I think of the critical issues around which a different approach to therapy with kids needs to develop as the "four R's"--Rules, Rituals, Reasons, and Regard. Though simple and straightforward--almost too ordinary for technically accomplished clinicians to be concerned with--they're radical, from the standpoint that they've largely disappeared from family life today.
"I'm sorry I'm late. Everyone was talking after school, and I lost track of time. . . ." "The bus broke down and I wasn't near a phone, so I couldn't call you to say I couldn't come." . . . "We went to the pizza place and just hung out.". . . "I thought insurance was paying you directly . . . ." "There's a big reading test tomorrow, and I have to stay home and study."
When many of us began doing therapy years ago, we believed our young clients' anxieties often resulted from too many rules and too much authority. So our training taught us that a warm, fuzzy therapeutic embrace was a godsend for children. At the same time, many of us--feeling hounded and harassed ourselves by the convoluted regulations of managed care companies and mental health agencies--are uncomfortable in the role of rule-enforcers. But today's kids are anxious partly because there are few rules that matter. We need to recognize that today a laissez-faire therapeutic frame is indistinguishable from the everyday chaos many of our young clients experience.
Establishing clear rules in therapy creates exactly the secure frame that young clients and their parents need to begin managing the disorder in their lives. In fact, addressing the concrete issues of maintaining commitments, setting priorities, and being serious about the process can bring to the surface issues that might otherwise undermine therapy. Instead of just skipping appointments or prematurely terminating therapy, families held accountable start talking about financial concerns or other fears that are threatening to devastate the home. When therapists challenge a family's casual attitude about showing up on time, parents may begin to openly discuss the everyday chaos that can be so frightening to children. In addition, almost without fail, when a preteen or teen is late to therapy, the missed appointment time is used for the very problem that the family is seeking help for--substances, after-school acting out, and so forth.
I was recently seeing Craig, 14, a very nice boy, who couldn't make friends. Like so many kids, he reverberated with anxiety, which he tried to overcome by being loud and forcing himself into people's conversations, much to the disdain of his schoolmates. Craig and his family were prone to cancel appointments at the last minute. After about the third time this happened, I reviewed the rules with them: they had to show up on time or reschedule within 48 hours. Reluctantly, they began to talk about their everyday concerns. Mom had been laid off and Dad wasn't making enough to meet their expenses. In fact, they were canceling at times when they didn't have the cash to pay for sessions. They felt humiliated and crushed by the pressure, and the situation wasn't at all helped by their son's increasingly expensive tastes for the latest fashions.