Description of the Working Model and Clinical Examples
Regular Meetings throughout the School Year
In recent years, a model that promotes interactions between arts therapists and parents within the school system has been implemented in Israel. Based on my experience in the field and discussions with many supervisors and arts therapists, we have instituted and in certain cases defined an agreement to convene three meetings with parents during the school year: at the beginning (intake), middle and end of the school year. Each meeting has a different goal, as described below in detail.
Intake session. The goal of these meetings is to collect extensive information about the student on current and pervasive difficulties, the student’s strengths, development from childhood to the present, the student’s functioning in various domains (educational, social, behavioral, emotional), family information, family structure, the parents’ perceptions of their child’s difficulties and expectations from therapy (Nissimov-Nahum, 2008). At times, new information emerges during this meeting that was previously unknown to the educational staff, as shown in the following example2:
The parents of Dan (pseudonym), a teenager starting art therapy, were invited to an introductory meeting with me. In the end only the mother5 attended and she seemed distant, hesitant and restrained in her disclosure of information. I had a feeling that she was struggling to keep a secret. Carefully, but also directly, I asked her a few questions and finally the “secret” was revealed: Dan wets his bed at night. He was ashamed and tried to hide it by avoiding sleeping anywhere except at home. This family secret was never discussed but prompted family members to engage in secretive behavior. The mother revealed this secret with mixed feelings: she regretted exposing her son, and repeatedly asked the therapist not to tell the school staff. At the same time, she also seemed a little relieved.
As suggested through this example, this meeting is designed to establish a therapeutic alliance with the parents based on trust, openness and confidence in the arts therapist and in therapy, to encourage parents to support therapy by recognizing its benefits for their children and to create a channel of communication and reciprocity. Individual arts therapists have their own approaches: some exchange phone numbers with parents, and ask them to contact them directly, whereas others prefer to liaise via the teachers. As in the example above, at times there is a split in the information provided to the arts therapist and to the educational staff. The arts therapist may feel conflicted in terms of loyalty to the client and to the school staff but can take the role of mediator. In the intake interview, after the therapist learns more about the larger picture, the parents and the arts therapist try to come to an agreement on the therapeutic goals. This step is essential because the referral of a student for therapy is most often carried out by the educational staff; i.e., the teacher in collaboration with an extended multidisciplinary team. Situations often arise in which parents ask why their child needs therapy. Occasionally, parents struggle to acknowledge or recognize their children’s difficulties, since it touches on their own narcissistic difficulties (Espasa, 2004). The therapeutic contract also includes an agreement on the treatment setting: When will the arts therapist meet with the children? Which lesson will the student skip to go to therapy? Will he/she be given individual or group therapy? How often will the arts therapist and the parents meet and for what purpose?
Thus overall, the initial meeting serves to establish trust in the arts therapist and in therapy, to counsel parents, to demonstrate the kind of communication that can take place between parents and the therapist, and to illustrate the benefits of future parental encounters with the therapist. For example:
Dan’s mother, after revealing her son’s bed wetting issue and their feelings about it, asked what could be done. She seemed lost, trapped in the secret that had prevented her from seeing how her son could be helped. After asking what steps had been taken in the past, I suggested she go with Dan for a medical check-up and briefly explained the different approaches to enuresis. The mother then seemed more hopeful, compared to her expressions of powerlessness and guilt at the start of the meeting. I also suggested that she should confide in Dan’s teacher to find solutions for extra-curricular activities that require sleepovers. Later in the year, we met several more times, and she told me about the steps she had taken and the progress that had been made. Dan’s bed wetting had not stopped by the end of the year, but it was no longer something to hide. The mother’s efforts had improved her relationship with her son and enabled more open communication in the family and with the educational staff.
Parents frequently raise other questions during the intake sessions. These can include the nature of the content of these meetings, such as what can be asked and the extent to which personal issues are discussed. This is because some of these questions may seem too intrusive to certain parents, particularly when the arts therapists are at the start of their professional careers. In addition, treatment within the educational setting can lead to confusion for both the arts therapists and the parents as to the legitimacy of asking personal questions or sharing personal information. In my experience, it is important to ask substantive questions and to clarify, both broadly and deeply, all issues related to the child that also shed light on the parents’ attitudes, steps taken in the past, the parents’ perceptions of their child and
Working with Parents within Education 19 the extent of the problem. Therapists should be sensitive to the way questions are formulated, as well as the gradual nature of more in-depth probing of a delicate topic. Other questions have to do with the nature of the parenttherapist relationship: How often should parents meet with the therapist? How can the parties involved maintain contact despite the difficulties of making time for meetings, given the therapists’ large number of clients and the limited number of work hours allocated to these meetings? Would the parents be willing to come to school more often? Should the therapist insist on having both parents in attendance during these meetings? Should the arts therapist consider direct telephone contact with the parents or only communicate with them indirectly through the teacher? What can be done if the parents call the arts therapist frequently? Will parents cooperate with the therapy? What is the most reasonable way to work with parents in light of the extent of cooperation with the arts therapist?
Other issues relate specifically to the arts therapist. Does he/she have enough background to work with parents? Does he/she have experience working with parents? Can he/she come up with creative solutions when parents cannot attend planned sessions? Is he/she willing to pursue them? How often should these meetings be rescheduled when parents fail to materialize? There is no single answer to these questions, and individual arts therapists need to develop their own work habits consistent with the framework in which they work, their experience and their personal preferences.
The parental intake session is only one part of the information gathering process at the beginning of therapy. There are also intake sessions with the student and meetings with the educational-therapeutic staff (teachers, counselor, psychologist and information from the student’s personal file). When the information is fully collated, the therapy begins. Approximately two to four months later, the parents are invited back to school for the midyear meeting. These meetings are scheduled as a function of the academic calendar to correspond to times when students get their report cards and when academic award ceremonies take place.
Mid-year meeting. This meeting is typically initiated by the arts therapists. The purpose is to provide a general update that does not compromise the client’s right to privacy and to get an update about the client’s daily life in the family. For example:
In the middle of the year, about four months after the start of the year, I met with the mother of Mor, a teenager who was in her second year of individual therapy. The girl’s father had never attended these meetings and the relationship thus far had been exclusively with the mother. Mor was very quiet in class and at school, avoided classroom and extracurricular activities, and secluded herself during breaks whereas at home she behaved differently. During the intake session, the mother told me about her tantrums and wild behavior at home that was manifested in protracted bouts of shouting and verbal and physical violence.
I inquired if there had been a change at home and she told me that a significant change had taken place: she and her husband had separated a few weeks earlier. The mother talked about how hard the divorce proceedings were for her and her problems dealing with her troubled daughter. She later added that Mor had a complex relationship with her father, the first time this topic had ever been brought up. Mor’s mother and I both felt pain and sadness and a deeper understanding of Mor’s emotional world. We ended the conversation with an overview of support options available to Mor’s mother and a referral to family therapy, where she could work with her children on the parents’ separation, get support, and learn strategies to support them. The mother expressed concerns that she did not want to reveal the “family secret” to anyone else and asked to meet with me a few more times for support. We met once every two weeks for several sessions. When the mother realized she needed parental guidance, she agreed to my recommendation to seek out family therapy.
In the mid-year meetings with the parents, the following questions arise even more frequently: What should be disclosed to the parents about the therapy and the emotional content that emerges? How much information should be revealed? Should the client be aware that this meeting is taking place? Should the client be asked what he/she would like to be said? Again, there are no clear answers to these questions because the situation is complex and depends on many factors. Arts therapists adhere to a code of ethics which stipulates which high-risk situations require disclosure to parents and/or reporting to the authorities. Apart from these cases, the answers to these questions are determined by the arts therapist’s role, the therapeutic approach, the framework in which he/she works, the relationship that has been established with the parents, the parents’ willingness to share information and the relationship with the client. In most cases, the discussion emerges from the content the parents bring up in the meeting. If the parents or arts therapist wish to discuss content that emerged in therapy, the topic should first be identified and then discussed in general. It is important to note that this issue is fundamentally different for populations of young clients, in kindergarten or elementary school, as compared to adolescents in junior high and high school. Among the latter, confidentiality and privacy are more intrinsic, given the natural processes of adolescent development. For example, adolescent clients should be informed about meetings with their parents, as shown below:
In the mid-year meeting with the parents of a teenage girl, two distressing issues came to the fore: suspicion of irregular eating habits, and provocative dress and behavior as a way to connect with others, alongside an abundance of age-appropriate preoccupations with her external appearance. These issues emerged during encounters with
Working with Parents within Education 21 rhe educational staff and in therapy. After much collaborative thinking with the multidisciplinary staff, it was decided that I would try to clarify the situation in a personal conversation with the parents to gauge their level of awareness and perceptions. The parents were slightly suspicious and reacted defensively while feigning cooperation. Nevertheless, it was clear they did not trust me or the educational staff enough. I deliberated about how to raise these emotionally loaded issues. I started by talking about her daily schedule and eating habits. Her parents claimed that her lack of appetite during school hours was due to the effects of her medication. I learned that both parents were aware of her provocative behavior but could not agree on a response. The mother avoided direct action, and the father responded with aggression, firmness and inappropriate punishment. I realized that parental guidance was needed that included discussing more balanced responses to each parent’s concerns.
As seen in this example, mid-year meetings provide an opportunity to raise issues that emerge not only during therapy but also in the school setting. In the example, given the parents’ suspicion and our intermittent interactions, I avoided trying to understand why the client was acting out in this particular way. This vignette illustrates the difference between therapy in a school setting and therapy in a clinical setting where parents can be convened more frequently, establish trust and gradually open up and process sensitive issues.
Therapy termination meeting. The therapy termination session typically takes place towards the end of the academic year. The purpose is to review the therapeutic process and the changes that the client has experienced, as well as give parents the opportunity to consider the next phase, possible summer frameworks (for at-risk children), and to make recommendations for continued therapy if needed. It is also important to clarify the parents’ perceptions of the process their child experienced in therapy, changes in the family and the client’s functioning at home, and their thoughts about the future, as shown below:
Yael is an adolescent with learning disabilities and has a complex family situation. She is currently transitioning between junior high and high school. During the last month of school, she seemed depressed and self-absorbed. In the summary session concluding therapy with her mother, I described her condition, as perceived by the educational-therapeutic staff, and I inquired whether her condition had deteriorated at home as it appeared to have done at school. The mother experienced her daughter differently, and described her as being full of life, happy and socially active. Together we tried to understand why there was such a difference between her behavior at school and at home. One of the possible explanations was her upcoming transition to high schooland concerns about the academic effort it would require. Yael was also saying goodbye to significant people in her school life: a teacher whom she was close to, some of her friends who were enrolled in other educational frameworks, and also from myself, after three years of working together. It is possible that all these changes weighed heavily on Yael. I restated the importance of continuing with art therapy, which would support Yael’s transition to high school. In addition, I met with Yael several times, during which we processed our therapy termination and her transition, along with the complexity of emotions that emerged. I also encouraged her teacher to have a personal conversation with her, and to deal with the separation processes from her class together with all the classmates by devoting time to activities on this theme.
This example illustrates the importance of the relationship between the arts therapist and the parents in acquiring a fuller picture of the client. The conversation with Yael’s mother resulted in recommendations concerning Yael and her family, Yael’s emotional needs, and systemic recommendations that helped Yael and others in her class experience a smoother and more gradual transition.