The First Session With an Adolescent

When the appointment time arrives, I invite the entire family into the consultation room. Once everyone is seated, I explain that I will speak first with the parents about their concerns and about the history of the child and family and that the child will have the option of entering the conversation or of remaining silent. I explain that I will not ask the adolescent anything "in front of them" and that I will then ask the parents to go back out to the waiting room while I speak with their son or daughter privately. I explain that my conversation with the adolescent will remain absolutely confidential except for the following three items:

Emergency recommendations. I will tell the parents if I perceive any immediate threat to life by suicide, homicide, or any other violent threat to self or others. By this, I do not include the recreational use of drugs and alcohol(Drug information on alcohol) or sexual matters. I ask them to understand that matters of that type will not be revealed. (The matter of how to approach illicit drug use is not addressed in this article.)

The diagnosis. I will tell the parents my opinion about the general level of pathology involved. By this I mean whether there is depression, thought disorder or other diagnosis, and the seriousness or urgency of the problem. I explain that it is rarely possible to establish an absolute diagnosis for an adolescent on one visit because of the rapidly changing ideas and feelings normally found during that period.

The treatment plan. Finally, I will tell the parents whatever their adolescent and I have decided to do about the problem, such as to meet weekly or not at all, and any other plan we come up with, which may involve contact with other family members if warranted. After explaining the above, I ask whether everyone agrees to those guidelines. If they do, I pick up a clipboard and record demographic information. I then ask about the current problem, history (social, medical, developmental, academic, psychiatric, family) and the goals of the parents for the consultation. The general inquiry can lead in many directions, and a full discussion is beyond the scope of this writing.

What requires emphasis, however, is the importance of learning each parent's feelings about their child: What it feels like to deal with them on a day-to-day basis; what they expect from their child that they are not getting; how their dream has been tarnished or shattered; how they have tried to cope with these disturbing discrepancies; and what is their worst fear concerning their child's future.

If it has not been stated, I inquire what the parents like about their child and what they do well. It also helps to find out how the household members interact and whether there are preferred children or special intrafamilial alliances or antagonisms. I also ask the parents whether they are aware of any use of drugs or alcohol, trying to be mindful of the adolescent's reactions to the parents' answers throughout.

Many excellent practitioners first meet with the parents alone in order to obtain information that the parents may not wish to reveal in front of their adolescent. The advantages of this approach must be weighed against the detrimental effect on some adolescents, who will feel they are being treated like children and will distrust the therapist because they perceive an alliance with their parents. This is especially true with older adolescents.

In practice, parents have phoned me afterward to apprise me of additional factors they neglected during the session, providing the best of both approaches while maintaining the principles involved in effecting separation and growth. This approach has been accepted by both parties and, while controversial, has been of benefit in the difficult task of establishing a trusting relationship with the adolescent while keeping the lines of communication open with the parents.

When the relevant areas have been covered, I invite the parents to the waiting room and begin the inquiry with the adolescent. I put down the clipboard (adolescents hate when I take notes as we speak) and make a seemingly offhand comment about the parents that I noticed during the family interview would be in line with the adolescent's feelings. This has the effect of creating an alliance quickly, and the work proceeds. I explain through word or gesture that I am working for them and that it would be to their advantage to tell me, as far as they know it, what they want--from school, family, friends and life, and that, if it is possible, I will try to help them to get it. For example, they may want "my mother off my back." If that is the case, I begin a discussion about the best way to approach her "so that I can be effective in getting this" for them.

This will include their ideas about what their mother will respond to and who she is to them, and it will let me know how intact their reality testing is in terms of the appropriateness of parental responsibility and how well they are able to reason, tolerate frustration, accept authority and compromise. And then I follow the plan we have developed.

If the demands are unreasonable, I explain that one necessary ground rule is that I must at all times retain my credibility "or else your parents will stop bringing you here." This generally serves to moderate the rebellious and dramatic nature of the requests, and it is reassuring to learn that most adolescents understand precisely what is acceptable and what is excessive. They are usually willing to protect my credibility, even while undermining their own. Thus, their reality testing appears intact, and the rebellious behavior or attitude shows itself to be the charade of mock independence that it is. Alternatively, other diagnostic possibilities will become apparent and lead the discussion elsewhere.

Unless there is an immediate danger that demands intervention during the first session, I do not try to accomplish too much and will limit the time spent to what is needed in order to establish the patient's willingness to return, to assist them in some way with the request they have made for my help, and to establish answers for the three areas we agreed earlier to share with the parents. The foremost is to ascertain that suicide is not an immediate danger. Having accomplished this, I invite the parents to rejoin us, and I ask the adolescent whether they would prefer to have me tell the parents about the three areas or do it themselves. They usually elect for me to do it, and I do.

If we have decided to work together and the parents give their consent, I explain several things about the work that everyone has a right to know. First is a clear understanding of the financial responsibilities involved. This involves a frank discussion of the parents' situation to include insurance factors, time-payment plans, late cancellation fees and so on. It is impossible to overemphasize the importance of this discussion at the outset of treatment, especially with an adolescent. This is because the party responsible for the payment is not the patient and may not be able to appreciate the work and the necessity for it, and may use money to sabotage treatment.

Next I explain that I consider it the parents' right to phone me at any time to impart information or to request advice about dealing with difficult situations within the scope of my work. I also explain that I will not maintain secrets from the adolescent and that I will inform them at the next meeting of any communications I have received about them from any source and the nature of the information. However, I must feel free to give his parents "general information" about how to deal with discipline, school matters and so on, while maintaining confidentiality of specific material revealed during sessions.

I also explain that many adolescents will "get worse" during the early phase of treatment because I am supportive of their right to express feelings, including anger, and I encourage them to be aware of and to reveal many feelings that may cause that anger. Further, I explain that I will be helping them to work toward a position of relative independence commensurate with their status as teen-agers, and that initial strivings toward independent functioning involve a period of testing and errors in judgment. I let patient and parents know that they may contact me as needed, but that I retain the right to share with my patient any information I receive about them from third parties, including the parents.

Teen-agers are ambivalent about their new independence and will make decisions designed to assure continued parental involvement. Warning the parents in advance about this will help them in times of stress and will serve to prevent them from losing confidence in the treatment at those times when the teen-ager acts out. They become more tolerant, and this is invaluable to the family in lowering its level of stress.

Development of a good working relationship with the adolescent patient involves challenges unique to that population. The initial telephone contact and first session establish the tone for all future work, and a thoughtful approach will head off many of the pitfalls that can undermine treatment in this very delicate and rapidly evolving population.