, and perhaps impulsivity.
The clinical response to the self-absorbed stance was the one planned intervention that regularly took place during the assessment itself. Together we would walk through several family members, friends, teacher, and others of importance to the client and discuss how each would react if the client did take their life. An instructive approach to help broaden the client’s perspectives of others under these particular circumstances can be corrective, and part of the subsequent work included a focus on empathic growth. The work did seem potent to the client. Occasionally, though, someone was unimpressed, and that youth would require more supervisory care and at the very least that referral to a child psychiatrist or psychiatric hospital.
One complication of SI being revealed by the client during the assessment was when the issue was an unknown to the parents. That happened maybe three or four times total. None of these study cases were involved. In general and if the child were under 13, I would do the evaluation, talk with the child about how and when the parents needed to be told during the assessment session. A good deal of therapeutic effort and support might be required, perhaps the length of the session itself. The carry through was usually toward the end of the session, with time made for appropriate planning.
If the child is over 12 and insists the disclosure about SI remain confidential and this being the State of Washington, the therapist has a problem. A discussion ensues about why the need to do so and why the need to include the parents, but that could go nowhere. Know where they are on the continuum. The issue of safety is determinate, replete with all the involved subjectivity just to further the difficulty, and an intervention may be necessary. Concerns about “losing” the case are moot. Concerns a unilateral act might trigger an attempt are not idle, but certainly not common because Lord knows we’d hear about it.
I went along with the insistence at least once, I think possibly twice. Nothing bad happened. Issues that skirt the rules of conduct do arise, and that’s one of reasons we have professionals, and one of the reasons we become one. These situations need tender care.
All this is said having not experienced either a suicide or an attempt during my practice. To what degree this is normal or talented or lucky is impossible to sort out. Come retirement, I did feel very fortunate.
Vis-a-vis the Moral Development Evaluation
All clients 8 – 18 were tested during the assessment session. Depending on maturity, 7 year olds were occasionally included, one rather remarkable 6 year I can remember, and none under that age. The test was given regardless of the child’s particular family circumstance, e.g., cancer in their own family, other premature deaths of parents, etc.
I remain thoroughly impressed with the almost universal way the 1000+ kids carefully listened, thought with appropriate gravity, and answered with a caring creativity concerning Heinz’s Dilemma, regardless of their own circumstance.This is not hyperbole. The story does have a capturing quality, to be sure, but still, these were just kids. Their answers were always interesting, and a point was made to share them with the parents in the next session.
The answers always focused on the husband, as per the question at the end of the story “should he or should he not….” The pharmacist was hardly ever a part of the answer, as if a neutral character, until somewhere in the 2000’s, during which he started being identified as a problem participant in a quite a few responses through to the end of the practice in 2015. These particular respondents were not limited to older adolescents.
As an aside, another observation of a change in patterns of child and adolescent behavior occurred at roughly the same time. Among other creative supplies in the waiting room was a set of about 70 old wood blocks of different sizes and shapes, out of which kids would create their own structures on the waiting room floor. These included siblings brought in with the parent to wait through the session, so lots of kids made all sorts of structures. Parents, by the way, in the era of electronics loved this activity. I also had them leave their creations there on the floor at the end of their sessions rather than putting them away, which the kids loved doing, because other youngsters coming in later would sometimes add to them. Getting back to the point here, boys would generally make structures that rose upward while girls tended to make wide and low enclosures, like villages or wide castle grounds. Again during that first decade of the century, girls increasingly made towers and such structures as well. What to make of either of these pattern changes I do not know.
Vis-a-vis the Self-Concept Evaluation
My take is that self-concept and self-esteem are essentially flip sides of the same coin; cognition is to self-concept as affect is to self-esteem.
The overall average of the clients’ self-concept was around 5.5 on a scale of 10, this in spite of the fact that their average overall functioning was 55, or moderately disturbed, on the CGAS scale. Statistically, the range of “normal” on the CGAS is in the 80’s, so one might expect a lower-than-five average among the study group. The catchment area of the practice is middle-to-upper middle class, leading to the question of whether that factor equates to higher-than-average self concept scores in general. And then what effect that has on overall mental health, which could lay question about national and global resource distribution.
The self-confidence evaluation was most helpful as an additional diagnostic, particularly with anxiety and depression. Those issues are directly evidenced through the anxiety and overall happiness and satisfaction scales, and indirectly by the degree of low scores across the six scales.
Unfortunately, the results are more inclined to point out existing difficulties than unanticipated strengths. In the search for potential sources of reinforcement, looking for areas in which the depressed or anxious child rates themselves at 7 or higher among the four categories occur with regularity, and the use of reinforcement in those instances did seem on the whole to have the desired impact, particularly with parents. The results of the self-concept evaluation were more often helpful to expand the understanding of the parents about their child than they did on the children themselves, but help is help and not to be discounted.
The utility of the tool was more oriented toward giving good, specific feedback about their child’s view of themselves to the parents. This afforded the parents to more objectively view their own parenting and begin to start thinking about adjustments big and small, mostly the latter. Discussions followed both in session and, presumably, afterward. ‘What is it that can get better here’ started to become a bit of a mantra in session. Most all this would be done in the following summary-and-recommendations session. The self-concept exercise was by far the most helpful to the parents of the four tools used on their child.
The one pattern I noted over the many hundreds of administrations was that the cases where an outcome that has low anxiety and overall happiness and satisfaction scores while the other four were above the mid-line usually had as a primary problem the relationship between the client and the mother.
Very few clients gave themselves uniformly very high grades, ie. 9’s and 10’s, or very low, ones 1’s and 2’s. To me anyway, this tended to reinforce the sense of overall validity in the answers.
Only on occasion would children under eight be given the questions. The problem was not so much understanding the questions. Objectivity may be more difficult for the young ones, but the concept of self-rating on a numerical scale made the interpretations of profiles problematic. The best example of a younger client’s struggle with the numerical rating system was another 6 year old boy who rated himself as a 1 for behavior, anxiety, and overall happiness and satisfaction, and 10 for the other three including intellectual and peer status, physical appearance and attributes, and peer status and social skills. He was absolutely correct about which were a strength and which were problems, but did not understand the mathematics of nuance.
Vis-a-vis The Ego Development Evaluation
.Ironically, the evaluative tool that was incorporated into the assessment format some fifteen years after the others became in ways the most valuable of the three. The same clinical benefits that the moral development evaluation offered, those of assessing the client’s state of personal growth, apply to this evaluation as well. Two other advantages also were present. Given that the four questions all pertained the family, the subject clients will often disclose salient perspectives that enhance the picture and offer threads to be followed. The second is that the instrument can be used with 5 – 7 year old children. The Piers-Harris system was validated for 8 yrs. old and above (although a contemporary 7 year old is likely to be more advanced than 50 years ago?), and I was just not comfortable presenting the Heinz test with most kids under age 8. The ego development tool includes all the children 5 and above.
Using Hy and Loevinger’s sentence completion system provided a better platform for unanticipated and meaningful positive reinforcement. A few respondents had answers that were levels higher than average for their age. Again, think of Johari’s Window – I’m clearly impressed at the moment, they could not have been aware of this particular precocity, and the relationship is subsequently enhanced just that little bit.
One specific observation pertained to older adolescents whose responses indicated a stage 7 on the ego development scale, advanced for any adult, let alone vulnerable 15-16 year olds. Relating to peers could be sadly problematic. Taking into account at the outset that they are entering counseling because of emotional, family, and/or social difficulties, they did seem to have particular problems establishing close confidential relationships. Dating relationships for the females seemed especially difficult as their partners tended to be older an/or players, leaving the client to be caught in painful double binds and a lack of peer support.
Part 4 – Summary and Planning
With some 5 – 10 minutes left in the session, the clinical information gathering and evaluative portions of the assessment were concluded and the conversation switched to summarizing, planning, and concluding. As stated earlier, this particular approach to the client assessment was generally for youth 8 years old and up.
The transition question was something along the lines of: “OK, so I’ve been asking a lot of questions”, pause for a nod, somewhere between faint and vigorous, “So, do you have any questions you’d like to ask me?”
With uncommon exceptions, the answer was a shake of the head. The question was asked as much for foreshadowing as for a response, establishing a facet of the clinical relationship that encourages the client to think about their questions and ask them later on in session. Those that posed questions were generally either older adolescents who may have questions about something I asked or said, or by the 5 – 7 years olds who might have something they wanted to ask about me. I usually answered anything expeditiously and moved on.
The next question was: “So, I’m going to be meeting with your parent(s) next week. Do you have any concerns about that?”
Some just shook their heads. I’d confirm “so you’re comfortable with that?”, and they’d nod. Most, though, came back with “Well, what are you going to tell them?”. That response more directly opened the summary of their interview to share with them, including clinical, evaluative, and impressionistic observations. Even with most of those who were ‘comfortable’ with this prospective parent meeting, a few minutes of extemporaneous review would follow.
Every experienced clinician has a method of taking notes and keeping a running side commentary, establishing the given facts and noting impressions, typically leaving the impressions for the margins. For the most part, the summary to the client of what I’d be telling the parents came from the margins, but also the problems that people wanted to see get better in some way or another that were central to the narrative. Those issues may be symptoms, relationships, losses, traumas, heartbreaks, or other unresolved hurts. The margins also contain noted strengths based on the clients words, history, performance during the evaluations, demeanor, and character as witnessed.
The young client wants to know that the therapist knows, that divesting of private and personal information has a value, that a helping route can be seen, all possibly without melodrama, maybe just get better. The praise that occurs must be based on direct observation and plausible conclusions. And don’t take more than a few minutes. In their realities, 50 of them in a therapist’s office can feel like an eternity.
“OK. So there are three ways we can go about working with these things. What we do is not my decision or your parents or yours, but rather this is something that we just work out among us. But if this were your decision, I’m interested in which one you’d choose. Number one, I can meet with you and your parents together. Or, I could meet with you and your parents and your sibling(s) together, like the whole family. Or, I could meet with you alone and meet with your parents separately, either split an hour here or see you for a full session and your parents the same at a different time. So, which one would you choose?”
If they choose being seen alone and I am normally thinking family, I’d ask them how they would feel if family work turned out to be the most favored choice. Again for the most part, they are fine with that, but occasionally the counter argument has real merit, and that gets taken into the parent meeting.
“Is there anything else you’d like to add?”
Usually not, and then comes a quick and genuine summation, apt to the person, including constructive, supportive feedback, and particularly what was appreciable about their input, cooperation, etc. Particularly for the difficult 11 – 14 year old boy, some kind of comment about having “…done a good job here, I think this could probably be of some help, and I look forward to seeing you again…” That helped. Just ten, fifteen seconds, not wanting important words to get lost in a tide.
What did not occur:
No given diagnosis, certainly not before conferring with the parent, but no youth of any age ever asked for one, that I recall. That may have changed during these past few years as the American population gets swept into health-speak.
No therapeutic assignments. No clinical contract with the parents yet, and no youth ever asked. That, too, may be changing. The main reason is that I want to see what was the impact of the session itself on the young client, what kinds of changes may have spontaneously developed. That is important information for treatment planning and part of the work with the parents in their following 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:
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.
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.