This goal can be the most challenging part of the child’s treatment for several reasons. Parents often feel guilty that they did not recognize that their child has a psychiatric and not a neurological disorder. They fear criticism of their parenting skills and how this might have contributed to their child’s disorder. So opening themselves up and sharing family stressors with you are difficult for these parents. In addition, the parents of children with PNES are frequently not “psychologically minded.”

The metaphor of peeling the layers of an onion in your work with the child also applies to your work with the parents. Because the child frequently is the one who informs you about the family stressors, it is therapeutically inappropriate to talk about them with the parents. In fact, in some cases, the parents’ focus on the child’s PNES symptoms allows them to avoid addressing some important family stressors. Therefore, you first help the parents manage their own distress associated with the child’s PNES symptoms and diagnosis (Parent Goal 1). Their rapport with you and trust in you will strengthen in parallel to remission of the child’s episodes. As the parents learn how to communicate with their child (Parent Goal 2), recognize the child’s stressors (Parent Goal 3), and begin to help the child problem-solve (Parent Goal 5); they might slowly become more open to bringing up other family stressors with you.

S is an11-year-old boy treated for PNES for 1 year. His episodes remitted after the first 3 months of therapy with occasional subsequent episodes. A month prior to his PNES diagnosis (not onset of episodes), S’s grandfather, with whom he was very close, died. He was the oldest grandchild and was the favorite of both the grandfather and the grandmother. About 8 months after the grandfather’s death, the grandmother started dating and married 2 months before the session below. Since then, she has had very little to do with her two daughters and their families, including the patient. In individual sessions, S has frequently brought up the topic of his grandmother and vacillates from feeling rejected to immediately stating that she has to live her life. S has mentioned that his mother on the one hand is sad but on the other hand justifies her mother’s actions and that they should not be upset at the grandmother. The repetitive nature in which S brought up the topic and the therapist’s sense that his mother was not allowing him to grieve the loss of his grandmother’s attention (the important therapeutic goal of verbalizing negative emotions) suggested a need for the family session presented below. The comments are in the blue (therapist), yellow (S), green (mother), and orange (father) bubbles.