Managing a ‘Family Session’

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.

Comments

[Yvette Vardy]

I'd be really interested in hearing about ways to handle a session when a child is misbehaving in the room (e.g. throwing things around) when the parents are present, either because the child ignores the parent(s) or because the parent doesn't try to intervene.

[Chris]

Thanks for your comment Yvette. Mark has a part II coming out next week which may answer this question.

Chris

[Mark Donovan]

In response to Yvette's question about a child throwing objects around the room, I had one of my few experience of this (in 15 years of therapy) a month ago with a 7yo boy who upturned table, chairs, and threw pens and his shoes at me as he walked into the room, and kicked me in the shins on the way out - he didn't want to be there! The FAQs posted a couple of weeks ago provide some ideas for this situation. I always try to think about the behaviour within the wider context.

In my situation, the behaviour was part of a wider testing out of whether adults could place limits for the child concerned, and whether these would be consistently maintained. It was important that we as adults (Mum and I) remained calm and let the child know that this behaviour would not mean he could get out of the session earlier. He had been sent home from school on many occasions for similar behaviour, which he experienced as getting his own way. In a different context, it may have been important to terminate the session immediately to provide the message that such behaviour was unacceptable and would not be tolerated. In this situation, future sessions with the child were scheduled for 15-20 minute reviews (for medication mostly). The 'real work' was done through supporting Mum to provide those consistent boundaries and consequences in a loving but firm manner.

For those interested in thinking about the dynamics between parents and young children further, I strongly recommend looking at the Circle of Security approach: http://www.circleofsecurity.org/
The CoS approach provides a family-friendly way of conceptualising the relationship/ attachment issues. One of the 'mantras' of this approach is the following advice (to all parents):
Always be: Bigger, Stronger, Wiser and Kind
Whenever possible: Follow the Child's Need
Whenever necessary: Take Charge
More on the CoS approach in a future Blog...

[Anthony Pisani]

Terrific post. A resource I use a lot to orient people to family interviewing is this one:
Weber, T., McKeever, J. E., & McDaniel, S. H. (1985). A beginner's guide to the problem-oriented first family interview. Family Process, 24(3), 357-364.

Tojny

[Calvin Klein]

thank you1