348 | When Families Stop Coming: Understanding Attrition in CCPT

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You're listening to the Play Therapy Podcast with Dr. Brenna Hicks,

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your source for centered and focused play therapy coaching.

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Hi,

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I'm Dr. Brenna Hicks,

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The Kid Counselor.

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This is the Play Therapy Podcast where you get

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a master class in child-centered play therapy

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and practical support and application for your

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work with children and their families.

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In today's episode,

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I'm answering a question from Sally and hers is about

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attendance and therefore attrition.

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This is a really important topic.

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I'm actually getting a lot of

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conversations recently about attrition rates

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and parents pulling their kids and not naturally terminating with kids.

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That has been a pretty hot topic

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in recent weeks or so.

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So Sally,

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thank you so much for the question.

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I'm actually really looking forward to discussing this.

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So let me read parts of the question and then we'll

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process together.

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I've noticed that after 5 sessions with the child and then the 6th with parents,

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there's a change in how kids attend sessions.

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They often drop off completely or their attendance becomes spotty and irregular.

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Parents are initially very happy with the progress,

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minimal as it might be,

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and they have some helpful strategies to implement at home.

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I have some families who try to go 3 months in between sessions.

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I ended up discharging families who do not regularly attend,

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and I also have families who abruptly stop CCPT midway.

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Then attempt to start up again

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with no information about why they stopped.

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If a child or family stops coming to therapy and or does not regularly attend,

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I discharge them and will not take the child back onto my case load

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as I feel it is detrimental to the process of building trust and predictability.

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Many of the kids I work with have separation anxiety,

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and I don't feel this is helpful.

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Some of my colleagues feel I'm too strict.

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Am I?

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How do you handle these situations?

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I send out a protocol reminder and what will happen.

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I also go over the attendance expectations thoroughly in the intake.

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I would appreciate your guidance.

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We now have a registered play therapist on staff who has questioned

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whether my approach is CCPT with how I keep the playroom.

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I reset it after every child and she stated that I

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should keep everything in buckets for time management and effectiveness.

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You and Landreth say that the toys should be visible.

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She also stated that she used to be child-centered,

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and there are no schedules for treatment.

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I usually tell parents between 20 to 30 session,

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but depends on the child.

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If the families cannot commit to this,

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I don't take them on.

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She also stated no change happens until around sessions 11 through 15.

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All right.

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So

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first and foremost,

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when you mentioned that you see the child for 5 sessions

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and then you have the 6th with parents,

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I just want to provide some clarity there.

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I don't know that this is how you meant it,

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but this is how I read it,

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so I might have misinterpreted,

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but I want to be real clear,

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we do not sacrifice a child session for a parent consultation.

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So if you see the child for 5 sessions and then the 6th week.

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The child does not get a session because you're meeting with parents.

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That is not the way we handle parent consults.

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Parent consults are a completely separate

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time and day

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from the child's regularly scheduled session.

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And so if Tuesdays at 4 or when you see the child,

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even on the 6th week,

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you will see that child Tuesdays at 4 and then

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you schedule a consult with parents maybe on a Friday

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at a completely different time.

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So I don't know if I misinterpreted that,

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Sally,

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but I just want to make that known for everyone's sake.

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OK,

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so the fact that you're seeing

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that

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the

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attendance shifts after

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this first parent consult.

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It either becomes spotty and irregular,

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they go 3 months in between,

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they

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not regularly attend.

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OK,

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that communicates to me

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that

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they're not bought into the process.

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I don't think it has anything to do with

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after 5 sessions,

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all of a sudden this happens.

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After 5 sessions they've finally

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been in it long enough and they've had a meeting with you

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and if they don't understand what's happening,

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if they don't feel that progress is being made,

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if they're not bought into CCPT,

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if they're not trusting you and trusting the process,

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they gave it a shot,

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they went 5 weeks,

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they met with you,

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and if they don't feel satisfied,

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they're going to bail.

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So I think that actually what this comes down to is articulation

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and communication.

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And setting expectations,

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making sure that they really are understanding and bought in

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and all of that comes back to your framework

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and how you structure that initial parent consultation as

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well as your subsequent 5 week parent consultations.

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This is one of the most crucial components of CCPT

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and it has nothing to do with clinical knowledge.

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We cannot continue to do our clinical work

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if parents aren't bought in and they're not

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on board and they don't keep bringing their kids

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and we spend so much time on the clinical as we should.

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I'm not downplaying that we need to have mastery over the model,

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but all of our time and energy and focus goes toward the model and the clinical pieces

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where the bulk of what we're doing in this profession is outside of the playroom

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and consults are a prime example of that.

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So it sounds as though

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they're happy with progress.

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I think that's usually honeymoon phase,

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and they're like,

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OK,

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we finally,

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we finally did something we finally took a step.

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Maybe this is it.

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I,

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I have a little bit of hope here.

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Maybe this is going to solve the problems that we're having.

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It's a honeymoon.

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And then

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things don't really get better.

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5 weeks in,

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we don't really expect them to.

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And then they meet with you

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and they don't feel like they really understand what's going on.

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They don't feel like it's been worth 5 weeks' worth of sessions.

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They don't feel like they're seeing enough change,

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so they're going to make excuses for why they can't come anymore.

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This is very consistent.

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So when you say that you have families who abruptly stop and then start up again,

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also very common.

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Typically it's the,

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the grass is greener on the other side mentality.

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So often they will stop and say,

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Well,

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maybe things will be OK and we don't need therapy and then things are not OK,

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so they revisit or they say,

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you know what,

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I'm gonna go down the road and see about this CBT

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children's therapist,

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thinking that that might be the solution,

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grass is greener on the other side and then they realize,

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well,

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that didn't work either,

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and they come back.

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Very common process if parents do not understand what to expect

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if they're not bought into the process and

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they're not trusting you and trusting CCPT.

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So when you said

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that you discharge them and will not take the child back onto your case load.

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I,

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I don't know that that is

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necessarily the hard and fast rule for every single case.

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There are certainly families

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for whom that makes sense because you know that they're never going to

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buy in,

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they're never going to commit,

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they're never going to be faithful,

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they're never going to take it seriously.

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And that's setting everyone up for failure,

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if you know that's the case,

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but those are very rare outliers.

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Most families that stop and come back,

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they still need and want help,

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they're just not.

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Feeling comfortable enough,

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they're not bought in enough,

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they don't understand enough

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so that falls on us that is our job

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to make sure that we are effectively articulating.

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We talk about this in coaching

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every single day I feel like,

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why?

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Because it's that important.

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We can't do our jobs,

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we can't help kids,

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we can't provide CCPT

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if parents quit bringing their children.

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It's just that simple.

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So the relationship with the parents is just

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as important as the relationship with the kid.

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And we put a lot of emphasis on the relationship with the child,

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we should be putting emphasis on the relationship with parents.

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They're the hinge pin.

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If that falls apart,

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we're doomed.

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And so I think Sally,

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maybe what's going on is you don't have a framework and a template.

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And a script for these consultations,

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I think maybe you don't feel confident in how to articulate some of the concepts.

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I think maybe you're not saying enough,

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maybe you're saying too much,

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maybe you're overexplaining,

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maybe you're under explaining,

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maybe it's too jargonny,

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maybe it's too highbrow,

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and it's

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not landing at all because these people have no concept of

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the clinical components of what's going on.

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So on and so on.

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So,

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if you mention that your colleagues feel that you're too strict in your approach.

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I don't know that look if we have boundaries

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and we have protocol we stick to them because

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we are bought in when we make business decisions.

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So if that's your protocol and that's your standard,

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you should stick to it.

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You may want to reconsider whether or not it needs to be

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those specific boundaries and protocol.

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Because it seems as though

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this probably goes back to communication and articulation

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more than

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the families

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themselves.

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I think these families need and want help.

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I just think they don't feel grounded in what's happening.

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So that may be a reworking of the process.

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And

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As far as the playroom itself,

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I know that was kind of like an additional question that was thrown at the end.

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You absolutely reset the playroom after every child,

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every time a child walks into a session,

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it is

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their playroom

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and it is reset

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to as much of a consistent playroom as you can provide.

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Obviously,

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one little figure might be in a different spot and you know,

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the stuffed animals might be rearranged differently,

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but they're still in the same place.

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We try to make it as consistent and predictable as possible.

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You should not keep everything in buckets.

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When kids have to rifle through things,

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dig through things,

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move things,

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it's prohibitive,

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it is interruptive,

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and it is a barrier to their work.

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The toys should be out,

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accessible,

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and inviting.

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Those three adjectives out,

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accessible and inviting.

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They shouldn't have to find them,

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open things,

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drawers,

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bins,

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boxes,

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containers,

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that that's become the lazy,

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I'm air quoting,

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but that's become the lazy CCPT

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is we're just going to keep everything in a bin with a label on the front of it.

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That gets in the way

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of what the child needs to do.

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So,

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you are actually very on target

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to not

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put everything in buckets and make sure that it is reset after every time.

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The average length of time for CCPT right now is 30 to 40 sessions,

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so you quoting 20 to 30 is actually a little bit

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scant.

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It should be 30 to 40

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with the quote ideal number being 37 according to meta-analytic research

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and

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obviously it does depend on the child.

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You said that it is a case by case scenario by scenario basis.

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No child is going to hit that number every single time,

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but 30 to 40 is the average.

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And

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it's actually more helpful to let a parent know they're committing to 5 at a time

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rather than 30 to 40,

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because every 5 sessions with the child,

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you're going to meet with the parent.

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And then you're going to reevaluate whether or not it makes sense for you to do 5 more.

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So when you said if they don't commit to this,

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I can't take them on,

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they don't need to commit to 40 sessions,

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they need to commit to 5 at a time,

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rounds of 5,

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and every round of 5 you meet and you determine

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if you're going to do another round of 5.

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And if your consultation process is tweaked and efficient,

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they will continue to commit to rounds of 5

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until the child is ready to terminate

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and they meet termination criteria.

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And your

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RPT that stated no change happens until around session 11 through 15?

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Sometimes children

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demonstrate change in session one.

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But I agree with the fact that on an average

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somewhere between sessions 11 through 15 is when work phase begins.

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So if she's specifically referencing work phase,

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I agree with that that is typically when kids move to work

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somewhere in that range,

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but

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often kids will make changes far earlier than the 11th session,

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but specifically in work phase is when you're going to see the bulk of progress.

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All right,

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Sally,

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thank you so much for the email.

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I hope that that's helpful for all of you.

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If you want to reach out to me,

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I'd love to hear from you,

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brenna@thekidcounselor.com.

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By the way,

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I have been getting so many emails from y'all lately.

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I mean,

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more so than I ever have gotten

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since I started this podcast.

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You all are sending so many emails.

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I read every single one of them.

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Thank you for those.

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I laugh at them,

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I cry with them,

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I,

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I share them with my team.

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It it is so special to hear what's going on in CCPT all over the world.

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And so thank you so much for the time that you spend

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to reach out and ask your questions and share your stories.

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It really does mean a lot.

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I,

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I read every single one and they really do bring

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so much value to the work that I'm doing.

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So just wanted to say a huge thank you.

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I love y'all.

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We'll talk again soon.

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Bye.

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Thank you for listening to the Play Therapy Podcast with Dr.

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Brenna Hicks.

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For more episodes and resources,

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please go to www.playtherapypodcast.com.