Most of us in the field love kids: babies, toddlers, and everything else in between the stage of a little ‘un and the arbitrary age when “cute” is no longer appropriate or politically correct. Okay, admittedly, teenagers are a whole other can of worms and I know many intelligent and protean therapists who would sooner stumble when, or steer clear away from, working with pubescent people governed by their raging hormones. However, knowing that mental health of children has been declining over the past year due to the impact of COVID-19 (Cowie & Myers, 2020), you’d think that more of us “caring professionals” would be willing to make exceptions to take your depressed and anxious adolescent as a new client to alleviate some of the emotional crises currently confronting not only your family but also the global society. Yet, despite recognizing the rising needs for mental-health services for youth and children, many mental-health practitioners still maintain that they only work with adults.
But why? You’d ask. My kid is in serious need of help – even more than I do!
Aside from the fact that some people simply do not click well with youth and young children, many practitioners are also justified in declining to work with these clients out of professional considerations. Just like there are pediatric dentists and pediatricians, therapists can also specialize in child counselling/therapy and have additional training in child-centered play therapy, such as sandplay, that can help properly assess and treat developmental issues. It is of sound ethical practice for any health practitioner to decline to provide services to clients with issues for which they have no competence in and child therapy is no exception: it is a specialized field due to considerations of developmental differences, socio-environmental circumstances, and the fact that these groups are simply a vulnerable population. However, in my observation, it is usually more than these objective reasons that make practitioners reluctant to enter the world of child therapy. Practitioners may prefer to work with adults because of one or more of the following reasons that deter them from taking children as clients:
#1: Family Complications and Parental Involvement that Intersect with Confidentiality and Privacy
Working with kids often means that you will be working with the community that is involved in their lives: parents, grandparents, and sometimes even extended family members. Most times, the family will have their children’s best interests at heart. They will usually ask questions, want to know what is going on between you and their child, make (unsolicited) suggestions, and may even try to become involved in the sessions, sometimes to the detriment of the primary client’s progress if it becomes interference. As the children are not yet at the age of majority, there are also more legal/ethical considerations about confidentiality and privacy that influence limits of disclosure. Accepting a child client would therefore mean that you essentially take on the family as almost an extended client, which can be difficult to manage at times if your therapeutic approach and philosophy do not agree with the family’s or if you also need to be mindful of other purposes the family has enrolled their children in therapy, such as to satisfy school inquiries or to make observations for family court trials.
My Personal Experience: Although most families have benign intentions, they may not always have the most suitable executions when it comes to translating their interests in their children’s care. Some even pathologize child therapy so much that the very fact that their child is even seeing a mental-health professional is perceived as abnormal and shunned. Those who do understand and are supportive of their children’s mental health demonstrate good boundaries and trust, which facilitate our sessions tremendously.
#2: Child as a Reluctant Client
Very rarely do we see a child who voluntarily asks for therapy and comes to us independently or we see families who proactively choose to enrol their child to therapy for preventative means. More often than not, you will see teenagers and young children either forced/coerced or entered into therapy unknowingly by their parents or authorities ensued from a “crisis” or “problem.” You can imagine how much efforts we would need to put into rapport-building and establishment of trust in the beginning of the sessions in these cases, especially if there are behavioural issues such as anger, impulse-control difficulties, and aggression. These factors can make initial progress slow and seemingly ineffective and families may not always be understanding of these extenuating circumstances. In addition, treatment adherence can be poor, which can be frustrating for both the clients and the practitioners.
My Personal Experience: New parents are more prone to ask about the amount of time/number of sessions it takes to “fix” their child. I can understand and sympathize with the urgency of their requests, but as I often only see the child after eruption of their distress it can be difficult for me to give a definite and satisfying answer. Fortunately, parents who have been or are also my clients are more understanding of these situations. In addition, they also know the importance of prevention and maintenance and would try to familiarize their children with me so that, in the future, their children would not shy away from asking for help.
#3: Limited Time and Resources
Most families are either reluctant to keep their children in therapy due to stigma and negative perceptions of therapy or simply do not have the time and/or financial resources to support their children for beyond a few sessions. Aside from practical reasons, there can also be other complications such as if the parents are involved in family court, if the school is requesting observational reports, if the sessions are funded and need to meet certain requirements, etc. If the child is already coming into therapy with resistance, these limited sessions often become even more constrained and providers can feel “forced” into meeting expectations of the authorities rather than prioritizing the needs of the primary child client.
My Personal Observations: Families can understandably become impatient when they see their children experiencing problems that led them to therapy. Ironically, the less patient that the family is, the longer it will take for them to observe identifiable progress in session for their children.
#4: Need for Additional Tools, Equipment, and Time to Prepare
Unlike adult clients who can enter sessions with just comfortable furniture and private place, child clients – even adolescents – will need additional investments in age-appropriate items that range from work desks, cards, games, toys, writing/drawing tools, to specialized therapy and educational products. To keep kids entertained and happy as well as to make the office as welcoming as possible, it is also ideal to update and refresh your child therapy equipment from time to time. An adult is unlikely going to complain about your office decor not being “cool enough” but a kid and teenage client will not hesitate to tell you that the Emotions Card passed down to you by your supervisor is “stupid” because the lingo it uses is way too outdated or that your Pokémon cards “suck” because you don’t have any legendary Pokémon in your measly collection gifted to you by your friends when you were in elementary.
My Personal Experience: I have learned that every child’s taste differs and that while one may like one game activity with you, another may very well just wants to cuddle with a stuffed snake. You simply cannot cater to all of them and can only try your best to pick and choose the tools and equipment that meet your professional needs based on common characteristics of your client population.
#5: Individual Child Dispositions and Behavioural Difficulties
In addition to having specific mental-health issues and conditions, children and teenagers may exhibit certain dispositional traits and behaviours that make them challenging to work with in sessions. Because they are often “reluctant clients” forced into therapy by their parents, they may refuse to attend sessions or to even talk, use profanity without discretion, or become physically violent. It is not easy to navigate through the power struggles and provision of control in the family that comes inherent in every child’s case, which deters many otherwise competent therapists from attempting work with these young clients. Imagine working with a teenager who comes to sessions to simply sit silently and stare angrily at you for one year (true story told by one of my facilitators at a training seminar). Or, encountering a particularly aggressive child who starts screaming and hitting their younger brother if the parents do not give them what they want (my client’s story). Simply hearing these “horror stories” are often enough to persuade many of my fellow colleagues to bow out from even attempt to work with children.
Personal Experience: Although I have not had any client who got directly angry at me and called me anything ill, I did have some who, out of anger towards their parents for “forcing” them into therapy, lash out in sessions. During those moments, it is important to have the parents’ support and understanding that some of these reactions are indicators of power struggles between the parents and child, and that boundaries and limitations must be set with patience and not simply because the behaviour is “inappropriate.”
I think what inspired me to write this article is the fact that this summer alone I have been asked to provide assessments for multiple children. The case that wrings my heart is a 9-year-old boy who apparently has been bullied regularly at school. I was told by the referring agent who decided to put their limited funding into this case because it is very “severe” and that “he needs to be saved.” However, the mother appears unwilling to let me see the child and would rather elaborate on their son’s issues over e-mail. My only meeting of the child was further hindered by the fact he was told nothing about the session and was simply instructed to be online for a meeting one day with a complete stranger. It was uncomfortable for the both of us: he felt cheated and deceived; I, confused by the apparent chaos and lack of cohesive communication in the family. To be honest, sometimes I would think back to this case and, admittedly, become angry at the parents who seem to care more for their work rather than their son and for the seemingly deliberate withholding of information and use of deception. The mother has even asked me to be responsible for reminding her of the scheduled session rather than noting down the appointment herself, which baffled me. In moments such as these and when encountering any situation that describes one or more of the abovementioned, taking the advice of others to quit does become rather tempting. However, I always stop myself from going down that rabbit hole too long because of reminders of positive encounters with (other) clients. I do not blame anyone for not including children and teenagers as part of their client population, but do admire those who do because I understand and sympathize with the many inherent difficulties and challenges that come with working with them. The good news is that with perseverance, patience, skills/competence, and a stroke of luck with parental support, the rewards of working with kids can be tremendous and keep me on a psychological-sugar high that fuels me through the tougher moments. I joke often with my young-adult clients that I am happy getting them so soon after their teenage years when they’re ready for therapy. The thought that sustains me is that at least/hopefully I will have left these children with a favourable-enough impression that will encourage them to seek help in the future when at least one of these factors become less relevant. It is with this determination that I will continue taking on children as clients and hope that more parents and family will come to understand and support us practitioners to help their children.
Cowie, H., & Myers, C-A. (2020). The impact of the COVID-19 pandemic on the mental health and well-being of children and young people. Children & Society, 35(1), 62-074. https://doi.org/10.1111/chso.12430