The most common concern I hear at continuing education workshops regards how to effectively partner with parents in helping their children. In these trainings I review evidence-based strategies for treating the conditions that present most commonly in an outpatient setting. Invariably, clinicians want to discuss how to apply such interventions when important players–most commonly the parents–are either not available or are unwilling to participate. In my previous column (which is available on the Division 42 website) I reviewed strategies for facilitating adherence and responding to resistance in working with parents. In this column I will review what I would recommend doing when these strategies fail or when other system pressures do not allow a clinician to access the resources and procedures necessary to affect cure or symptom management.
In short, I would recommend creating a damage control treatment contract.
I would argue that there are three types of treatment contracts in child clinical work: cure, management and damage control. There are certain child diagnoses that evidence-based interventions are designed to cure (e.g., Oppositional Defiant Disorder, adjustment disorders, single event Post Traumatic Stress Disorder, etc). There are other DSM-IV conditions that our treatments are designed to manage, given that ongoing interventions are required to keep the symptoms at bay throughout childhood (e.g., ADHD, Bipolar Disorder, Schizophrenia,, etc.). Of course, there are other conditions that sometimes are cured and sometimes are managed (e.g., unipolar mood disorders, substance abuse disorders, OCD, etc.). Child clinicians practicing from an evidence-based perspective are aware of these issues and try to communicate the distinctions when collaborating with families on treatment planning. However, what is a clinician to do in instances when limitations in the family (e.g. resistant parents who cannot be brought around) or other systems (e.g. restrictive managed cost companies) severely limit cooperation, resources or access?
Want to author a formula for engineering professional burn out? Create in a psychologist a sense of duty to reach an important goal, but do not allow the psychologist the resources required to reach that goal. Imagine I told myself that, in order to be a good psychologist, I need to bench press 325 pounds 12 times a day. As I cannot get anywhere near that weight, it would not take long for me to tell myself, either consciously or unconsciously, that I stink as a psychologist. Not long afterwards, I would probably start to hate my job and most things that are associated with it. I know that my weightlifting metaphor sounds ridiculous. However, is it any less ridiculous to tell myself that I ought to be able–if I’m a good psychologist–to heal a child suffering from ADHD, ODD, and Dysthymic Disorder when the only intervention I’m allowed is 600 minutes of individual therapy (i.e., 12 50 minute sessions)? How many times does it take for me to for me to participate in this sort of contract and mindset before I start hating what I do?
Moreover, do I not tacitly participate in enabling the family, and related systems, to believe that I ought to be able to pull this when I endeavor to pull it off without qualification? How many times have therapists cooperating with this sort of treatment contract been challenged thusly: “But I’ve been bringing him in for two months now and he is still breaking his curfew!”
Damage control contracts suggest a different path. I can illustrate by offering a composite example. Susan was 16 year-old who presented with symptoms of PTSD. The catalyst for the referral was the release of her former stepfather from prison; he was about to finish the term he had been given for sexually assaulting her. Susan had never had treatment before. But, with this man’s pending release, she was experiencing a great deal of anxiety. The assessment indicated that Susan had been essentially raising herself for the past few years. This was so because her custodial birth mother (Janet), had an untreated bipolar disorder while her current stepfather (Stan) was working two jobs and was often on the road. (Janet shared that she had been diagnosed with bipolar disorder for years, but refused treatment because she enjoyed the euphoria she experienced during the manic phases). Secondary to being unmonitored and undisciplined, Susan was becoming promiscuous and her grades were in sharp decline (she used to be an A-B student but was now in jeopardy of failing the 10th Grade). The diagnostic impression was PTSD, Dysthymic Disorder and Conduct Disorder, Adolescent-Onset Type. Several recommendations were offered to the family: (1) individual cognitive-behavioral therapy for Susan, (2) behaviorally oriented family therapy, (3) an evaluation for pharmacotherapy for Susan, (4) a re-evaluation for Janet’s apparent mood disorder, (5) school consultation with linkage to a home-based behavioral program, and (6) consultation with probation and parole. After a full vetting of the issues over the course of a few sessions, which included the offering of an affordable payment schedule, Janet would only agree to bring Susan in for one session of individual therapy a week.
The therapist then offered a damage control contract saying something like this: “Janet it is my impression that you both love your daughter and are deeply concerned about her. I also believe you understand our recommendations and the reasons for them, but, you either do not agree with them or find them impractical, given other important concerns in your life. So, I am prepared to offer Susan a damage control treatment contract. What that means is that I would like to try to serve as a harbor in the storm for her.
That is, by meeting with her once a week in individual therapy I would try to keep her symptoms from getting worse. Now, don’t get me wrong, it is possible that she could recover, as surprisingly good things can happen in treatment. But, the odds are not high that our work would do more than limit how much she suffers and even that may not happen. If you’re okay with that, I’m ready to go forward.” Janet agreed. Six months later she came in for a consultation and complained that Susan’s grades were still poor even though she had been bringing her in for treatment for six months. The therapist responded thusly: “Janet, it is frustrating to see your daughter hurting in this way isn’t it, especially given that you’ve been brining her in for six months? (Mom agreed.) Hearing your concerns now I can see that I must not have been clear enough when we did treatment planning several months ago. At that time I tried to relay my opinion that the interventions that would stand the best chance of improving Susan’s grades would be family therapy and school consultation. I still believe that. So, if you would like to try family therapy, I’m ready to help to bring that about.”
Reviews of the adult psychotherapy outcome literature suggest that non-specific effects are powerful healing agents (e.g., providing empathic attention, offering a clear schema for change, etc.), and perhaps even more powerful than specific effects (e.g., behavioral activation, accomplishing insight, etc.). Thus, providing a harbor in the storm for children is likely to have value even if (a) individual therapy is not indicated as the treatment of choice or (b) individual therapy is indicated but the youth refuses to complete work in between sessions. However, in order for the clinician to avoid burnout, and to avoid enabling a view that a compromised treatment plan is adequate for bringing about desired healing, calling a spade a spade can be most helpful. I’ve seen too many instances of skilled clinicians becoming burned out because they were handcuffed in what they were allowed to do and they did not alter their treatment contract accordingly.
I have also seen plenty of instances where the offering of a damage control contract motivated a family to take the challenging steps that a therapist was recommending. Another composite case can illustrate the point. Billy was an eight year old child suffering from ODD and an Adjustment Disorder with Depressed Mood, the latter of which seemed to be caused by his getting into trouble so much. The parents (Alice and George) were successful professional people who each worked about 50 hours a week; Alice and George were also raising a 13 year-old and a five year-old. The recommended treatment was parent training, which Alice and George agreed to. At three weeks in the treatment the therapist reviewed how to set up a token system. At six weeks Alice and George had still not set up the token system. During these weeks a comprehensive and empathic model for their obstacles was developed together with strategies for overcoming them. However, they continued to procrastinate. The therapist suggested that it was in no one’s interest to have the therapy morph into a weekly confessional. Instead, the therapist offered the option of a damage control contract, saying something like this: “Alice and George, I believe that you are loving, devoted and dutiful parents. Let’s face it, you have a lot on your plate. Besides Billy, you’re taking care of two other children, the demands of your careers, your household, two ill parents, your friends and your marriage. So, it’s not like you’re sitting around watching too much TV. That said, I think we can agree that this approach is not working and leaves us all with an unsettled feeling each week. How about this, why don’t we consider seeing what value their could be in shifting to a damage control treatment contact…” (explained in a similar fashion as the previous composite case). When they balked the therapist then went on to suggest that there appeared to be three viable choices: (1) start the token system, (2) adopt a damage control treatment contract (CBT was offered as the intervention with a fall back option of play therapy) or (3) seek out a second opinion from another clinician (i.e. whether there might be another evidence-based way to approach the work). This therapeutic confrontation served as the fulcrum that finally helped the parents to overcome their obstacles and to launch the token system.
Damage control contracts can also be used when the family indicates that their resources are limited to what a restrictive managed cost company will cover. Of course, therapists endeavoring to accomplish informed consent describe what would most likely alleviate a child’s symptoms in the quickest time frame possible, without regard to available resources. (Such therapists would rarely conclude: “I’m not going to tell them about indicated treatment X because their insurance will never cover it.”) Then, and only after a family has understood the recommendations, a secondary discussion can occur regarding what is feasible for the family given their priorities. Should recommendations be declined the clinician can speculate about the impact on the prognosis. Some of these discussions could have an endpoint of forging a damage control treatment contract.
The only caveat I would offer regarding damage control treatment contracts is that one needs to guard against becoming closed to the possibility of surprisingly good outcomes. There is a fine line between developing a reasonable damage control treatment contract and creating a self-fulfilling prophecy that establishes an artificially low ceiling for healing.
That’s it for this edition. Please do not hesitate to be in touch regarding this column, past columns or suggestions for future columns. I would enjoy that.
David Palmiter 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.
