Time-Limited, Intermittent Therapy With Children And Families

Thomas Kreilkamp

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781317736691
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

This book describes an approach to short-term therapy with children and families that has been developed at a health maintenance organization, the Harvard Community Health Plan (HCHP). First published in 1989. Routledge is an imprint of Taylor & Francis, an informa company.

1

The System Within Which We Work

I will begin by describing the setting within which our work is done; and I begin here because the setting within which child therapy occurs is crucial to the question of how the therapy is done. This view, of the importance of setting or context, is perhaps not central in the field, but it needs to become more accepted, and one of the tacit arguments throughout this book will be that context is always important. Many therapists will recognize that context is important in the discussions of symptoms; most therapists will acknowledge that attention needs to be paid to context in considering a patient. Such questions as where the patient lives and what role his symptom plays in the groups he is part of are not unusual. But as clinicians we need also to attend to the importance of our own settings, the contexts provided for us by the workplace in which we do our work.

THE TREATMENT SETTING

Let me briefly describe our setting. We are a growing health maintenance organization in Boston with many centers ranging in size from roughly 10,000 to about 60,000 members. The one I work in is in Cambridge and has about 40,000 members. Each center has its own mental health department composed of individuals from varying backgrounds, usually including—as ours does—psychiatrists, psychologists, social workers, and psychiatric nurses. There are often trainees as well, from any of a number of disciplines, though our training program is small.

I will be focusing on the work done by those of us in the child mental health portion of the larger mental health department. There are three or four of us, none full time, although this number may vary somewhat. Referrals come to us usually from the pediatrics department; a pediatrician may initially suggest the referral, or the request may originate with the family, but either way, the pediatrician fills out a form and sends it to us. Most referrals originate around a particular child who is the identified patient, although typically when we initially see a child we see his or her family as well, including particularly the caretakers, whoever they may be.

New patients are assigned by a staff person who books appointments, answers the phone, and handles routine requests for information. Ordinarily she will assign a new patient to the provider who has the next available opening; each provider is assigned some fixed number of new patients each week, the number depending on whether the provider is full time or part time. Typically a half-time person will see two new patients a week, a full-time person four, although this number varies depending on other factors (amount of administrative work, other kinds of clinical work such as running groups, etc.). The flow of new patients is unceasing and requires no intervention on our part; that is, we do not need to recruit new patients. The reasons for this include a generally accepting attitude in Boston about seeing a shrink (as the children will typically refer to the process), but important as well are the ease of access (in our institution), the cost (only $3 for each visit, up to a maximum of 10 in a calendar year),¹ the convenience (people who belong to our health plan typically do not live very far away, so that getting into our offices is not usually difficult), and the already existing institutional transference (or whatever the patients’ relatively favorable views of our system should be called).

In our setting, children are brought in by their caretakers to see pediatricians whenever there is a problem the caretaker wants help with, and thus the children we therapists see are accustomed to coming into our building for medical attention. Very few children come to see a therapist before they have seen a pediatrician (the system is set up so that having a relationship with a primary care provider—a pediatrician or an internist—is a prerequisite for seeing someone in mental health). Occasionally a family joins the health plan and then immediately requires mental health attention before they have had a chance to begin seeing other doctors, but this is uncommon. Thus, most of the children we therapists see have a relationship with other providers in our building, and in a sense they have a relationship with the building, with the setting in which we practice. Similarly, their parents know the building and are accustomed—more than the children, in fact—to coming to our setting for help. Children, certainly, may experience their visits to a pediatrician as painful, especially when they are given a shot! But parents nearly always experience pediatric attention as helpful. (If they consistently do not, they of course may leave the Plan.)

This creates an a priori positive transference, to use language which is conventional in our field. Perhaps it should be called an institutional transference; at any rate, that is the phrase we often use.² Thus, even before we begin seeing a child, we have something in our favor. We are seeing people—conventionally, each of us sees a child with his or her family, or at least with the primary caretakers—who are accustomed to coming to our setting for help.

But there are other factors in our setting which enhance our role. For example, there is the fact that there are few institutional barriers to access to our services. Anyone may see a mental health provider by making a request to a primary care provider. The pediatricians work closely with us and recommend us to their patients, and thus they are influential in helping us start off on the right foot with the patients. We see many children before their problems are very severe, although not every child with obvious problems will be brought to see us by the parents, since parents may resist admitting that there is a problem. But compared with many settings in which child therapists work, our setting brings us a large number of children and families in the early stages of the development of a problem. This makes intervention vastly easier.

Thus, care is provided within a system that involves multiple providers, all of them working in the same organization. This system of care has an impact on the patient whether or not the various providers involved in a given case meet face to face to discuss the case. What constitutes this system from the point of view of the patient?³

What seems to be most important is the fact that so much of the patient’s health care is organized under one roof. In practical terms, this means that in our Center, which has two floors, a patient may come in to see an eye doctor and run into the child mental health clinician, whom he has not seen for a while. Similarly, a parent who is referred by a pediatrician to child mental health can come to the same building that he and his children are used to coming to; the child is coming to a familiar place; if there are siblings, they can wait in a child care room until the others are finished with their appointment.

The physical organization of our Center also affects the providers. They can run into one another in the hallways and touch base, either briefly if the encounter occurs where patients are numerous and conversation must be restricted, or in a more detailed way if the encounter is in an area where there are no patients.

But the most important effect of our all being under the same roof is that it dramatically changes the nature of the barrier that ordinarily exists between most people and consultation with a child or family therapist. The whole encounter is made less weighty, less a serious life event; it becomes more like leaning over the back fence to consult with a neighbor who happens to be a flower expert about what is going wrong with the roses. This is an exaggerated comparison. Families are still worried when they come in to see us; children are still resistant to the consultation; and a substantial number of people—we suspect, though we have no data on this—still avoid coming anywhere near a mental health provider. But the encounter between us and the patients occurs in a different context in our setting than it would in most other settings.

To take another example, when a high school student can walk down the hall to see a guidance counselor, the likelihood of his doing so is greater than if he has to make an appointment to go to another part of the city. There still may be substantial resistance, but the ease of access is improved. And if the teacher comes to the guidance counselor and reports a concern about a student, the counselor can reach out to the student in a variety of ways. Similarly, if a pediatrician comes to us to report a concern, we can reach out by making a phone call, once the pediatrician has told the family to expect a call. The patient may still refuse to come in, but the sheer fact that this kind of arrangement is possible—not common, not routine, but possible—changes the nature of the system within which the care is being provided from that which obtains in the larger private practice sector of the city.

Thus, we have entrée into the family lives of our patients by virtue of their coming to us for medical care. The pediatrician, after establishing some leverage with the family based on months or years of providing reliable care, can suggest to the family that they come to see us; or the pediatric clinician can call us and ask us to call the family, having alerted the family that this would happen. Of course, ultimately everything is up to the family. We do not see them if they do not want to be seen. They have to get themselves to their appointments. But our group practice and our charting system, which keeps notes on each patient, together provide a degree of knowledge of each family not easily come by in many other settings.

The chart is useful in many ways, since it documents all encounters (including some phone calls made by the patient to our system) that have occurred between this patient and our system. If the patient has seen other providers (doctors, nurses, therapists, etc.), this information is in the chart. So we find out quickly if the person we are seeing has consulted other mental health people at our center in the past. This of course is not an exhaustive record; any contacts the patient has had outside of our system are not in this record unless the patient has asked or allowed the doctor to put them there. Children’s charts often have such outside information, from schools, from testing sessions which have occurred, from previous encounters with any of a number of other agencies. But the fact that such information is not there does not mean that it does not exist, and part of any initial evaluation includes inquiring about the other relevant sources of information.

But the principal use of the chart is to allow and encourage consultation among those of us who work at our center. When we see that someone else has known this family, someone besides the pediatrician, we can consult. I am most likely to do this when the patient has seen one of my mental health colleagues, and in those cases, such consultation is usually quite useful.

The chart also provides a convenient way to communicate back to the referring provider. Minimally, the referring provider will know that I have seen a patient and that an evaluation and intervention are happening. More may be learned if there is more detail in the note, and if the provider has time to read it carefully. In either case, if he has particular concerns, he can call or stop me in the hall and inquire further.

Probably the most important aspect of the way in which the system within which we practice influences the care we provide is connected to our knowledge that the patient usually will not vanish. The patient will stop a piece of short-term work with us but will return to the Center to see the pediatrician, and the pediatrician in turn will report to us if things are not going well (or occasionally, will even report when things are going well!). This is not to pretend that no one gets lost in this system. Our system is still mainly set up for families who can manage to get themselves into our Center for appointments, which are scheduled strictly by the clock. We have almost no drop-in capacity, and if a patient mixes up the day of the appointment, that creates problems. When the patient comes late, that creates problems. We cannot usually reschedule a patient tomorrow who does not come for his appointment today, and from the point of view of the patient, that is unfortunate. And we seldom can go after people who do not come in; we can make phone calls, but we do almost no home visits, and no seeking out of people on the streets (as a dedicated teenage counselor working for a citywide program might do). So there are certainly a number of people with difficulties in living who are not served well by our system. But there are a larger number who are served well.

FORMS OF INTERVENTION

Given that each clinician sees new patients each week—whatever the exact number of clinical hours in our week, they soon become filled with patients—how do we proceed? One immense difference between our setting and the ones most of us trained in is our current lack of the sense of leisure we usually felt in training to take our time collecting information about whatever the problem was. Many training settings presuppose a rather relaxed calendar, in which there are always more days and weeks if necessary. Our setting feels more like an emergency room, where the main imperative is prompt action, although most of the patients we see are not in acute crisis, and even the ones who are usually are not in mortal danger. Adapting to this unceasing flow of new patients is not always easy, but there are important stages in the development of attitudes (the clinician’s attitudes) that make this adaptation happen.

First, the clinician needs to see that working with a child and a family begins from the very first contact, and that the work is not neatly broken down into a period of evaluation followed by a period of treatment. Furthermore, the treatment—whatever it may be—must be seen as diagnostically relevant. For example, one may elect to focus on some issue in a series of sessions (between two and six, typically) and use the patient’s response to that intervention as an index of the appropriateness of more interventions. In our setting, research has shown that the average number of sessions per patient in a calendar year is five. However, some patients only come in once or twice (perhaps because their presenting problem has already improved before their first appointment, perhaps because they are not very eager for treatment in the first place, or for other reasons). Some come in for more than 20 visits in a given year. In my own practice, there are some people I see once a month, some every other week, and many others I see for a brief period of intensive work around a crisis. With some families, such brief interventions may occur more than once in a given year.

Some people and some families use therapy well and some do not, but it is hard to assess this without trying something with them. The fact that the family does not respond now to what I try with them does not mean that they would not respond to some other therapist, or that they would not respond at some later time when they’re more ready for whatever intervention I tried. But if they do respond, then that is evidence that further attempts would be useful, on later occasions, when and if other problems arise.

We often refer to doing a short-term piece of work, and what we mean is that we work on some limited problem for a series of sessions and then stop regular meetings, leaving the patient to work through on his own that which has been done in the therapy. Such working through is always imperative, in all forms of therapy, and we have discovered that when they are motivated, patients can do some portion of this internal working-through process without regular meetings with their therapist. Thus, a short-term piece of work is made possible when the patient can assimilate therapy and when he knows he can return for further help when he encounters a problem.

What forms of intervention are possible? The typical distinction made in the field of therapy is between supportive and insight-oriented therapy. This distinction is not totally irrelevant to the work we do, but it is not the most useful one available, because most of what we do, when it is positive, is experienced by the patient as supportive. So any positive contact with a patient is supportive at some level. Furthermore, it remains unclear to what extent insight contributes to change, or how it contributes. There is no question that people change, but there are many questions about the role of insight—as defined within orthodox psychotherapeutic approaches—in that process. Most of our patients come to us wanting some change in their lives, and this often seems appropriate to us. We do not tell them that change is a mere epiphenomenon, not worthy of our attention, merely behavioral, mere surface. Rather, we encourage them to think that this is a realistic expectation and hope, and necessarily our efforts are oriented toward trying to produce some change. (The work of Jay Haley, and his analysis of the work of Milton Erickson, are particularly relevant here.)

THE PEDIATRICIAN’S REFERRAL

Intervention, as I have said, begins at the beginning, and the simplest form perhaps involves the pediatrician agreeing with the parents that something needs to be done. This means that the pediatrician is legitimizing the parents’ concern, and agreeing with their point of view, at least to some degree (assuming they requested help). For some parents, this already is helpful; they may experience being sent to a specialist (i.e., the child mental health professional) as a form of being taken seriously. This phenomenon can be a problem in the medical world; the desire of many patients to see a specialist, and their sense that nothing really is happening until they see a specialist, may not be constructive in all cases, but sometimes it works to our advantage. Our setting is a medical setting, our referrals come from medical doctors, and whether we like it or not, patients come to us in a setting where we are seen as specialists. This works to our advantage when the patient feels that help is already occurring just in the very process of referral to a “specialist.”

Not all families experience the referral to us in this way. There are some who feel the pediatrician is making too much of what is in their view a trivial problem. They may resist the referral and not come until the pediatrician has suggested it several times, or until the problem has become much worse. Pediatricians often consult with us about such situations, although there is seldom anything we can do directly to encourage such patients to come in and see us. But in our setting, we know when such situations occur. The notes in the chart clarify the process that has led to the presence in our office of a particular person or family. This is often invaluable information.

Some parents come in seeking long-term therapy for their children. But for others, the idea of such therapy is frightening. If the therapy is open-ended, the parents may fear that it will go on forever. There...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Preface
• Acknowledgments
• 1. The System Within Which We Work
• 2. The Importance of Action
• 3. Our Work as Consultation
• 4. Guiding Points of View
• 5. Practical Applications
• 6. Containing Feelings
• 7. Family Dynamics
• 8. More Practical Applications
• 9. Conclusions
• Bibliography
• Index