ASK VIOLET Summer/Fall 2012
Question: How do you fit this system into a managed care treatment plan—having a limited number of sessions?
Answer: With a limited of sessions I would follow a brief therapy model. This is useful not only for managed care clients, but also for other short term requirements.
- See the situation as “crisis intervention.” Tell the child we only have a few sessions to make things better.
- Look at the number of sessions and plan for what you will do (without expectation that what is planned will happen.) For example, the first session would be used to establish the relationship by getting to know the child, engaging in nonthreatening activities and providing safety for the child. When the therapist is respectful, genuine, congruent and contactful, relationship and safety will be established.
- List the issues that are involved and set priorities and goals. Cut right to the core of the issues and feelings you prioritize. Depending on the age of the child, the therapist can share some of these items with the child, giving the child the choice to decide what he or she wants to work on. Be honest and clear with the child about the reason he or she is having sessions with you. Even a very young child can understand if the therapist uses appropriate developmental language.
- Include parents in some of the sessions if possible. Explain to them the process of your work. Assess the communication level. For example, a child I worked with whose father lost his job may felt he needed to cheer up his parents, reassure himself, and look at the “bright side” of things, thereby totally cutting off his fears and anxieties. Symptoms, such as falling grades and inability to concentrate prompted the parents to seek therapy for the child. In the family session he admitted that he was terrified about what was going to happen to the family. Both parents admitted they hid their own feelings of fear thinking this would be detrimental to the child. As they began to talk to each other, there was great relief and feelings of closeness and the boy’s symptoms gradually eased.
- Remember that therapy is intermittent with children and that each developmental level brings new issues to deal with. Parents need to understand this.
I think that it’s difficult for therapy to be effective in just a few sessions with children who have experienced trauma, but we do the best we can in the time we have.
Ellen, a 9 year old girl, was brought into therapy with me because she refused to talk. She had been molested by a neighbor and was questioned repeatedly by the police and child welfare workers. She eventually refused to speak to them and this generalized to school and somewhat at home. (She would whisper, “Pass the salt.”) I was told all of this by her mother who came with her to our first session. The child was mute though I noticed she continually glanced at the sand trays and miniatures on the shelves. When children stop themselves from talking, they are restricting and inhibiting many aspects of the self. At our time together I asked her to make a scene in the sand and assured her she didn’t have to speak to me unless she wanted to. She made a very crowded zoo with lots of animals bordered by fences and lots of people walking around looking at the animals. She put a bridge at one end and on the bridge she put a duck. When she was done I asked her to nod or shake her head as I articulated what I saw, she said, “This is a busy, crowded zoo,” She nodded. Finally I said, “I see this bridge over here and that this duck is all alone on the bridge. I wonder if it likes the space since everything else is so crowded. Ellen nodded her head vigorously and said, very clearly, “I wish I had my own room.” I restricted my desire to cheer and instead we casually talked about her room, which she shared with two other sisters. This was the first session out of the five sessions I would be seeing her.
We made a list, at the next session, of things that were troubling her. I reminded her that we might not be able to work through all of them. We alternated choices (I chose one, she chose one, and so forth.) My choice was anger. I brought out clay and asked her to pound the clay as she thought of the things that made her mad. She did not tell me what they were but smashed the clay with a rubber mallet with great vigor. With a big smile she asked me if we had time to play the game Connect 4 which she noticed on a shelf.
At the third session she chose the folks that questioned her so much about the molestation. “They made me feel like I did something wrong so I didn’t want to talk to them anymore.” She then drew a rough picture of her molester and I helped her articulate what she wanted to say to him.
At the fourth session I chose the issue of fault. I did a little puppet show about a girl puppet that was attacked by a wolf and how at first she thought she had made it happen, but then the fairy godmother puppet told her it was definitely not her fault. With the next encounter with the wolf, the girl puppet began hitting the wolf till he meekly slinked away.
At our last session she wanted to do another sand tray scene which involved her family having a picnic in the woods among lots of trees.
By this time Ellen was talking freely. She had many concerns that we did not deal with, but I do believe that the work we did was very helpful to her. Actually, a year later her mother brought her in again for a few more sessions and we followed the same process, though this time she made all the choices: more anger, her sisters, etc. Each time we focused on the issue through one of the projective techniques we often use.
Ten year old Adam lost his father to suicide. His parents had been divorced since Adam, the youngest of three children, was a baby. Adam was very close to his dad who was very involved with his life. The parents agreed that it would be beneficial for Adam to live with his dad for awhile, and just prior to the move, the father killed himself. Six months later Adam’s mother brought him into therapy when his behavior began to deteriorate into angry, aggressive outbursts. It is quite common for a parent to bring a child into therapy after a traumatic loss such as this after a few months have gone by and symptoms emerge and accelerate.
The first session took place with mother and son. The mother stated that ever since the father had died, Adam has had difficulties. “Things are getting worse,” she said, “and not better as I thought they would with time.” Mom stated that she had very little time and money for any long term therapy. At this session Adam was quite withdrawn and would not participate until after I asked the mother to go into the waiting room. I then asked Adam to draw a house and tree and person on a single sheet of paper. Adam seemed relieved that he didn’t have to talk to me and worked diligently.
Therapist: Adam, this is really a test, but I’m not using it that way. I’m using it to get to know you better. It tells me some things about you and I would like to check them out with you to see if it’s right since sometimes it is wrong.
Adam: What does it tell you?
Therapist: Well, for one thing, it tells me you keep a lot of things to yourself.
Adam: That’s true—how do you know that?
Therapist: Your house has very small windows and sometimes when somewhat draws windows like that, it could mean you close off a lot of feelings.
Adam: (Showing interest) what else does it tell you?
Therapist: It also might show that you keep in a lot of anger because maybe you don’t know how to get it out. Does that fit for you? The person looks kind of angry to me.
Therapist: See how the house tilting? Maybe you don’t feel very sure about anything right now. And the boy is at this corner, far away from the house. Maybe you don’t know where you belong. Adam: (Very low voice) that’s right. The therapist noticed tears in Adam’s eyes and gently told him that we would try to work these things out together in the sessions. She wrote her findings on the back of the paper and read them back to him. Adam listened intently. We had some time left and agreed to end the session with a game. The relationship appeared to be taking hold.
At the second session I asked Adam to make his family of clay. Adam fashioned his two sisters and his mother. When asked to include his father, he said, “He’s not here anymore.” I quickly made a rough figure and said, “This is your father. He’ll be over here.” I placed the figure at the far corner of the clay board.
Therapist: I would like you to say something to each person.
Adam: (To older sister): You don’t care anything about me. You’re always off with your friends. (To younger sister) I wish you wouldn’t tease me so much. (To mother) I wish you didn’t have to work so much and could be home more.
Therapist: Now say something to your father.
Adam: I don’t want to.
Therapist: O.K., You don’t have to. Adam, sometimes when a parent commits suicide, kids blame themselves and are ashamed to tell anyone. I wonder if that’s true for you.
Adam: Other kids feel that way?
Therapist: Yes, they are very common feelings.
Adam: I don’t know what I did, but I was supposed to move in with him and then he went and killed himself. I thought he was glad I was coming. I don’t want anyone to know it was because of me.
Therapist: It’s hard for you to feel those things. I’m sorry. No wonder you keep things to yourself.
Adam nodded and closed down—broke contact. This showed in his drooped body posture, and his decreased energy. I suggested we stop talking and play Connect Four (children love this game.) Adam visibly brightened and took down the game with renewed energy. I told him that his mother would be joining us at the next session.
At the third session with the mother present, I asked Adam and his Mom to draw something that made them feel angry. Adam watched as his mother drew and finally began on his own picture. The mother drew an incident that had happened at work and talked a little about it.
Adam: I didn’t do what you asked me to. I just drew my family.
Therapist: OK. I notice that you didn’t draw your father. Just make a little circle here in the corner for him. So tell each person something that makes you angry or you don’t like that they do, like you did with the clay. You don’t have to say the same things if you don’t want to.
Adam complied but again refused to talk to the father circle.
Therapist: (To mother): I wonder if you would be willing to say something to your ex-husband over here. It’s very hard for Adam to do it. Is there anything you would like to tell him?
Adam’s Mom immediately began to express intense anger at him for killing himself, causing so much hurt and pain to his children, especially to Adam, and leaving her solely responsible for the three children.
Adam began to cry and said he was angry too, and he was sure it was his fault that his father killed himself. Adam’s mother was astonished and emphatically assured Adam that this was not the case. “Your Dad had a lot of financial problems and he was depressed about it and didn’t know what to do. It just got too much for him. He loved you very much!” Adam continued to cry as his mother embraced him.
I suggested that Adam draw a picture of something he and his Dad enjoyed doing together. Adam drew a picture of a swimming pool and talked about how much fun they used to have swimming together. Then he asked if he could do a sand tray scene, and proceeded to make a graveyard scene announcing that one of the graves belonged to his father.
Therapist: Adam, I would like you to talk to your father’s grave and to your father now.
Adam: Dad, I hope you are happy where you are. I miss you a lot. I’m sorry things were rough for you.
Therapist: Could you tell him you love him?
Adam: I love you Dad. (long pause). Goodbye. (To therapist) Do we have time to play a game?
Adam and I had one more session together. His mother was unable to attend and sent a note saying that he was now behaving appropriately and she was very relieved.
I asked Adam what he would like to do at this last session, and he opted for clay. He made a pizza with various things on it. He said his Dad’s birthday was coming up and he knew his Dad loved pizza. “This is better than a birthday cake,” he said.
This work took five sessions. The issue of responsibility for his father’s death appeared to be dispensed with quickly. I called Adam’s Mom to tell her that Adam had worked on the loss of his father at his particular developmental level but that deeper feelings might emerge at a later time, involving issues that Adam did not have the self-support to deal with now. I told her that how he was functioning in his life now and in the future was the best measurement for whether or not he needed further therapeutic work.