Richard David Brand, MD

Many excellent books and articles address the theoretical considerations involved in the treatment of adolescents and the scope of information required to develop a diagnosis and treatment plan. This paper discusses a formulaic approach to the elements involved in the establishment of a successful treatment environment beginning with the initial phone contact through the first session.

While many of the elements described are universally applicable, they were developed for my specific setting. I practice in an affluent community, perform psychotherapy and medication management for most patients, do not accept patients for pharmacological management alone, and do not accept third party contracts of assignment of benefits. Therefore, my adolescent patients are from more affluent and educated families, which influences the techniques described.

The adolescence epoch is unique, with characteristics distinct from childhood and adulthood that must be contemplated from the outset of therapeutic contact for an effective treatment alliance to develop. Adolescence is a period of intense growth, emotional and sexual plasticity, and the rapid evolution of feelings, moods and behaviors. Your patients will be seeking answers to new questions, developing new roles, struggling with the shape of their new post-childhood reality and becoming impatient to develop an identity. Doing so involves the struggle for independence from their family, creating stress for the patient and others at home, as adolescents, more than other age groups, act out feelings and are exquisitely sensitive to issues of privacy, independence and identity.

One major consideration is confidentiality. Prepubescent children expect parents to be involved in their care and assume you will share information with their parents. Adults understand the mandate of confidentiality without much explanation. Adolescents under the age of 18 will not know the rules and will wonder what you might tell their parents, especially concerning school adjustment, romantic relationships and substance use. The developmental task of adolescence involves moving from the primacy of parental dependence to the world of peers and external role models. This mandates meticulous delineation of your role with regard to what information will and will not be shared with parents.

A related consideration involves the working alliance with the family. Parents often require some support to appreciate the rapidly shifting moods and behaviors of their child without sacrificing the confidentiality of your patient. Therefore, establishing an effective, trusting relationship with the parents at the inception will ensure that the treatment may continue through troublesome periods. It is with these considerations in mind that I offer my formula for the foundation of a therapeutic relationship with a teen-age patient.

The initial contact with an adolescent usually occurs when a parent, generally the mother, calls to ask questions and make an appointment. Some referrals come from sources familiar with your work, such as former patients, colleagues or people who have seen you speak. This group will already know something about you and have specific expectations. Others come from remote sources such as the phone book or physicians who supply your name from a list. This latter group of potential clients is less committed to the referral and may require additional information or reassurance during the initial contact.

The most important factor in making initial contact is availability. It is important to return calls promptly, even if only to say "Hello" and arrange another time to phone back. Among lost referrals, the most common theme is, "Thank you for returning my call, but I've already made an appointment with Dr. X." By the time a parent finally has decided to call, it is frequently because a crisis has developed, and the sense of urgency experienced by a distraught parent demands immediate acknowledgment and attention.

It is critical to spend sufficient time on the phone in order to accomplish several goals. I try to set aside a minimum of 10 minutes to confer by phone. This first contact sets the tone for all future work, and the time involved is well spent. Once the family has explained their problem, they feel relief from the understanding and acceptance you have already imparted to them by phone. In addition, they will feel appreciative for what they realize is an expenditure of time on their behalf, and this factor goes a long way toward establishing a basis of trust. You are experienced by them as having an interest in their problem above other considerations. Because it will be the adolescent patient rather than the parent who will be coming for sessions, the brief time spent with the parent will create a permanent impression and increase the likelihood of their cooperation with the treatment.

Additionally, you may establish that the patient must be seen at once, such as a suicidal child whose parent is in denial and may not recognize the potential danger of waiting a week for an appointment. Or, on the other hand, you may determine that the referral is inappropriate, such as a child with unique problems that require specialized settings. Simply put, looking at your appointment book without attending to the factors surrounding the referral can introduce many problems. Even when the call does not result in an appointment, the time spent will probably have been helpful to the caller and will enhance your reputation as a caring professional.

If the parent has not already given this information, I inquire about the nature of the problem and what prompted the call at this time. Some people may be reluctant to give information and reply that they are calling to make an appointment. They may be reticent about speaking with someone they have not met, or else may feel that they have no right to use up your time and so on. I explain that the reason for inquiring is to determine the urgency of their situation in order to decide when to see them. This is usually sufficient to encourage them to provide the essential information. Most people are willing to speak freely, so this situation concerns itself with those instances where there is an initial hesitancy.

There are gender differences: Mothers are generally less guarded and will report information about their family and their feelings, whereas fathers are often quite businesslike and elect simply to establish the time and location of the appointment. Mothers prefer to know something about the person to whom they are bringing their adolescent, and they will make inquiries designed to detect whether you are the right psychological "fit" for their child. Fathers appear, at least initially, to expect that, as a "professional," you will appreciate the correct approach automatically, or else that one professional is much the same as any other. Fathers, who are generally home less of the time, frequently feel they do not have a sufficient grasp of the problem and all of the details and often feel insecure about discussing things of this nature. While not valid in all families, these observations are pretty consistent.

Additionally, either parent may have feelings of guilt or embarrassment that block open communication. It is important to address these issues right away and to make them feel understood and therefore less fearful about coming in. It is crucial to convey that their feelings and opinions are valued and that they are going to be an important part of the treatment.

Having established the reason for the consultation, the referral source, the appropriateness of the referral and the urgency of the situation, I request that both parents come in with their teen-ager for the first visit. If other family members are directly involved in the presenting problem, I ask that they be present for the initial consultation as well. There is sometimes an unwillingness on the part of one parent to come in (as related by the other), and I have used various methods to overcome this.

Often the reluctant parent would be willing to participate if they felt their contribution would be valued. This resistance occurs often in families where the father has managed, for any number of reasons, to remain an outsider in the family. In those situations where the mother is unable to persuade him to cooperate (or covertly discourages his participation), it is possible to challenge the resistance by phoning the hesitant parent directly and requesting participation.

It is essential to meet both parents and allow them the opportunity to meet you, because it is common for non-involved parents to sabotage treatment when they do not know anything about the work and feel left out. In a face-to-face situation it is easier to persuade a parent to permit your work to go on, albeit reluctantly, even though they may remain unwilling to help actively with the treatment recommendations.

It is often difficult for a parent to relinquish control of their child to a stranger, even a "professional." Some parents are resentful when their child "gets better" during treatment because it makes them feel inadequate as parents and competitive with the therapist. It is therefore a goal during the initial call to form a working relationship with both parents, and this phase of the phone conversation addresses that by emphasizing the importance of their presence. A common error in adolescent work occurs when the therapist aligns with the interest either of the parents or the teen-ager and fails to address the legitimate needs of the other. If the parents are mistrustful, or if the youngster is turned off, the treatment will fail.

Next I suggest appointment times. After a date and time is selected, I explain the directions to my office and mention that if their co-parent or the adolescent wants to do so, they may phone me prior to the appointment. In the event that the parent attempts to use the call as a therapy session, I simply explain that my time is limited and that it would be best to use the remaining minutes to decide on whether and when to schedule an appointment. Finally, I ask for a telephone number where they may be reached immediately prior to the appointment time in the event of an emergency.

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:

. 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 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.)

. 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.

. 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.

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Beginning a therapeutic relationship with an adolescent patient requires an understanding of the family dynamics and the patient's experience of their unique stage of life. In this rapidly evolving population, a thoughtful approach is essential to prevent many of the pitfalls in treating adolescents.

Richard David Brand, MD

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