In the Room

Questions with a Punch: Your Favourite Question

As a therapist we develop our own repertoire of high-impact questions. Such questions open up territory in clients’ lives in powerful ways.

Much of my work in a child and adolescent mental health context requires that I chart back into a child’s developmental history, gain a sense of the child’s underlying temperament or emerging personality, and become aware of significant events in the family’s history including mental health issues and family scripts (Byng-Hall, 1985). After completing a three generation family tree, I find the following question allows me to respectfully approach all three of these areas. Hat tip Evril Silver for this one.

Of all the people in your family (referring to the genogram), who does this child remind you of the most and why?

I have always found answers to this question informative. Sometimes I need to ask the question without the child in the room, as well as with the child present. Sadly many mothers tell me that their child reminds them of an abusive ex-partner. However even in this instance we are then able to move onto exploring ways in which the child is just a child, rather than the parent’s representation of the ex-partner (Fraiberg, 1975). The parent is then more able to take charge when necessary, rather than stepping around the issue of control to avoid feared conflict (Marvin et al, 2002).

The question also allows easy entry into discussion of family mental health issues – often the parent’s concerns for their child are linked back to difficulties experienced by other family members (e.g., schizophrenia). Again, once space is opened up for exploration of such issues, parents are often able to revise some of their perceptions and concerns (family scripts). On occasions when the question is asked with both parents present, marital conflicts may surface where it becomes apparent that one parent ‘blames’ the other for their child’s behaviour. Progress can be made here by addressing such implicitly-held beliefs openly. There are many other benefits, including of course discovering possible genetic influences.

So what is your tried and tested question? Please share it with the readership of this Blog…

Mark

Difficult Situations with Children and Families: Mark's FAQ

Some useful ideas on what to do and say in those difficult situations with children and families. More from our guest blogger Mark Donovan.

Children misbehave in session

Ideally you want the parent or carer to respond and set limits for their children, as this provides useful information about how they manage misbehaviour and set boundaries. It can be helpful at this point to say.

Please feel free to do what you do at home.

Please feel free to do what you normally do when they ….

You may, however, need to intervene if the child is doing something potentially dangerous. I will often use this as an opportunity to explain:

I can’t let you climb on the table/chair in case you hurt yourself, please get down

Then maybe redirect towards toys etc. Your directions to the child need to be firm but fair.

A child gets too physically close (sits on your lap etc.)

Again this is useful information about the child’s knowledge of social boundaries and/or ability to inhibit impulses. I usually remind the child: You don’t know me well enough to sit on my lap/hug me. Then redirect so it isn’t received as a punitive comment. Everyone in the family starts arguing or talking at once More useful information! Try to move from the particular content level to the general process level.

Is what is happening right now a good example of what happens at home?

I noticed that everyone wanted to get their point across – did you feel listened to when you did this?

What do you think might be happening?

What happens at home when…

How to Talk to Adolescents

Here is a great article on interviewing adolescents in Contemporary Pediatrics.  Although it is written for doctors, its is full of good questions to ask.  It provides a structured psychosocial screen and includes examples of useful and not so useful ways to ask your questions.  Hat tip Mark Donovan.

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.