Passport to Practice

Psychotherapy with Children and Adolescents

By Alice Rubenstein, Ed.D. Independent Practice, Monroe Psychotherapy and Consultation Center

It is estimated that between 17 to 22 percent of children and adolescents suffer from emotional, behavioral, or developmental problems. A meta-analysis of child and adolescent outcome studies conducted between 1952 and 1993 found that 76 to 81 percent of the children and adolescents who received treatment “were better off” than those who did not receive treatment (Tirengel, 1998). One out of five adolescents has a diagnosable mental disorder, and these numbers are on the rise (Dougherty, 1993). As these findings demonstrate, there is a significant need for psychologists who are qualified to provide psychotherapeutic treatment for children and adolescents. However, in the vast majority of cases, in order to access the services of a psychologist in independent practice, children and adolescents must have the cooperation and support of their parents. Therefore, it is critical that parents be made aware of psychologists who are specially trained to treat children and adolescents, have an understanding of the kinds of problems which may indicate that their child or adolescent needs the help of a psychologist, and know what to expect during the course of their child or adolescent’s treatment. In order to access the vast number of children and adolescents in need of their services, psychologist must reach out and educate their parents.

Educate Parents About... How You Can Help

All children go through difficulties in the process of growing up. However, when problems persist for more than a month or two, parents should consider the possibility that their child or adolescent may be in need of a psychologist. Some signs that a child or adolescent is in need of help include disruptive behavior at home or at school, peer problems, learning problems, changes in eating or sleeping habits, or other significant changes in affect or behavior. Explain to parents that you are a psychologist specially trained to treat children and adolescents as well as providing support to parents in helping their child. Let parents know that you will offer them specific recommendations which may include individual, group or family therapy, psychological testing, or a medication evaluation.

Many parents hesitate to seek out a psychologist because they lack an understanding of the process, are afraid that their child’s difficulties will be seen as their fault (that they are “bad” parents), or fear that they will be “shut out” in some way. Parents need to be reassured that you do not look to “blame” or judge them, that you believe that they are doing their very best, and that your goal is to help their child, not judge their parenting. Let parents know that, when it is deemed appropriate and with their permission, you will work collaboratively with their child’s school, physician or other professionals.

Educate Parents About...The Different Modalities You Might Use in Treating Their Child

Describe to parents the different treatment modalities you might use in treating their child or adolescent. If play therapy will be the primary modality, describe what play therapy is and how it works to help children access and express their feelings. Many parents do not understand why their children are “playing” with their therapists. If the child or adolescent will be involved in group therapy, provide an overview of what group therapy is, as well as your reasons for choosing this treatment modality. Similarly, if family therapy is the treatment of choice, explain how family therapy works, who you suggest be included in the family sessions, and what they can expect in these sessions. If, at times, you make use of more than one treatment modality, either concurrently or sequentially, let parents know this at the beginning of their child’s treatment.

Educate Parents About...Your “Special” Relationship with their Child or Adolescent

The basis of any psychotherapeutic relationship is trust. When a parent chooses to bring their child or adolescent to a psychologist, they are entrusting the psychologist with one of the most important people in their lives. Therefore, it is critically important that parents have an understanding of the “special” relationship you will have with their child or adolescent. Explain to parents that, in order to help their child, you must work to establish a safe and trusting relationship with them. Therefore, you cannot tell their parents everything that happens in their child’s sessions. While some parents may find this threatening at first, or fear that you will “take their place” in their child’s life, most parents will be reassured if you also explain that this boundary does not mean that you will not talk to them at all. Rather, it means that unless you have their child’s permission, you will not reveal specific things their child says in his or her sessions.

Educate Parents About...How You Will Communicate With Them

It is important to be clear and specific with parents about how, and in what context, you will review their child’s progress with them. Parents want to understand their children’s problems, and most want to know what they can do to help. Some psychologists meet with parents periodically to review progress, others do so on an as needed basis. Tell parents how you work and encourage them to call you if they feel too far “out of the loop.” Parental support and cooperation with their child’s treatment is essential. If parents do not support and trust the process they may well terminate treatment. Parents should be assured that, as required by law in most states, you will immediately inform them of any serious concerns you may have that their child is in danger of being hurt, hurting him or herself, or hurting someone else.

It is helpful for parents to understand that, most often, the older the child the more sensitive they may be to any contact you may have with their parents. Sometimes, having the child or adolescent present during feedback sessions is necessary to simultaneously maintain trust and keep parents informed of their child’s progress. Each case differs depending on the individual child or adolescent, their age, and the dynamics of their relationship with their parents. It may be necessary to wait until you have begun treatment before telling parents the specific kind of feedback process you will use. It is, however, critically important to encourage parents to contact you if they sense, after a few sessions, that their child is uncomfortable or upset about coming to see you.

Educate Parents About...Preparing Their Child or Adolescent For the First Visit

Often parents do not know how to talk with their child or adolescent about their decision to have them see a psychologist. Providing parents with some guidelines can be quite helpful. While on occasion, a child or adolescent may ask to “see someone,” most often therapy is initiated by the parents. Suggest to parents that they be clear and honest with their child about why they have decided to take them to see a psychologist. With younger children, it is best to wait and tell them about their appointment a few days before it is going to occur. This will reduce the amount of time they are left to possibly become anxious. With older children and adolescents, timing may also depend on their anticipated resistance or the need to consider their schedules before setting up an appointment. Encourage parents to enlist your help if they need assistance in communicating with their child about their first visit. Warn parents that while their child needs to feel safe and comfortable with their psychologist, initial resistance is normal.

Educate Parents About...What to Expect After the First Visit

It is helpful for parents to know what may happen after their child’s first visit. While some children will talk freely about their visit, others, especially adolescents, may say very little. It is important for parents not to push or cross examine their child about their session, but simply listen to whatever their child may choose to tell them. Emphasize to parents that telling their child or adolescent that they don’t have to tell anyone what they talk about with their psychologist can be helpful. Let parents know that it is normal for them to feel “left out” when their child or adolescent does not share what happened in their session with them.

Educate Parents About...Maintaining Their Child’s Trust During the Course of Treatment

As treatment unfolds, most psychologists find that parents’ feedback about their child’s behavior at home is important and helpful. While this feedback may be accessed through direct face-to-face contact, some psychologists mix direct contact with periodic phone communication, while others may utilize the latter almost exclusively. Whichever method you use, it is important that the child or adolescent know that while you will certainly maintain their confidentiality, you will be soliciting feedback from their parents. In some cases, however, especially with adolescents, it may be necessary to refrain from any contact with parents until well into treatment and, in some instances, contact with parents may, by mutual agreement, be totally eliminated. What is critical in all of the above is that the therapist, parents, and the child or adolescent have a mutually agreed upon understanding of the boundaries.

With younger children, especially those that are experiencing school difficulties, it may be necessary and helpful to talk with a child’s teacher(s) or other school personnel. When this is the case, be sure to not only get written permission from the child’s parents, but inform the child or adolescent that you will be talking with specific individuals at their school. Let parents know that in some cases, in order to maintain their child’s trust (particularly with adolescents), you might recommend that their child attend meetings with collateral contacts.

There are numerous factors which will determine the context and frequency of your communication with parents. What parents need to know is that except under specific circumstances, (which you have already reviewed with them), you will not communicate with anyone about their child without their written permission, and that you will discuss with them the basis for any recommendation you may have for collateral contacts.

Educate Parents About...Your Availability After Treatment Has Been Terminated

When it is time for termination, review the reasons for ending treatment and the progress that has been made with the child or adolescent and their parents. Stress to parents that having established a relationship with their child or adolescent, the door remains open if and when they need help again. Stress your availability for short-term interventions. Let parents know that, on occasion, their child or adolescent may initiate wanting to see you again.

Educate Parents About...The Importance of Understanding Their Insurance Coverage

Some psychologists regularly meet with parents before their first session with a child or an adolescent. However, before any meetings take place, be sure that parents have checked with their insurance company regarding their coverage. This is particularly important when working with children or adolescents, as many insurance companies differ in regard to coverage for sessions with parents or on-site meetings with school personnel or other agencies. It may be necessary for you to contact the insurance company directly to be sure what services are and are not covered and specifics as to how bills are to be submitted.

In Conclusion...

There are many more children and adolescents in need of psychotherapeutic interventions than there are psychologists qualified to treat them. Providing parents with information about how to access a psychologist who is trained to work with their child or adolescent, providing them with an understanding of how a psychologist can help, and making sure they are informed and comfortable with treatment process is essential. One of the most effective means of marketing your services to this population is to educate parents about psychotherapy with children and adolescents, and get your name and skills known to your community. To this end, the Divisions of Psychotherapy and Independent Practice have embarked on a joint venture to publish a series of marketing brochures “Talk to Someone Who Can Help.” One of the series, Psychotherapy with Children and Adolescents: A Parent’s Guide is an excellent public information and marketing tool for helping to expand your practice with this population.

This brochure highlights the impact of separation and divorce on both adults and children. The brochure describes ways in which adults and children react to separation and divorce, and gives and their children during this difficult time. Each brochure order is accompanied by a skill building resource list as well as tips for marketing your services.

References

Dougherty, D.M. (1993). Adolescent Health: Reflections on a Report to the U.S. Congress, American Psychologist, 48, 127 141.

Tirengel, J. (1998). Here’s Looking at You Kid: Children, Adolescent, and Psychotherapy Outcome Research. The Los Angeles Psychologist, November/December 1998.

Alice Rubenstein, Ed.D. is Past-President of the Division of Psychotherapy and Co-Director, along with Sandra Haber, Ph.D., of the Brochure Project. Dr. Rubenstein is the recipient of the Division of Psychotherapy Distinguished Psychologist Award (1997) and the Co-Guest Editor of Psychotherapy “Special Issue: Adolescent Treatment: New Frontiers and New Dimensions.” She served as a member of the APA Task Force Adolescent Girls: Strengths and Stresses and has been in independent practice treating individuals, children, couples and families for over 20 years. She can be reached at (716) 586-0410; E-mail: AKR19@aol.com