One of the most common questions I get as a supervisor is what do I do with children and families. For a number of reasons interns get more anxious about this than just about anything else.
There is a lot to be learnt from seeing a whole family, rather than just meeting with a parent or a referred child, however sometimes chaos ensues! The following ideas are based on my own experiences over a dozen years. You need to develop your own style; however this might provide a starting point.
Should I meet with the adults first before meeting with the child?
I invite the immediate family members including children over 4-5 years to the initial assessment. Some clinicians prefer to meet with the adults first. In some cases you may want to arrange a professionals meeting before seeing any family members (e.g., abuse cases). There are costs and benefits of each, so think about the issues, age of the referred child and what you are comfortable with as a clinician. Most of what is written below relates to an initial ‘family session’.
Heading them off at the Pass : Create a ‘Child-Friendly’ culture from the outset.
Children are usually brought to therapy by their parent/carer(s). They may be ambivalent about attending, and sometimes are not informed or are misinformed about the purposes of their attendance (e.g., “we’re going to see the doctor”). In cases where they are told, it may well be in terms of ‘you are the problem’ and so unsurprisingly children need a little warming-up before they can become active customers of therapy.
I will always have at least some pencils or felt-tip pens and lots of paper, and depending on the age of the child may have other toys (e.g., tea-set, dolls, figures, plastic animals, construction toys like wooden blocks/lego, simple puzzles, few books). Think about how the room is set up. Is it sufficiently child-friendly and safe? When children enter the room I usually ask that they sit down for the first part of the assessment, and then can draw or play with the toys “after I’ve found out a little about you all”. The overall guide here is: children need firm and reasonable boundaries and warmth and genuine interest in them. Our job is to provide a structure that meets these two aspects.
My general approach is to ‘meet the person before the problem’ (see Freeman, Epston & Lobovits, 1997). I often introduce this after going through the general clinic setting introductions and confidentiality.
Before we turn our attention to the difficulties that have brought you along today, I’d just like to take a few minutes to get to know you all/as a family.
I will often then draw a three-generation genogram and get the referred young person to help me as much as possible
Can you introduce me to your family?
Who else lives with you?
Are there any other important people to you, like grandparents, aunts or uncles?
Once you know who is around, you want to find out a little about each person, starting with and focusing on the referred child (e.g., school, what like/hate most about school, any friends, what like to do with friends, any school/out of school activities/sports, what like to do at home/with family). It is helpful to find out a little about each of the other family members, main supports for the family, and whether there have been any major events for the family. However, you also want to keep this section to about 10-20 minutes, and you want to keep out of ‘problem-talk’ for the moment (e.g., if they bring up some of the problem issues I will often say
Thanks for raising that, we’ll come back and talk more about that in a minute, for the moment though I just want to find out a little about you all. You were telling me about school…
Once you have found out enough, you can move on to the referral issues.
Thanks for that background. Let’s talk about what has brought you along now.
Who do I talk to first? How do I keep a child interested?
Generally it is good to start with the referred person. It is helpful to explain that:
I want to hear from each of you today and it is likely that you may have different ideas about what has brought you along, and how you would like things to change…most families do.
If you’ve done a reasonable job with the first bit, hopefully the young person will feel able to talk to you. If they think that you are genuinely interested in them and their account of things, then they’re more likely to open up. If they think you’re on Mum/Dad/ teacher’s side, then you may get the silent treatment or maybe worse! Parents need to be in charge, so watch out for inadvertently undermining their authority in your efforts to get the young person on board.
Do I need to talk to children and adults separately?
This depends on the age and the referral issues. With younger children, most of the interview will include their parent or carers with maybe 10 minutes to talk to the child to see if there are any issues they want to discuss with you without others present, as well as to check out risk/ and abuse issues
Is there anything else that is important that you’d like to talk about today?
There are a few questions that I ask all young people who come here – first of all, do you generally feel happy, or sad, or angry, or something else?
Do you have any worries or things that you are frightened of?
Has anybody ever done anything to hurt or harm you in any way, like hitting or slapping hard, or touching you in your privates (pointing to own privates)?
It is good to meet with parents separately also, although in general this can be done at another appointment (when child is at school usually). After seeing the child separately, it is generally fruitful to share some of what has been covered and gain the adults assistance in generalizing therapeutic material to the home domain.
For older children and adolescents you may spend most of the time talking individually with them however it is still important to gain the wider picture from adults as adolescents will tend to give a limited (egocentric) view of the issues. At 16 years young people can be seen without the consent of their parents.