TAPLINK

Support for
Pennsylvania
Adoptive & Foster Families

Taproot issue 43 - October 2002

Gordon R. Hodas, M.D. is the Statewide Child Psychiatric Consultant for the Pennsylvania Office of Mental Health and Substance Abuse Services (OMHSAS) in Harrisburg, PA.

There are no ready-made solutions to the difficult problem of how parents (and other legal caregivers) can encourage unwilling children and adolescents (children hereafter) to participate in mental health treatment. Parenting is always a challenging enterprise, and inevitably involves degrees of disagreement and even struggle between parents and children. These struggles intensify as the child grows older and there is tension between the child's allegiance to the family and a move toward greater independence.

"How can I help my unwilling child receive necessary outpatient mental health treatment?" Answers to this question, like many others, often exceed the bounds of the law, since laws typically deal with only limited circumstances.

If a child appears to represent a threat to self or others, a parent or other adult can initiate what is known as a 302 process. Through this process, the child is evaluated in an authorized emergency setting to determine if the conditions for involuntary psychiatric inpatient treatment, as specified in Pennsylvania's Mental Health Procedures Act, have been met. However, many situations arise where parent and child disagree over the need for mental health treatment and the child does not appear to fulfill the criteria for involuntary treatment. In addition, even when such criteria may be present, parents may reasonably prefer that the child enter treatment on a voluntary basis, if at all possible.

In Pennsylvania, a child between the ages of 14 and 18, unless legally emancipated, does not have a legal right to refuse outpatient treatment if the treatment is initiated by the parents or other legal guardians. However, the fact that no legal basis exists for a child's refusal of mental health treatment does not ensure that the child will agree with the parents' recommendation. The child may not recognize that he/she has a treatable mental health problem, may believe that the problem lies elsewhere, may regard the parents as overreacting, or may be otherwise involved in an ongoing power struggle with the parents such that the issue is not considered on its merits.

A major premise in my work with families is that parents and child are on "the same team" and need to be able to recognize this. While disagreements are inevitable, these become tolerable and capable of resolution when all parties recognize that they share common interests and goals, and are "on each other's sides." In my experience, the realization that child and parents are on the same team is often absent when there is significant family conflict and when a child is unwilling to accept parental leadership. Instead, the child may believe that the parent does not care about him/her, is too controlling, or is somehow "trying to get over" on the child.

All efforts to engage angry or otherwise uncooperative children should build on the need for child and family to recognize that they are on the same team. Therefore, the manner in which the idea of therapy is framed by parents becomes crucial. Children, like the rest of us, do not like to be singled out and blamed. In fact, they have a strong need to save face.

Parental discussion should take place with the child privately, away from siblings and other family members, and should proceed as calmly and respectfully as possible. The goal of parents should be to use a language of caring and concern toward the child, not accusation and criticism. Thus, the presentation should focus on how the parents know that the child wants to do well but that there have been increasing concerns, rather than just listing all the things that the child has "done wrong."

Therapy should be described as a helpful, time-limited process, not as punishment or of indeterminate duration. It may be helpful to frame the first contact with a mental health professional as a "consultation" rather than as the beginning of "treatment." This concept of consultation is an accurate portrayal of what typically occurs, because neither party can reasonably agree to work together on an ongoing basis until they have met and discussed concerns, goals, and ways of working together constructively. In addition, there needs to be a sense of comfort and compatibility with one another, before long-term commitments to treatment are made.

Some parents find that they are better able to interest their child in the possibility of mental health treatment by broadening the intended focus of therapy. Thus, in addition to identifying concerns about the child, the parent might say, "We also want to get help, so that we are better able to understand and help you, and so that we all can enjoy our family more." Such a non-confrontative statement may be experienced by the child as a supportive, face-saving "high road" by the parents. It avoids blame, with the focus instead on everyone working together to achieve positive change. Responsibility for change is shared, and unnecessary provocation is avoided. During such discussion, parents should encourage the child to respond, so that they can understand the child's point of view and a dialog can ensue.

There are additional constructive steps that parents can take. If, for example, a parent or another family member has benefited from mental health services, this experience can be shared with the child. The process of mental health treatment and therapy can be explained, if this has not already occurred or is not understood. Key points include the idea that mental health professionals "work for us, and will try to help us identify and reach our own goals."

Parents can explain that the child, when seeing a therapist, has a right to confidentiality, but that, at the same time, the parents are willing to - and in fact, are committed to - participate actively in the child's treatment. Different ways that this participation may occur can also be discussed. The previously identified idea that child and parents are on the same team can be conveyed, with the child assured that the goal of treatment is to help increase the child's sense of responsible control, not take it away.

When contacting a mental health center, agency, or individual practitioner, a parent should explain that the child is reluctant to participate, so that the person meeting the child and family has this information in advance. This is also an appropriate time to ask any questions about procedures and to ask other questions and offer suggestions, as appropriate.

Additional approaches to the challenge of persuading a reluctant or unwilling child to enter therapy include expanding the helping network. For example, parents can invite in other family members, which could include an older sibling, grandparent, aunt or uncle, or godparent. Beyond the family's own boundaries, inclusion of the pediatrician or a religious leader may be helpful. Other options include the school counselor, teacher, or a representative of the school's Student Assistance Program (SAP). Involvement of a team coach or other community leader may have merit, but usually it is prudent to discuss this with the child before making contact.

Parents can also call organizations such as Parents Involved Network (PIN). The child can be encouraged to make contact with peer support. The Student Assistance Program (SAP) is a statewide program providing a variety of mental health and substance abuse services in public secondary schools. Parents and students in Philadelphia can also contact the Peer Support Project of the Mental Health Association of Southeastern Pennsylvania, 215-751-1800 ext. 513.

Although the focus of this article has been on identifying ways to enlist cooperation, another option involves parents' setting up, and attending, an initial appointment with the therapist without the child's immediate participation. A subsequent focus of the therapy would be to include ways to engage the child. If a child is categorically defiant and inflexible, parents reserve the right to invoke consequences and withdraw privileges.

In the process of pursuing discussion with the child on the need for mental health treatment, parents may find unexpected solutions. For some children, the desire to avoid therapy may lead them to make changes, or make a commitment to make changes. In some instances, due to the nature of the underlying serious emotional disturbance or for other reasons, the child may not be able to make the desired changes and therapy will still be indicated. The point is that discussion and negotiation between parents and child can be positive, and the outcome need not always be a decision to pursue therapy. However, even if mental health treatment is not pursued, parents should help the child understand that such an outcome, if necessary in the future, will be acceptable.

As discussed, there are extreme situations in which the child's need for mental health intervention requires the pursuit of an assessment for involuntary treatment. Since the request for involuntary treatment must be assessed by an emergency psychiatrist, sometimes it will be determined that the child does not meet the criteria for involuntary inpatient admission. While such an outcome may in some ways be disheartening to the parents, this effort should not be viewed as a failure. The experience may nevertheless help the child appreciate the level of parental concern and the parents' degree of readiness to take extreme action when needed, on behalf of their child's safety and well being.

Again, resolving disagreements about therapy between parents and child is not easy, and there are no pat answers. All recommendations offered here are predicated on the idea that parents and children need to see themselves as being on the same team. In addition, parental leadership is typically more effective when it involves the use of a language of caring and concern, rather than primary reliance on the exercise of parental power.

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