December 2009

First Encounters of the Close Kind

What to Expect From Family Counseling

By Loriann Hoff Oberlin, MS, LCPC

Many people who are asked, "Have you ever considered counseling?" question what mental health treatment involves.

Prior to becoming a licensed counselor, I was a journalist/author and had my first introduction to psychology through that work. But it wasn't until I was a single mother in my 30s that I embraced the value of face-to-face counseling, seeing how cognitive-behavioral work helped me move from the stress-filled days of marital separation and divorce to a self-confident way of life.

First Encounters as a Client

Whether given a referral or finding a name through your health insurance, there's that first call.

"One of the biggest misconceptions is that people may perceive counseling as their weakness or failure to resolve an issue on their own," says Dr. Ara Thomas-Brown, an Arlington therapist and adjunct professor of counseling. "Parents often question their ability to parent and see themselves as having failed, or question whether they are bad parents."

I try to address this same vulnerability. When therapists are in session, they cannot answer calls directly, so many of them use voice mail to step clients through the process of what to share, including a snapshot of the presenting problem. Clients may be directed to the therapists' websites where they can learn how the therapists practice and communicate via e-mail. In this way, the therapists discover whether their strengths match the clients' needs, if they can meet at mutually convenient times and if the clients feel comfortable with their practices, policies and fees. They may also guide clients through obtaining authorizations and asking about their deductible/co-insurance fees.

"When parents call me for an appointment for their child, I am very clear to explain that the way I work is that parents must be involved in the consultations," says Donna Troisi, LCSW-C. "As an emotional system, family members impact each other." Troisi, who practices in Frederick and Montgomery counties, asks parents if they're willing to work this way. "I want to see some combination of the family--sometimes just the child, sometimes just the parent(s) and sometimes both," she says. When parents are willing to lead and increase their own functioning, they're in a better position to assist children to do so.

Insurance Matters

If clients want counseling without insurance as the pacing point, therapists can often get to work more immediately. Otherwise, managed care implies that someone else sets limits on the number of sessions, type of therapy, paperwork required and reimburse­ment. Insurance will not pay for missed appointments and consults to coordinate a client's care (i.e., with prescribing physicians, school counselors/teachers), and it will not reimburse the fees to generate or read correspondence, reports and treatment summaries--out-of-session tasks often vital to the proper standard of care. Misunderstandings can arise when clients do not realize the limitations of their policies and erroneously believe that their insurance will cover all expenses.

"Many clinicians don't accept insurance because the reimbursement can be so low that it doesn't cover the hourly cost necessary to maintain an office and support services," says Shara Sand, Psy.D., in New York, pointing out that therapists set aside more time unlike many physicians who schedule 10-minute visits. "Insurance companies frequently require details regarding patient issues that many, including myself, find intrusive," says Sand. Some clients object to having a diagnosis, thus would rather pay privately.

"Once a therapist joins an insurance panel, there is always a chance [she] may have to divulge confidential information. If not a part [of a panel], there is less likelihood," says Jennifer Kogan, LICSW, in the District of Columbia.

Some health care practices have implemented periodic administrative fees due to increasing paper­work, says Mark Lanci, coauthor of The Therapist's Starter Guide.

Counselor and Client Responsibilities

Therapists are required to share policies with their clients and to keep them abreast of changes, a process called informed consent. This means that each party understands the therapeutic relationship and contract for services. The contract exists between the client and the clinician--not an insurance company. Thus, clients remain responsible for charges on their accounts.

In The Paper Office, Edward Zuckerman, Ph.D., interviewed a range of clinicians about administrative details, sharing that appointments are boundaries to be respected, showing time and value of the treatment. If clients miss appointments or cancel without adequate notice, it prevents others from being seen. To ignore such matters would set a poor model in a profession that's all about improving perceptions and behaviors. Counselors would send very mixed messages.

"Therapists charge for missed sessions because the appointment is a commit­ment between clinician and client. If a client misses many, or is frequently late, that should certainly be explored within the therapy," says Kogan. In groups where members bond, wondering where a member is (en route, ill, absent) can draw attention to the absence, detracting from the group's focus and again showing the need for advance notice.

Finding the Best Therapy Approach

At Johns Hopkins University, we were trained to have one or two psychological theories we could embrace and articulate well, though we were required to learn many more approaches.

Some therapists chose cognitive-behavioral therapy (CBT), emphasizing self-expression or play with younger clients, along with family systems theory, because our thoughts and behaviors are rooted in our first relationship lab--our family of origin. If we don't consider how we became reactive to current stressors, those patterns continue. When we become more thoughtful about the family's emotional transmission, we can more effectively partner with a counselor to move forward toward change.

If we don't meet with the parents, we not only miss important facts and dynamics, but all those caring about the child's progress may not be aligned. This type of therapy work joins families. If children or teens resist counseling, we often encourage mothers and fathers to come themselves. As leaders, their change impacts their family system.

Additionally, group therapy helps clients learn how to better manage themselves in a system (a family, group, classroom), and peer feedback often seems effective to improving social skills, self-esteem and mood.

Theory involves descriptions like family systems, CBT, psychoanalytic, Jungian, humanistic, feminist and other types of behavior therapy. Techniques include interventions associated with the particular theory: art movement or play therapy to maximize self-expression, Gestalt techniques focusing more on process (what's happening) than on content (what's being discussed), and genograms (pictorial views of family patterns).

Younger clients, unlike adults who can more readily articulate feelings, benefit from therapeutic games, art and play, but I have used creative approaches with older clients to help them relax, manage frustration or get in touch with their emotions.

Seasonal and Societal Considerations

The holiday season, winter doldrums and economic pressures can trigger bouts of anxiety and depressed mood warranting even a short-course of counseling to help focus on strengths useful in overcoming problems or in facing one's family dynamics.

Cultural factors may cause some families to feel they don't need assistance. "In some cultures it's not appropriate to discuss personal issues outside of the family," says Thomas-Brown, acknowledging that counselors take cultural sensitivity into account.

Academic pressure mounts for kids/teens navigating peer pressure and uncovering their learning styles. Psychoeducational testing may help if scholastic demands exceed abilities or affect coping skills or self-esteem. "Children should be reevaluated at least every three years to ensure they're receiving appropriate accommodations," says Christine A. Newell, Ph.D., who tests for learning and other challenges in Gaithersburg. Testing data may help obtain accommodations on the SATs and throughout the college years.

Tight budgets may cause people to hold back on psychological services, yet the outlay for a few sessions may forestall greater costs, such as a higher level of care or special education placement. Counseling can be well worth the time and effort for all ages, and the Wellstone-Domenici Parity Act, which takes effect January 1, 2010, covers all diagnoses for mental and substance-use disorders. Whatever a plan covers must be covered at parity with physical health benefits (while still allowing for medical necessity and under terms of coverage contracts).

Loriann Oberlin Counseling & Mediation, LLC, offers individual, family and group therapy including parent support and school success/social skill groups in the Washington, D.C., area. She's the author of The Angry Child, Overcoming Passive-Aggression and Surviving Separation & Divorce. Reach her through her website loriannoberlin.com.

To Ensure a Successful Counseling Experience