Monday, July 25, 2011

An introduction to how I work

Some of you have expressed interest in my work as a psychologist, so this week's posts will be about that. Of course, my thought processes bleed into my writing, so Wednesday's post will touch on that intersection, but for today ...

For those of you who don't know, I'm a child psychologist. (See this post if you want to know the details of my education and training.) I have worked with kids of all ages, from infancy to late adolescence, but about ten years ago, while I was still in training, I began to specialize in early childhood. Most of my clients are under the age of six.

Kids are usually referred to me because of concerns about disruptive behavior (noncompliance, defiance, and aggression), anxiety (selective mutism, specific phobias, separation anxiety), and common behavioral problems such as sleep, toilet training, and feeding issues.

I think the most common question people have is: what exactly do I do behind that do not disturb sign hanging on my office door? Do I have some kind of magic touch with kids?

Can I fix them?

Well. The easy answer is no, but I also believe that question is the wrong one to ask.

Here's a simple description of how I work:

Through assessment and observation, I develop a sort of working model of what's causing problems for my client, and in collaboration with that client (or, usually, the client's parents), I construct a plan for intervention.

Here's an example of one of those working models. The reason five-year-old Johnny has been brought to see me is in the center circle.

The boxes around the circle are what I think are the causes of the problem. Now, if you thought the above was a pretty good model of what was going on, how would you spend that precious (and expensive) time in the therapy room? You pretty much only get 50 minutes a week. Who would be there? The kid? The parents? Both? What would you talk about? What would you do?

A while back, Stephsco asked a related question: "Do you use art therapy in your work with children?"

The answer is no, not really. There are a few reasons why. The simplest is that I just wasn't trained that way. Sure, I use drawing and playdough and stuff like that to get to know a kid, build rapport, and observe things like cognitive organization, mood, imagination, activity level, attention span, and social reciprocity. But I don't ever read too much into what a kid creates apart from judging its developmental appropriateness/typicality in terms of content and theme. I'm not confident in the research evidence about more projective interpretations, or in my own ability to translate that into helpful information. I'll leave that to professionals who have that training.

But also, if you look at all those boxes up there, notice how many of them involve Johnny's parents? If I work individually with Johnny, it's going to be fun. Johnny will enjoy himself, and he'll want to come back to see me. I'm friendly, goofy, attentive, and I have an office FULL of toys. However ... I'm not sure that's going to make a big difference in Johnny's life, at least, not the kind of difference it would make if his mom and dad can get on the same page and create a home environment that makes it possible for a sensitive, intense, tricky-to-parent kid like Johnny to thrive.

So I keep my therapy sessions tightly focused on the items in the boxes. With this particular (imaginary) client, I would:
  1. Work with both parents on co-parenting and discuss whatever issues are getting in the way of that.
  2. Explore the parents' understanding of Johnny's behaviors, including what's appropriate for his age, but also WHY he's doing what he's doing.
  3. Help his parents reframe/re-interpret any thoughts they are having about Johnny (and his behavior) that are getting in the way of them being able to respond to him in ways that help him improve his behavior.
  4. Work intensely to help them repair and maintain loving emotional bonds with Johnny, including specific types of play and a focus on noticing when Johnny is obeying (and doing other great stuff)
  5. Work with them to set consistent behavioral rules, consistent consequences, and to follow through every single time (which isn't really humanly possible, but maybe we can get close)
  6. Work with them to respond to Johnny's anger as opportunities for closeness and teaching, in ways that validate his experience (while setting appropriate limits on behavior) and help him calm down more quickly
All along the way, I deal with whatever barriers come up that keep the parents from being able to make all those changes we're discussing. Because parents are people too, with stresses, heartbreaks, memories, traumas, wishes, and hopes of their own. If those aren't acknowledged, leveraged, or addressed, we're not going to reach our goal of helping Johnny do what his parents say.

If I worked with older kids, I might do more individual stuff with them, but with the 0-6 crowd, most of my sessions are with either parent-child together or with only the parents. Because, once I make a map of what's causing the problem, that's the thing that usually makes the most sense (and note--I design my treatment plans for each unique client, so there are always exceptions and sometimes I do see kids individually ... it all depends on what's in those boxes).

Any questions for me?

Be sure to check out Lydia's Medical Monday post, as well as Laura's Mental Health Monday post!


  1. Very informative post. I often wanted to put my children in counseling, just for the experience, but I have pretty normal children that don't cause me problems.

  2. I am writing a book where the MC goes to a support group for families who have experienced a loved one's suicide. I would LOVE if you could do a post on the typical structure of meetings like that. I would like to visit one in person but I don't want to intrude unnecessarily into other peoples grief.

  3. Thank you for this interesting post. In the hypothetical case you used, the one thing that stood out to me was the fact that the parents "don't always notice" when their son is compliant. Made me think of something I was taught in psych class many moons ago, and that's that children prefer negative reinforcement to being ignored.

    OK, you asked for questions. Do you work with any autistic children? Can therapy help them relate to other people?

  4. I was intrigued (and surprised) by how much your description of the process resembled what happened when we brought dog trainers to our home for obedience training for our dog. We were surprised to discover that they spent their time training us, the owners. I guess behavior is behavior -- in children, adults,and dogs.

  5. Wow, Sarah. This absolutely fascinates me! (I grew up wanting to be a psychologist--then got to college and chickened out after one psych class.) It sounds like you have a really great method because I would think someone's difficulties don't always just stem from themselves, but from outside sources as well. Including parents. :)

  6. I loved this post. I wanted to go into child psychology too. But my father frowned against it. He wanted me to get a real job. Okay, I can understand why he didn't want me to be an archaeologist (which only last until I took a class in the subject), but psychology has tons of benefits (like for my writing).

  7. How long does therapy usually take to get Johnny back on track? Not to mention instill understanding and change behavior in the parents? Too bad parenting isn't a course everyone takes once they're IT. I'm guessing this sort of thing could save a lot of marriages, as well as help Johnny.

  8. This is fascinating, Sarah. But I must say, what you do sounds really, REALLY complicated and difficult to me. Kudos to you for using your skills and making a difference.

  9. very cool. I love how you focus on the parents in this situation--even ole untrained me can see that's the right approach. What interesting (and ultimately beneficial!) work you do~ :o) <3

  10. *takes notes* Hey free therapy!!! Kidding. Sort of. LOL.

    Seriously though, I appreciate you sharing how you approach an issue. I was so close to pursuing psych, I'm always intrigued.

  11. Sarah, this is my favorite line: "I'm not sure that's going to make a big difference in Johnny's life, at least, not the kind of difference it would make if his mom and dad can get on the same page and create a home environment that makes it possible for a sensitive, intense, tricky-to-parent kid like Johnny to thrive."

    I'm no longer in the field but that is the number one thing I learned for the 0-6 (or even higher crowd). Parents (and meds--when applicable, like for ADHD) make all the difference!!

    Thanks for the reminders (and I'm sure you are very good at your job)!!

  12. From the outside, being a psychologist seems really easy, almost like giving advice to your friends and helping them cope with a recent break-up. But it's not--especially with kids! This is an awesome post because hopefully more people will understand psychology isn't all "talk therapy," and that understanding some basics can actually REALLY help with writing and character development. Or at least I think so. Ahem. *biased*

  13. You put so much thought into your stories. That can only mean that they're authentic and emotionally tangible. I can't wait to read them! How cool that you can incorporate your knowledge of psychology into such a fruitful and creative venue, you know?

  14. Do you ever get attached to the kids?

  15. Interesting that the problem appears to be the parents, not the kid. Johnny is responding to the inconsistency with which he's being presented, and who can blame him? It must be tough to get parents on board to work together...I know from personal experience it has not always been easy for me and my hubby to stay on the same page, even though we always did our best to present a united front. He's a better disciplinarian than I am; I'm too much of a softy. I know this is different for each child, but on average, how long does it normally take to see meaningful progress, assuming both parents are cooperating?

  16. Lots of info here. Fantastic!