Meeting the Parents


Most private practice cases start with a phone call. On the line, typically, is the child's mother, driven to seek help by her child's or her own distress, yet hesitant to leap into the unfamiliar world of psychiatry. In asking for a summary of the current problem and its urgency, I also garner impressions about the parent: Is she coherent? Is she anxious? Is she allied with her spouse in the decision to seek assistance? The tone of the initial phone contact is crucial, as it raises expectations in the parent which often influence the ensuing therapist-parent relationship. The parent gets an idea of the methodical, unpressured manner in which the assessment will be conducted. I also outline the structure of the consultation?cost, frequency, approximate number of sessions?and insist that both parents attend the first meeting.

The face-to-face part of the assessment begins with the gathering of essential diagnostic data, such as a description and history of the current concerns, developmental and medical history, marital and family history, and state of the family structure. I ask the parents to describe the child's typical day. Along the way, I observe how the parents interact with one another and assess whether their behavior might factor into their child's problems. I also try to get a sense of their attitude toward their child, their capacity to introspect and their willingness to consider my initial observations.

Gurwitt, who is in a private practice specializing in adult and child psychiatry and psychoanalysis, suggests asking the parents toward the end of the evaluation session their theory of their child's troubles (private communication, 1998). This "team approach" strengthens the ensuing therapeutic alliance and promotes the parents' own thoughtfulness about causation.

I attempt to conduct the data-gathering phase of the assessment in chronological order, commencing with pregnancy, labor and delivery and proceeding to the present. I obtain a similar chronological rundown of the child's symptoms. However, the flow of the interview frequently becomes nonlinear, as parental concerns or questions lead to unexpected, and often fruitful, paths of exploration. Sammy's mother recalled with some emotion the day she and Sammy were stringing a bead necklace. Sammy had become agitated, discarding one bead after another. He had asked desperately, "How can I pick the right bead?"

I interrupted the data-gathering process to focus on this anecdote. When asked how she had handled this upsetting moment, Sammy's mother responded that she had immediately stopped the activity and started to read to him until he calmed down. With further exploration, I learned that this was her usual way of dealing with emotional turmoil. She could not tolerate strong affects and tried to distract Sammy whenever he was in distress. We discussed her early history as it related to affect tolerance. Both parents agreed that the mother's strategy, while meant to comfort, might in the long term make it difficult for Sammy to deal with emotional discomfort. The anecdote led to other questions: What conflicts, anxieties and imaginings did the act of choosing bring up in this child? Might he have a neurocognitive burden, such as impulsivity or an obsessional state, that affects the act of choosing? The entire interchange, though brief, proved to be extremely informative.

Many of my assessments include individual meetings with each parent in the knowledge that certain information is more freely divulged in private. This is where I tend to hear about marital discord, family secrets or developmental burdens of each spouse. In Sammy's case, for instance, I felt that issues surrounding adoption, infertility, birth defects and the Holocaust warranted an individual session for each parent.

Once a decision has been reached to have me meet with their child, the parents and I discuss how they can help the youngster comprehend the purpose of seeing a therapist. Typically, I suggest choosing one of the child's concerns as a reason for the visit. Sammy's nighttime fears had kept him from having a much desired sleepover at a friend's house. His parents told him of their meeting with a "feelings doctor," and that I was curious about this problem and thought I might be able to help.

Meeting the Child


On the basis of the initial parent interview, I occasionally refer an acutely and severely ill child for immediate assessment in a hospital setting or by a clinic team. In most cases, however, I arrange to see the child to gather further information about the seriousness of the problem and to decide on appropriate intervention.

 

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