Selecting and Working With an Adoption Therapist
Factsheet for Families
Author(s): Child Welfare Information Gateway
Year Published: 2005
Adoption has a lifelong impact on those it touches, and members of adoptive families may want professional help as concerns arise. Timely intervention by a professional skilled in adoption issues often can prevent concerns from becoming more serious problems.
Professionals with adoption knowledge and experience are best suited to help families identify connections between problems and adoption and to plan effective treatment strategies. Sometimes a difficulty that a child is experiencing can be directly linked to adoption, but sometimes the connection is not readily apparent. In other situations, issues that seem on the surface to be related to adoption turn out not to be at all. It is important that the therapist understand that although the adoptive family is often not the source of the child's problems, it will be within the context of the new family relationships that the child will begin to heal.
This factsheet offers information on the different types of therapy and providers available to help adoptive families, and it gives some suggestions on how to find an appropriate therapist. Specifically, this factsheet covers:
- Professionals who provide mental health services
- Approaches to therapy (including attachment therapy)
- Treatment settings
- Finding the right therapist
- Working with a therapist
Many issues experienced by adoptive families will not require professional assistance. For many families, postadoption services like support groups or education workshops and seminars will provide all the help that is needed. For information about the different kinds of postadoption services available and how to find them, see the Information Gateway factsheet Postadoption Services: A Factsheet for Families.
Professionals Who Provide Mental Health Services
Many different types of professionals provide mental health services. The person or team best suited to work with a particular family will depend on the family's specific issues, as well as the professional's training, credentials, and experience with adoptive families.
Pediatrician or Family Practice Physician. These medical doctors specialize in childhood or adolescent care and typically treat routine medical conditions. They serve as primary care physicians who refer children for additional diagnostic studies or procedures and who coordinate referrals to specialists.
Psychiatrist. These medical doctors (with M.D. degrees) specialize in the diagnosis and treatment of medical and emotional disorders and substance abuse. After completing medical school, psychiatrists receive postgraduate training in psychiatric disorders, various forms of psychotherapy, and the use of medicines and other treatments. Some psychiatrists complete further training to specialize in such areas as child and adolescent psychiatry. Psychiatrists are able to prescribe medications.
Clinical Psychologist. A clinical psychologist has completed a doctoral degree (Ph.D. or Psy.D.) in psychology and usually has completed advanced courses in general development, psychological testing and evaluation, as well as psychotherapy techniques and counseling. Many clinical psychologists develop a subspecialty in child and adolescent development, psychological testing, or family therapy. Clinical psychologists assess and treat mental, behavioral, and emotional disorders, including both short-term crises and longer term mental illnesses.
Clinical Neuropsychologist. A clinical neuropsychologist holds a Ph.D. degree. These specialists have completed training in biological and medical theories related to human behavior. Their postgraduate training focuses on the assessment and treatment of brain diseases and injuries and neurological and medical conditions, including traumatic brain injury and learning and memory disorders. These professionals may be able to help in distinguishing organic (medical) problems from psychological problems.
Social Worker. A social worker has completed a bachelor's (B.S.W.) or master's (M.S.W.) degree in social work. Social workers are trained to focus on a child or family within the child or family's social environment. Some social workers may refer to themselves as psychotherapists; however, they may or may not have professional training in psychological testing. Licensed clinical social workers (LCSWs) have a graduate degree and have passed a clinical test to become licensed in their State to offer counseling to individuals and families. Licensure and titles differ from State to State.
Marriage and Family Therapist. Marriage and family therapists have graduate degrees in counseling or psychology and may have taken a licensing exam to receive their Marriage and Family Therapy (MFT) license. Almost all States have licensing laws for marriage and family therapists. These professionals evaluate and treat mental and emotional disorders and other health and behavioral problems, addressing a wide array of relationship issues within the context of the family system. Family therapists focus on communication building and on family structure and boundaries within the family.
Licensed Counselor. A licensed professional counselor has a graduate degree in a specialty such as education, psychology, pastoral counseling, or marriage and family therapy, as well as a State license to practice counseling. Licensed professional counselors diagnose and provide individual or group counseling with a variety of techniques.
Pastoral Counselor. Pastoral counselors include pastors, rabbis, ministers, priests, and others who provide faith-based therapy and counseling. They usually have a graduate degree (many have completed doctoral training), and many also have a special certification in pastoral counseling. They focus on supportive interventions for individuals or families, using spirituality as an additional source of support for those in treatment. Not all individuals who provide faith-based counseling have been formally trained or are credentialed as pastoral counselors.
It is important for adoptive families to share openly with their mental health professional that their family includes one or more adopted persons and to inquire about the counselor's training and experience related to working with adoptive families and adopted persons. A growing number of States offer a postgraduate certificate to mental health professionals to help them to understand the dynamics of adoption and to tailor treatment modalities to the needs of families and individuals impacted by adoption.
Approaches to Therapy
Different mental health professionals use different types of treatment. The type of treatment or the combination of treatments chosen may depend on the type and severity of the presenting issue, the age and developmental level of the child, and even the experience and preferences of the professional and family. Parents should be sure to ask prospective therapists about the different types of treatment that they might use. Some of these different types are described below. (A resource that rates the effectiveness of different treatment interventions for specific populations of children and families is the National Registry of Evidence-Based Programs and Practices.)
Play Therapy. Therapists customarily use this form of therapy with very young children, who may not be able to express their feelings and fears verbally. The therapist will engage the child in games using dolls and other toys, since play is a way for children to communicate. Through gentle probing, the therapist will try to draw the child out. In this way, the child may be able to act out feelings and reveal deep-seated emotional trauma.
Individual psychotherapy. This therapy may take many forms. Often the therapist will work to help the client first express problems verbally and then find ways to manage them. This type of therapy tends to stress that people should assume responsibility for their own actions and ultimately for their emotional well-being. The therapist will offer challenges, interpretations, support, and feedback to the client.
Group therapy. This therapy allows a small group of clients with similar problems to discuss them together in an organized way. Group therapy makes efficient use of a skilled therapist's time and offers the extra advantage of feedback from peers. Occasionally, family members may be asked to join the group. Group therapy frequently is used with adolescents and usually is the treatment of choice for individuals and families affected by substance abuse.
Family therapy. Increasingly popular, family therapy is based on the premise that all psychological problems reflect a dysfunction in the "family system." The term "dysfunction" means that members of a group or system are working together in a way that is harmful to some or all of its members. The therapist requests the active participation of as many family members as possible and focuses on gaining an understanding of the roles and relationships within the family. Family therapy seeks to achieve a balance between the needs of the individual and those of the larger family system.
Behavior modification. A commonly used form of therapy, behavior modification has many practical applications. The basic approach in behavior modification is to use immediate rewards and punishments to replace unacceptable behavior with desirable behavior. The therapist will identify specific changes desired and will establish a system of rewards and punishments. The reasons behind the objectionable behavior are seen as irrelevant; the focus is on change. This therapy is especially useful with children who may not be inclined or able to examine and understand their inner feelings.
Cognitive therapy. Cognitive therapy is based on the belief that the way we perceive situations influences how we feel emotionally. It is typically time-limited, problem-solving, and focused on the present. Much of what the patient does is solve current problems through learning specific skills, including identifying distorted thinking, modifying beliefs, relating to others in different ways, and changing behaviors.
A Word About Attachment
Many adopted children experience problems that may be the result of breaks in attachment that occurred during the first 3 years of life. These problems impair, sometimes severely, the child's ability to trust and bond—to attach—to other human beings. Children who have experienced maltreatment or traumatic separations may be hesitant to trust others enough to attach quickly or easily.
Attachment can be viewed as a continuum, with healthy attachment at one end and attachment disorder at the other. While a small percentage of children with attachment problems can be correctly diagnosed as having Reactive Attachment Disorder (RAD), many more adopted children display signs of some attachment difficulty, a midpoint along the continuum. Signs of attachment problems can include lack of conscience, lack of cause-and-effect thinking, superficial charm, obvious lying, stealing, indiscriminate affection with strangers, and cruelty to animals and people.
Attachment therapy. Attachment therapy includes a number of different approaches to therapy with children, but all approaches are based on common principles and theories of attachment and healthy development. Attachment therapy (sometimes incorrectly equated with holding therapy) includes an ever-expanding continuum of interventions based on treatment theories from an array of therapeutic approaches, including behavioral and cognitive therapies.
The focus of any attachment therapy should be to build a secure emotional attachment between the child and the parents. Because the primary focus is on the attachment relationship, not on the child's symptoms, one or both parents must be active participants in the therapy. The basis of attachment therapy is that the development of a trusting attachment relationship will provide the security essential to healing the psychological, emotional, and behavioral issues that may have developed as a result of earlier disruptions and trauma. These issues may include posttraumatic stress disorder, grief and loss, depression, and anxiety.
While some families find attachment therapy to be a useful approach, there is less evidence to support its effectiveness. As a relatively newer form of therapy, few studies of attachment therapy have been evaluated for outcomes. ¹
Treatments such as "holding therapy," "rebirthing therapy," or other types of treatment that involve restraint of the child or unwelcome or disrespectful intrusion into the child's physical space have raised serious concerns among parents and professionals. Some States have written statutes or policies that restrict or prohibit the use of these therapies with children in the care or custody of the public agency or adopted from it.
Other therapies. There are a number of other types of therapies, as well as variations of therapies, that may prove useful. These may include art therapy, music therapy, and couples therapy. Parents should ask the professional to explain the treatment and goals before deciding on a particular therapy.
Therapy may take place as in-home therapy, outpatient counseling, group or residential treatment, or inpatient hospitalization.
Most therapy sessions take place in an outpatient setting. This means that the client is seen in the therapist's office, typically in a 50-minute session once a week. Most emotional and psychiatric problems do not become serious enough to require treatment beyond this level. Many adoption-sensitive therapists believe that therapy for adoptive families benefits from a more flexible time schedule and is best done when the entire family is included.
Sometimes a child can best be treated with the limits and structured environment that a residential treatment center provides. Residential treatment is often the treatment of choice for children and teens with emotional, behavioral, or substance abuse problems. Residential treatment centers, which provide 24-hour care, are generally private, nonprofit facilities set up for children with severe psychiatric or substance abuse needs. They may be organized in individual community homes, in a campus-type setting of cottages, or in a large institution (similar to a hospital setting).
Residential treatment programs focus on the development of positive coping skills and personal responsibility. Behavioral therapy often is practiced in residential treatment programs; that is, the child's good behavior will bring about appropriate rewards and privileges. Children in residential treatment usually have regular visits with their parents. Family connections are critical to help motivate children to change their behavior so that they can return home.
Hospitalization in a psychiatric hospital is available for clients with serious emotional problems that cannot be modified through outpatient therapy. It may be necessary for children who become suicidal or dangerous to themselves or others to be hospitalized to avert a crisis. It is important that parents stay involved; in fact, most child and adolescent units of psychiatric hospitals insist that parents participate in family meetings or therapy. If they are not automatically included, parents should be proactive in emphasizing the involvement of the family in their child's treatment.
Finding the Right Therapist
Locating the right therapist requires that a parent identify some prospective therapists who have adoption experience and then conduct preliminary interviews to find the one who seems best able to help the child or family.
Identifying prospective therapists. It is important that parents take the time to find a mental health provider who has the experience and expertise required to address their needs effectively. Professionals with adoption knowledge and experience are best suited to help families identify connections between problems and adoption and to plan effective treatment strategies. At a minimum, a therapist must:
- Be knowledgeable about adoption and the psychological impact of adoption on children and families
- Be experienced in working with adopted children and their families
- Know the types of help available for adoption-related issues and problems
- Have received training in working with adoptive families
Parents may contact community adoption support networks, use the Internet, and ask their placement agency for referrals to therapists. Many public and private adoption agencies and adoptive parent support groups have lists of therapists who have been trained in adoption issues or who have effectively worked with children in foster care and adoption. Some adoption agencies and specialized postadoption service agencies have mental health therapists trained in adoption on staff.
Parents can check with the following resources for therapist recommendations:
- Agency social workers involved in the child's adoption
- State or local mental health associations
- Public and private adoption agencies
- Local adoptive parent support groups
- Specialized postadoption service agencies
- State adoption offices
- National and State professional organizations (see National Resource Organizations below)
Interviewing prospective therapists. Using the recommendations that they gather, parents can call prospective therapists or schedule an initial interview to find out basic information. Some therapists will offer an initial brief consultation that is free of charge. Parents should start by giving the clinician a brief description of the concern or problem for which they need help. The following are some questions to discuss:
- What is your experience with adoption and adoption issues? (Parents should be specific about the adoption issues that impact their problem, such as open adoption, transracial adoption, search for birth relatives, children who have experienced abuse or institutionalization, children with attachment difficulties.)
- How long have you been in practice, and what degrees, licenses, or certifications do you have?
- What continuing clinical training have you had on adoption issues?
- Do you include parents and other family members in the therapeutic process?
- Do you prefer to work with the entire family or only with the children?
- Do you give parents regular reports on a child's progress?
- Can you estimate a timeframe for the course of therapy?
- What approach to therapy do you use? (See Approaches to Therapy above.)
- What changes in the daily life of the child and family might we expect to see as a result of the therapy?
- Do you work with teachers, juvenile justice personnel, daycare providers, and other adults in the child's life, when appropriate?
There are other practical considerations when choosing a therapist. Parents should be sure to ask about:
- Coverage when the therapist is not available, especially in an emergency
- Appointment times and availability
- Fees and whether the therapist accepts specific insurance, adoption subsidy medical payments, or Medicaid reimbursement payments (if applicable)
Working With a Therapist. If the child is the identified client in therapy, the family's involvement and support for the therapy is critical to a positive outcome for the child. An adoption-competent therapist will value the participation of adoptive parents. Traditional family therapists not familiar with adoption issues may view the child's problems as a manifestation of overall family dysfunction. They may not take into account the child's earlier experiences in other care settings and may view adoptive parents more as a part of the problem than the solution. Adoption-competent therapists know that the adoptive parents will be empowered by including them in the therapeutic process and that no intervention should threaten the parent-child relationship.
Parents' commitment to the therapy may also contribute to the success of the therapeutic process. For instance, parents are obligated to keep scheduled appointments. They should refrain from using therapy sessions as punishment for a child's misbehavior. Family members must communicate regularly with the therapist and ensure that the therapist has regular feedback about conditions at home. The success of therapy depends heavily on open and trusting communication.
Parents may want to request an evaluation meeting with the therapist 6 to 8 weeks after treatment begins and regular updates thereafter. Evaluation meetings will help all parties evaluate the progress of treatment and offer the opportunity to discuss the following:
- Satisfaction with the working relationship between the therapist and family members
- Progress toward mutually agreed-upon goals for treatment approaches and desired outcomes
- Progress on problems that first prompted the request for treatment
- The therapist's tentative diagnosis (usually necessary for insurance reimbursement)
- The therapist's evaluation of the chance that therapy can improve the situation that prompted treatment
Insurance Coverage and Other Funding for Therapy
The cost of therapy varies and may be covered in part by health insurance or the child's adoption assistance agreement. Some therapists, and most community mental health centers, provide services on a sliding fee scale based on income. Parents should ask about costs and when payment is expected (after each session, at the end of the month, or after reimbursement by insurance).
Insurance companies have different requirements for coverage of mental health treatment. Parents may have to choose from a list of approved therapists, and there may be a limit on the number and types of sessions covered. Parents should find out from the insurance company:
If the child has an adoption assistance agreement, parents should see what the subsidy covers.
Members of adoptive families may encounter issues at different points in their lives that affect their behavior and emotional well-being and that require treatment from a professional therapist. Adoption-competent therapists, who understand adoption issues and adoptive family dynamics, are best suited to provide clinical interventions. With some research, parents can find the therapist best able to support their child and family.
National Resource Organizations
The American Academy of Pediatrics
The American Association of Pastoral Counselors
The American Psychiatric Association
The American Psychological Association (APA)
The Association for Play Therapy
The National Association of Social Workers
For contact information on State adoption offices and local adoptive parent support groups, access Child Welfare Information Gateway's National Adoption Directory.
This factsheet was developed by Child Welfare Information Gateway, in partnership with Susan Freivalds. This document is made possible by the Children's Bureau, Administration on Children, Youth and Families, Administration for Children and Families, U.S. Department of Health and Human Services. The conclusions discussed here are solely the responsibility of the authors and do not represent the official views or policies of the funding agency.
Suggested Citation: Child Welfare Information Gateway. (2005). Selecting and Working With an Adoption Therapist: A Factsheet for Families. Washington, DC: U.S. Department of Health and Human Services.
This material may be freely reproduced and distributed. However, when doing so, please credit Child Welfare Information Gateway.