The parents’ role in their child’s therapy
When your child or teen starts counseling or therapy, it can be unsettling to see a new, unknown adult enter your child’s intimate life. Parents can feel uncertain about how to interact with their child regarding therapy — or how to interact with the therapist regarding their child’s therapy.
“When a child or teenager gets therapy, parents should know at least a little of what the big-picture plan is,” advises Jocelyn R. Lebow, Ph.D., L.P., a pediatric clinical psychologist at Mayo Clinic. “The level of involvement varies depending on the age of the child and the nature of the problem, but if you’re dropping your kid off at therapy and you have absolutely no idea what’s going on, I don’t love that.”
If the therapist practices cognitive behavioral therapy (CBT), dialectical behavioral therapy (DBT), exposure therapy, or other action- and practice-based therapies, then you should expect to see homework for your child between appointments. With all methods of therapy, you want the therapist to have a plan in place for your child to work through, with clearly outlined goals and clear criteria for ending treatment.
“For me, the biggest thing is for therapy to have a goal,” explains Dr. Lebow. “Ask your child and ask the therapist, ‘What are you doing?’ Both should be able to very clearly articulate what they are working on. So it’s not, ‘We just talk.’ Teenagers will sometimes say this. But the therapist should be able to articulate it better: ‘We’re trying to work on emotion regulation,’ something that feels tangible and correct with your understanding of what your child is going through.”
With younger children — but also with kids and teens as necessary — Dr. Lebow says parents might also reasonably attend part of a therapy session if they have questions. “Parents may want updates on progress, or have concerns about progress, or want to make sure the therapist knows some context or background information,” she explains. “I recommend going to a session and asking to have 5 to 10 minutes with the therapist for updates at the start or end so the kid knows this is happening. Ideally, the therapist will also reach out to keep the parent appropriately in the loop as therapy is going on. For other types of therapy — including FBT, parent management training, PCIT, DBT and parent-coached exposures — parents are actively involved in delivering interventions and should be part of the majority of many or all sessions.”
How to talk to your teen about therapy sessions
When your teenager starts therapy, it’s usual for a parent to feel awkward or self-conscious about knowing the appropriate amount of involvement. It’s a delicate line between wanting your teen to feel supported and respecting that there might be discussions of issues the teen wishes to keep private from you.
“For teens, therapy works best when the adolescent feels like there is some autonomy and privacy,” Dr. Lebow explains. “And the limits to that are well defined by the legal system. For patients under 18, there are limits to confidentiality around reporting thoughts or behaviors related to harming themselves or others, or reports of abuse of vulnerable groups like kids, older people and people with disabilities. It should be explained at the start of therapy that any reports of dangerous behaviors will need to be shared with parents or guardians by the therapist.”
Around this baseline of privacy, a parent can then gently show support, explains Dr. Lebow. “I might suggest being transparent with the child in a way that shows interest without being intrusive. This can be saying something at the start of therapy, like ‘I want you to know I’m always here to talk about your therapy, especially if stuff comes up that you want to discuss, or with which you need my support or help.’ “
Dr. Lebow also then recommends specifically checking that your teen has a good rapport with the therapist before underscoring that this is the teen’s therapy process. “I would say something like this: ‘I want to make sure you feel like you can talk to your therapist openly and to also let you know I’m not going to pry — either by trying to get details out of you or by trying to get them from the therapist.’ “
Once this initial setup is out of the way, parents can move to showing routine support. “You can ask follow-up general questions occasionally without pushing, like ‘How was therapy today?’ ” Dr Lebow says. “And doing this is probably sufficient to keep the door open while respecting your teen’s privacy.”
Your child’s relationship with the therapist
It is common for children and teens of all ages to depend on their therapists and develop close relationships. Therapists are trained to manage this bond with appropriate boundaries. However, if you feel your child has become overly attached to a therapist, Dr. Lebow recommends addressing it straightaway.
“The first step would be to bring it up to the therapist, maybe with the child there so there isn’t any secrecy.”
Parents may feel nervous about raising this topic, but therapists are used to dealing with boundaries and issues within the therapy relationship. “Part of our job as therapists is to identify things like this and discuss them,” Dr. Lebow says. “Your child’s therapist can say something like, ‘It feels like you’re thinking you have to come see me and that you won’t be well without me. Let’s talk about that.’ “
If the therapist takes your inquiry badly, Dr. Lebow says this might be a red flag. “If the therapist is weird about it or defensive or doesn’t seem to be responsive, then that’s a concern. At its most extreme it might indicate you need to consider switching therapists.
“Remember, though, that it is typical and important for your child to connect with the therapist independently, and part of the change we see in therapy is due to having that trust and relationship.”
How long therapy should last and when it should end?
Successful therapy doesn’t always happen quickly. “However, there should be an end point,” Dr. Lebow says. “Kids shouldn’t have to be in therapy for 20 years. Some kids do need a high level of therapy. But especially for life transition issues, a lot of what we are doing in therapy is trying to get kids back into their lives.”
There is also the reality that therapy adds a new item to a family’s schedule, and appointments may only be available during the school day.
“Sometimes therapy is disruptive,” Dr. Lebow adds. “You have to take your child out of school. But it’s a cost-benefit question because if your kid’s not functioning, the disruption may be worth it. If your kid’s functioning pretty well in life and then is suddenly getting pulled out of activities one or two times a week for therapy, that is a concern to me. Rather than being a barrier, therapy should be a tool that helps children get back in their lives.”
Dr. Lebow cautions that children will sometimes say they don’t want to go to therapy, and a parent should not misread this as an indication that it’s time to stop.
“Not wanting to go to therapy is not always a good indicator that something is wrong,” she elaborates. “Sometimes children say this when they’re just getting started and it’s hard. Honestly, most good therapy is a little unpleasant because it’s pushing you to do something you wouldn’t do otherwise.”
Ultimately, all methods of therapy should lift children from what they are having difficulty with and equip them with new skills. It’s important for parents to reinforce that therapy continues outside of sessions and long after therapy stops.
“It’s part of our ethical responsibility, especially with kids, to make it clear that this isn’t something that only works while you’re in it,” Dr. Lebow concludes. “This isn’t something that you’re dependent on your therapist for. This is something where you’re learning skills and eventually you’re going to be able to do it yourself. Therapy solves problems but it also helps build up kids’ resilience.”
Where medication, if applicable, fits in with therapy
“For most things that impact kids, therapy should be the first line treatment,” Dr. Lebow explains. “Therapy requires at least a little bit of action. Medication can be very helpful in giving you a little wiggle room in order to engage with therapy. But most of the data supports therapy as the first line option.”
This can be frustrating for parents who feel that their child has been struggling for some time. “I completely sympathize with families who want something fast,” Dr. Lebow admits. “Therapy does take time, but psychiatric medications are not antibiotics. It’s not like when your child has an ear infection and you want medication immediately because the clock’s ticking on when you child can sleep or go to school again. Psychiatry medications don’t work like that. They typically take 4 to 6 weeks to work (with some exceptions) and they don’t make you ‘happy.’ What they do is create wiggle room for children to be able to participate in therapy if they’re really having trouble doing so. This is something your therapist can weigh in on, as can your primary healthcare professional.”
Related articles in the Mayo Clinic Press Series: Navigating theraply for your child
Part 1: What kind of therapy is right for my child?
Part 2: How do I find the right therapist for my child?
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