What Children Feel About Their First Encounter

Contemp Fam Ther (2009) 31:177192
DOI 10.1007/s10591-009-9090-x
ORIGINAL PAPER
What Children Feel About Their First Encounter

with Child and Adolescent Psychiatry
Monica Hartzell Jaakko Seikkula Anne-Liis von Knorring
Published online: 19 April 2009

Springer Science+Business Media, LLC 2009
Abstract The first meeting in psychotherapeutic and psychosocial work, has a big impact
on the continuation. It is a less explored research field. Childrens voices tend to come in
the back-ground in family therapy and other settings. In a project at CAP (Child and
Adolescent Psychiatry) the childrens views were collected in interviews with parents and
therapists present. The grounded theory analysis process was used. The children addressed
the importance of the therapists actions and positions in helping them to be able to
communicate and to be in a dialogue. To be accepted and allowed to express feelings was
important, and so was how the therapist managed to adjust to each person in the room and
give space for various perspectives.
Keywords
Family therapy Child psychiatry First interview Childrens views
Introduction
In child and adolescent psychiatry (CAP) it is common to meet with both children and
adults, often simultaneously. An individuals first encounter with the therapists of the
organization and the way it plays out are vital for continued contact. Although the
importance of first meetings is acknowledged in all family approaches, few descriptions
and studies of the subject exist. The aim of this article is to describe childrens experiences
of the first family meeting at a child and adolescent psychiatric unit.
Family therapy offers valuable ways of thinking and acting when working with
children and parents, making it a useful resource in the CAP field. Although family
therapy is applicable in CAP, there are variations in training and its use. Since psychiatry
M. Hartzell (&) A.-L. von Knorring

Department of Neuroscience, Child & Adolescent Psychiatry, University Hospital,
751 85 Uppsala, Sweden
e-mail: monica.hartzell@bredband.net
J. Seikkula
Department of Psychology, University of Jyvaskyla, P.O. Box 35, 40315 Jyvaskyla, Finland
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is a medical approach, the theoretical framework of family therapy is but one alternative
in the psychiatric discourse. In studying the first meeting the perspective of family
therapy seems fruitful as it takes into account relationships, hierarchical structures,
dialogue, and more.
Many professionals have described how and what to consider and do when meeting
clients in psychotherapy or social work for the first time (Bryant 1984; Stierlin 1980;
Tomm 1992). Important topics have encompassed the skills the therapist needs in order to
conduct a successful first interview (Heller 1987; Paterson Williams et al. 1998; Weber
et al. 1985), including how to ask adequate questions (Cabie and Fride 1990) and who to
invite (Sveaass and Reichelt 2001). The process of joining the family and finding a
suitable way of interacting with them has been emphasised (Minuchin 1993). Flexibility
and spontaneity have been seen as key elements in building rapport with a family (Haley
1980). Using simple language and being clear about the reasons for the meeting, as well as
focusing on the child have been emphasised by others (Wilson 1998). The first meeting has
been seen as especially critical (Coleman 1995), and can be predictive of the following
process (Odell and Campbell 1998). In therapeutic relationships many authors talk about
the first 10 or 15 minutes as crucial, even in a long-term setting (Bachelor and Horvath
2002; Odell and Quinn 1998). From all the information communicated only a small part is
possible to take into account and the information that can stay conscious and kept in shortterm memory is limited (Christiansson 1994). An open and empathic attitude coupled with
a readiness to acknowledge ones own pre-understanding and reactions can make it easier
to receive what the others are communicating (Andersen 1992). There is a risk that the first
meeting can be filled with insensitivity and misunderstanding (Andersson et al. 1990;
Salamon 1993) and the choice of therapeutic method seems to be of less importance than
establishing a dialogue with clients and seeing the polyphonic nature of their reality
(Seikkula et al. 2003).
When studying the process of any session, as Orlinsky et al. (2004) point out, the
aspects the researcher as an observer finds helpful for the clients do not necessarily correspond to the clients opinion of what is helpful. Studies seldom consider how the clients
themselves describe therapists attitudes towards them or what the clients find helpful or
not in the first meeting. The context of child and adolescent psychiatry includes the
challenge of working with both children and adults (Kazdin 2004). A follow-up study of
treatment satisfaction of adolescents suffering from anorexia nervosa and their parents
showed that parents were more pleased with the therapists than were their children
(Paulson-Karlsson et al. 2006). Indeed, it has been found that the voice of the child tends to
become secondary in family therapy settings (Cederborg 1994). In interviews following a
series of family therapy sessions, children expressed a desire to be active and to be
included (Stith et al. 1996). Strickland-Clark et al. (2000) interviewed children about their
experiences of family therapy and found they needed more support. The children appreciated being listened to and not being judged, but it was sometimes difficult for them when
the adults reacted to what the children would say, or when the conversation concerned only
the parents.
On the whole, little research exists on first encounters in therapeutic settings. Gustafsson
(2000) asked adults via questionnaires about their first meeting in a psychiatric practice and
received mainly positive responses. We have found no published studies on first encounters
using qualitative research approaches. The lack of knowledge about what families, and
especially children, feel about their first experience with professionals warrants an
exploration. The aim of this study was to attain a deeper understanding of the first face-toface meeting with CAP as expressed by the children.
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Methods and Material

The design was qualitative, based on the grounded theory method (Charmaz 2006; Glaser
and Strauss 1967; Thulesius 2003). The study was approved by the Ethics committee of
Uppsala University (dnr 01-356, 01-359). The data derives from a project carried out
between 2002 and 2007 to analyze and develop the first family encounter at CAP, an
organisation intended for children up to 18 years of age. Fourteen cases were analyzed, of
which four were from an emergency unit, and ten were from an out-patient unit. Compared
to an earlier study of CAP in Sweden, the cases match the distribution of sex, age, and
contact reason as described by von Knorring et al. (1985). Only about 2% of the families
who visited the unit for the first time were interviewed. One reason for this was that many
families declined participation. Also, some families were not asked to participate for
ethical reasons cited by the therapists. The 14 initial research interviews were supplemented with 11 interviews 6 months later. In one case both interviews were attended only
by the staff (case S). Table 1 shows an overview of the participants including age and sex
of the children, contact reason, and persons present at the interviews.
Table 1 Overview of the participants in the research interviews
Participants
in first
meeting
Age
Contact reason
of child
Therapists
Attended
first
research
interview
Attended
second
research
interview
S: son, father
10
Anxiety, lack of parent

responsibility
Doctor, nurse
No
No
B: son, mother, social

worker
11
Neglect, behaviour
problems
Doctor, nurse
Yes
No
C: daughter, mother
15
Depressed
Doctor,
psychologist
Yesa
Yesa
L: daughter, father,
sister
16
Avoids school,
adjustment disability
Doctor, nurse
Yesa
No
A: son, mother
12
Domestic violence
Psychologist,
psychiatric
social worker
Yesa
Yesa
R: daughter, mother
13
Sexual abuse. Avoids school Two psychologists Yesa
Yesa
W: son, father, mother
Yesa
D: son, father, mother
14
E: son, father, mother
Sexual harassment
Psychologist
Yes
Yes
Depressed
Psychologist
Sexual harassment
Two psychologists Yesa
Yesa
Yes
F: daughter, mother
12
Refuses school, depressed
Psychologist,
psychiatric
social worker
Yesa
Yesb
G: daughter, mother
13
Aggressive behaviour
Psychiatric
social worker
Yesa
Yesa
H: son, mother
12
Depressed, not motivated

for school
Doctor
Yesb
Yesa
N: daughter, mother
11
Eating problems
Doctor
Yesa
Yesa
J: daughter, mother
a
One reflector present
Two reflectors present
15
Depressed, suicidal
thoughts, self harm
Doctor, nurse
Yes
No
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The emergency unit handles all kinds of child psychiatric problems. The out-patient unit
deals with a range of problems including depressive symptoms, abuse, and anxiety. At the
emergency unit, the families generally meet a nurse and a doctor when they come for the
first time. The out-patient unit offers other combinations of staff, and sometimes families
meet only one professional. At the emergency unit half of the staff actively took part in the
project, although the whole staff was supportive. Almost everybody on the staff at the outpatient unit were engaged in the project. The extent of family therapy training varied
greatly; some had had several years of training and supervision, while others had only
attended short courses or workshops.
Families who visited the organisation for the first time were informed by the therapists
about the project by mail if the meeting was planned in advance or when the therapists
came to the waiting room to pick them up. Information was given both verbally and in
written form. Ordinary clinical routines were followed whether or not the family chose to
participate in the project. If the family agreed to participate, the therapists video-recorded
the first meeting. The film was archived, so as not to bias the interviewer.
Within 2 weeks of the initial meeting the first author (MH) interviewed the family and
the therapists. A second interview, intended to provide extended information about the first
meeting, was organised 6 months later and was arranged in the same way as the first
interview. In the study, 14 first research interviews and 11 seconds research interviews
were conducted; 25 interviews were conducted altogether. The second interviews also were
video-recorded.
The Research Interview
At the research interview, both the family and the team in charge were present, and
everyone was encouraged to tell their story about what the first meeting was like while
the others listened. Thus, each interview was co-constructed by everybody in the room.
The research interview included one or two trained research assistants, reflectors (Collen
et al. 2006). Their assignment was to reflect on the interview process as well as help the
first author to adhere to and develop the subject and to prevent interviewer bias. The
latter was important as the first author could be a member of the therapeutic team as
well. During the interview the reflectors were invited by the first author to share what
they had been thinking or felt was missing while listening and thus give space to as
much information as possible from the first meeting. Their presence and function could
also help maintain a positive atmosphere (Andersen 1995). None of them was employed
by CAP.
The first author followed an interview plan, which was roughly outlined in advance and
was modified (Lincoln and Guba 1985), especially in the beginning of the project. The plan
was as follows:
1. The initial interview question can be phrased: What is the first thing that comes to
mind when you think about the first meeting?
2. Begin by turning to the family/network, first the parents, but very soon to the child,
and ask each person about the first consultation. Encourage them to help each other to
describe their encounter. If somebody from the familys professional network is
included, he or she is asked after the family members.
3. Ask about what was important to each person, words that made an impression, what
they remembered afterwards, expectations, etc.
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4. Talk about what the therapists did in connection to the memorable or crucial situations.
5. Stop the questioning and listen to what the reflector has to say. Common themes can be
what the interviewer did not follow up on, and going back to what the therapists did or
said, as well as wanting to hear the family relate more about certain themes. This can
be done early in the interview and usually 24 times altogether. The reflectors can for
example comment on whose voice had not yet been heard much in the research
interview, or say they would like to hear the family say more about what the therapist
did in a certain sequence of the first meeting.
6. Turn to the therapists and ask if they agree or have a different view of what the first
meeting was like. How does it feel to think about what the family says? Do they have
questions?
7. Members of the family can give feed-back to the therapists, and are also free to say
more if they wish.
8. The interview ends with the last words coming from the family.
Data Analysis
Grounded theory (Glaser and Strauss 1967), which inspired the present analysis, offers a
way of evaluating the data without pre-knowledge of or prejudices toward the material
(Charmaz 2006). Conclusions are formed without constraint of an a priori hypothesis
(Levitt et al. 2006). Thulesius (2003) describes how concepts and categories emerge in the
analysis process by constantly comparing data with the found categories. Each level of
categorisation is more abstract than the previous one. When choosing a method of analysis
for the present study, the grounded theory analysis process appeared suitable in that it
could satisfy the need both to present the data in a form as close as possible to the
childrens own descriptions and to delve deeper into understanding the process of the first
consultation and the topics connected with it. Also, it could be possible to achieve a
theorisation of the subject matter.
The first author transcribed the data from the video-recorded interviews into 760 pages
of text with one column for each person present. This gave a graphic and time-related
overview of the interviews. Spoken words and certain visual expressions were noted. The
interviews lasted between 23 and 58 min. Apart from the reflectors, a total of 47 persons,
the 14 children included, were interviewed, most of them twice, both in the first and in the
second research interview. The data were analysed as follows:
1. The first author read and re-read the transcripts with as little pre-plan or anticipation as
possible.
2. Utterances from the children about the first meeting were marked as meaning units
(Rennie 2000). Negative data were not excluded.
3. The meaning units, a total of 951, were sorted and put into preliminary categories.
4. The preliminary categories were repeatedly compared to each other and to the text as a
whole. Categories were then created.
5. The categories were split into two groups because of their differing nature.
6. A senior researcher not involved in the project examined the material and helped the
first author to scrutinise the analysis process.
7. After a further comparison phase, two core categories emerged out of one of the
categories.
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Findings
Opinions and descriptions about the first meeting expressed by the children during the
interviews were collected and analysed. The following categories emerged: Previous
experiences, Parents presence or absence, Accept person, Accept description, Allow
feelings, Be alert, Ask questions, Adjust and correct vis-a`-vis each person, and Mind the
time. These were further divided into two groups, intra-process categories and extraprocess categories, the former of which gave rise to two core categories. These had the
form of verbs and were labelled active position of the therapist (consisting of the categories
Ask questions, Adjust and correct vis-a`-vis each person, and Mind the time), and passive
position of the therapist (categories Accept person, Accept description, Allow feelings, and
Stay alert).
Extra-Process Categories
The extra-process categories (Previous experiences and Parents presence or absence)
represent phenomena that certainly influence the ongoing process, but were set in advance.
Previous Experiences
This category pertains to the families earlier experiences of similar meetings. Members of
the family make comparisons between the present meeting and others they have attended.
Parents may have visited other institutions and services, and children have perhaps been in
meetings at school. Previous experiences are likely to affect how the first meeting with
CAP is seen. The effects of the families previous experiences or whether or not the parents
are in the room are handled by the therapists.
A son of 14 could not at first find ways to describe differences between the meeting here
and meetings at school. Later he said that there were other kinds of questions here. His
mother meant people were much more confronting in meetings at school; here it was much
calmer, and that was to the benefit of her son. He talked more:
First author (MH): Is it true, D, as your mother noticed, that you said more here than at
school?
D: Mhm. The questions are different.
A mother with an eleven year old son had attended many meetings before the first one at
CAP. Her experiences were very negative, possibly followed by iatrogenic injury. For her
son, this was one of the first meetings that left him with a positive attitude.
MH: Did you think of anything in advance, B, about what they might help you with
here?
B: No. (Quiet for a little while) I think it will get better.
MH: You think it will get better?
B: Mhm. It felt good when we were here. Mum thought so, too.
Parents Presence or Absence
The second extra-process category is about whether parents should be in the room or not
and its impact on the meeting. In this study, most of the children wanted them to be there.
Some children seemed ambivalent.
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A boy of 12 surprised his mother by telling the therapist so much about himself in such
a thorough and calm way. His mother was present throughout the session. She had had
thoughts in advance of leaving the room to give space for her son. For him, this had never
been an issue to consider:
Mother: Is there anything he doesnt want to tell me, but that he should or wants to say
without me being present. Thats what I was thinking.
MH: What do you think about this, H?
H: No, I dont think so.
Mother: Do you want me to be in the room?
H: Yes!
One father wondered if his son was too considerate when the parents were in the room.
He asked his son of seven if it would have been better for him if the parents had not been in
the room. The boy pondered the question and answered no. He also stressed that the
parents presence did not stop him from expressing how things really were:
Father: Maybe he thought a lot about what we might think or feel.
W: (firmly) I say how it really is! Humph!
Father: A question to you, W: Would it have felt better if Mum and I had not been here?
W: (turns in his chair, thinks) No.
In another case, the father did not give any space for his ten-year-old son to speak, and
the team could not find a way to get him to talk. He was rejecting, and showed physically
that he disliked and even suffered in the situation. The therapists said in the research
interview (the family was unavailable) that it probably would have been a relief for the boy
to be released from the consultation.
One father who had a son of six, had wondered whether it would have been easier and
less embarrassing if the parents had not been present. Asked about it, his son believed it
would have been more difficult.
A sixteen-year-old girl had been very clear from the beginning that she wanted time
alone with the team. In the research interview she described that this was good and nothing
she would have wanted to change, which was confirmed by the mother. Later in the
interview she was asked more about this, and said two things at the same time: it both
would and would not have been very different if her mother had been present all the time.
MH: how would it have been if your mother had been in the room all the time? Would
it have made any difference?
J: Well yes, of course it is different to talk with that person being therebut not much.
Its the same thing as, sorry, your worst friend or something being in here right now. I
guess you would act differently just now, dont you think so?
A seven-year-old boy said that he would have been so much more nervous if his parents
had not been in the room:
MH: What would it had been like, do you think, if you had met N (therapist) alone the
first time?
W: The first time I believe I would have been very, very nervous.
MH: So, having Mum and Dad present made you less nervous?
W: Yes, it did, actually.
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Intra-Process Categories
The intra-process categories were connected to the therapists attitude and actions during
the first meeting. They were divided into passive position of the therapist and active
position of the therapist as described by the children. The categories connected to the
passive position were Accept person, Accept description, Allow feelings, and Stay alert.
The active position of the therapist included Ask questions, Adjust vis-a`-vis each person,
and Mind the time.
Passive Position of the Therapist
Accept Person. The children felt they were accepted for who they were by the therapists.
One boy of six said the therapists listened to him, which he thought was good. A twelveyear-old girl, F, thought it was important to have been accepted as an individual who has
struggled to find solutions:
F: It doesnt have to be perfect from the beginning.
Mother: Yes, maybe
MH: Ok. Do you feel the therapists accepted
F: that this is how things are.
MH: That this is the way things are right now?
F: I mean, not make us feel guilty: like, why did you do this? Like, this is your fault.
Not like that.
Thirteen year old G felt it was important that the therapist had no previous opinion of
her. She feared it might have affected questions and answers:
G: that they dont already have an opinion about you when you come. I think it
isbecause that is what usually happens even if you dont want it to, you most often
have an image, an opinion, about a person. It doesnt have to be, like, a bad opinion, but
still. It might affect the questions she asks or my answers or so.
Accept Description. This is a category about being allowed to tell your story on your
own. One girl of 11 said she felt she was allowed to say what she wanted to say. Fifteen
year old C was given the opportunity to express herself:
C: You asked, I mean, whats going on with me, you gave me questions, but not Mum,
not then. And then I responded to that, and it became a certain picture of it all. So you
got a good picture of what it is like.
Allow Feelings. Some of the children felt there was room for feelings. H, a twelve-yearold boy, remembered that he experienced a lot of feelings:
MH: What is the first thing you come to think about?
H: (quiet)well
MH: It says click and suddenly something comes up in your head?
H: All the feelings that appeared.
C, a 15 years old girl, talked about how the emotional level was activated during the
session:
C: Many feelings. (Quiet) (To her mother) We talked about things I had not talked to
you about before. Things you didnt know and so on.
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Stay Alert. This category catches the therapists ability to be present, attentive and ready
to act. J, a girl of 15, described how she saw the therapists:
J: They looked kind of relaxed. And then, well, it felt as though it wasnt just a work
assignment, they took it more like something else, I dont quite know how to explain
MH: No, it wasnt just
J: It wasnt as though you go to work and do your assignment, like some people do. It
felt more like, not a problem that should be solved
N was 11, and she said about the therapists attitude:
MH: How did you think K (therapist) acted towards you?
N: Kind.
MH: Kind. Mhm. In what way did you notice that she was kind?
N: (thinks, smiles) I dont know.
MH: How can you tell someone is kind?
N: That she listened.
MH: I see. She listened to everything you said?
N: Yes, that she understood.
MH: Did you feel she understood?
N: Yes.
J, fifteen years old, said it felt nice to be there, the therapists smiled as they came, and
the two cooperated well together. All this made it easier for her to open up. She added
later:
J: They were friendlier than I had expected them to be. They were not so stiff or rigid.
They didnt just sit there and talk.
To sum up, the passive position of the therapist includes neutrality, acceptance of each
person and what he or she describes, and allowing feelings to occur. It also involves being
ready to deal with serious matters, being mentally present and alert. The passive position
does not imply doing nothing. Rather, it means being in a state of readiness and acceptance
of each person present. It also implies reflecting and keeping the inner dialogue going
(Andersen 2003).
Active Position of the Therapist
Ask Questions. Comments connected to the therapists questioning occurred frequently. A,
a twelve year old boy, felt uncomfortable with some questions and said they were
dodgy. Eleven year old B blamed himself for becoming irritated sometimes. But perhaps
the therapists could have handled it better:
MH: Was there anything you found strange or you thought Why are they doing it like
this?, or
B: There were some questions that made me irritated. But (silent)
MH: Ok. Do you remember what those questions were about?
B: I dont know, but, sort ofSometimes I just become grumpy and also irritated and
sometimes I can be tired, too, so I dont know.
Fifteen year old C described that the reason why she was able to reveal things she had
not been able to say to her mother before, was because of the questions she was asked, not
because she could not hold it inside anymore:
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C: Mhm. Only because you asked. So I answered.

The therapists questions led twelve-year-old Fs thoughts in other directions:
F: You start thinking about other things, so to speak.
D, boy of 14, found some questions difficult to answer, but felt they still filled a
purpose:
D: Sometimes you cant answer, but it is ok to be asked.
Questions served as a good start and helped structure the discussion, something G, a girl
of 13, articulated:
G: It felt very good, and there was no problem, sort of letting it out and so on. If you just
got somebody to, like, asking a little and so on, you sort of get started.
G: nice and easy, so I can go through everything the way I want. I felt I could take it in
my own order, the way I have seen everything myself. And I can do this because she
asks such open questions. So I can, sort of, go through piece by piece and tell how it
happened.
J, 15, said that the way questions were asked was more important than what was asked.
She added later that some questions seemed unnecessary, and she understood during the
interview that what was clear to her was not clear to the therapists. Being asked questions
made her ponder, which she appreciated:
J: Yes, but I have already answered that question. Thats how I was thinking But I
think it is good, because, it is very good, because then you start thinking thoroughly, you
know. Maybe you havent thought so much at all.
Adjust Vis-a`-vis Each Person. The way the therapist related to the client and to the other
persons in the room was noted by the children. C, 15, liked that she and her mother both
had the opportunity to speak.
C: No, I mean, I thought, Mum talked a little, and then I talked a little, and with Mum. It
was kind of fair.
MH: Ok. I see.
C: It wasnt like: Well, now Mum talks a lot, now they sort of forget to talk more with
me. Not like that. So, it was good.
For G, a girl of 13, it was important that the therapist did not jump between subjects.
That would have confused her:
G: But that you dont sort of mix the questions, because then you can almost be a bit
confused, obviously. It is like you were able to tell the first time, rather long answers,
like, otherwise you might be confused yourself and maybe forget something that you
actually found important.
G also reported that the therapist took her time, took the problem in, and listened to both
parties.
The interviewer asked 12 years old A if he remembered something that the therapists
did to make it easier for him to say what he wanted to say. He described how he thinks they
helped him to cope and keep the conversation going:
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A: Yes, they assisted a little. They probably noticed if it was a little more difficult, so
they helped me a little.
MH: What did they do to help?
A: They asked like this added some things to make it a little easier, in casea little
easier, like, words. Like: Tell us. What I should give answers to, sort of. I dont
know
Interviewer: Ok, so they could use other words?
A: They could, eh, they could simplify!
D, a fourteen year old boy, found it positive that the therapist was calm and asked in a
direct and nice way. H, a twelve-year-old boy, appreciated that the therapist held on to the
difficult questions, even though he was afraid of starting to cry. For N it was good to be
asked if she wanted to say something:
MH: What did K (therapist) do to make you feel welcome to talk and to tell what you
found important?
N: She asked me if I wanted to say something.
MH: Yes. Was that a good way for you?
N: Yes.
MH: Could she have done anything more to help you to speak?
N: No.
Fifteen year old J felt neither forced to talk nor to stay, both which were important to
her. She explained further that the therapists conveyed that the reason she and her mother
were there was not just about her, which made her feel relieved.
J: I felt like this, somehow, that if I might find that it wasnt good, I could walk away
from here. No, I thought, in advance, ok Im gonna be kept there, and theyre gonna,
like, force me to talk. And I didnt feel that way, because I knew, that if I find it is really
tough, then nobody canthen I just sit there quiet and look justweird, or I just leave.
And then I knew they wouldnt put handcuffs on me. Well Im joking, but
J: it felt as if it wasnt just about me, thats how I felt. It didnt feel like now were
here, its your problem
J would have liked to hear the therapists views on her difficulties, although she figured
this was not common, and she never asked for them. Something 11 years old N found
lacking were tips on how to cope with her problems. In her view, that would have helped.
Mind the Time. This category is about the therapist taking responsibility for the length
of the session. Some of the interviewed children found the first consultation to be too long.
One boy of fourteen, D, suggested there could be two shorter meetings instead of one long
one.
A ten-year-old son, S, took part in a first meeting, which lasted for about two and a half
hours, during which he conveyed strong feelings of discomfort, although he did not speak.
His father did not seem to notice that the time span and the situation were too difficult for
the boy to endure. The therapists were not aware of the importance of considering the
length of the first session until it was brought up in the research interview. Long sessions
may be acceptable for the parents and therapists, while the childrens needs in this sense
might be overseen.
In summary, much of the active position is about helping the children communicate.
Some children said that the therapists corrected themselves if they found they had made it
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difficult for the child to express herself or himself, and that it then became easier. Many of
the children found the therapists to be good listeners. Some conveyed the importance of
letting all parties be heard. Some children described how the therapists facilitated for them
by asking clarifying questions, by simplifying, and by suggesting answers. These are all
examples of the therapist acting and being in an outer dialogue (Andersen 2003), asking
questions, adjusting and correcting vis-a`-vis each person.
Discussion
Children in the study wanted to communicate when they felt bad about things, even though
it was sometimes hard for them to do so. Helping the child find the words and the courage
to say them is one of the therapists key responsibilities according to the children. In
several examples the children described what they liked about the therapists behaviour. If
we accept that what they liked about the situation is also conducive to a positive therapeutic process, they give the therapist plenty of tips. Some of the children described how
the therapists facilitated communication by listening, asking questions, simplifying questions and words, suggesting answers, correcting themselves and adjusting in an active
dialogue with the child and the other family members.
Many of the children found it natural to have the parents present in the room. The
children depended on their parents in the meeting, regardless of how the team members
reacted. The balance of also creating an alliance with the adults was delicate.
The children were not satisfied with everything. There were things that they would have
liked the therapists to handle differently, for example, approaching the most difficult areas
more delicately and keeping consultations shorter. Another example is that they wanted the
therapist not to leave the difficult subjects too soon.
The findings of this study suggest that it is beneficial and appreciated by the children
when the therapist moves between being active and being passive but prepared to act. The
children described the importance of the therapist being neutral, accepting each person and
his or her story, and allowing emotional communication. This included being mentally
present, alert, and ready to deal with all types of serious matters. To link together the intraprocess categories, it could be said that the therapists assist in getting the children to talk in
these first consultations by shifting between action and readiness (Fig. 1).
What helps, what is regarded as helpful, and how this is decided are universal and
currently debated questions in the field of psychotherapy research (Hubble et al. 2002).
When listening to what the children had to say, it became evident that not all children can
be treated the same way. It is a challenge for every therapist to adjust to a certain child or
family. The therapists approach depends on the culture at the centre, the therapists
training, and the family members expectations and behaviour. The context in which the
therapist works can limit flexibility in choosing how to work. Wampold (2001) writes
about the situation in his native country:
It is fully recognised that managed care limits the freedom that therapists have to
deliver treatment that they deem to be optimal. In a sense, such limitations result
from imposition of a medical model onto the practice of psychotherapy (p. 159).
CAP is a medical institution, where information is collected for decisions about diagnosis, level of functioning, treatment planning, and treatment. If collecting information
becomes the main purpose for the staff in the first meeting, it may clash with the childrens
wishes. The children in the study addressed talking, telling, and listening in the first
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Desired achievement
Therapist moving with sensitivity between
action and readiness to facilitate
communication
Intra-process factors
Passive position by therapist
Accept person
Active position by therapist

Ask questions
Accept description
Adjust vis--vis each person
Allow feelings
Mind the time
Stay alert
Extra-process factors
Clinical context
Families previous
Parents presence
Therapists training
and culture
experiences
or absence
and background
Fig. 1 What the children appreciate about the therapist during the first consultation, and what limits the
possibilities of the consultation
meeting. It seems communication was a major issue for them. Although collecting
information and maintaining communication at a satisfactory level are not necessarily
opposing endeavours, being aware of these two essentially different perspectives is a
challenge for the staff. Figure 1 shows a theoretical model of what children appreciated
about the therapist during the first consultation, and what limited the possibilities of the
consultation.
Unlike the children in most sessions in Cederborgs (1994) work, most of the children in
the present study expressed that their voice had been heardthey had been listened to
during the first consultation. It can be noted, however, that in Cederborgs study there were
always two parents and sometimes siblings in the room. In our study the childrens
description of the importance of therapists listening both to them and to the parents fits
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well with the statements of both Anderson (1997) and Seikkula et al. (2001a, b) regarding
the importance of giving everyone involved the opportunity to contribute their views.
None of the children showed any signs of iatrogenic injuries (Salamon 1993) from the
first meeting. Instead, the aspects valued by the children can be expected to make them
open to a continued therapeutic process and give them hope and confidence that change for
the better can be achieved.
We suggest that the childrens impressions of how they have been received and how the
team members acted towards them are central aspects for the children in these first
meetings. As Miller (2004) points out, it is the clients perception of the relationship with
the therapist that determines a positive outcome of the therapeutic relationship.
It was beneficial to the children when the team members conveyed that the children
were able to answer the staffs questions, and that their answers were important and
interesting. The members of the team gave the children space, and conveyed that things
can get better. As Seikkula et al. (2003) would describe it, dialogue in its therapeutic sense
has been going on, and it has been possible to express reality from different perspectives.
The childrens views give signs of what can be useful for professionals when meeting
children and adolescents and their families for the first time, to make them feel comfortable
enough to be ready to continue a therapeutic process.
Design and Analysis
The ethics of interviewing families in an especially vulnerable situation was discussed
continually throughout the project. It was only possible to interview a few of the families
who visited the CAP centre for the first time, and the cases represent a convenience sample
(Patton 2002). The data collected are precious and rare, especially the childrens
utterances.
The interviewer must be knowledgeable in the field of study to be able to ask relevant
questions (Patton 2002). This was assured as the first author is a clinical psychologist with
more than 15 years in the field. Now and then the children needed guiding questions in
order to be able to express themselves. The advantages of seeing everybody together and
giving them the opportunity to fill in and comment on each others stories made it more
likely to recreate an accurate, multifaceted image of the first meeting.
The second research interview after 6 months was conducted to gather more data about
the first consultation. There were no comparisons made between the first and the second
research interviews, since changes in opinion over time were not the focus of the study.
The reflectors comments were helpful for the interviewer to be able to hold on to
themes and to broaden answers. The use of reflectors in the research interviews gave
transparency to the research process and helped to secure a greater amount of data.
Limitations and Further Research
The lack of relevant research findings to compare to the present results makes the conclusions somewhat tentative.
The data were collected from a small convenience sample, and the results may therefore
not be representative of families or children visiting CAP for the first time.
The first author served as interviewer, researcher, and therapist in the study, which
could be both a weakness and a strength. There is a risk of being overly involved and
lacking nuances (Patton 2002), while involvement at several levels gives access to the
entire research process.
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Contact reasons were not taken into account by the study design. The families included
represented common child and adolescent psychiatric clientele. The results may have been
different if we had interviewed children who were seen for the same reason. Our interest,
however, was to look at how the first consultation would be described, rather than to search
for differences in perspectives among children based on contact reason.
The study sheds some light on the first encounter with CAP from the childrens perspective. It is suggested that the results are applicable in other contexts where children and
their parents meet with professionals for the first time. The results could be useful in
continued research in the field, both qualitative and quantitative. Forthcoming studies from
the project will present the adults perspective.
Acknowledgments This work was supported by grants from the Gillbergska foundation and the foundation Professor Bror Gadelius Minnesfond. For valuable comments thanks go to professor Rolf Holmqvist,
Linkoping, and professor Per Jensen, Oslo. We also thank Dr Kristina Haglund for important help with
analyses and comments.
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Contemp Fam Ther (2009) 31:177192