An Independent Practitioner's Introduction to Child and Adolescent Psychotherapy

Playing with Ideas

Deirdre Dowling

• Publisher: Routledge
• Year: 2019
• eBook ISBN: 9781351378543
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

An Independent Practitioner's Introduction to Child and Adolescent Psychotherapy: Playing with Ideas is a comprehensive guide to child and adolescent psychotherapy, taking the practitioner from the initial meeting through the therapeutic process with young people of different ages, to the ending of psychotherapy. It includes approaches to working with parents and the family, introduces theoretical ideas simply and provides references for further learning.

Part of the popular Independent Psychoanalytic Approaches series, this book is written from an Independent perspective, but it is also an account of Deirdre Dowling's approach, developed from her considerable experience of working in the NHS and now as a private practitioner.

An Independent Practitioner's Introduction to Child and Adolescent Psychotherapy will be an indispensable guide for child psychotherapists (especially trainees), colleagues working in child and family mental health settings, play therapists, counsellors and support staff in schools and child care professionals working therapeutically in residential and community settings.

Part 1

Mapping the territory

Chapter 1

The therapeutic process

In the Introduction, I mentioned Winnicott’s (1968) idea that psychotherapy should offer a creative space where the patient and therapist can play with ideas. He believed that to achieve understanding and emotional change requires us to trust the unconscious process in the child’s creative play or the adolescent’s conversation to reveal core problems concerning the sense of self. This can only occur within a reliable therapeutic relationship, where the patient feels safe.

So how do we establish that creative space in our therapeutic work? Often, as child psychotherapists, we don’t have willing patients in the room. Young people are there because their parents or carers are worried about them. So, creating and maintaining a therapeutic alliance can be difficult. I am aware of a noticeable difference in sessions when a young person has joined me in the search to understand what is wrong, rather than dodging and diving to avoid emotional contact and painful realities.

In this chapter, I will look at five aspects of the therapeutic process that help create a framework for the treatment. They are: creating a safe space for therapy, understanding children’s play and communication, understanding our defences and making interpretations, working with our feelings, and ‘working through’, the process of change. Of course, these different aspects of therapy are interconnected, like the different-coloured threads that create a pattern in a piece of weaving. But it is helpful to look at each thread individually to see, in practice, how it contributes to the whole.

Creating a safe space for therapy

We create a safe setting in psychotherapy by our ability to listen deeply and observe closely, as we try to understand the underlying themes in a child’s play or a young person’s conversation with us. Many children have not experienced such careful attention before and they respond with relief that there is someone available to hear their worries. They may also feel anxious, and resistant to being in this dependent position, particularly if the adults in their lives so far have not been trustworthy.

Being thought about deeply is a necessary precursor to being able to think about and understand one’s own moods and feelings. In his chapter ‘The theory of thinking’ (1962a) W.R. Bion describes how children learn to understand their own feelings by having them heard and reflected back in a manageable form by the parent caring for them. Bion calls this ‘containment’ (1962b). Winnicott (1945) uses the term ‘holding’ in a similar way, but he stresses the importance of parents’ practical care given to their children in a loving way, to develop this sense of inner security. We have all seen an infant or toddler wailing with frustration after falling down or losing a toy, who can only be soothed by a loving and firm parent who comforts and tries to understand what is wrong.

Bion suggests also that the baby or infant who is not comforted in this way, but is left alone to cope with overwhelming feelings, experiences a sense of terror he calls ‘nameless dread’ (Bion 1962a: 183). A mother, feeling alone and distressed, may be unable to comfort the child because she feels frightened by the intensity of these feelings in her baby. Perhaps this is because the baby’s crying triggers her own memories of being distraught as a small child. She may withdraw, or react angrily, especially if she has no one to support her in these difficult moments. An infant can survive some distressing times if, at others, the mother and father offer comfort and love. We only have to be good enough parents (Winnicott 1953). But the infant or child who is left alone too often with unmanageable feelings will never learn to calm down and may become irritable or withdrawn. These are the children we so often see later in psychotherapy: loners, full of anxiety, or subject to outbursts of aggression that alienate those around, who might otherwise try to help.

So, by our close attention in therapy, and our ability to be in touch with the child’s feelings, we offer an emotionally holding experience. This can help the child begin to understand what is wrong. Sometimes, with very emotionally deprived children, it is as if we are starting at the very beginning, naming the feelings for the first time.

Many years ago, when I was a social worker, I was asked to see Tom, a West Indian boy about 10 years old, who was very withdrawn at school. He had been brought up by his depressed lonely father who worked long hours to keep him. They had only recently settled in this country. When I saw Tom for regular weekly meetings, he would watch my face with close attention, reminding me of a small infant studying his mother’s face, trying to work out the feelings he saw there. He would sometimes ask me if I was happy or sad, as if he did not know how to read my expressions or behaviour, nor his own. I would tell him what I thought he was feeling at that time, and how that made me feel, and this led to conversations about his life and his loneliness. I was not a trained child psychotherapist then, but I recall how Tom became more animated and how he looked forward to our conversation on my weekly visits. He gradually gained the confidence to reach out and be comforted by others around him, like the teachers in the special school he attended.

It was as if this lad knew that he was missing a thoughtful person who could help him understand himself and he sought this out in me. I have met this longing for an understanding adult often in the more deprived and troubled children I have seen. Although they may be resentful and suspicious of psychotherapy, they may also be looking for a sense of connection and understanding, and this need has survived intact, despite their fury and disappointment with adults about their early deprivation or trauma.

Understanding children’s play and communication

What is truer than truth? The story.

Jewish proverb

Playing and telling stories is the natural way for children to think about themselves and their world. When we provide young people with play and drawing materials in therapy, we are letting them know that we see their imaginative world as an important source of ideas, a way of exploring their concerns. In fact, it is not until young people start to express themselves spontaneously and imaginatively, and we begin to link this with how we think they feel and see life, that children really understand how therapy works.

The purpose of play and encouraging young people to tell stories is to discover their inner world, by this I mean their view of themselves and their life experiences. When the therapist is more directive, suggesting topics for the play session or asking a series of questions, children reveal only what is on the top of their minds or what they think the therapist wants to hear, rather than the underlying emotional tensions and conflicts that have troubled them. So, when a young person spontaneously begins to tell a story, maybe by setting up a scene with two armies fighting, I encourage the storyteller to elaborate. Who is involved? What led to the battle? What has made them angry? Usually this tale develops, sometimes in a way unexpected to both the child and me, as fears and fantasies rise to the surface of the child’s mind and become themes in the narrative. As the Jewish proverb suggests, these stories have their own truth as the young people are talking about themselves, but the feelings are held at a safe distance in the story, so they do not feel exposed. At first, I just listen and show interest, but gradually I may begin to empathise with the challenges facing the characters. I might talk about how the characters may feel, and why I think the events happened, and at some level the young people recognise this story is about themselves too.

Over the weeks, these stories develop in the sessions, and themes emerge which represent aspects of the child’s feelings about himself. The beauty of a child’s play and stories is that they resonate on many levels as they are rich in metaphor and symbolism like poetry and myth. However, children may resist this idea in practice. Peter Wilson suggests why in his paper about latency children (6–10-year-olds) entitled ‘Latency and certainty’. He writes that, despite the fascinating play of children at this age, they often deny it has any meaning beyond the concrete facts, to the frustration of the therapist:

The latency child presents the psychotherapist with a peculiar doubled-edged challenge: to overcome seemingly unmoving, even obtuse resistance, and to unravel and understand rich and imaginative fantasy material. There is, in a sense, no ambiguity.

(Wilson 1989: 59)

No ambiguity because, he suggests, ambiguity is not easily tolerated at this age. Children insist on knowing and on being certain, to defend themselves from having to face complex feelings at an age when their confidence can feel precarious because of the many new skills they are trying to learn. One of the interesting questions is whether the process of a child playing through such a fantasy is itself curative, as the process of imaginative play brings about internal change, or whether the play needs to be put into words and consciously linked to the child’s own experience by the psychotherapist to be understood and internalised. I am not sure.

One of the challenges of psychotherapy is managing the anxiety that arises when a child begins to explore a painful or worrying issue that has been shut away, as it was too upsetting to face. Children naturally break off and direct their attention elsewhere when feelings become too intense, and we allow this to happen so that they can face their anxieties at a pace they can manage. Alternatively, the child may become quite disruptive and I will discuss how to manage this later in this chapter. As children become more resilient, we may draw attention to this defensive avoidance, to encourage them to face issues they may have been too fragile to consider before. But this is a matter of careful judgement by the therapist.

Children’s stories have elements of fantasy, magic and reality interwoven, and the symbolism of their play allows us to explore the meaning of their play in more depth. Like the young girl I described in the opening chapter, who hung pictures of stormy weather on a line to describe the emotional turbulence of her life. Children’s fairy tales are alive with this imagery, as in the Grimm brothers’ story of Snow White where the poisoned apple that the witch gives the princess is a symbol of her envy and hatred of this beautiful young princess. A similar image was used by a young girl in her play with me. She made me a ‘nice’ cake out of plasticine but when I broke it open I saw that inside was a worm, an unpleasant surprise. It was a powerful way of communicating her fear from past experience that beneath the surface of our ‘nice’ relationship there lurked feelings of hatred.

As psychotherapists, we allow our imaginations to range freely as we sit and observe children’s play or listen to teenagers talk about their lives. It is an interactive process and we have to be aware which aspects of our own experience we are bringing to the relationship and what belongs to the patient. Cultural differences can be crucial here in defining how we experience particular symbols and words, partly because of the diverse meanings they carry in different societies but also because the reality of the children’s living environment can be so different. A Malaysian therapist once told me that his fear of spiders and the snakes came from growing up in the tropics where they can threaten life, and they had a very different meaning for him than for children raised in England where they can represent something scary, but in reality quite harmless. Allowing children to tell us what their story characters and symbols mean to them, and testing out our associations carefully, ensures we enter their imaginary world and feel it as they do.

Freud suggested that our dreams are another fertile avenue for exploring our inner world, the royal road to the unconscious (1900). In my experience, children’s dreams are often less disguised than adults’ and easier to understand, although they may take some unravelling before children become open to our suggestions about their meaning. As in psychotherapeutic work with adults, it is important never to take a dream on its own, out of the context of the child’s recent therapeutic work. A little girl may tell you there is a monster in her dream who threatens to eat her up, or a scary cat who will scratch her face, but these images of hunger, fear and anger need to be understood as part of the child’s history and ongoing clinical material. Talking to children about their dreams allows them to become part of the child’s conscious mind, and often defuses the terror of nightmares as this dream material becomes part of the child’s ordinary understanding of life.

Playing does not come easily to all children. For some, their imaginative world is terrifying, and they feel safer in the structured world of games and conversation. Others are too withdrawn or ‘lost’, as Anne Alvarez describes them, appearing to have no interest in us or the world, because they no longer expect to be comforted by this experience. This can occur when children have been so deprived as infants or have become locked away in an autistic-like state. Alvarez (1992) describes how we have to reclaim these children by offering ourselves as live company. We invite them to play or talk with us, and when they do briefly come out of their shells, we amplify these moments with lively encouragement. Our aim is to gradually restore these young people’s belief that people, and the world, have something to offer them. In her book, Live Company, Alvarez describes beautifully the patient, determined approach needed for therapy with very deprived or autistic children.

Once the therapeutic alliance has been established, the critical issue of what to interpret and when becomes important. I will explore this in the next section.

Understanding the defences and making interpretations

A challenging aspect of psychotherapy is to know what to say and when, how to put our thoughts and observations into words for our young patients so that they make sense to them. We have to be sensitive to a child’s emotional capacity to hear what we want to say before we speak. If the child is too upset, bewildered or suspicious, then our words will have no meaning or, worse, will be interpreted negatively. Of course, talking is only part of the therapeutic response. How well we are able to listen, and provide a calm and thoughtful presence, is just as important. Helping children put their feelings and thoughts into words makes it possible for them to begin to understand themselves, to think things through. Then they can communicate their feelings of anger and distress to others, and there is no longer such a need for them to act them out in their behaviour.

This skill of responding to a child and making interpretations at the right time and in the right words is one that develops with time. I am using the word interpretation in its broadest sense as it is defined in the Oxford dictionary: the action of explaining the meaning of something.

There is a more particular use of the word in psychoanalytic thinking where the definition of an interpretation is more focused on making latent meaning evident:

Interpretation is the process of putting into words – making conscious and known to the patient – fantasies, aspects of relationships, anxieties, conflicts and defences, and insights into the way the patient’s mind works which previously could not be known because they were unacceptable and thus had remained repressed in the unconscious mind.

(Lanyado & Horne 1999: 168)

Before I discuss this further, I would like to consider more simply why and how we speak in the session. Imagine watching a child play. You might show interest by briefly reflecting on what you see, or you might ask a few opening questions to help the child or the adolescent tell you more and develop the story. What and how questions are often more useful than why at this early stage, as they encourage children to describe in detail what is happening and build up their narrative.

Anthony, a withdrawn teenager, was referred for psychotherapy because of his anxiety and lack of confidence. He tells me in his session that he had spent the afternoon trying to write a song. I encourage him to tell me more about his song. At the same time, I am alert to his mood, how anxious he is talking to me. Anthony offers to play the song to me on his phone. I listen. The lyrics relate to his life, how confused and alone he often feels. I do not say anything at first as I do not want to stop the flow or for Anthony to feel I am intruding, but when I feel the timing is right, I suggest that the song tells us about him too. He nods and says no more, but that moment of connection between us has been important and I can return to these themes later or in a future session.

This is where psychotherapy is more of an art than a science. There are no clear rules to approaching this type of conversation. But there are guidelines that can help us recognise what level of intervention children can use at a given time.

First it is important to understand how defences work, as we need to approach these self-protective strategies in children with respect when mak...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgements
• Foreword by Ann Horne and Monica Lanyado
• Preface
• Introduction
• PART 1: Mapping the territory
• PART 2: Hard times: the challenges of child psychotherapy
• PART 3: Therapeutic work with children and parents in crisis
• PART 4: Taking child psychotherapy outside the psychotherapy room
• Index