Excerpts from Must Read Books & Articles on Mental Health Topics
Books, Part XVII

Behind the One-Way Mirror: Psychotherapy & Children
Katharine Davis Fishman

Jonathan Wheeler, talking about the youngest of his four children, speaks haltingly, trying to summon events he has worked hard to put behind him. "Carl had been a nervous, excitable baby with digestive problems, so he always needed more attention than the others. Then, when he was three, something happened that required intervention. While we were on vacation, Carl rolled in a clump of poison ivy. We didn't get to the brown soap soon enough, and he was covered with a nasty rash--which, of course, we kept smearing with calamine. On the pediatrician's advice, we even threw out all the clothes Carl was wearing that day.
    "But weeks after we'd done all this, the rash persisted; it appeared every morning,. and he scratched and scratched until his arms and legs were covered with open sores. The dermatologist gave him test after test and could find no organic explanation for the rash that was there now. We finally took him to a child psychiatrist, who after several weeks concluded that the problem was psychosomatic: Carl had somehow internalized the original experience and was reproducing the rash overnight. After several months of therapy the welts began to disappear. We decided we'd gotten through the episode, and hoped for better times.
    "Then Carl started school, and we again saw odd patterns of behavior. He'd hide under tables and chairs, and his teachers complained that they had difficulty keeping tabs on him. We knew we had a complicated child. He also showed some musical talent at an early age, making up tunes and picking them out on the piano. We got him lessons, which he always enjoyed.
    "In fifth grade Carl became very volatile. He punched two women teachers, and the principal told us he couldn't stay unless he learned to control himself. So we sent him to a private school that specialized in dealing with problem children. The next year we put him in therapy with a psychologist, partly because he seemed resolutely unwilling to do any academic work no matter how hard we and the school tried to engage him, even though by all tests he was in the top two or three percent of his class intellectually. He failed almost everything, and we hoped therapy might provide some answers.
    "Carl grudgingly agreed to go, and stuck with it for three years. I think he came to like the therapist, though he wouldn't admit it and we saw no sign that he was learning much. At first the therapist wanted the family there too. Then, after a few months, we decided it should be mostly Carl's private time, and I didn't intrude with questions. But my relationship with Carl had become tense and angry.
    "Still, the family sessions did enormous good for me. I was perplexed about my responsibilities as a parent. Worried that if I became too tolerant of what I saw as Carl's irresponsibility toward other people, I would fail to meet my obligations. In the therapy I was encouraged to see myself as the children might see me, and to reconsider my rigidity and the weight of my anger. I came to realize that I'd had no useful models of parenting in my own life. And perhaps it was helpful for Carl to hear me talking about the difficulty I had knowing how to be a father.
    "But by eighth grade we decided Carl himself wasn't benefiting, emotionally or academically, and the therapist agreed that there was no point in going on. Then Carl was asked to leave the private school. We sent him to public high school in the suburb we'd just moved to, and once again he began this pattern of hostility and failure in everything but music. Gradually he got into smoking and drinking and pot, and had two terrible years of deterioration, until he was stoned most of the time and even selling drugs out of his bedroom. Having him in the house was almost intolerable. After several school conferences I suggested that Carl just leave school. A month later he was arrested for breaking and entering a convenience store, and received a suspended sentence. This brought us to two other therapists, both of whom he met with hostility. One was a court-recommended specialist in drug abuse, who said that Carl was certainly at risk but not yet addicted to drugs or alcohol. I didn't take to this therapist, but we stuck it out for eight sessions.
    "Still, Carl, despite his resistance, was clearly shocked by the conviction. It seemed to be a turning point. Suddenly he agreed to study for GE Ds, with hopes of getting into a nearby conservatory. He moved into an apartment, he studied, he took music courses, he practiced, he passed the GED easily and got into music school, where he was quickly understood to be someone with talent. He was beginning to win approval, which was unusual for him in a school. Success begot success: this year he's working night and day, one of his pieces is being performed at school, and we seem to be getting along well."
    Jonathan Wheeler's story raises many of the questions that baffle parents and stir debate among professionals in the field of child psychotherapy. Carl had been, as Wheeler puts it, "well on his way to being an enemy of the people." Did his various therapeutic experiences have a delayed effect, or did he outgrow his disorder. What combination of biology, temperament, environment, and experience caused this child's problems? How, if at all, were the symptoms he showed at different ages connected? What part did changes in family dynamics play? The feelings that pervade Wheeler's own account of the family's turmoil--bewilderment, self-doubt, vulnerability--are typical of parents, however competent and well educated, who must make decisions while they and their children are suffering, and who feel at a loss to monitor the treatment: the least they might do with a physical disorder. And the story's mysterious happy ending offers little comfort to professionals, or to other parents.

Choosing a Therapy
For the past twenty years, government and scholarly estimates of the number of children eighteen and under who suffer from mental disorders have hovered around 12 percent of that population. But a recent report from the Institute of Medicine of the National Academy of Sciences suggests that the figure may actually be as high as 17 to 22 percent--11 million to 14 million children--an increase attributed to sharper methods of diagnosis and classification, not to some new mal du siecle. Still, in almost everyone's estimation the times seem to be especially difficult for children. The suicide rate for white adolescent males has tripled in the past thirty years, as has that for all young people aged fifteen to twenty-four. And as Michael Thompson, a member of Independent School Psychological Consultants and a psychologist who practices in Cambridge, Massachusetts, points out, "We've had a thirty-year epidemic of divorce and a generation of shell-shocked children. We have only begun to understand the long-term effects of having so many busted-up families."
    Today's college students (yesterday's children) are likely to have experienced mental health problems of some sort and to have sought help for them. R. David Kissinger, Ph.D., the director of the counseling center at the State University of New York at Binghamton, says that the center routinely asks freshmen who come in whether they've ever seen a psychiatrist, a psychologist or a social worker for therapy. Ten years ago 30 percent had. In 1989 the figure was 44 percent. "Traditionally we like to work with college students over the rough spots in development," Kissinger says. "Forming an identity, establishing relationships, choosing a career. That's a luxury we could afford twenty years ago. Now we're not working with developmental problems; we're too busy with severely damaged students. They're suicidal, or they have long-term character disorders. The degree of pathology is more intense."
    In contrast, Randolph Catlin, M.D., the chief of the mental health service at the Harvard Health Service, says that he is seeing primarily developmental problems. Recently, Catlin says, a young man presented himself saying, "My friends tell me I should be more tolerant. They think it's a psychiatric problem." Someone who was simply considered unpleasant twenty years ago, Catlin observes, might now be deemed in need of therapy. There seems, then, to be both a proliferation of serious problems and a broadening definition of what's grist for the clinical mill.
    Unless a child is clearly psychotic, the idea of therapy troubles and perplexes most parents. Since many laymen haven't caught up with research on the complex origins of mental disorders, the assumption of parental guilt, however wrongheaded, is bound to creep in, subtly or overtly encouraged by popular literature and by some school officials and mental health professionals. So perhaps the child is just a really terrible two, or having a very difficult adolescence.
    Indeed, although the durability of Carl Wheeler's sudden improvement is uncertain, some problems do appear to go away without treatment. (In his book Child Psychotherapy, Alan E. Kazdin, a professor of psychology at Yale, cites fighting, stuttering, and bed-wetting as behaviors that sometimes disappear without intervention.) Some problems don't, however. ("Children who show early signs of dysfunction such as unmanageability, aggression, social withdrawal, or speech and language problems, are at risk for subsequent psychiatric disorders," Kazdin writes, and he notes a need for "intervening in response to early signs ... to prevent them from becoming worse.") Particularly when the symptoms are mild, parents may wonder whether therapy is a useful emotional vaccination or a fashionable indulgence.
    Those who believe in informed decision-making may be daunted by the choices: Kazdin identifies 230 different types of therapy available to children, from "activity interview group" to "Z-process." (Perhaps he's exaggerating to make a point, but the point is telling.) The approaches can be vastly divergent in the time they require, and therefore in cost. And whereas insurance reimbursement for some sort of therapy is now widespread--98 percent of employees with health insurance in middle-sized to large firms have it--the extent of coverage varies widely. Only two percent of those employees, according to the Bureau of Labor Statistics, receive the same benefits for mental as for physical outpatient care: their policies may impose a do dollar limit, a limit on the number of visits (say, twenty a year), or a lower coinsurance rate for outpatient psychotherapy.
    Moreover, different approaches, not to mention different practitioners, relate to parents in different ways, and this affects the parents' own comfort. In child therapy the patient is not paying the bill--a circumstance that raises difficulties for the parent, the child, and the therapist. Few children come in saying, "The pain is intolerable, give me relief"; the decision to begin therapy will likely have been made by an adult (who may have hauled the child in by the hair). That is one of three special characteristics of child therapy that professionals have long noted and that parents should be aware of too. The others are that the child's verbal and conceptual abilities; the entry points for psychotherapy, are limited; and that in every area of development the child is a moving target. While most therapists would agree with the late British psychoanalyst D. W Winnicott that the purpose of therapy is to let "the developmental processes simply take over as the analysis begins to succeed," each therapeutic approach meets the challenge differently.
    In July of 1982 American Psychologist published a survey of 415 members of the American Psychological Association in clinical practice in which they were asked to label themselves, as it were. The largest proportion, 41 percent, said they were "eclectic"; 11 percent said they were "psychoanalytic"; 10 percent called themselves "cognitive-behavioral"; nine percent were "person-centered, " seven, percent "behavioral," and three percent "Adierian. " Smaller percentages were "family," "reality," "Gestalt," "existential," "rational-emotive," and "transactional"; and, with all those tags available, nine percent still called themselves "other." Even though psychotherapy generally, and so child psychotherapy, may thus seem hopelessly splintered, all the approaches may reasonably be grouped into three broad categories, each with a distinctive view of its task and of the patient. (All the therapies may be used in conjunction with psychopharmacology, which I won't address here.)
   Psychodynamic therapy looks inward: it aims at helping the child understand his or her emotions. To do this, the therapist must get to the roots of the problem. Dynamic therapists tend to view the patient as a text to be explicated, with clues often presented in symbolic form. Classical psychoanalysis, which generally requires four sessions a week, is only one form of dynamic therapy, and while it is the form best known to laymen, it is so expensive and time-consuming that it is seldom used on children. Dynamic therapy involving one or two weekly sessions is likely to take several years.
   Cognitive-behavioral therapy looks outward: it trains the child to see the world differently and to change his or her behavior patterns. It has its roots in experimental psychology and employs rigorous data-gathering and measurement of results, practices that prevail in laboratories. Cognitive-behaviorists, who prefer the term "client" to "patient," tend to look at the child as a machine with a broken part that needs fixing. Aimed at alleviating a particular group of symptoms, cognitive-behavioral therapy usually lasts from four months to a year.
   Family-systems therapy holds that no problems are individual; all reflect a malfunction in the family unit. The family-systems model--in which a symptomatic child is called the "identified patient"--draws on cybernetic theories of how the parts of a system (in this case, the family) interact, and resembles cultural anthropology, which explores the way beliefs are transmitted from generation to generation. It uses both psychodynamic and cognitive-behavioral techniques. Family-systems therapy might take two sessions or several years.

Diagnosing the Problem
To learn something about the clinical state of the art I recently spent several months with senior and student practitioners in each of the three orientations, discussing how they solved problems, and watching and listening to children (in the flesh or on tape) in therapeutic sessions. My goal was not to explore theoretical or scholarly differences, except as they affected actual clinical practice; I wanted, simply, to find out what children experience in therapy.
    I limited my observations to moderately disturbed patients, assuming that disorders like autism and schizophrenia are beyond the scope of a general article. I also disregarded the educational aspects of learning disabilities, although their psychological by-products are an appropriate concern here: As Kim Lord, whose son Matthew has a reading disability, remembers, "He had lots of friends and no trouble until he started first grade. But very quickly a bright child who doesn't learn knows something is wrong and begins to try and compensate in various ways. Matthew became bossy and attention-seeking, and began to alienate other kids because of his behavior, even though we were quite clear that the initial problems were academic." A dyslexic child who feels humiliated might, for example, become depressed, hyperactive, or bulimic.
    "A symptom is a call for help," says Michael Thompson, the psychologist in Cambridge, Massachusetts, who treats pre-adolescents and their families and consults to a number of private schools nearby. Thompson defines a symptom as "normal behavior that is displayed too much, too intensely, or in the wrong place at the wrong time."
    By way of illustration, Thompson remembers a boarding-school student who exploded in study hall one day. "He got into a fight with the teacher about homework, and all of a sudden he began to heat up. He said an extraordinary number of obscenities to the teacher and read the teacher out in an astonishing way. The other kids were just riveted. He was thrown out of school, because what he had done was too intense, too public. What he was saying was 'Something's going so wrong that I have to use this language,' which all children use when they are away from adults, and adults use when they're not around children, but he jumped over the line and used it to an adult about the adult in front of other children. That made it a symptom. He got himself out of school and into therapy in a big hurry."
    When behavior is less explosive but still conspicuous, Thompson and other professionals look at how long it's been going on. "If a child has always been shy and inhibited, his shyness may be constitutional and not symptomatic," Thompson says. But a sudden change in temperament that persists longer than it should--weeks of depressed behavior, for example, or mourning that goes on longer than a year--is cause for alarm.

The Psychodynamic Approach
When lay persons think of a psychiatrist, they probably imagine someone like Charles A. Sarnoff, M.D., a scholarly, gray-haired man of sixty-two with an almost whispery voice, apt to pursue the answer to any question with terrier-like tenacity. His explanations, besides citing cases, roam the cultural landscape from Aristotle to Congreve to Foucault to James M. Barrie.  Sarnoff practices in Great Neck, New York, a Long Island suburb. He also lectures at the Psychoanalytic Center for Training and Research at Columbia University's College of Physicians & Surgeons, and is a supervisor in child and adolescent psychiatry at Long Island Jewish Medical Center. In addition to the requisite training in adult and child psychiatry, Sarnoff has four years training in the psychoanalysis of adults and six years training in the psychoanalysis of children. In more than thirty years of practice he has seen enough patients to make a fair-sized longitudinal study.
    Sarnoff is the author of two widely used textbooks on latency and one on adolescence ("latency" is a Freudian term for the years from six to twelve, and a tip-off to Sarnoff's orientation: a non-Freudian might use the term middle childhood"). In his later years Freud--and thus most of his followers--characterized latency as a period in which sexual and aggressive drives diminish to permit the child to be educable; Sarnoff follows an earlier Freudian theory that the drives don't diminish but are dammed up by a retreat to fantasies that calm the child, with the same net effect.
    Samoff's books, filled with case histories from his practice, depict latency as a bubbling cauldron of psychologically significant activity. He defines himself as a Freudian primarily because he believes that drives motivate fantasies, which then contribute to the formation of symptoms (other orientations, even psychodynamic ones, don't assign this weight to unconscious drives). Moreover, his therapy often draws on the Freudian concept of transference, according to which the patient loads onto the therapist repressed feelings for others in his life. Noteworthy, however, is that Sarnoff uses words like "contribute" and "draw on." "Within mental illness or human emotional reactions today we can find a multitude of contributions, " he says, "including head injuries, genetic factors, social factors, and psychological factors--and we also have to include early childhood experience." A Freudian in the 1990s needn't be a monomaniac.
    When feelings and events are too stressful or humiliating to deal with directly, a healthy latency-age child, Sarnoff has written, "can fall back into a web of symbols, which, woven into a kind of mythic map, can be used as a guide to a land where his power and self-esteem are reinstated." Sarnoff explains the way this works by recalling the old movie Forbidden Games, in which "children are exposed to the death of relatives and seem to be calm and able to integrate and handle things, and then something strange begins to happen in town: crosses disappear from catafalques and no one knows where they're going. The children have been burying birds and little mice and having play ceremonies. They're involved in the use of three-dimensional objects that Piaget calls ludic symbols. " A symptom is an unhealthy symbol. By approaching a child through play, Sarnoff hopes first to decipher his or her symbols, then to help the child work through conflicts by playing them out, and finally to give the child insight into his or her feelings and behavior.
    "I call latency-age children biologically celibate soldier-dwarfs," Sarnoff says, "to show the restrictions with which they live. The child is so little that if someone picked him up and he tried to hit that person he'd be swinging in the air, and if he has any kind of sexual fantasies, he certainly doesn't have the organ capacity for carrying out his designs. Later there's a stage called ludic demise, when the play symbols are no longer used, because the children now have, say, orgastic potential available to them.
    "I have devised one office after another in such a way that the child has two doors he can walk through, or he comes into the room and the way I stand makes it possible for him to choose whether he's going into the playroom or the consulting room. You actually see them go back and forth. A youngster is making Play-Doh figures of robbers. One day he moves into your office and wants to sit at the desk--he's the judge, you're a robber, and you're coming to trial."
    The technique that a therapist uses to assess a new patient tends to be characteristic of both the therapeutic orientation and that individual therapist. Sarnoff orders such educational evaluations as are necessary, and pointedly calls attention to the stethoscope, ophthalmoscope, and reflex hammer in his office--the competitive arsenal against nonmedical practitioners--but his main assessment tools are interviews with the parents and child.
    He starts with the parents, both to take the usual case history and to establish a working relationship, whose nature varies according to the child's age. "If it's latency," he says, "I'm in touch with the parents, they know how to reach me, they can call me two times a week, they can come and see me, we work together as a team. If it's an adolescent, then you do your best to keep the parent at a distance and the child is your patient."
    How a therapist deals with parents is, of course, of major importance to the parents. A minority of psychodynamic therapists and analysts will have nothing whatsoever to do with parents; family therapists, at the other end of the spectrum, virtually always treat parents and children together. Sarnoff, like most psychodynamic therapists, follows the traditional "child guidance" model. He has written, "I prefer not to see parents and children together. There is danger that the alliance between adults . . . will be interpreted by the child as a sign of disloyalty, betrayal, or simply being left out."
    At the same time, Sarnoff, whose position on most doctrinal issues is "I hew as close to the ideal as I can, but go as far away as I have to," says that in some circumstances an adolescent's parents must be dealt with. "If you have a relatively healthy neurotic child, keeping your distance can work out, but it is a perilous course when you have severely disturbed people, manipulative people. Then you have to break the rule and make yourself available to the parents. You tell the patients everything, treat them like adults, but unfortunately some of them are not adult enough to be treated that way. It's hard to maintain a relationship with patients if they think you're talking to their parents, so you really are in conflict."
    With younger patients, although one or both parents are there to identify the "zone of pathology," the interview with the child is clearly the key. Sarnoff points out that the thought patterns of children differ from those of adults, and the child may even be proud of his or her symptoms. Sometimes play, drawings, and ludic symbols are the only means of communication.
    All therapeutic assessments start, logically enough, with a concept of normalcy, both biological and cultural. (Sarnoff once worked at a clinic where an unusual number of child patients reported hearing holy voices; he discovered that in the parochial schools they attended, this phenomenon was not a symptom but a mark of status.) Sarnoff needs to know whether the child has entered latency, whether he or she can produce calming symbols, and how far the child's abilities to remember and understand have progressed. "I'll ask children to tell me about their favorite TV cartoon," he says. "If they can tell me a whole story, then I know they are reducing their sensory experience to a verbal memory system, and maybe even moving into a fine level of abstraction. But so many times I'll hear them say, 'I like when Bluto hits Popeye, then Popeye hits Bluto back, and they fight,' and that's all. Or they take two little figurines and they have them battling each other, constantly hitting or punching, and you know this youngster is not making up a story, he's just involved in aggressive interaction. This is perfectly all right for a three- or four-year-old, but when you get to a five- or six-year-old, you've got a problem there."
    A skilled therapist can make surprisingly sophisticated concepts understandable to children. It might seem a hopeless task to convey to an elementary school child that he fears not an actual cat but his own angry feelings that he has projected onto the cat. Sarnoff does it with an object called a ghost gun, a sort of slide projector that throws a picture of a ghost on the wall. Inside the gun is a needle that punctures the film, so that the child can "shoot" the ghost; Sarnoff can then demonstrate to the child that the shooting appears on the screen but is actually going on inside the gun and being projected onto the screen, just as the feelings inside the child's head are being projected onto the cat.
    Pre-adolescent children may not play with dolls and puppets, but they are usually willing to draw and model clay. Even when such older children talk, they may be talking symbolically. Sarnoff describes a twelve-year-old boy who's depressed. "Back when he was five, he was in an accident with his friend. They were playing and he threw something with a sharp point which hit the friend and paralyzed his hand. Now, the boy is perfectly willing to come into therapy, and he's even a good talker. He reads a lot. He likes to read Stephen King novels, and he begins to talk about Pet Sematary, in which a man's child dies, he brings the child back to life, and the child dies again. It becomes very clear--every story this child tells is about doing and undoing. He's not telling about this directly. If I were to say, 'You're depressed because of what you did with someone as a child,' he might get up and run out of the room. He's dealing with it in a displaced manner, passively using the symbols of Stephen King.
    "Little by little, you keep on getting him to talk about these stories. You gather stories like this. You wait for him as he goes through all of them. Eventually he's going to get to this. You know when to ask him to tell more--'What do you think the character should have done?' You begin to discuss the material in a displaced form. By inadvertence, almost, you bring the material to the surface, and get a kid to work on it and talk about it and deal with it as if he's talking about someone else. That's as close as the ego can get to the trauma. He may never say it, but still he achieves a certain amount of catharsis and does better.
    Parents may worry about what they perceive as the indefiniteness of psychodynamic therapy: it seems to go on and on, with no clear termination point. Sarnoff, in sharp contrast to cognitive-behaviorists, believes that just clearing up the presenting symptom is not enough; unless the underlying problem is rooted out and worked through, another symptom will come along to replace the first--"old wine in new bottles," as Sarnoff puts it. "There are many external symptoms that can change with maturation," he says, "so a sadomasochistic fantasy that had been expressing itself in the form of fear of persecution--by robbers, by dogs--may appear to remit when the child goes into adolescence. But the boy has a very sadomasochistic persecutory relationship with a girl." Cognitive-behaviorists say that no one has conclusive data to substantiate the notion of "symptom substitution"; Sarnoff says he sees repeated evidence of it in his practice.
    What Samoff does expect to see, in addition to resolution of the presenting symptom, is greater success in academic and social activities, a healthier choice of friends, and developmental progress as fast as that of the child peers. In other words, as he has written, "further therapeutic work will only produce progress that age-appropriate natural development could provide as well"--the same termination point that is cited by D. W Winnicott, the British psychoanalyst.

Kevin, An Eleven-Year-Old Boy
One afternoon Sarnoff and I drove out to Schneider Children's Hospital, a division of Long Island Jewish Medical Center, in New Hyde Park, New York, to watch Emanuel Falcone, M.D., a thirty-three-year-old resident completing his fellowship in child psychiatry, in session with Kevin, an eleven-year-old boy. In hopes of helping other children, Kevin and his parents had agreed to let me observe behind a one-way mirror.
    Before the session Falcone, a dark-haired man with wire-rimmed glasses and a close-cropped beard, briefed me on Kevin: "He was ten when he came to us. He had many fears of separation. He was concerned that he might be kidnapped, that his parents might be killed or injured somehow. He was afraid of going on subways either alone or with his mother, because of the subway rapist. He also suffered from obsessional thinking and some compulsions.
    "He was obsessed about being poisoned or food being contaminated. Once when the food was heavily peppered, he was convinced the specks were dirt, not pepper, and the lasagna dinner had to be thrown away. It was also impinging on his functioning: he wouldn't go on Boy Scout trips using the subway. He had trouble sleeping alone, and he would often go into his parents' bedroom.
    "When he came to us, he had some rituals, like repetitive hand-washing, twenty times a day. There's a whole obsessive-compulsive disorder involving that behavior which is untreatable except by medication and a strict behavior-modification approach--many people feel that psychotherapy won't do any good at all. However, we saw some things off the path which had us hold off those interventions. He was able to relate--the key thing in psychotherapy. And the hand-washing stopped pretty quickly when a doctor and his parents explained that if he kept it up, his hands would become infected. One fear replaced another, but that's telling, because someone was able to break through his distorted view of reality.
    "There is worrying within Kevin's family. His father and paternal grandmother are worriers. The father checks the gas jet and rattles the front door, checking it several times before he leaves, waking up the family. Kevin used to be quite anxious about this, feeling that someone was breaking into the house. What he does now is go to the window, and if he sees his father leaving, or his car isn't there, he doesn't worry.
    "When I started doing a little work with the family, I got a lot of mileage out of it," Falcone said. "I asked how they had been treating his worries. They didn't mean it, but there was over-concern. For example, he didn't want to go out in a rainstorm or stand on the porch when it was drizzling. They'd say, 'It's only drizzling; the odds are that lightning won't strike. You can certainly take an umbrella and just go to the store, because even though the umbrella is metal, it would only hit the trees first.' Well, there's more worrying than reassurance in that reassurance.
    "It was very hard for them, but I had them say, 'Don't be silly, just go out, hurry up back.' I said, if you must allay your anxieties, do it from a window, not the door, and don't let him see you. That was a very small piece of work--I used to see them five minutes before Kevin's session and five minutes after."
    "With one session a week his response has been very good," Falcone continued. "He went with the Scouts alone on the subway, no problem. He has started to stay out till it gets darker and they have to tell him to come in, where he used to run home the minute it got dark. He's playing rougher kinds of sports. So we were going to evaluate whether to continue treatment, and at that point he started to do worse.
    "We had one failure. On an overnight Halloween outing it was his job to frighten the Cub Scouts. When they got to the campsite, they found it had been vandalized, possibly days ago, possibly hours ago. No major damage, just graffiti. That was at the back of Kevin's mind. He dressed up in his spooky outfit and went to scare the younger kids, but he just couldn't do it. He didn't have the size or the conviction; the little kids laughed at him and ganged up to beat him up. It was a humiliating experience. He's a very sensitive, empathic child. The one point in the night when he managed to scare someone, the child admitted he was scared and Kevin just couldn't bear it anymore and said, 'Now, look, it's me.'
    "So what happened to the anger Kevin felt toward the kids who were laughing at him, abusing him, and beating him up? He dealt with the anger later that night, when things were quieting down. At bedtime he became terrified that the vandals were going to come back and beat people up, possibly kill them with knives and guns. He became uncontrollable. His mother and the scoutmaster couldn't manage him, and they had to send him home."
    Falcone and Sarnoff agreed that Kevin's fears contained a kernel of realism, but the paranoid reactions were always triggered by situations that gave him cause for anger. In this case he was not alone in the wilderness but protected by Scouts, scoutmasters, and parents.  In recent sessions Falcone and Kevin--who was now waiting outside--had been talking about bullies at school. One goal, logically enough, was to teach Kevin to stand up to the bullies without becoming a bully himself. "The larger purpose," Samoff pointed out, "is to have him reach the point where he can recognize and accept his own rage, so he doesn't have to defend against it by producing fantasies that distort reality. Once you do that, you can achieve a state of calm in the individual when he goes on to deal with reality itself."
    Kevin proved to bean appealing boy with shaggy brown hair, wearing jeans, a heavy sweater, and sneakers. Sarnoff and I installed ourselves behind the mirror as Falcone began to ask how the week had gone. The conversation sounded like ordinary small talk. Kevin had joined a video club to rent Nintendo games. He was fidgeting a bit, pulling his sweater sleeves over his hands and looking around the room; perhaps he was thinking about being observed. Falcone continued to chat about video games, searching for a handle. Kevin was playing with his ear.
    "That," Sarnoff whispered, "is an autoerotic gesture. Something about the, games made him regress." I asked if it was stage fright; Sarnoff said Kevin, who was now sitting on his hands, was afraid of his dawning sexual feelings. Falcone had asked Kevin what was happening in school, and they were up to Tuesday. Kevin began to tell a long story in a casual tone. He was smiling a bit, but the story was about a beating-up. Kevin's friend Bruce had been accused of writing graffiti about one of the bullies; when he denied it, the bully said he would fight Bruce after school. So Kevin and Bruce tried to duck out together, but this bully got some big kids and they cornered the two boys. Kevin's sister was there and the two of them escaped, but the bullies got Bruce.
    Falcone questioned him about the incident in detail, almost like a policeman or a reporter, and said, "Hey, that's scary, your friend's helpless, you have to watch, there's nothing you can do." He was trying to get Kevin to admit to the emotion in the situation. Finally Falcone asked Kevin what he did next, and Kevin said that he and Bruce had rented a Friday the 13th video game. (Later Falcone told me that the horror-movie villains Jason, Freddy Krueger, and Michael Myers are very important figures to kids in latency and early adolescence. "We use them like a Rorschach where the child projects his own feelings onto the characters," he said. "Psychiatrists have to keep a finger on the pulse of youth. Most of us who go into our business keep the aspects of childhood close to the heart, so it's really not difficult.")
    Falcone pointed out that Jason is a big bully you get to beat up in that game. "And you just got beaten up."
"I didn't want to be the big guy, because the big guy got beaten up," Kevin said. "In the video game I kicked him across the street."
"When you play the video games," Falcone asked, "how do you feel?
"I enjoy it.. I get into it."
"Do you think they help kids?"
"Yeah. "
"Hand-eye coordination." Kevin looked around. Something was getting him.
Falcone continued. "Maybe the video game stirs up the anger."
"I don't think so. It lets it out."
"So maybe that's good."
    Falcone and Kevin talked more, but clearly the major work of the session was getting Kevin to understand that the video game was a way of letting off steam. (It's not enough, Sarnoff pointed out later; Kevin must also learn to deal with angry feelings directly. Video-game parlors, he said, are filled with men in business suits at high noon, all zapping their bosses.) One source of mild disagreement between Sarnoff and Falcone, whose background is Sullivanian (a school of psychodynamic therapy that focuses on interpersonal relationships), is Falcone's preference for talk over play: Sarnoff thinks that Kevin is on the cusp of ludic demise, and that some information will be lost if Falcone doesn't allow more playtime. When Kevin gets fidgety, Sarnoff says, he needs to play.
    The amount of apparent filler in a psychodynamic session is notable to a lay observer, though professionals say that some of it will prove significant later on. "You're panning for gold," I said. Falcone liked this image; Sarnoff didn't, feeling that it implied passivity and randomness. "We have to go after these golden moments," he said.

The Cognitive-Behavioral Approach
Perhaps the most characteristic expression of Philip C. Kendall, Ph.D., is "There's no hard data, but my belief is . . ." That idiom (which would be foreign to Sarnoff) identifies him as a cognitive-behaviorist, a member of a school "identified as much by its epistemological dedication to the search for rigorous standards of proof as by alignment with any set of concepts," according to a recent article in the Journal of the American Academy of Child and Adolescent Psychiatry. Although Kendall has beliefs that come from his clinical experience, he is always careful to separate those from conclusions supported by research data.
    Kendall, forty-one, holds a cornucopia of titles at Temple University, in Philadelphia: professor of psychology, head of the Division of Clinical Psychology, director of clinical training, and director of the Child and Adolescent Anxiety Disorders Clinic. He is the author of innumerable journal articles, a co-author of Cognitive-Behavioral Therapy for Impulsive Children, and the author of the Stop and Think Workbook for use with hyperactive children in therapy. Kendall practices privately in Merion Station, Pennsylvania, and was the 1990 president of the Association for the Advancement of Behavior Therapy, the chief professional organization in his field.
    As Sarnoff's personality seems to fit his therapeutic orientation, so is Kendall's manner evocative. A tall, thin, dark-haired, fair-skinned man with horn-rimmed glasses and the requisite beard, he suggests a science teacher who also coaches the tennis team. And he does say, "I'm an interpersonal psychological coach, and I'm going to find out if the backhand's good, if the serve is good, do they volley well, do they focus, and wherever they need the help, that's where we're going to put it"' Kendall's aura of common sense is one that many parents, especially those turned off or intimidated by the idea of psychotherapy, would find accessible and reassuring.
    A patient who signs on with Kendall needn't worry about endless therapy. "We use time-limited chunks, sixteen or seventeen sessions, and at the end we say, 'Where are we now?' If we feel we need more, we renegotiate. I say, 'Okay, you came in wanting to make friends and not get in trouble. You're getting in trouble less in school but still haven't made friends. Let's work on that for sixteen more sessions.' I even give the kids certificates when they finish. They accomplished something. They didn't go to tennis camp, so they don't have a better game to show, but they went to a psychologist and completed a program."
    Traditional behavior modification aims to change a behavior by manipulating stimulus and response or by offering punishments and rewards. Because pure behavioral intervention is effective only for certain problems (and because some of its benefits may not last), many professionals have moved toward cognitive-behaviorism, which attempts "to change behavior and feelings by changing thinking patterns," as the AACAP journal article defines it. Nearly 70 percent of the membership of Kendall's organization now labels itself cognitive-behavioral.
    Like psychodynamic therapists, cognitive-behaviorists believe that mental disorders arise from distortion of the meaning of experiences. The two groups differ about the reason for the distortion and the way to set it straight. In a chapter of Kendall's most recent book, Child and Adolescent Therapy: Cognitive-Behavioral Procedures, he writes,

Consider the experience of stepping in something a dog left on the lawn. The first reaction ("Oh, sh--") is probably a self-statement that reflects dismay. Individuals then proceed to process the experience.... Some may attribute the misstep to their inability to do anything right; such a global internal and stable attribution often characterizes depression.... An angry individual, in contrast, might see the experience as the result of someone else's provocation ("Whose dog left this here--I bet the guy knew someone would step in it!"); attributing the mess to someone else's intentional provocation is linked to aggressive retaliatory behavior. . . . An individual who brings an anxiety-prone structure to the misstep experience . . . would see the threat of embarrassment and the risk of germs, and process the experiences accordingly. Anxious cognitive processing of the experience might include self-talk such as "What if somebody notices the bad smell; they'll think I'm dirty." "What if germs get into my shoes and then to my socks, and my feet? Should I throw these shoes away?"

Later in the chapter Kendall writes, "Knowing that we all, figuratively, step in it at times, what is needed structure for coping with these unwanted events when they occur." Cognitive-behavioral therapy aims to provide that structure by helping the child analyze whether his perceptions are justified, modeling ways to deal with stressful situations, and giving him opportunities to rehearse a competent response. While a good, flexible psychodynamic therapist will offer some help with coping strategies, Sarnoff describes this as "what one does while waiting for insight to arrive." Kendall, on the other hand, says, "I think other schools pay too much attention to cause. Once they find a cause, miraculously things will get better. I don't believe you can find an exact understanding of cause. We want to get as good a handle as we can, because fifteen to twenty-five percent of the time it will help us design a more accurate intervention. Then we want to move forward."
    Kendall points out that cognitive therapy is not effective for severe disorders like autism and schizophrenia, and he prefers straightforward behaviorism for retarded children. At the other end of the spectrum, he says, "a child might come in for what's labeled depression by the parents but is really adjustment to the loss of the grandparents, who both died of cancer within six months of each other. He's allowed to be depressed for up to a year. He doesn't need therapy, just support. But if he starts thinking, 'Oh, I did it, it's my fault because they told me to clean my room and I didn't,' then we can provide some help in correcting that false belief."
    Unlike the stripped-down, beat-up playrooms of dynamic therapists, Kendall's office--he runs his private practice out of his home--is traditionally furnished, with a wing ,chair, mahogany tables, an Oriental rug, a rocker with a needlepoint cushion, and books that are largely academic and professional. It seems to belie his informal manner, but reflects both his therapeutic bent and his original specialty--treating hyperactive children. "'It sets the tone for you to behave," Kendall says. "If I have a child who can't sit still and I put him in a room with a million opportunities not to sit still, that's tough. I bring him in here, I set the expectation that we're going to do some work. The first ten minutes we talk, and I take out the workbook or whatever and say, 'Don't forget we're going to start our work.' Gradually, over time, I just point to the clock and they go, 'Oh, yes, we've got to start our work.' Then the last ten minutes we play computer games or hangman or draw pictures. The fun activity is a reward for work."
    Most therapists play with children, but the purpose of play differs with each orientation. "I often play cards with impulsive kids," Kendall says. "Here's a book, The Official Rules of Card Games. Impulsive kids will start a game and switch the rules in the middle, and it's frustrating for their peers. So I say, 'Let's look it up. I'm not telling you to do it my way or your way; let's see what the rules say.' When we play, we play by the rules, we can't switch in the middle, we don't change games, even though we don't have to play the same game all the time."
    When a family is referred to Kendall, he begins by meeting three times with the child. "With a hyperactive kid," Kendall says, "I'd say, 'Hey, we've got some things we have to do today. First, we've got to get to know each other, and second, I have some materials and pictures and some games or tests. I want to see how you do on those, and I want to ask you what you like and don't like. The deal we made with your mom is were going to meet for three weeks, and if we can identify some things to work on, and if we both like each other and you want to try it, we'll pursue it.'
    "Some parents say, 'This kid is hyperactive.' I get him in here, he's six years old, he's wiggly, but a six-year-old should be wiggly, and he's no worse than an average kid. The parents' expectations are that the child should sit still in church for three hours, and that's developmentally inappropriate. If that's my conclusion, I'll get them in and say, 'I used these tests, here's a distribution of scores nationally, here's where your child fits, right where most kids fit. I wonder why you think he's hyperactive. What do you see that I don't see?' They might tell me, and I'd say, 'This is my opinion, but if he were to behave in your home as he did in my office, I don't think that's a disorder. Maybe there's more energy than you'd like, and maybe you'd like to reduce your stress, but he seems to be within the borders of normal behavior. Maybe we can ask you to try and tolerate it a little more.' That happens two out of ten times in the case of hyperactivity."
    Kendall also uses parent and teacher questionnaires that compare the child's behavior with a nationwide norm. Like most professionals, he rates teachers' opinions high, because the teacher has met enough children to have a good standard of comparison.
    The essence of Kendall's therapeutic techniques is laid out in the treatment manuals that he and his students have written for those working with impulsive children and with anxious children. In the anxiety manual, for example, the authors describe seventeen sessions. The therapy delineated here is notably different in ambience from the psychodynamic approach, in which the therapist remains a blank screen. Therapist and child ask each other get-acquainted questions, and, the manual says, "it will be helpful throughout the treatment if the therapist is comfortable with the child's asking personal information about her and with providing answers to appropriate questions." The down-home style of the therapy should be pleasing to most kids; it will engage some parents and turn others off.
    The child begins by learning to identify anxious feelings and the somatic responses to them. After each session he takes home a "Show-That-I-Can" (STIC) task. The first of these is to write down

a brief example of a time when he feels really great--not upset or worried. The child is asked to try to think and focus on what made him comfortable and what he felt and thought at the time. To help the child understand the assignment, the therapist should provide an example of a time when she felt really great and should describe it in terms of what she felt and thought.

    By completing the STIC task, the child earns two points, which can be used to buy rewards the child and therapist agree on: small toys, books, or games in the earlier sessions, and later on, time spent playing a computer game or going out for ice cream with the therapist.
    The sessions continue with role-playing and storytelling exercises that show the child how people express their emotions physically. The child picks a real or fictional hero and with the therapist makes up stories about how the hero would cope with worry and overcome challenges. Gradually child and therapist begin discussing situations in which each of them feels anxious, and describing their feelings. The therapist notes which situations are most taxing for the child, and the child keeps a journal between sessions. The child learns to recognize the symptoms of his or her own anxiety--butterflies in the stomach, flushing, trembling--and picks up relaxation techniques and self-talk to use when he or she feels tense. The therapist keeps in touch with the parents and even allows them to sit in on part of a session.
    The course moves from understanding feelings to figuring out coping strategies ("I expect . . . to happen, or I am afraid . . . will happen. How else can I think about it? What else could happen?"). In later sessions the child begins a graduated series of custom-tailored in vivo exercises, in which he's exposed to situations that might make him anxious and, with the therapist nearby, gets to practice his skills. Finally, the child makes a brief TV commercial in which he shows how his hero copes with a tense situation.

Treating an Anxious Child
The Anxiety Disorders Clinic at Temple University is a federally funded research project to test the effectiveness of these techniques and to learn more about anxiety disorders in children; this is, Kendall points out, the first major clinical trial of cognitive-behavioral therapy for these disorders. "The majority of children identified for psychological help fall in the category of externalizing problems," he says. "They act out, they aggress, they wiggle, and it affects people around them. Other kids are referred because they don't do well in school. But a problem that I think is understudied is the kids who are anxious or depressed. They don't bother anybody. You ask the teacher, 'How's Bobby?' and she says, 'Terrible. He acts up, he's rough, he needs help.' You ask, 'How's Billy?' 'Oh, he's fine.' 'Does he have any friends?' 'No.' 'Does he ever talk in class?' 'No. But he's fine.' Billy's sitting in the back thinking, 'If I raise my hand, lightning will strike me dead."' Kendall's grant proposal cites a study reporting symptoms of anxiety in 10 to 20 percent of school-aged children.
    Over the life of the trial eighty children will be treated--sixty in the initial group and twenty more in the waiting-list control group. Children are assigned at random to one of four doctoral candidates who have been trained in workshops and who are supervised regularly. Most of the subjects are nine to thirteen years old. Sessions are taped, and the treatment is free. When I visited the clinic, three months of the two-year trial had passed; after the trial will come a year of follow-up studies, and then Kendall and his students will analyze and write up the results.
    The children have been carefully screened to make sure they conform to research requirements. They must show one of three anxiety disorders listed in DSM. "The classic thing we see in our kids is they worry about absolutely anything and everything," says Fran Sessa, who does the screening. "They may hear about a plane crash and suddenly become very worried about a relative having to take a plane somewhere. A lot of the kids are very bright--they're on the gifted-and-talented track. You'd think with the type of therapy we're doing, that would be easier, but they are almost like little adults. They've either forgotten how to be a kid or never been allowed to be one. They come on with this pseudo-maturity and it's very difficult to work with them, because you want to treat them like twenty or thirty, not nine or ten."
    I watched the tapes of screening interviews with Bill, a bright, husky eleven-year-old who met the criteria for overanxious disorder, and his parents. Dad seemed morose and frustrated, Mom volubly strung-out, as they answered detailed questions about Bill's anxieties on the Child Behavior Check List, rating some reactions on a scale of 1 to 4.
    "He's very hard on himself," Mom says. "He would get into these moods where he'd go in his room and just lie down because he was so upset with himself. Then he put the blame on us for everything. I know how it feels, because it used to happen to me. He would come home with a lot of homework, he would get so panicked. 'How am I going to do it?' He gets himself so crazy about it, you can't say to him, 'Well, Bill, sit down and do this first."'
"Has he ever gotten himself sick from worry?" Sessa asks.
"Terrible headaches," Mom says. "He makes it like his head's going to fall out. Sometimes he'll get a nosebleed.
Dad says, "He gets tired. He never had a headache at school, never at camp, only at home."
"Does he need more reassurance than the typical kid needs?" Sessa asks.
"I don't reassure him a lot, because he gets a big head," Mom explains. "He'll put his brother down. He gets a little obnoxious."
"He's too smart," Dad says.
"He's not straight As anymore, but he used to be the one who'd take a book and read to the class," Mom adds.
"What does he worry about in social situations? Would he try to avoid situations because he's worried?"
"Yeah," Mom says. "At camp this summer he was very self-conscious about the way he looked when he had to go swimming. He went, but he felt very in conflict. He was wearing the same bathing suit every day, because that was the only one he looked all right in. He's not an easygoing kid at all, he's hard, he doesn't just roll with the punches."
    In the mornings Bill asks his mother over and over what jacket to wear. Bill is afraid of thunder and lightning and bees and moths and slugs, and runs on for half an hour before going to the dentist, after anticipatory hysterics the night before.
    Bill sits through his interview with a visibly furrowed brow. His voice is very soft, and he is not forthcoming. "When Bill showed up for this interview," Sessa says, "he brought a backpack I couldn't lift, all stuffed with books. He was worried about spending too much time here and not being able to do his homework for the night."
    Bill has now had two therapeutic sessions, Sessa tells me, and shows himself to be a typical anxious kid. "The therapist asked him to write down one good experience a week. Bill came in and had filled up the entire notebook with good experiences because he didn't know which good one to pick and he was afraid of showing the wrong one to the therapist."
    Anxiety is an equal-opportunity disorder; the children at the clinic don't necessarily have anything in common but their symptoms. Tyrone is a fifteen-year-old black boy from north Philadelphia. His public school had sent him to an annex that deals with its problem kids: he was at risk for dropping out and possible delinquency. "He has this negative peer group that pulls him to stay out of school," says Kevin Ronan, the student therapist who works with Tyrone. "In addition, he's very fearful of going to school, particularly at the beginning of the year. He has a real hard time just showing up. His fears tend to revolve around failure, having people find out that he's no good. He's phobic of a lot of specific things: dogs, airplanes, and subways. Those things, his mother had initially targeted to work on-they're kind of easy. But after tossing it around in our supervision sessions, we decided a more appropriate focus was getting him to attend school regularly and helping him to become more adaptive in his environment--to be able to say no in a simple fashion.
    "His mother is a very nice woman, very supportive of him, but she's not outstanding at setting limits. I think his mother's done a good job of giving him moral values. He abhors drugs. He's very much into sports, and that's helpful in our therapy. His favorite player is Magic Johnson. Sometimes we talk about what Magic Johnson would do in a situation, how he'd get psyched for it."
    I listened to a tape of Tyrone in his twelfth session, in which Ronan was focusing on school attendance and getting an afternoon job. Ronan explained to me, "He's very fearful of the whole process, what to wear, how to get an application, how to get an interview." When Tyrone says he went to school, he might mean he went to one class in a whole week, so Ronan tries to pin him down. "Well, I mostly go every day of the week," Tyrone says. "What is the problem with going to school? What is keeping you out of school?" Ronan asks Tyrone. "I been trying to figure it out since this all began. If I could get a tutor, I would get a private tutor and stay at home." One problem with anxious kids, Ronan thinks, is that "their anxiety is sort of clouding them and they can't focus on exactly what it is that's bothering them." He says, "We're trying to help them relax a bit so they can sort it out."
    Tyrone is now on a treadmill trying to catch up with what he missed and move along with new work, hoping to pull his grades up. "I don't know if Tyrone's telling me the God's-honest truth," Ronan says. "He's prone to not immediately coming out with the truth. He'll say, 'I've been attending school for three weeks straight.' He hopes you're going to brush it over, but when you say specifically, 'Did you go to this class?' then he'll back off and say, 'No, I couldn't make it to that class.' I called yesterday morning at seven-thirty to make sure he was up and getting ready for school. That was part of our agreement last week, to call him nightly in order to see how his day at school went, so after the weekend I called Monday morning."
    Ronan asks Tyrone, "When you get up in the morning, what are you thinking about when you don't go to school?" and Tyrone answers, "That's mostly on my mind--if I can make it this morning." Tyrone worries that his mother will push him out the door. It's tough just getting out of bed, and when he gets out of bed, it's tough seeing if he's actually going to go to school, and when he gets to school, it's a struggle to stay there. "Can I take a guess?" Ronan asks Tyrone. "Will you tell me if I'm right or wrong? When you start something new, you get nervous about it, you need to warm up?" "It's like a car battery that's gone dead," Tyrone says. "This is like when I first got into seventh grade, but it's totally different. I got more freedom."
    With all this, the boy doesn't sound unsavable, and Ronan says, "That's why I have chosen to stay with him when he was skipping therapy so much. There was a point where we could have said we've got to make a contract here: if you don't show up for so many sessions, that's it. But I think these kids need particular follow-up, and you've got to be really persistent with it."
    Going to school is Tyrone's in vivo situation, which Ronan cites as the reason he feels free to call Tyrone on the telephone even if that seems to be pushing the research boundaries a bit. But while the therapy is cognitive-behavioral, social and family issues are apparent as well: Ronan wants the boy's mother to go to his school and try to have him switched into a more structured program. "We're holding to the integrity of cognitive-behavioral treatment, but not necessarily going blunk blunk blunk down the manual."
    Like Tyrone, Vicki, who's eleven and lives in the suburbs, has trouble getting to school, but when she doesn't want to go, her parents cart her there. Vicki is a perfectionist, and she's painted herself into a corner: she's afraid she might fail, and because she's always done so well, she fears that everybody will laugh at her. In the audiotape I heard, Vicki and her therapist, Elizabeth Kortlander, are going over how Vicki approached a homework assignment. "She has a tendency to keep going on something even if she feels she should stop," Kortiander says. It's the eighth session, and Vicki has learned Kendall's FEAR acronym: Feeling frightened? Expecting bad things to happen? Attitudes and actions that will help. Results and rewards. "I had this space project, and I was working on it for a long time," Vicki says. "We had to go make a copy of something, and while we were in the car coming back, I had a funny feeling in my stomach, and I tried to brush it off ..."
    Kortiander asks her about the funny stomach feeling. "I pull my hair when I'm a little bit anxious," The therapist says, "When you feel anxious, catch yourself, take a deep breath . . . try it now." "I said to myself, calm down; I took some deep breaths," Vicki continues. "I said to myself, you did enough of the space project." "You're sort of jumping ahead," Kortiander says. "Do you know what you were feeling before you did that nice job of calming yourself down? Do you know what you were thinking of? The social studies? You were expecting not to get it done if you didn't put all this work into it? I want to catch the thoughts that were leading you to put all that work into it."
    Vicki is making some progress; she decides to move from the space project to writing a story, which is what she enjoys. Her tone is not depressed but cute and perky. "That's something you have to watch for," Kortiander says. "She's so good at being a perky cute girl and doing everything perfectly. Every week we have these STIC assignments, and she always does them just right. So I said, 'In the next few weeks, when I tell you to do something, you have to make the choice not to do it.' That's very hard for her. She'll have to come to the session with her notebook without the assignment. We'll look through what's hard for her in that situation."
    A fairly typical in vivo for the clinic might involve a girl who can't order food in a restaurant or ask for help in a bookstore. "The first thing you do is here, on this floor, with an adult we have prepared for her visit," Martha Kane, another therapist, explains. "You work out a situation where the child speaks to that person, asks directions, or borrows a pen. Once the child masters that, you go to the next step, which might be approaching someone we haven't prepared for her coming, so there's that element of surprise. Then you gradually have the child and therapist going into a bookstore, just being there. Then the child goes in without the therapist, beginning to navigate around the bookstore; if the panic hits, you're close by. Eventually you get to a point where the child goes into the bookstore and interacts with the adults while you're out of sight."
    Anyone who spends time at the clinic and talks to Kendall and his students is likely to suspect that the compelling part of their therapy lies in the commitment and skill of the therapist--that is, the part that's not in the manual. To some extent Kendall has come to terms with this. "Way back, manuals were verboten," he says. "You couldn't put therapy on paper. Then the behaviorists said you can't study it without a manual, and the graduate students became mechanical. Now we've backed off from rigid adherence to manuals. They're a guideline; you operationalize as best you can. And when you're doing research, you tape the sessions to see that the therapy doesn't deviate too far."
    Very often the therapists at the clinic run up against problems with the patient's family. "There are two tines in the fork when you have accurately identified interactions with the parents that are maladaptive," Kendall says. "One strategy is to teach the child to distance himself from it, to say, 'That's my parents, I don't have to believe them if they say I'm the worst person on the face of the earth. That's their problem, not mine.' The other tine in the fork is, you change the environment. Do you get the child to adjust to the world he lives in in a healthy way, or do you change the world he lives in to make it healthy? That question comes up in fifteen hundred different ways, and there's no hard evidence to say one way is better than another. What we're going to do next is get some of our students trained in family therapy and conduct a research test to see if a family intervention makes a difference."

The Family-Systems Approach
Back in 1962, when Richard Chasin, M.D., was a second-year resident in adult psychiatry, he was assigned to the outpatient clinic at Massachusetts Mental Health Center. "We were given six interviews in which to dispose of a case," Chasin remembers. "'Dispose' could mean 'have admitted to hospital,' 'bring about a cure,' or 'start in long-term therapy,' but we were a walk-in service and we had just those six meetings to make a decision.
    "Frequently the people were very disturbed, some of them mute or incomprehensible. Their families were in the waiting room. They were Boston- and Brookline-area residents who weren't using private services. I did what many of the social workers were doing, which was to talk with the family after talking with the patient. I developed a lot of information, but it sometimes didn't jibe with what the patient was telling me.
    "So, as a simple matter of expedience, whoever the patient came with, I would just bring them in too. It was obvious to me that anybody who brought someone to a walk-in center was himself very concerned. So suddenly they were all in the room, and I would say, 'What's the story?' The interplay was highly mobilized by this context. They might yell and scream at each other, and suddenly I was in the middle of a very hot drama. I was able to make sense out of what was going on and even think of something to do very quickly."
    "What struck me about it was the efficiency. The family was willing to pitch in because they were in crisis. These cases made sense to me much faster than the ones where I was alone with the identified patient and the social worker saw the families. It seemed only natural to continue doing this. My turnover was very rapid. Six meetings were much too long. I was working from no theory, just common sense. I was a naif. I knew there was a thing called family therapy, and that it was bad. There were two people in our hospital who were doing it, and they were considered wild."
    The next year Chasin was the chief resident and worked intensively with one of the two wild people. "I must have interviewed a hundred and twenty families, and learned something about how to survive such an interview, how much you could get done, and some of the dangers. It got so I could no longer tolerate not knowing all the players and what they were like with each other. Sitting in a room with one person was a tremendous handicap, like wearing blinders."
    Alan Kazdin, in Child Psychotherapy, cites a 1977 study reporting that 94 percent of psychiatrists and psychologists see children concurrently with their parents at some time during therapy. But concurrent sessions are not necessarily the same as family-systems therapy, which is marked by the way it defines the patient. Chasin says, "I'm trying to step back from the pathologizing of an individual. Let's say there is a twelve-year-old girl who one day says she really doesn't see the point of living out her life. Mother hits the panic button. Father says all twelve-year-old girls are like that. I start to talk with the mother, and it turns out one of her parents committed suicide. Father is really worried about this girl, but he frightened that his wife's going to go off the deep end hearing this stuff, so he doesn't say quite honestly how he's feeling.
    "The girl doesn't understand why he's so unconcerned with her. Do you see how complicated this is? One of the reasons she feels so depressed is that every time she brings up a problem her mother goes off the deep end with terror and her father pooh-poohs it, so she doesn't get an honest down-the-middle response from anybody. Any one of these people in a different context could look very good. If the daughter had acute leukemia and the mother said, 'I have to drop everything and deal with this kid,' you'd say, 'What do you expect this woman to do?' And if the father played a sort of jolly role, people might say, 'Somebody's got to keep some balance in this horrible picture.' But here they are all stuck in a problematic behavior where the girl is facing life feeling abandoned by two people who are being relatively useless to her.
    "It's not that I don't believe there are problems that inhere in people--there are genetic problems, developmental problems. But people are different in different contexts. If somebody is the same way in every context, then it becomes increasingly interesting to look at the kid's biology or maybe certain intrapsychic things. I would still think of the other people in the system as being potentially of value to the kid, but he may also need something more--a drug or individual therapy. That can go on side by side with family therapy, or after it, or before."
    What family therapy doesn't do, barring cases of outright abuse, is blame the parents for the child's problem. Rather, its approach suggests the familiar bumper sticker INSANITY IS HEREDITARY-YOU GET IT FROM YOUR KIDS. The notion of linear causality is anathema to family-systems people. "The idea that A causes B, which causes C, is a very limiting way to think about causal chains and mutual influences," Chasin says. Indeed, for parents, family-systems is the most collaborative of the therapies. No one person has the problem; no other person caused it; the family is in a knot and must unravel it together.
    Therapy with families has been practiced since the thirties, but it has gathered considerable steam since the sixties, and the people in the field and the way they practice have a flavor of egalitarian rebellion. Lee Cornbrinck-Graham, M.D., a peppery woman of fifty who until recently was the director of the Institute for Juvenile Research, in Chicago, and who has written frequently on family issues (and who went through seven years of analysis herself), says, "I don't tend to use psychodynamic formulations, while I love to read about them. That's because I believe it's a kind of patronizing process. The theorist has the theory about someone else's internal workings. I believe people's internal workings are basically their own business, not mine. When a child goes into analysis, you as therapist urge the child to form a deep, abiding, and secret relationship with you. Unless you plan to adopt the child and the family is willing to give the child up, I think that's outrageous."
    Psychodynamic therapists revere the towering figures in the history of psychoanalysis, most of them dead. Cognitive-behaviorists revere controlled double-blind clinical trials. Family-systems therapists revere the live geniuses who are constantly dreaming up new metaphors for framing a family's problems. The family-systems counterpart to the behaviorists' apology "There's no hard data, but. . . " is "The field has evolved away from that." A family undergoing systems therapy may encounter a therapist who does elaborate genograms of grandparents and great-grandparents or one who doesn't; a therapist who tries to mix into the family drama as it unfolds or one who stays carefully neutral; a therapist who perceives the family in terms of structure, or boundaries, or belief systems, or intergenerational loyalties. However particular therapists may vary in technique, their common ground is the focus on the group, not the individual.
    Because of this focus, that many therapists have M.S.Ws is not surprising; the number who do is a factor in the field's disdain for "elitist" credentials and pecking orders--which in turn can sometimes make it difficult to check out a particular therapist. Richard Casin's establishment credentials (Yale undergraduate, Harvard Medical School, Boston Psychoanalytic Institute, five years of residency in adult and child psychiatry, current appointment as an associate clinical professor of psychiatry at Harvard Medical School) give him credibility in the outside psychiatric and medical worlds, which tend to be uninformed and nervous about family-systems therapy.
    Chasin practices at an office in his home and also at the Family Institute of Cambridge, of which he is a co-director. The most arresting feature of both sites is the abundance of elaborate television equipment. The control room at the institute might well be part of NBC News, with screens hooked up to four cameras. In viewing rooms as many as twenty people can watch one family; interviews can be broadcast throughout the building. Every office at the institute has a one-way mirror into some other office, "so we can look at each other's work." Some rooms have stages for psychodrama. Chasin's home office is a smaller version of the studio setup.
    Clearly, privacy is not the crux of this practice. "The whole atmosphere in family therapy is more open and comes much less from an expert, position than many other therapies," Chasin says. "When one is learning family therapy, there's someone behind a one-way screen who's watching and calling in moves. The tapes are shown to supervisors. Consultation is frequent. 'Needing a consult' means only that we need an infusion of new ideas from a therapist who probably himself or herself would get stuck at points along the way and ask for consultation. It's in the culture of family therapy to work in the open."
    "It's offered to people as an opportunity," says Sally Ann Roth, M.S.W, Chasin's colleague. "To have more people thinking about their case, more people focusing on what they need." Among the variations one might see in a course of family therapy are Mom and Dad watching children and therapist through one-way mirror; therapist watching consultant and family; consultant watching therapist and family; team of consultants watching therapist and family; family watching team of consultants discuss their case.
    On the other hand, nobody has to be watched by anybody, and the watching is only occasional. Since the family generally pays for one practitioner per session, the others are donating time for their own professional development. In addition, good therapists work with a strict set of rules, which might state that any family member may "pass" on a particular question and that, when necessary, parts of the family can discuss certain things with the therapist in private. (Chasin will agree to keep the child's comments confidential if it's "safe" for the parents not to know; the older the child gets, the broader the definition of safety.) just as other therapists often talk with a child's parents, family therapists sometimes see individual family members alone, but the focus of therapy remains on the family context.
    Chasin's office reflects not only his therapeutic culture but also Chasin himself. His waiting room is filled with blowups of Steig and Feiffer cartoons on psychiatric subjects. Chasin is fifty-five, has shaggy, grizzled hair, and looks as if he started the day near and proper but life interfered. His most memorable mannerism is a belly laugh that racks his frame and seems to express unending wonder at the varieties of human behavior. "What a piece of work is man," it says, or, less elegantly, "Get this!" I watched a number of tapes with Chasin sitting by to provide play-by-play commentary. Although he presumably sees these tapes repeatedly in the course of training and writing, he seemed as astounded by what was going on as if he were watching them for the first time.
    The institute's adult consulting room and theater playroom are both stocked with psychodynamic therapy's usual array of puppets and rag dolls. "Without psychodynamic and behavioral techniques I'd be helpless," Chasin says. Chasin uses play not to unravel symbols but to help children act out what they haven't the courage or skill to tell him directly: the puppet king and queen say the same things Daddy and Mommy say. I also heard him ask some questions that duplicated those of the cognitive-behaviorists at Temple. Chasin remembers a case of a teenage boy with "horrible self-esteem problems." He says, "I asked the family to name the things they liked about him, and almost everybody cited his terrific sense of humor. It then became a source of interest--How did he get this sense of humor? What might it mean for him if he grew up and had such a charming sense of humor? As we talked about this, you could see his face changing, and then he would say something clever and I would say, 'Is that an example of what they're talking about?' and he'd say, 'Not a very good one.' I'd say, 'They're even better than that?' You could just see how the mood moved. It's highly behavioral, on-the-spot conditioning, eliciting the behavior, shaping it, and rewarding it."
    Chasin calls himself a technician, by which he means that he doesn't come up with theories and test them out in practice. His greatest skill lies in the therapeutic interview, in which the way he pulls information out of people becomes therapy in itself. In this therapeutic questioning and other interventions he draws on whatever theories seem useful, particularly one that holds that a problem is almost always associated with some issue on which the family varies very little. Chasin says, "When they are in a particular context, they always do the same damn frustrating thing. If you ask the family, 'How would you do this?' and they honestly say that there are eleven different ways they could do this that would be satisfactory, it's unlikely that's going to be an area of trouble. But if you say to a teenager, 'When you're going out at night, what happens in the family?' and it's always the same thing, it's like a little flashing mark. Then the question would be, 'And the way you always do things, does it work?' If they say it usually doesn't and I say 'Do you try other ways?' and they say no, I know that's a problem."
    In two out of three family cases Chasin sees, the child is the lead problem, and in the third (warring couples, for example) "there's another problem, but I see the children." Like Kendall and Sarnoff, Chasin will order neurological and educational tests when he feels they are appropriate, but if a purportedly hyperactive child comes out normal, he won't leave it there. "If the family perceives there is a problem, there is a problem, even though it may not go by the name they advance. How is the family dealing with the fact that there's such variation in itself? I had one this morning where a woman was saying she had this intense kid who does everything at a fast pace. He rushes the family along, and she finds herself getting explosive about it. I suggested she tell the child it's wonderful he can do things so speedily; that probably makes him very good in school and a terrific soccer player. It's unfortunate he has to live with people who aren't so fast, and she must apologize. Then I talked with the kid about his mother's thoroughness. 'What a wonderful thing--when the two of you do something, you provide the speed and she provides the thoroughness. You must make a great team!' That's called reframing, and it's a whole lot better than saying to this kid, 'What is with you? Why are you pushing everybody all the time?"' Chasin willingly accepts that some family therapy just involves teaching people tact (which is a form of child guidance). Most of his work, however more complex.
    Family therapy begins with a process called "joining, which involves forming a new system composed of the therapist and family. (Chasin is free of one besetting sin of doctors and psychologists: he starts off saying, "My name is Dr. Chasin. You may call me Dick if you would like to," and then asks family members to introduce themselves by the names they themselves prefer.) Chasin seldom starts by asking what the problem is: he feels that's a bad beginning, and usually has individuals describe their strong points; then he asks the family members their goals. "I'm not interested in finding out how bad things are to the last little detail. I want to know where they want to go and how they're going to get there. If you start off by asking people all the ways they're stuck, it demoralizes them and tends to aggravate the stuckness. You will discover the problem soon enough.

The Tyler Family
The efficiency that Chasin describes is evident on tapes of sessions he's held: a surprising amount of work gets done in a few hours of family therapy with a skilled practitioner. I watched the second and third sessions he held with the Tyler family. Jane Tyler, an elementary school teacher, was a patient of Chasin's wife, Laura, a psychiatric social worker (both Chasins do adult therapy and sometimes work as a team, presenting psychodrama workshops).
    "It's common for an individual therapist to call in a family person when she feels the whole family needs work," Chasin says. "She doesn't want to change her relationship with her patient. My therapy with the Tylers was mostly separate from Jane Tyler's therapy."
    Jane and Peter Tyler and their three sons had, however, started family therapy by meeting with both Chasins. The obviously symptomatic family member, four-year-old Bobby, was encopretic (in the nontechnical language used by the boys, he "pooped in his pants"). But as the Tylers' story unfolded, they proved to be a good illustration of the systemic point of view. Jane now remembers, "I was locked into a bitter struggle around Bobby's bowel training, and I couldn't distance myself from the intensity of our conflict. I was extremely angry and scared, and I wasn't getting much support or understanding from anyone else in the family."
    Chasin found other problems. "The oldest boy, Ted, who was thirteen, was moving into adolescence a little too fast. I had the sense he was being disaffected and trashing things too much, precociously trying to put his family behind him. It would be okay for him not to abandon childhood so rapidly. On the other hand, Andrew, the middle kid, who was nine, was super-clean, over-organized, compulsive. One boy was too bad and the other too good, and in opposite ways each was unable to deal with his impulses." Chasin says, "The whole male subsystem was so poorly bonded. The kids were not supported by each other, and the mother was dealing separately with each of them and with her husband. The concept was to find links, bonds."
    As session two began, Chasin and the boys were sprawled comfortably on the floor, nestled in pillows and cradling batakas, the large soft bats he offers to patients who are feeling violent. The older boys were talking maturely; Bobby was giggling, making faces, bopping Chasin with a bataka, and saying things like "I'd like to pee inside your hair." Chasin, acting unflappable, got the story from Andrew:

A: He has to have medicine to make him do it in the toilet.
RC: Have you ever told him how you feel about him pooping in his pants? Have you talked about it? A: Yep. We tell him it's disgusting. I told him that only babies do poops in their pants.
RC: I see. And that doesn't seem to help very much?
A: I tell him it's really disgusting.
RC: I see. You tell him it's disgusting. And what do you do for him when he stops doing that, when he does it in the toilet?
A: Well, we used to give him a prize, but now just everyone starts cheering.
RC: I see.
A: And my mother does a jig dance.
RC: Well, why should he bother to grow up? Why will it .be good for him to grow up?
A: It's fun to play with him when he's bigger.
RC: You like him better when he's bigger, huh? It's important for him to know why he should grow up, because otherwise he'll just keep on pooping, and stay a baby. What would be a good reason for him to grow up, besides what Andrew mentioned?
A: So we can communicate with him better.
RC: You want him to go to the bathroom like a big boy and you want to talk with him like a want to play with him like a big boy. So you want him to be part of your club, huh? You have a big-boys' club in your house ...

    The "boys' club" is one of the themes of this session, and the other is "control," which Chasin has introduced by asking the boys about their mother's explosions of temper; summarizing their account of it, he says, "So this anger of hers used to be more frightening. Now there's more control."
    Andrew also says that Bobby bites and pinches, and he wishes that Bobby would stop. Meanwhile, Bobby continues to carry on, and Chasin, who is growing sterner, finally says, "I can see how the silliness is used to get attention." But when he asks the older boys how their relationship could improve, he learns that Andrew wants Ted to play with him more and Ted is getting punched by Andrew as well as Bobby. "People get attention for the wrong things, being silly or hitting," Chasin says.
    Now he asks Bobby to stand on a chair and show him how tall he would like to be. The brothers seem pleased when Bobby climbs up, and Chasin says, "Now let's make believe you're very big, okay? And see what happens." Chasin, Andrew, and Ted all kneel down. "You're the biggest one right now," Chasin continues. "Now let's turn it upside down, let's make believe that Andrew's the baby." Andrew and Ted are having a wonderful time regressing, rolling on the floor and hitting each other with pillows. "Okay," Chasin says, "now look at those. babies, look how they're carrying on! You can tell them to stop because you're bigger."
   "Stop! Stop!" Bobby says, and the older boys' compliance is instantaneous. Now Chasin, ever the magus, asks Andrew, the over-controlled middle brother, to pretend he's pooping in his pants, and Bobby to tell him what to do. "Do it inside the toilet!" Bobby shouts commandingly, and Andrew immediately pretends to obey. Bobby orders the boys to do pee-pee in the toilet, and the boys, laughing wildly perform, until Bobby says, "Hold it, hold it!" and they stop. Chasin is standing next to Bobby, coaching him gently, and says, "You're a terrific grown-up."   Bobby tells Andrew not to hit Ted, and Chasin says, "They're getting good at holding it. Are you going to sing to them?" The game continues with Bobby getting to stay up later than Andrew and Ted. The brothers are clearly enjoying one another.
    Now Chasin introduces "a very strange game called Poops. Everyone is a poop in this game." The boys get into this, with Ted yelling, "Someone's flushing me, and Chasin saying, "We're all poops. What happens after we go down the toilet?" "We drown. Aaaah!" Andrew shouts, and all the boys jump off the chairs. Now everyone, including the therapist, is rolling on the floor, and the boys are laughing wildly. Chasin says, "Now we're swimming in the sewer somewhere. We're going into the ocean. Did you ever swim in the ocean?" There's lots ( squealing, giggling, and roughhousing-"Look out! "Get off me, you poop!"--and Chasin says, "I bet you didn't know your poops had this much fun after they left the toilet. I want to interview each of these poops." The interview goes this way:

RC: Now, did you go into a toilet?
A: Yep, I almost drowned.
RC: You almost drowned, but what happened? You seem to be quite alive right now. Did you go into the ocean?
A: No, I think I was resting in the sewer drain for about fifty years. I'm almost faded, you see?
RC: I see, you don't look quite a good color. Now, what about you?
T. I'm an old hand, I've been in the sewer for about thirty years. Sixty years!
RC: All right, and are you a poop over here? Did you go into that toilet, poop?
B: Yes, I just went down a big tube, yesterday.
RC: And what's at the bottom of the tube?
B: Poops! [The boys pile up on each other.
RC: All his brother poops. A whole family of poops.

    By the end of the session the boys seem much more of a unit. Chasin observes that he was drawing on psychoanalytic ideas--"Many kids are afraid their body parts are slipping down the toilet"--and playing symbolically, but the psychodramatic techniques were much different from those Sarnoff might use: instead of taking his cues from Bobby, Chasin directed the play himself. "Bobby was getting attention by being a baby. I wanted to see if he could develop an image of himself as big, and have it fortified by his brothers, so I turned everything around. The other kids were given enormous license to be childish. Each kid learned something about stopping impulses. For Bobby it was highly rewarding to replace this fearsome lavatory where you drop your parts with the idea of a romp with his brothers--a whole family of poops taking a trip."
    The encopresis stopped soon after this session. Chasin's next-and last-move with the Tylers was a "bash" for Dad, Andrew, and Bobby, in which Peter Tyler and his two sons joined in picking up batakas and having at the people who needed bashing in each of their lives, represented by a giant soft-sculpture doll. Dad, a management consultant, wanted the boys to help him bash 11 clients that don't let me come home on time"; Andrew had a couple of teachers he wasn't fond of, and Bobby offered up some bullying playmates. The Tylers also got to bash one another (for specified reasons) and the absent Mom and Ted, who were then going to look at the tape, but the family-bashing was followed by a countervailing ritual in which each Tyler thanked the others for one good thing. The striking feature of the bash was its good humor. It was designed not to smoke out deep resentments but to build empathy.
    Jane Tyler was pleased with the results. "I think the issue was to get me out of this problem completely and try to give it some lightness. The boys formed a sympathetic bond with Bobby in a way they couldn't at home because I was so uptight about it. I had been very down on myself, because I couldn't deal with the problem alone. But then I thought if Dick doesn't see it as such a horrendous thing, maybe I'm not such a terrible person."
    While Jane, outnumbered by the men in her family, still needed individual therapy to deal with her own angry feelings, the Tylers decided after the family sessions that Bobby and his brothers would benefit from particular shared activities. He and Andrew started karate classes together, and "little by little we began to look more diligently for ways to involve Bobby in the life of the other boys." After three sessions Chasin felt that his work with the Tylers was done. "When the ice breaks, things begin to flow and the therapist gets out of the way," he says.
    I asked Chasin whether he felt that Bobby's infantile behavior had served some buried family purpose, a notion of a kind that various family-systems theorists have propagated over the years. "They were just stuck," Chasin says. "I don't know why, but unless I see a family resolutely rewarding symptomatic behavior and undermining my therapy, I give them the benefit of the doubt. I assume solutions that once worked for them may no longer be useful, and they have simply developed some crummy habits for the next stage of life. They want to move on, but don't know how."
    Homework assignments are common in family therapy: they're seen as a way to introduce variety into the family's behavior. "For example," Chasin says, introducing a hypothetical family, "Mother, whose parents abused her, feels Father is too rough on the kids. Father either smacks them or screams at them or stands there helplessly while she says, 'You poor children. There's no discipline. So you make a homework task: Monday, Wednesday, and Friday, Father's way will prevail, and Mother will sit and watch. Tuesday, Thursday, and Saturday, you do it Mother's way, and Father watches. Sunday you do whatever you want. So the father might find that because he's not so angry with his wife for tying his hands, he gets less furious with the kids. He might grab them, but he doesn't beat them up, he just says, 'Go to your room, I don't tolerate this,' and the kid comes out quiet. When Mother's day comes, she's ready for a little variation. Father notices she's more assertive, so he's somewhat more respectful of her. At the end of the week, if the therapist stays out of it, the two of them will work out what to do. They reconstruct their belief system."
    If the parents don't do their homework, Chasin explores in a neutral, collegial tone whether it came into their minds to do it, how they dismissed the idea, what they did instead. "When you introduce something new, you change the context, and there's a possibility of their learning something." In essence, this technique is cognitive, altering the family's behavior and feelings by changing its pattern of thought.

Evaluating Therapy for Children
What is known about the effectiveness of psychotherapy for children? Very little. Alan Kazdin, whose book is subtitled "Developing and Identifying Effective Treatments, " cites a 1985 meta-analysis of smaller outcome studies which established that the average child who is treated is better off at the end of therapy than 76 percent of those who did not receive treatment. This figure is slightly less optimistic than one reputable but arguable figure of 80 to 85 percent better off for treated versus untreated adults. At the same time, Kazdin notes an absence of empirical data that would make it possible to compare therapeutic techniques. In varying degrees, all types of therapy are understudied.
    According to Morris B. Parloff, a clinical professor of psychiatry at Georgetown University and a retired chief of the psychosocial-treatments research branch of the Division of Extramural Research Programs at the National Institute of Mental Health, what studies exist tend to cover behavioral therapy, because it lends itself to easy measurement and because courses of the therapy are short enough that it is a manageable dissertation subject. Psychodynamic therapists tend to find outcome studies reductionistic," and since they've long been the establishment, they haven't felt the need to prove themselves.
    Parloff, an adult psychologist, has written frequently about the "nonspecificity" hypothesis and its implications: "Since different forms of psychotherapy, using quite different 'specific' techniques and procedures, nonetheless achieve equivalent effects, then such effects may be attributed not to the specific techniques but to some 'nonspecific' elements common to these therapies."
    In discussing what these nonspecific common factors may be, Parloff notes the work of Jerome Frank, who held that all therapy treats the patient's "acute sense of demoralization," and does it in four different ways: it offers "a trusting, confiding, emotional relationship"; it does this in a setting with a special "safe" aura; the therapist offers, in Frank's terminology, an explanation for "bewildering subjective states and behaviors"; and therapy provides a "prescribed set of procedures based on the conceptual scheme."
    The nonspecificity hypothesis is not meant to be simplistic. It doesn't apply in the case of severe psychoses, for which therapy is neither the cure nor the sole treatment but simply a rehabilitative measure. It doesn't deny the need for skill and experience on the part of the therapist, who is more than just a paid chum. As Parloff points out, "The expert therapist knows when to turn down the rheostat and do something else. The novice, who is uncertain of what to do, has no justification for doing anything other than being a nice guy."
    Neither Parloff nor Kazdin believes that comparisons are impossible: both hope that research will eventually find out more about what treatment, by whom, is most effective for this individual with that specific problem under which set of circumstances. Kazdin calls attention to the complexities of defining a problem, structuring rigorous studies, and measuring success, but he also points to some promising avenues for future research.
    Meanwhile, the ball appears to be in the parents' court. During the course of my research I heard stories of bad experiences with child therapists; most parents have probably heard some too. The common thread in these stories seemed to be that the parents--suffering, intimidated, and guilt-ridden--had suspended the informed skepticism that a consumer usually brings to any high ticket purchase. A therapist is not a stereo set, but parents do shop for schools and camps: such quests might be a model for seeking a therapist.
    What, first of all, might parents expect therapy to achieve for a troubled child? I began with the fairly common layman's assumption that therapy should be like orthodontia: The child has buck teeth, you have the teeth straightened, and that's that; if the overbite returns, the job was not well done. I came to realize that mental-health problems are more like lower back pain: You have an acute episode and you choose an orthopedist or a chiropractor who relieves the acute symptoms. A good practitioner also gives you a regime for managing your chronic problem; you hope life will cooperate and not oblige you to lift something heavy, because your sacroiliac is naturally vulnerable.
    Most child therapists expect to see some sort of positive results in a surprisingly short time. Even Charles Sarnoff looks for the first signs of improvement after two or three weeks of semiweekly sessions, although the therapy may go on for three years.
    Emanuel Falcone terminated therapy after a year with Kevin, who now feels strong enough to deal with the fears and bullies that once laid him low. "We talked about where the anger went," Falcone says. "I showed him how he hid it and it snuck out in the form of fears. We talked about what he'd do if Jason and Freddy came, and he said he'd hit them but not kill them, because even murderous creatures have rights: that's Kevin. I believe he may be in treatment again, because problems he's had in separating from his parents will re-emerge when it's time to leave home. But I think I sold him some understanding."
    In the book chapter cited earlier, Philip Kendall writes,

A rational expectation for therapists to hold is that psychotherapy does not cure maladaptation. Therapy does provide help, but the help is more of the form of a strategy for the management of psychopathology. The anxiety-disordered adolescent will not receive a treatment that will totally remove all perceptions of situations as anxiety provoking, but he/she will be able to employ newly acquired strategies in the management of anxious arousal when it does occur. The attention deficient child may not erase all impulses for immediate action, but will have available skills that can be implemented when more cautious, thoughtful action is needed.

    The definition of success is "that the family no longer feels stuck with the problem," according to Richard Chasin. "They feel they're dealing with it rather well. This may mean the problem is eliminated, or it may mean it's not eliminated but they're doing damn well with two schizophrenic children, or they send the mother to AA and she's doing well and Dad's going to Alanon and he doesn't feed into the temptation to drink. They're on their way."
    In family therapy, of course, the parents will directly experience the therapist at work. Lee Combrinck Graham says, "The most important thing is that the therapist is part of something happening in the session which makes you think. You should feel there are things to think about that you didn't know to think about before you got there, and some of them are questions that are disturbing and some are new choices."
    Most often, a child's school--from nursery school on up--first suggests that the child needs psychotherapy; the parents then call their pediatrician. Joseph A. Silverman, M.D., a clinical professor of pediatrics at Columbia University's College of Physicians & Surgeons, says, "My practice is to get the services of a couple of people; one does a complete psychometric evaluation and the other does a learning work-up. This is all done with the parents' understanding that the real reliability of this kind of testing doesn't come about until a child is perhaps eight years of age--only you can't wait that long if he's tearing up the kindergarten or disrupting the whole family. So you say, 'We'll use what we can glean from it, but we may have to do more testing down the line."'
    Once they have some understanding of the child's problem, parents can think about the sort of therapeutic experience that makes sense for it--a therapy based on insight or one that favors skill-building. Whatever the problem, a symptomatic child is bound to disrupt the even keel of family life: the child will require extra attention, and this will affect siblings; the parents may disagree on how to handle the child. Thus, even in a family where everybody is fond of everybody else and the child clearly has a neurological disorder, a few sessions of family therapy may be helpful, to resolve tensions.
    To be suitable, a therapist must, of course, have training and clinical experience with patients the child's age, and with similar problems. These credentials are basic, but it's also important to get a referral from someone--a pediatrician, a friend in the field, a satisfied patient--who knows the therapist. "My experience with people who do damage is that it's independent of their credentials," Parloff says. "Their problem is zealotry. Truth has been revealed to them, and they push on regardless."
    Particularly with adolescents, parents should be wary of therapists who might, in the name of confidentiality, let them twist slowly in the wind. While this sounds like an argument for family therapy, neither Kendall nor Sarnoff takes a rigid position about talking with a teenager's family. Kendall says, "It's the therapist's final responsibility to get the child back into the family. There are iatrogenic effects in clinical practice, but if relationships have gotten worse, part of. the therapist's job is to fix them." Parents who don't find out beforehand how the therapist plans to deal with them are asking for trouble.
    When parents are unhappy or perplexed, they have a right to talk with the therapist. If he or she is not helpful over the phone, Silverman suggests, "the next time your child has an appointment, you show up instead of the child. Say, 'Look, I'm paying for the time and Frank has the flu, so I thought maybe we could have a chat.' Sometimes psychiatrists don't like that, but I've always felt doctors are supposed to work for patients; it shouldn't be the other way around." If the chat is unsatisfactory, parents should seek a second opinion, which can be obtained without putting the child through additional diagnostic interviews by having the consultant talk with the therapist and report back to the parents.
    If the bad news is that child psychotherapy offers no guarantees, the good news is that many different techniques can relieve suffering, and often they work; skilled and sensitive therapists can change their patients' lives. If parents inform themselves and do not yield their inherent authority, they and their children may well find relief.