This edition of the CCC will focus on the most common question I receive from child clinicians at the workshops I offer: “What should I do when the parents refuse to cooperate?” I this column, and the next one, I will offer my two part response to these sorts of questions. In this column I will review my favorite strategies for facilitating adherence and responding to resistance. In the next column I will discuss what I recommend doing when these strategies fail. Before I begin I’d like to quote the philosopher Terence: “Nothing is said that has not been said before.” That quote is certainly true regarding the material in this column as you can find most of these ideas reviewed in such works as Donald Meinchelbalm’s Facilitating Treatment Adherence, John Norcross’ (editor) Psychotherapy Relationships that Work, and Scott Henggler et al’s Multisystemic Treatment of Antisocial Behavior in Children and Adolescents. Finally, this is hardly an exhaustive list of strategies, but only the ones that seem both clinically relevant and possible to review in a brief space.

Obtain Informed Consent Regarding the Goals and Methods: I’m struck by a finding in my practice. When a family has seen another mental health professional, but are now choosing to switch to me, I’ll ask three questions regarding the previous work. “What diagnostic impression was shared?” “What were the goals for the work?” And, “what methods were used to try to reach the goals?” Most of the time the parent(s) cannot answer any of these questions, and rarely can answer two or three. My theory is that those parents that can answer all three questions are less inclined to switch providers. In all fairness, the previous clinician may have discussed all three issues, but, somehow, the content did not sink in. (I imagine that clients who have left me for other therapists would struggle to answer these questions too.)

From the point of the first phone call through termination, it is critically important to teach and agree: teach the parents what goals and methods you believe are advisable and then either secure their agreement or make adjustments (this process would include having them confirm their understanding by repeating back what you’ve said). Being an organized and kind teacher captures a number of non-specific effects that facilitate adherence.

Assess For and Reflect the Strengths: We may be so focused on the child’s and family’s pain that we may (unintentionally) give the message to the family (and even ourselves) that they are defined primarily by their problems and limitations. By assessing for strengths we give a more positive and accurate message. I use several strategies along these lines. After I’ve interviewed the child and family about their chief complains I next turn to the child’s strengths, asking the parents: “Okay, we’ve discussed the problems. Now can you tell me what is good about Susan’s behavior and personality?” Most parents eat this up. I then ask for the kid’s reaction to the parents’ assessment and ask her to add to the list. This discussion typically ends with me reflecting back that the child has many more strengths than symptoms. I will then do a similar procedure for the family as a whole. Finally, I try to understand and reflect back the strengths of others within the system with whom I interact (e.g., teachers, probation officers, etc.). Assessment tools for strengths are limited but there are some. For instance, I use portions of the BASC-2, the Multidimensional Self-Esteem Inventory (for adolescents) and the Signature Strength Survey.

Assess for Parental Psychopathology: Given how often parental psychopathology is indicated as a negative moderator variable in the child psychotherapy outcome literature (i.e., a monkey wrench in the works), I routinely screen for it using the SCL-90-R. At the end of the first family interview I assemble packets of rating scales for the parents, the child and the child’s teachers to complete. I always put the SCL-90-R on top of the parents’ piles and say, speaking to the parents: “Janet, Bob all of the forms I’m giving you to fill out are about Billy, with one exception. Fill out the top form regarding yourself. It will give me a sense for what toll stress is taking on you.” While I sometimes get them back with straight zeros, I rarely have a parent object. Stress is a magical word with adults. If you ask them if they have mental health issues or psychological problems you get one answer. If you ask them if they suffer from stress you get another.

If one of the forms comes back with an elevation I explain it and recommend further evaluation. Should the parent decline I’ll say “Ok. I won’t bug you about it. I need to say just one last thing though. I’m optimistic that the treatment plan I’ve share for Joe will work in the way I’ve described. However, if it doesn’t, I’m going to want to return to this discussion in order to see if helping you to feel better might not give new life to our efforts to help Joe. Would that be okay to do should it come to it?”

Collaborate: This overlaps with the informed consent strategy, but is different too. Donald Meichenbaum demonstrates the principle by quoting a dentist who would tell his patients “only floss the teeth you wish to save.” Early in my career I used to try to pressure parents to do the things that I thought were advisable (and I can still sometimes fall into that trap when I’m weary). However, my effort now is to try to educate parents about their choices, the pros and cons attached to each, and which of them I believe are most advisable. Then if the parents prefer to go in another direction I’ll still participate, as long as the family is informed about their choices and I believe I can be of help. This approach is especially important when crafting damage control treatment contracts with families (the topic of my next column).

Use Empathy: I believe a useful assumption in parent work is that your average parent loves her child more than her life. So, if a parent is parenting in an abusive, neglectful or ill-advised fashion, it usually means that she is in a degree of pain that interferes with her capacity to consistently act with intention. An effective clinician endeavors to understand and to empathize with this pain instead of adopting a disparaging model of the parent(s) or family. So, if a parent no-shows for an appointment, bounces a check, doesn’t complete therapy homework, etc. I try to refrain from jumping right to scolding (no matter how wrapped in silk), reviewing the consequences of the lapse or suggesting how we might fix the problem. Instead, I first try to understand the human condition the parent(s) experienced that caused the lapse and respond with empathy; this can work for any human behavior, no matter how unsavory or hurtful. Following such a dosing of empathy most parents are more willing to engage in problem solving in order to avoid the behavior in the future (the chief exception would be those parents who suffer from paranoia).

In addition to providing an effective method for responding to resistance, empathy also facilitates our learning about important matters. Empathy acts like the sun on a spring tulip, which is why psychoanalyst Paul Ornstein refers to it as “one of the best research tools we have for studying people.”

Remember that Crisis = Danger + Opportunity: When one of my parents displays resistance it usually means that there is something important about him which I have not yet understood. (If I understood everything that is relevant, and assuming that I am on my game, then I would not be experiencing resistance.) Hence, the resistance affords me an opportunity to learn something valuable. How I typically proceed is to say “Ok, let’s take (recommendation x) off of the table for now. But, tell me, what are you concerned could happen if you/we did it?” Parents don’t say things like “well, he’ll be too successful.” Instead, they’ll say things like “he’ll get the idea that you solve problems through popping a pill,” “I don’t want him thinking that he’s crazy,” etc. In other words, they say things that are easy to empathize with: “I see where you are coming from. I would not want one of my kids getting the idea that pills solve their problem either.” We then discuss this until they run out of steam (it usually takes just a couple of minutes). Ever had someone you’re annoyed at respond with empathy? Granted, that is not a common human response to annoyance. But, it is difficult to stay mad. If I think of resistance as providing the opportunity to understand and to empathize I go a long way to reducing it’s power to upset me and to derail the work.

Reframing: No matter how hostile or regressed a parents resistance may be, a skilled clinician can reframe aspects of it and enhance the chances of establishing or preserving the alliance. Let’s imagine a hostile attack from a parent who has just received a recommendation that her child receive an evaluation for medication: “Here we go. You guys are all the same. Drugs. Drugs Drugs. What?! If I fill a ‘script for my kid you’re over the top for this month for a drug company sponsored golf outing?!” Clinician employing a reframe: “I see how upset this recommendation makes you, and I want to find out more about that in a second. But first, I just want to say that I respect the passion you are displaying in order to try to protect your child. And, I also value the fact that you are being honest with me about your concerns. Should we end up working together I hope I can continue to count on both your passion and your honesty.” As is the case with empathy, most find it difficult to remain upset following a genuinely felt and accurate reframe.

Not Shying Away From Therapeutic Confrontations: Isn’t it tempting to ignore elephants in the living room when working with parents? These elephants can serve our countertransference or seem too powerful to challenge. Let’s take the example of the family who consistently misses appointments; I might enjoy the extra time to do charting or I might be concerned that bringing it up will lead to them dropping out, so I gaze over and around the elephant and compromise my efforts to understand and to heal.

Let me give a sample script of a therapeutic confrontation offered to the parents of a depressed teenage girl who miss many appointments. “Bill, Mary, I’ve come to believe that helping Annie to overcome her depression is a priority for you given how much you love her. Have I understood that correctly? (Most will say yes.) We have a dilemma then don’t we, as it’s been tough for you to get her here regularly. Bill, you’re working lots of overtime to make ends meet because you want to be an honorable husband and father. Mary, you’re taking care of three other kids, your sick mom and Bill’s sick mother, plus managing the household; you do this because you wish to be an effective mom, wife and daughter. So, it’s not like you guys cancel for unimportant reasons. On the other hand, it’s much tougher for the treatment I’m offering Annie to work if she isn’t coming in consistently. So, I’d like to institute a change to support your desire to see her get well. From now on I’d like to have you pay for the next session in advance. Then, if you cancel you would forfeit that money (obvious exceptions would apply). I have found that such a policy can offer helpful support to parents such as yourself who are overextended with important matters.” If they agree, we’re set. If they balk, I’ll insist on a trial period during which if there are additional cancellations I’ll either insist on the policy change, change the treatment approach or refer them to another clinician for a second opinion about the work.

Okay, I’m out of space. In the next edition I’ll describe what I suggest doing when strategies such as these fail. For now, let me wish you well in your work with parents and offer that you may feel free to be in touch with me regarding the content of this column.

David Palmtier is a practicing psychologist, a psychology professor and director of the Psychological Services Center at Marywood University and a member of the Board of Directors of the Pennsylvania Psychological Association. His webpage is www.kidtherapist.com. His email address is palmiter@marywood.edu.