Individual and family counseling

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Cancer is a crisis of major proportions for even the strongest of families. Parents do not need to face this crisis alone and unassisted. Many find it helpful to seek out sensitive, objective mental health care professionals to explore the difficult feelings—fear, anger, depression, anxiety, resentment, guilt—that cancer arouses.

Family responsibilities and authority undergo profound changes when a child is diagnosed with leukemia. Sometimes members of the family have difficulty adjusting to the changes. Although some families discuss the uncomfortable changes and feelings openly and agree on how to proceed, many need help.

Seeking professional counseling is a sign of strength, not failure. In dealing with children with cancer, problems often become too complex for families to deal with on their own. Seeking advice sends children a message that the parents care about what is happening to them and want to help face it together.

One of the first questions that arises is, "Who should we talk to?" There are numerous resource people in the community who can make referrals and valuable recommendations, including:

• Pediatrician

• Oncologist

• Nurse practitioner

• Clinic social worker

• School psychologist or counselor

• Health department social worker

• Other parents who have sought counseling

Ask your community resource people for a short list of mental health care professionals who have experience working with your issues, for example, traumatized children, marital problems, stress reduction, or family therapy. Generally, the names of the most well respected clinicians in the community will appear on several of the lists.

Choosing to get therapy isn't easy. And going to a psychologist isn't easy The only way to really work through the emotional pain is to look closely at it. Sometimes they ask hard questions. But it has been very beneficial for me. The best part about therapy is the person you are talking to is impartial. They aren't related to you, don't go to church with you, don't live with you, and have no connection to you or your situation. A totally unbiased perspective can be helpful when it feels like you are at the bottom of the pit, with no handholds, no ladder, but a shovel right beside you to help you dig deeper.

If you decide to go with one, do your research. I called and asked for references from a cancer help line and the social worker at the clinic. Then I talked to a couple of therapists before I decided which one to go with. She was willing to work with me on a payment schedule.

In making your decision, it helps to understand the different levels of training and education of the various types of mental health care professionals. You will be able to choose from individuals trained in one of these four related fields:

• Psychology (EdD, MA, PhD, PsyD). Marriage and family psychotherapists have a masters degree; clinical and research psychologists have a doctorate. (In some states, the use of the title "psychologist" may also be allowed for those with a masters degree only.)

• Social work (MSW, DSW, PhD). Clinical social workers have either a masters degree or a doctorate in a clinically emphasized program.

• Pastoral care (MA, MDiv, DMin, PhD, DDiv). Laymen or members of the clergy who receive specialized training in counseling.

• Medicine (MD, RN). Psychiatrists are medical doctors (and only they are able to prescribe medications). In addition, some nurses obtain postgraduate training in psychotherapy.

• Counseling (MA). In most states, school and agency counselors must have a masters degree and a year of internship before they can be hired as a counselor. To be a licensed professional counselor (LPC) requires a masters degree, additional coursework, thousands of hours of supervised counseling experience, and passage of a state licensing exam.

The designations LCSW (Licensed Clinical Social Worker), LSW (Licensed Social Worker), LMFCC (Licensed Marriage and Family Child Counselor), LPC (Licensed Professional Counselor), LMFT (Licensed Marriage and Family Therapist) refer to licensure by state professional boards, not academic degrees. These initials usually follow others that indicate an academic degree. If they don't, inquire about the therapist's academic training.

You may hear all of the above professionals referred to as "counselors" or "therapists." Most states require licensure or certification in order for professionals to practice independently; unlicensed professionals are allowed to practice only under the supervision of a licensed professional (typically as an "intern" or "assistant" in a clinic or licensed professionals private practice).

When you are seeking a counselor for yourself, ask the professional how long she has been in practice. A licensed marriage and family therapist who has been seeing patients for ten years may be a much finer clinician for your needs than a licensed psychologist or psychiatrist in his first year of practice.

Another method to find a suitable counselor is to call the American Association for Marriage and Family Therapy in Washington, D.C. at (202) 452-0109 or http://www. aamft.org. This is a national professional organization of licensed/certified marriage and family therapists. It has more than 23,000 members in the US and Canada, and its membership also includes licensed clinical social workers, pastoral counselors (who are MFCC/LMFTs), psychologists, and psychiatrists.

A psychiatrist who is the mother of a child with cancer offers a few thoughts:

Counseling helps, preferably from someone who regularly deals with parents of seriously ill children. This therapy is almost always short— although there may be some pre-cancer problems complicating the cancer issues that need to be hammered out.

Antidepressants definitely have a role in the "so your child has cancer" coping strategy. They cannot make the diagnosis go away They can improve concentration, energy, sleep, appetite, ability to get pleasure in life, and hope for the future—all of which you, your child with cancer, your spouse, and your other kids need you to have! They are not a magic bullet. They take two to eight weeks to work, and you may need to change once before you get the right medication, but it can make all the difference.

Also, nurture yourself. Take bubble baths. Buy flowers. Let people pamper you. Say yes when people offer to help. Redefine normal so things can be good again. Make time for yourself. Spend time with your spouse (even an hour to walk and talk and hold hands). Find time for your non-cancer kids, reveling in their accomplishments. Celebrate what is good about your life.

Pick out things that you feel are important to keep up with and do them. (For me it was laundry.) Ignore things that don't matter for the time being. (For me it was tidy rooms and cooking.) Make peace with your decisions and follow them.

To find a therapist, a good first step is to call two or three therapists who appear on several of your lists of recommendations. During your telephone interview, the following are some suggested questions to ask:

• Are you accepting new clients?

• Do you charge for an initial consultation?

• What training and experience do you have working with ill or traumatized children?

• How many years have you been working with families?

• What is your approach to resolving the problems children develop from trauma? Do you use a brief or long-term approach?

• What evaluation and assessment procedures will be used to define the problem?

• How and when will treatment goals be set?

• How will both parents be involved in treatment?

• What are your fees? Do you bill the insurance company directly?

The next step should be to make an appointment with one or two of the therapists who you think might be able to best address your needs. Be honest about the fact that you are interviewing several therapists prior to making a decision. The purpose of the introductory meeting is to see if you feel comfortable with the therapist. After all, credentials do not guarantee that a given therapist will work for you. Compatibility, trust, and a feeling of genuine caring are essential. It is worth the effort to continue your search until you find a good match.

I called several therapists out of desperation about my daughter's withdrawal and violent tantrums. I made appointments with two. The first I just didn't feel comfortable with at all, but the second felt like an old friend after one hour I have been to see her dozens of times over the years, and she has always helped me. I wasn't interested in theory; I wanted practical suggestions of how to deal with the behavior problems. My 4-year-old daughter asked why I was going to see the therapist, and I said that Hilda was a doctor, but instead of taking care of my body, she helped care for my feelings. She asked to go to the "feelings" doctor, but was concerned about whether her conversations would be private. I asked the counselor to explain about the limits of confidentiality. So that began a very helpful course of therapy for my daughter. To this day I don't know what was said, nor would I ever ask my daughter or Hilda. I do know that they did a lot of art therapy, and I know that it helped immensely.

We went to family counseling because I was concerned that my son seemed to be increasingly withdrawn and depressed. It was a disaster. The kids clammed up, I talked too much, and my husband was offended by some of the remarks that the counselor made. She was not a good choice for our family. It's a hard decision to change counselors when you know you need help, but it's better to make a move than to stay in an uncomfortable situation.

We went into family therapy because every member of my family experienced misdirected anger. When they were angry, they aimed it at me—the nice person who took care of them and loved them no matter what. But I was dissolving. I needed to learn to say "ouch," and they needed to learn other ways to handle their angry feelings.

Children need to be prepared for psychological intervention as for any unknown procedure. The following are several parents' suggestions on how to prepare your child:

• Explain who the therapist is, and what you hope to accomplish. If you are bringing your child in for therapy, explain why you think talking to an objective person might benefit him.

• Older children should be involved in the process of choosing a counselor. Younger children's likes and dislikes should be respected. If your young child does not get along well with one counselor, change.

• Make the experience positive rather than threatening.

• Reassure young children that the visit is for talking, drawing, or playing games, not for anything that is physically painful.

• Ask the therapist to explain the rules of confidentiality to both you and your child. Do not quiz your child after a visit to the therapist.

David had a very difficult time dealing with his brother's cancer. Realizing that we were unable to provide him with the help that he needed, we sought professional help for him. I think the reason that he feels so comfortable with his therapist is that he is aware of the rules of confidentiality. After his sessions, I'll always ask him how it went. Sometimes he'll just grin and say that it was fine, and other times he might share a little of his conversation with me. I never push or question him about it. If it is something he needs to discuss, I wait until he decides to broach the subject.

• Make sure that your child does not think that she is being punished; instead assure her that therapists help both adults and children understand and deal with feelings.

• Go yourself for counseling or to support group meetings to model the fact that all ages and types of people need help from time to time.

In the beginning of treatment, my son had terrible problems with going to sleep and then having nightmares, primarily about snakes. We took him to a counselor, who worked with him for several weeks and completely resolved the problem. The counselor had him befriend the snake, talk to it, and explain that it was keeping him awake. He would tell the snake, "I want you to stop bothering me because I need to go to sleep." The snake never returned.

Some other types of therapy used to help children with cancer are music therapy (http://www.musictherapy.org), art therapy (http://www.arttherapy.org), and dance therapy (http://www.ADTA.org).

In Armfuls of Time, psychologist Barbara Sourkes quotes Jonathan, a boy with cancer, who told her, "Thank you for giving me aliveness." She discusses the importance of psychotherapy for the child with a life-threatening illness:

Even when life itself cannot be guaranteed, psychotherapy can at least "give aliveness" to the child for however long that life may last. Through the extraordinary challenges posed by life-threatening illness, a precocious inner wisdom of life and its fragility emerges. Yet even in the struggle for survival, the spirit of childhood shines through.

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