Getting Started: Initial Evaluation Sessions with Adults—With an adult who has been referred for possible treatment, I initially meet for three or four sessions on an evaluative basis to gather history and to try to gain a thorough understanding of what has brought a person to seek treatment at this time in life. Once these evaluation sessions have been completed, I give feedback about my opinions regarding the causes of the current difficulties, and then discuss my recommendations about what can be done to try to help. These could include a number of different options, including psychotherapy, psychological testing, a referral for a medication evaluation, specialized education, tutoring, or some other form of intervention.
Initial Evaluation Sessions with Children—Evaluating and treating a child is a bit more complicated. Unless the child is about sixteen or older, I generally meet with both parents first—separately or together, according to their preferences—to gather a complete history of the child’s development and functioning in a number of areas, including academic, social, family, and elsewhere. It is also important for me to gather a thorough history of each parent’s childhood and family origin, in order to better understand the contributions these factors bring to both parents’ current philosophies and approaches to raising their child. I then meet with the child alone for two or three sessions. Here, I try to assess a number of things—how well children are able to talk about themselves and their inner thoughts and feelings, whether they appear to be functioning socially and emotionally at the level expected for their age, and any understanding they may have regarding the difficulties which caused their parents to seek treatment for them.
For older children—around ten and above—this can often be accomplished simply by talking with them and carefully asking them questions which encourage them to reveal themselves. With children younger than this, techniques involving play are often more effective. These allow children to relax more and “have fun” while expressing feelings and themes about their lives which may cause them concern or trouble them. After two or three of these sessions, I meet with parents in the feedback session, offer my opinions, and discuss recommendations for further intervention.
With older adolescents, the process is fairly similar, except that I find they often prefer to meet with the therapist before parents ever do, so they can decide on their own if they feel comfortable or not with me before going forward with the entire evaluation. Likewise, I often offer feedback directly to the older adolescent before giving it to parents, so they have the opportunity to hear it first and give their own responses to me in private. Afterwards, I meet with parents alone for a similar discussion, followed by a meeting with the adolescent and parents together for any further discussion. In all cases this initial feedback meeting may be followed by additional joint meetings and discussion to make sure everyone is in agreement with any treatment or further evaluation plan decided upon.
My aim in psychotherapy is always to help people understand the hidden reasons why they think, feel, and do the self-defeating things they do, so that they can make better choices in their lives. This can only occur in a professional atmosphere that is safe, ethical, and absolutely confidential.
Frequency of Psychotherapy—Sessions often occur twice per week, though at times less often. This level of frequency, contrary to many patients’ fears, is not encouraged because of the severity of a patient’s problems. Rather, it is usually offered to patients who are emotionally stronger, and can take more advantage of the intensive level of involvement in psychotherapy and the greater continuity of discussions gained in this way.
Psychotherapy with Adults—Adults are really the easiest group of patients to work with. They come voluntarily, they’re in distress and therefore usually motivated to work to feel better, and so they are generally the most cooperative group of patients. They are urged to “think out loud” so that together with the therapist they can study their patterns of thinking and feeling and can begin to consciously understand how their minds and emotions work. Thus, they become more able to make better decisions for themselves in the future, rather than being driven to make decisions—automatically and without thinking—based on unconscious motivations they don’t fully understand. Of course, this takes time, patience, and determination.
Psychotherapy with Younger Children—Up to age 8-10 or so, young children can have great difficulty openly saying what they’re thinking and feeling in response to a therapist’s questions. Conversations which focus directly on conflicts in their lives are too uncomfortable for these youngsters to engage in. Therefore, psychologists have come to use play therapy techniques to help young children express their concerns in an activity they find more enjoyable and more comfortable. As you might imagine, it takes great skill and patience on the part of the therapist to keep the child engaged in the process, and to use the play scenarios constructed by the child to assist him or her to feel better about the emotional conflicts they express there. Again, it’s a slow, methodical process which is greatly aided by meeting twice per week or more.
Psychotherapy with Older Children and Adolescents—Above the age of 10 or so, kids begin to be able to tolerate thinking and talking more directly about themselves, even when the discussion isn’t altogether positive. Here, it’s most important for the therapist to build a working alliance and a sense of positive rapport. Without this as a foundation, treatment with these kids goes nowhere. An extremely important promise I make to all kids (and to all adults as well, I just emphasize it more to kids) is that with only a few exceptions, everything they tell me is absolutely confidential, and I promise to keep everything they tell me secret, including from parents—and I do! The exceptions, as you might imagine, are rather extreme situations, and generally involve some kind of physical danger, such as the child informing me they have plans to seriously harm themselves or someone else in the immediate future, or the child informing me of the occurrence of physical or sexual abuse, where they are either the victim or the perpetrator. Once assured of this kind of privacy in their therapy, most kids begin to open up and really talk about what bothers them, which is a huge step towards positive growth and change.
Parent Counseling—Whenever a child or adolescent is treated, their most important sources of influence—parents—should be included in some fashion as well. Even if a kid were seen in psychotherapy seven days a week, their parents still have a far more powerful influence over their lives than a therapist could ever hope to have. Likewise, even the most skillful psychotherapy could be sabotaged or undone if parents are not fully supportive of and cooperative with the therapy, or if they are not supervising the child in a way that collaborates well with the aims of the therapy. Said more plainly, therapy for a child works best when everyone—therapist, parents, and child—are all on the same page and working closely together.
So parents need to meet with the therapist in some fashion, and there are several different methods, each with its advantages and disadvantages. In my opinion, the best way to involve parents in a child’s treatment is usually by having them meet with another mental health professional, one different than the child’s individual psychotherapist. This arrangement strongly supports the existence of confidentiality in the child’s individual psychotherapy, and gives the child the clear message, “Your therapist is your confidante, your special person who is on your side and does not have an agenda to be a parent towards you, nor a direct agent of your parents.” An advantage here for parents is that the time spent in these separate sessions is completely theirs, and they can focus on their difficulties maximizing the effectiveness of their strategies used to supervise the child patient. The time can also be used to examine the ways parents have conflicts working together and supporting each other in presenting the “united front” that is spoken about in so many written works on parenting.
An alternative to this strategy, less preferable in my view, is for parents to meet regularly with the child’s therapist. Here, parents can provide valuable information about the child’s current functioning, and about any progress or problems which might be occurring. The child’s therapist must then wear “two hats,” and function as direct advisor to parents as well as remaining confidante and wise consultant to the child; meanwhile, the child/adolescent patient can have worries about the therapist telling parents the private things they have discussed in therapy sessions.