What can I expect when my child begins psychotherapy?

Beginning a course of therapy is often a significant decision for families. It can occur at times when a family may be under a great deal of stress, or experiencing an increase of concern about their child's emotional wellbeing. At other times, families may be feeling entirely unclear about what is going on. Beginning therapy with some knowledge about what one can expect from the therapy can go a long way in assuaging initial feelings of uncertainty for both parents and children. This post will discuss the general process of beginning therapy, what is expected of parents and children, some ways to discuss beginning therapy with your child and finally, the importance of endings.

Psychotherapy with children is very much a process which involves the commitment of the family system. Due to this, it is essential that the first meeting with the therapist is a meeting with parents, caregivers or other key whānau members in the child's world. This allows the family and the therapist to spend time getting to know one another, clarifying the purpose of therapy and discussing expectations openly. Therapy is very rarely a quick fix, and can struggle to be helpful in cases where there are many competing factors which impact the family's ability to attend regular sessions. Sporadic or unpredictable attendance can interrupt the momentum of therapy, slowing down the development of relationship. The consistency of time allows a fundamental sense of stability to form, and speaks to the commitment that both family and therapist make to being regularly present for the child each week. This can go a long way in creating a reassuring atmosphere for anxious, hesitant or defensive children.

Child psychotherapy can involve a great deal of trust, as parents will be expected to support their children to attend sessions one to one with the therapist. It can be quite an unusual experience trusting another adult with your child. The therapist will also rely on the parents to provide emotional support, safety and containment to the child outside of sessions. Therapy itself can stir up difficult emotional experiences for children, and fundamentally requires a safe home base for this to occur within. Furthermore, psychotherapy can challenge existing patterns within families. This means that parents must begin their child's course of treatment with an openness to their own personal change and reflection.

Preparing your child for attending therapy

At times, children indicate clearly that they would like to have someone external to talk to about their emotions, experiences or worries which may have surfaced. Attending therapy appears to have become more normalised in peer groups, and many children may have already had prior experience meeting with a school guidance counsellor or other helping professional. At other times, parents may make a decision on their child's behalf that should see a therapist.

In the first instance, the path to attending the first session may appear a little smoother. In preparation for the parent meeting, it is helpful to talk with your child in a non-confrontational way about what they would like from therapy; what do they imagine therapy might be like? What are they hoping the therapist might help them with? What kind of person do they want the therapist to be? Is there anything they are hesitant about? It is best to put these questions into your own words, or in ways which better reflect your child's level of understanding. Young people may not have clear or complete answers to these questions, though providing an open space for these questions lets your child know you are curious about them, and keen to support them to find the right kind of help.

In the second instance, you may need to find ways to discuss your intentions with your child prior to their attendance. This discussion will need to be tailored to your child's age and developmental stage, to best equip them with the understanding needed to begin. It is best to be transparent with children about the intended purpose of therapy, letting them know it is a safe place to go to where their worries can be explored by playing and/or talking. It is a place where they will be listened to, and that the therapist’s job is to help all kinds of children to feel more settled and safe within themselves. Children are often relieved to hear that therapy is not a test, nor a punishment, that there are no set things that they must do, other than to spend time allowing the therapist to get to know them at their own pace. This can offer some relief for children who are particularly anxious or pressured at the thought of having to talk about difficult things from the outset.

If a child is prone to angry outbursts for example, it might be best to frame therapy as a way to try and better understand where the big and angry feelings might come from. It is essential to avoid the suggestion that therapy is going to "fix" them or make them "better", as children may feel that they have been bad and therefore therapy might be a place where they might get into further trouble. It can be useful to highlight instead that the therapy might be an opportunity for the family to think together about what is going on, and to understand more helpful ways of responding.

Your child may be interested to hear that although their family will be included in the therapy process, that the therapy is a confidential space. If this is not a word your child is familiar with, it may be possible to reframe this concept in a simplified manner.

The assessment phase

In the initial parent meeting, the therapist will spend some time orienting the parents to the therapy process. This begins the assessment phase, in which the therapist takes time to understand the family system; the context the child lives within. The first parent meeting involves making time for introductions, discussing the format of therapy sessions, confidentiality, fees and attendance. Following this, time will be spent exploring the parents current concerns for their child, which informs the aims of treatment. The therapist will then enquire about the child's developmental history, asking pertinent questions about the child's experiences of life to date.

Following this, the child will need to be seen one to one for 4-6 assessment sessions. These will occur weekly at the same time per week. The child will similarly be oriented to the therapy process, discussing the rules and expectations of the playroom. These boundaries are designed to support the child to feel safe to explore (physically and emotionally) during their time in the playroom. Each child utilises the assessment sessions differently, though often as the child becomes more comfortable in the therapeutic relationship, they will find ways to communicate something about what may be troubling them. This communication can happen in words, though more commonly is expressed through the child's play, behaviour and responses to the therapy space.

To end the assessment phase, the parents will attend a parent feedback session in which the therapist can share their observations and offer recommendations about whether or not a course of psychotherapy is indicated. The parents will be invited to reflect upon what they have noticed in the preceding weeks, the challenges which have emerged and any questions which may have arisen over the assessment period. There will be a discussion about what course of therapy the family feel they can reasonably commit to. An analogy I often use relates to the image of cleaning up a house, as it is possible to clean a house in several different ways. One may choose just to tidy the papers and things from dining room table, another may have the time and space to clean the whole dining room, another family may have the resource to comprehensively tidy the entire house. As it is in therapy, each family has the autonomy to choose which of these ‘packages’ is best for them at present.

Beginning a course of therapy

Following the parent feedback session, if it is decided the therapy will continue, the child will resume attending one to one sessions. As a general rule, the child will attend a further 4-6 sessions followed by another parent feedback session. Although it is difficult to predict exactly how many sessions may be needed for each child, a moderate course of therapy is usually approximately 20 one to one sessions with the child.

Children respond to therapy a number of individualised ways. Some children particularly enjoy coming to therapy, while others find attending therapy very difficult. Some children may enjoy it for a time, then find it increasingly challenging to attend as the content becomes more complex. Others may find the beginning stages particularly hard, though over time become more connected to the process. Furthermore, some children may have symptoms which resolve quickly whilst others may develop new, challenging behaviours.

The range of individual responses which arise are central to the therapy work, and are crucial to explore in the parent feedback sessions. Certainly, in the instance that your child finds attending therapy particularly difficult, the therapist will work closely with the parents to identify ways to support the child to continue attending sessions. Whilst it is not the intention of the therapist to upset or distress the child, it is often vitally important to face into any distress which may arise.

Conclusions

This post briefly describes the process of beginning a course of child psychotherapy. It is a process which can be summarised in some general terms, though the specifics of this process are uniquely constructed in response to the family context and presenting difficulties.

Below is a simplified timeline of the assessment process (green) and the beginning weeks of treatment (blue)

For a follow on discussion about the importance of ending therapy, please see my other blog posts.