INTRODUCTION

This chapter details the elements of counseling with children and adolescents that are essential to setting a solid stage for deeper work. Techniques addressing the initial contact and important contextual issues, such as setting up a child- and adolescent-friendly office space, are covered.

INITIAL CONTACT

Initial contact sets the stage for the therapeutic alliance (Hofmann, Sperth, & Holm-Hadulla, 2015). The first interaction with the client’s caregiver is typically on the phone as the result of a referral. The caregiver is seeking counseling for their child because of a concern they have or one that has been brought to their attention from a school, agency, or pediatrician. The relationship with your client begins here. Whether this first communication is directly with you or with an office staff member, the demeanor should be warm and professional. This conversation is intended to briefly explore the nature of the client’s concern and to ascertain the fit between client and counselor.

Once you have a basic understanding of the needs of the child and you have determined that your qualifications are appropriately matched with these needs, provide a review of your practice location, hours, and rates. Again, this information may be provided by you or an office staff member. Keeping in mind that the caregiver may be apprehensive or nervous about counseling, you can establish comfort in this first conversation by describing what the first appointment will look like so they know what to expect:

Finally, schedule the first appointment and offer to schedule follow-up appointments ahead in order to ensure regular visits. Close the conversation with thanks and that you are looking forward to meeting them.

RESPECT CAREGIVERS AND FAMILY MEMBERSIN THE PROCESS

Since children rarely self-refer, the counseling relationship with children includes caregivers. Beginning with the first contact, safety and trust must be established with family members (de Greef, Pijnenburg, van Hattum, McLeod, & Scholte, 2017). It can be difficult for caregivers to let go and allow another adult to develop a caring relationship with their child, especially if the relationship between caregiver and child is stressed. You must demonstrate that your intention and your counseling approach is always in the best interest of the child. Your support is simultaneously present for both the child and caregiver (de Greef et al., 2017; Hawley & Garland, 2008; Tsai & Ray, 2011).

THE FIRST APPOINTMENT

The first appointment is unique in a variety of ways. You and your client are meeting for the first time. Furthermore, guidelines and paperwork must be formally reviewed. As with all appointments, you should be on time and greet your client warmly (i.e., with eye contact, a smile, and a handshake). After introductions, describe the office setting (waiting area, reception, other offices, restrooms, and other facilities such as kitchen or vending machines) as you lead them to your office. You can also describe for them the office etiquette of keeping the waiting area a quiet and safe space for others—that the privacy of everyone is respected. Once in your office, allow the child and caregiver(s) to sit wherever they like. You can explain the variety of things in your office—toys, games, sand tray, books, white board, and so on. Begin the first session by pointing out that it is indeed unique because of the formality of it and that future sessions will be less formal. Next, provide an overview of the contents of this first session. As an example, you might go over your plans to:

SHARE YOUR BACKGROUND

When sharing your background, it is important to summarize your training and professional experience. What specialized or advanced training have you completed? How are your education, training, and professional experiences well suited, in your opinion, to address the concerns presented by the child and family? You may also include personal interests, if appropriate. This may help with early rapport establishment for some clients.

EXPLAIN COUNSELING

Research has shown that educating clients about counseling improves treatment progress and outcome and attendance, and helps to prevent premature termination (Coleman & Kaplan, 1990; Reis & Brown, 2006; Walitzer, Derman, & Connors, 1999). Meier and Davis (2011) caution, “Clients frequently approach counseling with misconceptions about the process…. If mistaken expectations are ignored, clients drop out or fail to make progress.” Your explanation of counseling should be concise, rather than a dissertation on the theories of counseling or an overview of the field of psychology. Therapeutic counseling is not easily summarized, as it is has breadth and depth, and encompasses many perspectives, theories, and approaches to growth and problem solving. It also varies depending on the personality of both the therapist and the client, the particular chemistry of counselor and client, and the particular issues that the client brings. Regardless of theory, counseling is a relationship with the client’s personal growth as the goal. Counseling provides a safe, nonjudgmental space in which clients can self-reflect, identify strengths, experiment with new ideas of self and ways of being, and learn effective emotional regulation, relationship, and life skills.

It is wise to establish realistic expectations about the fact that counseling is a process that takes considerable time and effort (Swift & Callahan, 2011). It is equally important to instill a sense of realistic hope that counseling will lead to improvement and positive change (Meier & Davis, 2011; Swift, Greenberg, Whipple, & Kominiak, 2012).

In this initial session you should also emphasize the importance for the client to express their feelings about the counseling process on an ongoing basis so that you can both address any concerns as they arise. Giving them the permission and the opportunity to provide feedback that you can respond to is not only helpful in terms of process but also very empowering and validating to your client (Knox et al., 2011; Swift et al., 2012). Since your client may not have the skills to do this, you will check in with them occasionally to process this with them.

Ultimately, your objective is to help your client grow to a place of self-reliance in coping with their life to the point where they no longer need your assistance. This is, therefore, also an opportunity to talk about closure, that when growth and goals have been achieved (progress will be discussed at various times throughout the counseling process), counseling will come to an end. Since saying goodbye can be a difficult experience for many, exploring this at the onset helps clients considerably when the time actually comes (Swift et al., 2012). Help your client conceptualize what it might look and feel like when they have met their goals.

Often, clients like to do something special that symbolizes their work and growth when they say goodbye. For example, this author’s (LK) client led her on a hike, which reversed roles, empowering the client not only to lead her counselor on a journey but also to symbolize her growth. The process of closure or termination may take several sessions.

PROVIDE AN OVERVIEW OF LOGISTICAL GUIDELINES

There are logistical guidelines to discuss during the first session, which also help to set limits with your client, such as:

However, one of the most significant guidelines in counseling is that of confidentiality.

ADDRESS CONFIDENTIALITY AND PRIVACY

The American Counseling Association (ACA, 2014), American Psychiatric Association (2010), American Psychological Association (2017), National Association of School Psychologists (NASP, 2010), and the Code of Ethics of the National Association of Social Workers (NASW, 2017) all address confidentiality, privileged communication, and privacy.

DETAIL YOUR POLICY AND PRACTICES FOR PARENT INVOLVEMENT

With these guidelines established at the onset of the counseling relationship meeting the aim of supporting both the child and the parent(s), explore with them the manner in which they would feel comfortable proceeding with parental involvement and clarify your policy regarding this. Include:

Ultimately, again referring to state laws, if parents persist in requesting information regardless of the fact that the client does not want to disclose and you do not feel that it is necessary, and if you are legally obligated to share, inform the parent of the potentially negative impact on the client and on the counseling relationship (Glosoff & Pate, 2002). As stated in section 7, support your client by making them aware that this is about to unfold and give them options of how this will occur.

EXPLORE THE CLIENT’S STORY—TAKING A HOLISTIC APPROACH

With the introductions, guidelines, and preliminary information established, it is now time to begin to explore with your client what brings them to counseling and begin to develop initial goals for therapy. While a full discussion of this is introduced in Chapter 3, the first session should offer time to generally explore the nature of your client’s concern and begin to conceptualize what the client is hoping to achieve. Although you will provide an intake questionnaire for the caregiver to fill out, during the first session you can directly ask pertinent questions to collect information about the client’s past and current history. Choose the questions you ask carefully, leaving less relevant details to be left to the intake form. Use this time wisely so that the relationship can begin to be formed. These questions are the segue and invitation for the client to begin to tell their story.

Our clients’ lives are a complex web of interrelated interpersonal and intrapersonal, multisystemic components. These include the self (thoughts, feelings, physical self, gender, sexuality, race, ethnicity), family, friends, peers, school (relationship and interaction with teachers, being a student), community (neighborhood, school, religion), culture, and society. As such, it is essential to use a holistic approach to tease out the multiple determinants of a client’s psychosocial, emotional, and physical wellness. Although the parent and/or client may present with a focus on one or two concerns, all of the domains of the child’s world should be explored in order to reveal sources of struggle and strength, patterns, relationships among domains, and avenues for growth.

COCREATE COUNSELING GOALS

Ryan, Lynch, Vansteenkiste, and Deci (2011) review many theories and therapies that highlight the need for autonomy in the counseling process in order to elicit motivation for lasting growth and change. At the onset of counseling, creating goals is one of the first stages of the process. Engaging your client’s autonomy from the start involves creating goals with your client rather than for your client. “Autonomy support includes methods that foster or encourage voice, initiative, and choice and that minimize the use of controls, contingencies, or authority as motivators” (Ryan et al., 2011, p. 230). Thus, motivation to grow and change is increased when clients have participated in creating goals, eliciting a sense of ownership by incorporating their ideas and voice as opposed to feeling told what to do, which can elicit the adverse reaction of resistance.

The interviewing dialogue can begin with the concerns brought up by the client and parent, follow with the exploration into the holistic domains listed in the section above, and move to a reflection of the desired outcomes the client and parent have expressed. Together, these can be listed in priority, or ranked using a 5- or 10-point scale in terms of importance or intensity. A global summary can then be given, for example:

It is helpful to list or have your client list the goals you cocreated. You can use a white board to draw, write, and diagram with the client, and then both counselor and client take pictures of the board to reflect on in future sessions as well as for the client to easily access between sessions. Be creative!

CREATE A DEVELOPMENTALLY ACCOMMODATING OFFICE SPACE

In order to create a warm, peaceful space that elicits or is conducive to a child feeling comfortable, it is helpful to consider a wide variety of factors, including:

Depending on the counselor’s training, the following therapeutic tools may be available:

Ideally, the space should be large enough to allow for movement so that kinesthetic learners can be accommodated and physical therapeutic approaches such as yoga could be included.

The outer office, waiting area, or reception area should provide a comfortable sitting area with quiet music, a variety of reading materials, and perhaps some toys or drawing materials. Sound machines should be placed outside the counselor’s office to provide privacy.

Dress appropriately—professionally and comfortably. Business suits can seem off-putting to a child and make you appear less approachable or relatable. If you will be using play therapies, sitting on the floor, or doing yoga, of course you must dress accordingly.

BE ON TIME

Be on time for all appointments. It is important to stay on time with your appointments when they are scheduled back to back in order to respect all of your clients and to maintain boundaries. If agreed upon with your client, an alarm can be used, preferably with a soft or soothing tone, music, or nature sounds, to indicate that a session will be coming to an end in a specified amount of time (5 or 10 minutes). This will allow the client to pace the conversation so that he or she does not have to end or feel cut off in the middle of sharing something. This provides for comfortable closure of each session.

INDIVIDUALIZE COUNSELING

Meeting your client’s individual needs means understanding his or her age and developmental level, personality, and where he or she falls on the continua of openness, extroversion, and comfort level. Meier and Davis (2011) also suggest considering psychological sophistication, level of motivation, social maturity, intelligence, prior experience in counseling, awareness of strategies that have worked and not worked in the past, and use of language that the child understands.

Swift et al. (2012) recommend accommodating client preferences with regard to such aspects as type of treatment, therapist behaviors such as giving advice, and whether or not to give homework. Giving choices elicits engagement in treatment modalities that clients prefer and ultimately increases willingness to participate. This research was with adult subjects, and the authors add that with clients who lack awareness regarding what treatment may be best for them, counselors should present various approaches and collaborate with clients to decide which approach to take. Walitzer et al. (1999) also support this, suggesting that the counselor “provides a menu of options for change, based on clinical research regarding effective treatments” (p. 146).

Working with children and adolescents means that you must be able to work with and relate to the very wide range of distinct needs of the toddler, preadolescent, and adolescent. You must understand the perspective of that person’s current relevant cultural norms and cohort as well. Your client must feel that you “get him or her” while also feeling that you are the adult and role model. You may be seen as a caring, capable adult, teacher, coach, mentor, and leader. Ultimately, you must be adaptable and responsive.

Given this wide range of needs and treatment methods of the broad age group of childhood and adolescence, it is important that you do not accept referrals from clients if you are not comfortable with a particular age group. You must always practice within your training and competencies.

WORK WITHIN A DEVELOPMENTAL FRAMEWORK

Human development occurs in broad, overlapping stages of early childhood (ages 3–5), childhood (ages 5–13), and adolescence (ages 13–21). These are not mutually exclusive stages or categories. Instead, they are transitionary periods, overlapping circles, or Venn diagrams; age ranges are only averages. Some development is continuous and gradual: achievement at one level builds on achievement at previous levels. Some development is discontinuous and occurs at distinct steps or stages. That is, changes achieved are qualitatively different than at earlier or later stages. Development occurs through change and growth as well as through stability, consistency, and continuity. Development is also multidimensional, including physical, cognitive, personality, and social dimensions.

There are universal principles that exist regardless of culture, ethnicity, or gender. There are also cultural, racial, ethnic, and environmental differences that play a role in determining when developmental events occur. There are individual differences of trait and characteristics. Individuals mature at different rates and reach developmental milestones at different points.

Development is also influenced by the following, which should be explored in counseling:

For an overview of child and adolescent development, refer to Berk (2017).

It is also important to be mindful of and to explore with your client the various multidimensional environmental levels that simultaneously affect him or her (Bronfenbrenner, 1986, 2005):

On a very pragmatic level, interactions with your client must be aligned with his or her levels of comprehension and maturity. It is important to communicate in terms and modalities that the client understands, frequently checking for understanding. Responses and explanations should be provided in a variety of ways while asking the client to explain back to you in his or her own words. Not only will you be listening reflectively, but you will also ask your client to reflect back to you how he or she understands what you have communicated. (“Does that make sense? What does that mean to you? Can you give me an example? Tell me how you interpret what I just expressed. What are your thoughts about what I might mean by that?”) This reciprocal process minimizes incorrect assumptions and miscommunications and allows you to scaffold your client’s learning upon prior foundations of his or her understanding.

ADDRESS RESISTANCE AND CREATE A WORKING ALLIANCE

Although some children welcome the opportunity to talk and share their feelings, many are brought to counseling against their will. It is your job to overcome a child’s resistance to counseling. “The challenge is to involve the child in treatment and to work toward a change that the child may not view as necessary or even potentially useful” (Kazdin, 2003, p. 256). Resistance can manifest itself differently at each developmental level. Younger children may exhibit apprehension more in the form of a fear of the unknown adult, while young adolescents are seeking autonomy and therefore may feel that participation in counseling threatens this. Adolescents may feel invalidated, coerced, blamed, misunderstood, threatened, resentful, and/or a loss of control. Resistance may be a reflection of the need for autonomy and/or safety and therefore must be honored (DiGiuseppe, Linscott, & Jilton, 1996; Fitzpatrick & Irannejad, 2008; Hawley & Garland, 2008). To this end, creating a comfortable space, exploring what counseling is, and establishing guidelines that allow for a child’s privacy go a long way in establishing safety and alleviating apprehension.

Fitzpatrick and Irannejad (2008) explore how readiness for change and the working alliance interact. They found that with adolescents who have not made a commitment to change, bonding with the client is most effective, whereas with clients who are ready for change, finding agreement on goals and approaches is effective in creating a working alliance.

To create connection between client and counselor, conveying empathy and reflective listening are imperative (Walitzer et al., 1999). A child needs to feel truly heard and understood. It is not necessary to agree or even express agreement or disagreement. When a child experiences the feelings of being understood and validated, an emergence of trust and the freedom to open and explore begins, releasing the potential to problem solve and to reshape coping skills and emotional regulation.

In a review of alliance literature, Zack, Castonguay, and Boswell (2007) highlight that the therapeutic relationship is critical for effective therapy. A weak alliance predicts premature termination, whereas a strong alliance predicts symptom reduction. Hawley and Garland (2008), in their research with adolescents, found that “youth alliance is significantly associated with several domains of therapy outcomes, including decreased symptoms, improved family relationships, increased self-esteem, and higher levels of perceived social support and satisfaction with therapy” (p. 70).

In a review of the literature on psychological factors that inhibit seeking help, Vogel, Wester, and Larson (2007) outline the avoidance factors of social stigma, treatment fears, fear of emotion, anticipated risk, discomfort with self-disclosure, social norms, and protection of self-esteem. They also outline the moderating factors of gender, cultural values, treatment setting, and age. As adolescents age and mature, the stigma of counseling often decreases (Boldero & Fallon, 1995), and as adulthood emerges, openness toward counseling often increases. This may depend, in part, however, on level of education. According to Vogel et al. (2007), “most of the literature on help-seeking … has consistently shown that individuals who are in their 20s and who have a college education have more positive attitudes toward seeking professional help” (p. 415).

BE INFORMED AND SENSITIVE TO DIVERSITY IN ALL FORMS

Diversity exists in many forms:

Individuals with diverse lives, backgrounds, or experiences may encounter life obstacles, bias, prejudice, marginalization, aggression, hostility, violence, or victimization that may be chronic. Although a thorough exploration of diversity is beyond the scope of this text, the essential element is to maintain ongoing awareness of diversity in all its forms. Diversity and cultural sensitivity competencies in counseling can be accomplished by staying informed through continuing education, diversity and social justice training, ongoing participation in professional associations, and continuously reading current literature.

Hendricks (2005, pp. 3–4) highlights that counseling should be a dynamic learning process between counselor and client, and he provides the following guidelines for beginning clinicians:

It is imperative to reflect on your diversity and cultural sensitivity competencies in counseling and congruence with clients and whether or not a lack thereof creates a poor fit and results in harm to the client. Ultimately, know when to refer the client to a more appropriate therapist if your skills are not developed enough for that particular client.

COMPETENTLY SUPPORT OR EFFECTIVELY REFER LGBTQIA CLIENTELE

The acronym LGBTQIA refers to lesbian, gay, bisexual, transgender, questioning/gender queer, intersex, and asexuality.

To date, there is limited research with LGBTQIA adult populations, and even less research in this area among children and adolescents. The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling Competencies (ALGBTIC) states that “the aim of these competencies is to provide a framework for creating safe, supportive, and caring relationships with LGBTQIA individuals, groups, and communities that foster self-acceptance and personal, social, emotional, and relational development” (ALGBTIC LGBTQIA Competencies Taskforce et al., 2013, p. 2). Overarching tenets include being vigilant about not interpreting differences as psychopathology as well as maintaining ongoing awareness of the many current issues that affect LGBTQIA people. The task force outlines 120 competencies in the areas of human growth and development, social and cultural foundations, helping relationships, group work, professional orientation and ethical practice, career and lifestyle development, assessment, and research and program evaluation. Some salient examples are paraphrased here (ALGBTIC Competencies Taskforce et al., 2013, pp. 9–13):

As always, counselors should seek appropriate supervision to foster ethical practices and should refer to other qualified agencies or counselors if not adequately prepared to counsel a particular client.

BE TRAUMA INFORMED

The impact of trauma on child and adolescent development can be pervasive, affecting social, emotional, cognitive, and psychological development. Frydman and Mayor (2017) provide a table outlining the wide range of outcomes and symptoms, including impaired family and peer relationships, isolation, emotional dysregulation, lowered frustration tolerance, increased behavioral problems, inhibited executive functioning, impaired working memory, and detriments in inhibition.

To be trauma informed means to be aware of and sensitive to the impact of trauma, being alert to triggers and symptoms, having the ability to differentiate between symptoms and behavior and put adverse behavior into perspective, and understand how to approach youth who have been traumatized to prevent further traumatization.

Trauma-focused cognitive behavioral therapy (Cohen, Mannarino, & Deblinger, 2012a; Cohen, Mannarino, Kliethermes, & Murray, 2012b) and dialectical behavior therapy (Mazza, Dexter-Mazza, Miller, Rathus, & Murphy, 2016) are the primary evidence-based treatment models. Treatment includes assisting the client to increase a sense of safety; to identify and understand the trauma and resulting triggers; to differentiate past experience from the present; to learn, synthesize, and apply adaptive skills such as stress reduction, anxiety management, distress tolerance, emotional regulation, and social problem-solvingskills; and to make new meaning of their trauma (Conners-Burrowet al., 2013). Comprehensive resources can be found at nationally established trauma organizations such as the National Child Traumatic Stress Network (NCTSN) and the Child Welfare Information Gateway (2012) and Child Welfare Collaborative Group, National Child Traumatic Stress Network (2008).

KNOW SUBSTANCE USE WARNING SIGNS AND HOW TO REFER FOR TREATMENT

According to the Substance Abuse and Mental Health Services Administration (SAMHSA, 2017), adolescent substance abuse is prevalent and there exists a wide range of impacts and a high cost to children, adolescents, and their families; schools; and health systems. Substances include alcohol, tobacco, and illicit drugs: marijuana, cocaine, heroin, hallucinogens, inhalants, methamphetamine, opioids, or prescription psychotherapeutic drugs that are misused (i.e., pain relievers, tranquilizers, stimulants, and sedatives). Furthermore, in 2016, among adolescents aged 12 to 17, use of illicit drugs was higher among those with co-occurring major depressive episodes (MDE):

Thus, it is possible that clients may present with MDE and not be forthcoming about their drug use. In order to effectively diagnose, treat, or refer a client for treatment of substance abuse, one must know the warning signs. In addition, knowing the current common vernacular of the slang or “street” names of drugs is important in order to be alert to and recognize possible drug use.

Here are some warning signs for substance use problems (adapted from the National Council on Alcoholism and Drug Dependence, Inc.; NCADD, 2018):

Counseling can include individual, group, and/or family counseling and clients can be referred to outpatient treatment or inpatient rehabilitation or hospitalization. The reader should refer to Chapter 6 of this text for further information regarding referral for treatment.

SEE THE BIG PICTURE

Ultimately, children and adolescents are a work in progress. They are discovering who they are and are trying out various aspects of their personality. Many behaviors that elicit a reaction from the adults in a child’s environment are actually part of normal development. In his review of the research in child and adolescent therapy, Kazdin (2003) summed it up nicely: “Deciding whether and when to intervene presents special challenges because many of the seemingly problematic behaviors may represent short-lived problems or perturbations in development rather than signs of lasting clinical impairment” (p. 256). Adolescent problem behavior is often resolved by early adulthood. In their review of the research on adolescent development, which explores the void of any widely accepted new theories of normative development since the decline of the theories of Erikson, Piaget, and Kohlberg, Steinberg and Morris (2001) point out that a recent focus of research is in discerning the difference between problems that are displayed during adolescence versus those that have earlier onset and are persistent across the life span.

You may see only artifacts of adult-onset disorders. Do not jump to adult diagnosis. The very nature of adolescence includes features that are used in the diagnosis of disorders. For example, the American Psychiatric Association (2013, pp. 663–664) outlines the following diagnostic features for borderline disorder, which are relatively descriptive of adolescence:

Many teens exhibit these features, which are actually within the range of normal childhood development. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) clarifies that “it should be recognized that the traits of a personality disorder that appear in childhood will often not persist unchanged into adult life” (p. 647).

On the other hand, do not ignore or dismiss the indicators of disorders. The work is in understanding and discerning the source. Is this normal, albeit tumultuous, development, or is it the actual onset of disorder? Monitoring over time is critical. Trends must be noted rather than immediate conclusions drawn from limited information or from a narrow perspective. Normal development is not always systematic, steady, or with consistent growth or progression. The pace of development varies widely, and milestones are met within a range of time. The backdrop of normal adolescence must be incorporated and be the lens through which you view your client.

SUMMARY AND DISCUSSION QUESTIONS

Setting the stage for counseling is quite involved and demands the use of a wide variety of counseling skills. A counselor must be organized in their preparation for and thoughts about what they will need to accomplish in the first session. Consider:

Some counselors feel that the first interactions and session are particularly challenging. Beginning counseling can be quite stressful for some children and their caregivers, and breaking down barriers is essential. Once relationships are established and counseling is flowing naturally, both the counselor and the client feel more relaxed. It is helpful to reflect on the following questions:

Confidentiality is a critical element in counseling and is governed by codes of ethics as well as by federal and state laws. A counselor must have a clear conceptualization of confidentiality and privacy in the therapeutic setting. To help you apply this information, summarize how you would communicate confidentiality and privacy with your client and your client’s caregiver.

Individualizing counseling to meet your client’s needs at their developmental level is also quite a complex undertaking. To begin to clarify this for yourself, reflect on the following:

REFERENCES