Monday, August 17, 2009

Blind Date

I remember one particular referral phone call I received from a woman. She began by asking if she could make an appointment with me. Before I gave her an appointment, I asked her why she needed to see me. It took several minutes before she was wiling to talk, but then she started sharing a multitude of problems. First of all, she was actively suicidal. Second, she was consuming huge amounts of alcohol on a daily basis. Third, her husband had left her and she was totally overwhelmed by her children and household demands.

After she finished providing the highlights of her difficulties, we had a good talk about what she really needed in order to address the problems she faced. She finally agreed that meeting with me for an hour a week would not begin to handle her problems. We started talking about other resources. I gave her a number of referrals, including a variety of social service agencies which could be helpful with her situation. By the time we ended the phone call, I had significantly helped her and I had not even met with her.

In my opinion, I would have been cheating her if I had given her an appointment. I never could have addressed the seriousness of her problems in a one hour a week format without putting her at risk. She needed more than I had to give. I believe this was an ethical and responsible clinical decision, although probably not a popular one among clinicians.

Carl Whitaker was concerned with how therapists went about scheduling initial appointments. He thought the idea that anyone could call you up and tell you what insurance they carried and receive an appointment was ludicrous. He compared it to the blind date.

An individual you've never met calls you up and asks if they can make an appointment to talk. They want to come into your space and reveal intimate details of their life. Without knowing anything else, other than their insurance carrier, many therapists proceed with scheduling the appointment. Carl considered this a dangerous gamble. By calling it the "blind date," he emphasized the risk that goes with making the first appointments with clients.

If you thought of it as a blind date you would be more suspicious. You'd want to find out what you were getting into. You would ask about the person and why they want to meet you. In fact, most people would set up the first meeting in a public place, which would be safer than letting them enter your space.

Carl felt that the first phone call should be used to screen, negotiate and assure the therapist that the appointment is a good decision. He sometimes spent forty-five minutes to an hour on the first phone call. He would ask questions about who they were and ask them to describe their problems. He wanted to know why they wanted to see him. He believed that once you meet with families the first time, you have accepted some level of responsibility for them. If you are not the right therapist, it is better to provide appropriate referrals and avoid the meeting.

Carl had two beliefs he used to support his actions. First, most families rarely sit together and talk about their issues. When an entire family talks about their issues for the first time, there can be immense pressure. This pressure was one of the major reasons Carl referred to his work as the family crucible approach. When the family finally sits together, it heats things up and makes things happen.

Second, knowing this, Carl believed when the family first calls and tells you who can attend the therapy, they will offer only enough of the puzzle to maintain homeostasis. Their initial phone call will reflect a desire to have you change the scapegoat. He suggested that the family was like a puzzle. When they called up for the first session, they would offer you some of the pieces. He would challenge the situation by trying to determine how many of the pieces of the puzzle were needed to solve the problem. He insisted that all the relevant family members attend. If the teenager or the father were not available, he believed that they knew better and that he would agree with them by refusing to meet with the family. Their reluctance to attend signaled Whitaker that they did not believe in change. Awareness that the family will offer you just enough to not change is a motivator to use the initial phone call to get more help from the family. Once they have come in for the first meeting, in later sessions, it is more difficult to increase the size of the system.

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