Untying the Knot

Working with Children and Parents

A.H. Brafman

• Publisher: Routledge
• Year: 2018
• Print ISBN:
  9780367329532
• eBook ISBN:
  9780429923630
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

Untying The Knot sets out to present a clinical approach to cases where the referred patient is a child or adolescent, but in which the parents are intimately involved in the therapeutic situation.Three fundamental principles inform the work: firstly, that early experience influences present lives; secondly, that unconscious feelings and fantasies are elements which shape everyday conscious experience; and thirdly, that the interaction of children and parents leads to patterns which become self-perpetuating and make it virtually impossible to define what is cause and what is effect in their relationship.Dr Brafman acknowledges the pioneering work of Donald Winnicott in the treatment of children, emphasizing particularly his refusal to be bound by rigid notions of treatment modalities, but instead to go to the heart of the matter - an understanding of the child's own confusion and pain, and then, through its elucidation and expression, to bring relief.

Chapter One
Introduction

Psychoanalytic theory and practice focus exclusively on the psyche of the individual. In the course of the decades since Freud's fundamental discoveries, there has been a proliferation of theories and techniques and a multiplication of names to describe them. At the start of the new millennium, psychoanalysis sensu strictu has become a respected body of theories, but its clinical application appears to be restricted to training purposes and the treatment of an ever-decreasing number of patients. "Psychoanalytic psychotherapy" is now more prevalent, and this seems to encompass a large number of treatment modalities whose common elements can, at times, be difficult to distinguish.

Two of the main therapeutic offshoots of psychoanalytic theories have been the application of its principles to the treatment of children and of groups. Each has yielded a rich field of new concepts and techniques, but, in broad terms, child psychotherapy still focuses on the psyche of the individual child, whereas group approaches unravel the dynamics of individuals having to associate with others. Not surprisingly, the family also came to be put under the analytic microscope, and, since the 1940s, family therapy has carved out its own territory. Initially, it was the families of schizophrenics who were studied, and soon enough parents who were supposedly "normal" came to be described as having a powerful influence on the development of the psychotic picture of the presenting patient. At about the same time, child psychiatrists also brought the children's parents under clinical scrutiny, but somehow it came to be very rare that these approaches paid sufficient attention to the child's experience of the family life. This may well have been due to the fact that most therapists were used to working with adults, and, depending on the child's age and capacity to articulate his thoughts,* it was simply easier to concentrate on the adults.

This book sets out to present a clinical approach to cases where the referred patient is a child or adolescent, but the parents are intimately involved in the therapeutic intervention. Three fundamental principles guide the work: (1) our present life is influenced by earlier experiences; (2) our behaviour and conscious life is influenced by our unconscious feelings and fantasies; and (3) child and parents influence each other in such a way that it may be impossible to establish what is cause and what is effect in their interactions.

I have often used Winnicott's term "therapeutic consultation" to describe the case studies presented in this book. This is not just because most of the children were seen only once or twice, but also because I was following his approach and many of his concepts, which I find very convincing. As will be seen, I have developed my own way of dealing with children and their parents in this work, but my debt to Winnicott cannot be emphasized enough. It is his respect for the child as an individual that singles him out from many other professionals. His wish to help the child had nothing to do with the doctor's sense of pride in defeating illness or the scientist's triumph in finding confirmation for his or her theories, but, instead, it seemed to flow from his desire to bring relief to the child and make it again happy, well functioning, and moving towards independence and self-sufficiency. In other words, his commitment was to the child and not to his theoretical convictions. It is a model worth adopting.

Winnicott made valuable contributions to several clinical areas. Besides seeing "ordinary" neurotic patients, his work with psychotic and borderline patients set standards that are respected and followed; in addition, his experience in paediatrics, child psychiatry, and child analysis meant that he had contact with thousands of infants, children, and adolescents, whom he followed very closely for extended periods in different clinical and social settings. These parallel fields of work meant that, while other analysts conceptualized human emotional development on the basis of inferences from their work with adults, Winnicott could draw on his extensive experience with babies and young children to put forward an object-relations developmental theory that is particularly persuasive. Some of the concepts arising from the body of his theoretical framework have become part of the everyday vocabulary of most practitioners in the caring professions—for example, the "good-enough mother", the "average expectable environment", "transitional objects", the "holding environment", and the "antisocial tendency". Considering how his theoretical concepts are so widely accepted, it is puzzling to find that Winnicott's accounts of his actual, clinical work with very regressed patients and with children in his hospital clinics tend to be seen as reflections of his personal attributes—that is, not so easy to be put into practice by other professionals.

Discussing the diagnostic consultations with children that had produced therapeutic results, Wirinicott defined their motto (his word) as "How little need be done (to help the child)?", whilst in psychoanalysis, he wrote, the motto was "How much may the analyst be allowed to do?"* I believe he was referring to the ever-increasing length of psychoanalytic therapies and the rationale for this approach. Since Freud's warning (1910) against the misleading results of brief therapeutic interventions based on false or premature interpretations of psychoanalytic concepts, psychoanalysts had taken the length of treatment and the frequency of interviews as yardsticks of the validity and effectiveness of the therapy. Winnicott himself had had lengthy analyses, and this might have influenced his formulation. It is also possible that he might be referring to the concept of psychoanalysis as an instrument of research into the workings of the human mind; as such, however long the therapy, there would always be something further to put under scrutiny. From all these points of view, Winnicott's formulation rightly emphasized the importance of the consultant being able to balance out patients' needs and wishes against his own view of what treatment he might want to recommend. Winnicott's contrast of the two clinical options is a succinct summary of the complex range of factors that influence the consultant's eventual advice to the patient regarding the decision they must, together, make on how to proceed.

Because of his medical training, Winnicott would be intensely aware of the steps followed by every doctor when seeing a new patient: clinical examination, differential diagnosis, consideration of different therapeutic interventions, and prognostic evaluation of each of these—and only then the decision as to which therapy to prescribe. The complexity of the problem of finding the best compromise between the doctor's view of the ideal treatment and the patient's wish for immediate cure is part of every doctor's daily life. The decision to recommend long-term psychoanalysis or psychotherapy may derive from recognizing that this is the treatment modality most beneficial to the patient, or, occasionally, consultant and patient will agree to study in detail the psychopathology underlying the patient's problems; however, at times this decision may result from the consultant's a priori belief that only a prolonged, intensive therapy may be able to bring to that patient the relief he seeks. This latter viewpoint would move from discernment and judgement towards the biased statement of faith. I suspect that it is this approach to the issue of "helping" and "healing" that Winnicott had in mind when he formulated his two mottoes. I believe he was trying to call his colleagues' attention to the existence of therapeutic options and, hopefully, get them to accept the fact that many children can benefit from brief psychotherapeutic interventions.

Implied in Winnicott's phrase is the reminder that, first and foremost, children come to us hoping to find relief, to find help with their problems. Meeting a new child patient, Winnicott's first concern was to make a diagnostic evaluation of the child's physical and emotional development. Before deciding on the actual therapeutic intervention, Winnicott assessed the parents' capacity to offer the child the environmental provisions that he considered necessary—and only then did he decide whether the child could benefit from a brief intervention or whether, instead, the child required a more long-term therapeutic input. In practice, these stages tend to blend into each other, and perhaps they are not so easily identifiable as I have defined them; however, this sequence constitutes a valid philosophy of work, and it has served as my model, as will be seen.

History: Winnicott

Winrricott's book Therapeutic Consultations in Child Psychiatry was published in 1971. In the Introduction to the book he emphasized that his aim was not to present cases illustrating symptomatic cure, but, rather, to report "examples of communication with children" (emphasis in original). This formulation probably followed from Winnicott's awareness that his psychoanalytic colleagues viewed with suspicion, if not open disapproval, his claims of therapeutic results in the course of brief clinical interviews. Psychoanalysts were moving towards ever more prolonged analyses, and any attempts to shorten the treatment of people with emotional problems were viewed with mistrust. This is particularly surprising when no reader of that book can fail to marvel at the beneficial results following from Winnicott understanding the child's "communication" and putting this into words for the child.

Winnicott never conducted his therapeutic consultations with the aim of demonstrating his virtuosity or to obtain quick results in his work with children. He was a clinician of exceptional sensitivity, and he had the capacity to recognize new findings and proceed to explore them rather than to explain them away by turning to some accepted dogma. Having found that a diagnostic interview could produce clear, dramatic improvement, he must have decided to investigate further whether this was an isolated, fortuitous good result or whether this could be duplicated with other children. As it turned out, he went on to find a large number of similar successful consultations, some of which are reported in that book.

Therapeutic Consultations (1971b) can be read in many different ways. The clinical cases are vividly described, and they represent fascinating reading, even if read as no more than interesting stories. The "Squiggle Game" that Winnicott employed in the cases described is a most effective way of bringing to light the child's unconscious conflicts, and Winnicott cannot be contradicted in his claim that the game is a valuable way of "communicating with children". The finding of significant improvement in the child after one or a few interviews poses a challenge to the clinician, but even more so to the theoretician who might want to discover the rationale for the changes experienced and presented by the child. Critically minded therapists have plenty of clinical material that they can use in order to argue how they would have preferred to deal with a particular child. Professionals who work with children have much to learn from Winnicott's account of how he approached and engaged the child. Considering the many different ways of learning from this book, it must be surprising to find that there have been recurring criticisms of Winnicott's therapeutic consultations. These were aptly summarized by Phillips (1988): "there was something 'magical', his critics thought, in the fluency of his contact with the children he saw, as though all one could learn from his clinical accounts was that one was unable to be Winnicott" (p. 16).

Winnicott certainly had a unique capacity to tune in to his patients' wavelength, and this comes across in all his clinical accounts, both when working with children and with adults. But I tend to think that the "magic" that many critics picked on is probably linked to the objective pursued when meeting the child. Most practitioners will approach the child with the goal of identifying the child's suitability for a particular treatment; many will attempt a diagnostic evaluation, where data are gathered to match different categories—but as I understand him, Winnicott set out to find the nature of the child's experience of his problem, which is a goal that has many important implications. Much as in any similar situation, the answer one finds is influenced by the question or task one sets out to resolve, and, even more important, the consultant's utterances and emotional posture are profoundly influenced by his aim in addressing the patient. Gathering data does not require any emotional involvement, since "a sympathetic attitude" of professionalism is considered sufficient to gain the confidence of most patients, whatever their age. When the consultant wants to learn the nature of the problems experienced by the patient—that is, not just "the facts", but what the patient believes afflicts him—this is interpreted by the patient as a warm, humane personal interest in how he feels. Winnicott knew how to convey to the child his readiness and desire to make deep emotional contact, and it is this mutual coming together that probably gave readers and outsiders (Winnicott usually had visitors attending his consultations) the impression of something magical.

The cases described in Winnicott's book (1971b) show that identifying the specific unconscious fantasy underlying the child's symptoms brought about a resolution of these conflicts—and, at this point, an altogether different question comes to the fore: is this relief enough? Or does the child need more help/treatment? Those who believe that only treatment that is prolonged and "deep" can claim true psychotherapeutic value dismissed Winnicott's interventions as superficial and not truly effective. Analysts and therapists who worked in National Health Service clinics, and who had learnt to adapt their psychoanalytic knowledge to the constraints of the facilities available, could recognize the advantages of Winnicott's approach, but, on the whole, whether they applied the squiggle game or not, most of these therapists considered their consultations exclusively a diagnostic tool: preference was still given to the prescription of long-term, individual or family therapy.

The present book presents a number of cases where children were seen along similar principles to those described by Winnicott: they were children referred for a diagnostic assessment, which eventually turned out to be a therapeutically effective intervention. But I hope to show the advantage of including the child's parents in these meetings. This departs from Winnicott's definition of the parents' role in the child's treatment, and I discuss the clinical and theoretical implications of this closer scrutiny of the parents' relationship to the child.

The squiggle game played a central role in Winnicott's cases. After an apparently brief introduction during which he made the child feel at ease and settled into a comfortable position, sitting near him around a table where paper and pencils were available, he proposed to the child that they should play a game. This entailed a sequence of drawings in which Winnicott made an impromptu, meaningless doodle and asked the child to transform it into anything at all; most, if not all, children responded to this without difficulty, Winnicott went on talking to the child, continuing their previous conversation, but he now asked the child to make a squiggle, which he, Winnicott, proceeded to transform into whatever it was that he "saw" in the child's squiggle. As they continued the drawings, it could be seen that the child and Winnicott had isolated themselves from people and things around them and were now engaged in a close, intimate relationship where words and drawings complemented each other. At some point of the sequence the child would notice that a picture he had drawn represented or reminded him of a dream, and Winnicott discovered that this dream presented the necessary clues to recognize the unconscious fantasy that underlay the child's presenting problems. I imagine Winnicott was surprised when he first discovered that the articulation of this unconscious fantasy brought about such a dramatic improvement in the child, but it seems that he came to expect similar results with later cases.

The parents did not take part in the interviews. Winnicott's accounts convey vividly the child's growing trust and closeness, gradually becoming immersed in the game, as if entering into a special kind of contact with Winnicott, where the child's conscious vigilance appeared to be suspended and his unconscious seemed to come to the fore. Winnicott postulated that when this closeness occurred, the child was not relating to him, the doctor sitting down next to the child, but to some figure that seemed to be part of the child's internal unconscious world: "here I was, as I discovered to my amusement, fitting in with a preconceived notion. The children who had dreamed in this way were able to tell me that it was of me that they had dreamed. In language which I use now, but which I had no equipment for using at that time, I found myself in the role of subjective object" (Winnicott, 1971b, p. 4; emphasis in original). In other words, the child was turning to Winnicott as the person (object) in the outside world who would embody the attributes of that ideal helper he had dreamt of and who would, therefore, be able to understand his problems and bring the relief he craved for.

Once the consultation was finished and Winnicott had discussed his interpretation with the child, he invited one or both parents to join them. It seems that early in his work he showed to the parents the drawings their child had made and shared with them what had transpired in the interview, but he must have found serious disappointments in this, since he writes of parents betraying his confidence ("Parents might perhaps abuse the confidence that the therapist has placed in them, and so undo the work that depends on a kind of intimacy between child and therapist": Winnicott, 1971b, p. 4). Beyond this particular aspect, he drew a distinction between parents who had the ability to support the child in building further on the initial improvement and other parents whose personality and/or social circumstances would not allow them to play this role. In the latter case, when parents were unable to give the child the protective care he needed, it was necessary to consider other therapeutic interventions:

if the child goes away from the therapeutic consultation and returns to an abnormal family or social situation then there is no environmental provision of the kind that is needed and that I take for granted. I rely on an "average expectable environment" to meet and to make use of the changes that have taken place in the boy or girl in the interview, changes which indicate a loosening of the knot in the developmental process. ... Where there is a powerful continuing adverse external factor or an absence of consistent personal care, then one would avoid this kind of procedure and would feel inclined either to explore what could be done by "management" or else to institute a therapy which would give the child the opportunity for a personal relationship of the kind that is generally known as transference. [Winnicott, 1971b, pp. 5-6; emphasis in original]

In the work to be presented here, parents play a prominent role. Their active participation in the interviews allows us to have a firsthand view of how child and parents relate to each other, as well as giving us an opportunity to explore what the child's symptoms mean to each of them. The goal of identifying the child's unconscious fantasy underlying the symptom is still pursued, but an additional objective is the understanding of the factors operating in each parent which are related to the child's problems. In other words, these joint meetings give us an opportunity to understand each parent's role in the creation and /or persistence of the child's problems, as well as to gauge how much h...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• CHAPTER ONE Introduction
• CHAPTER TWO The clinical encounter
• CHAPTER THREE Child and parent interacting
• CHAPTER FOUR Mainly the child
• CHAPTER FIVE Virtually only the child
• CHAPTER SIX Summing up
• REFERENCES
• INDEX