Work with Parents

Psychoanalytic Psychotherapy with Children and Adolescents

Siv Boalt Boethious, Birgit Hallerfors, Ann Horne, John Tsiantis, Siv Boalt Boethious, Birgit Hallerfors, Ann Horne, John Tsiantis

• Publisher: Routledge
• Year: 2018
• Topic: Psychology
• eBook ISBN:
  9780429924217
• Subtopic: Mental Health in Psychology
• Index: Psychology

Drawing on the rich range and depth of the clinical experience of the contributors, this welcome volume will be a valuable tool for clinicians and trainees. The authors share a powerful commitment to the relevance and value of psychoanalytically based work with parents - an area all too often inadequately provided for - and provide heartening evidence of the resilience and intellectual vitality of the various strands within this tradition. Part of the EFPP Monograph Series.

Chapter One
Dialogues with parents

Margaret Rustin

This chapter is intended as an overview of current practice at the Tavistock Clinic. The approach described also represents a significant strand within child, adolescent, and family mental health services of the British National Health Service. I shall sketch a map of some varieties of approach, provide clinical examples, raise some ethical concerns, and explore how work with parents is encompassed within the identity of the child psychotherapist.

History of work with parents within child guidance

Perhaps it would be useful to start with some historical background. The early generations of child psychotherapists could rely on close working partnerships with experienced social workers (Harris, 1968). The postwar child guidance clinics were fortunate in their genuine multidisciplinary ethos and particularly in their social workers, who usually had a commitment to a psychoanalytically based understanding of human development and family relationships. Much of Winnicott's writing about his hospital work is imbued with his sense of the multidisciplinary teams within which his creative potential developed and standards of good practice were established. This was a very particular culture of care.

The child cases I took on during my training and in the early years after qualification were often supported by either long-term work with the mother of the referred child or work with the couple, where the focus might be on the couple's relationship. Psychiatric social workers had the skill of bearing the actual child in mind while finding ways to address the anxieties of parents (Shuttleworth, 1982). Their work tended to be on the borderline of case work (by this I mean work intended to support parental functioning) and psychotherapy. Proper use was made of the transference as a source of evidence of emotional conflicts, but it was rather rarely used explicitly. However, during this period there was a sea-change going on in the training and professional framework of social work, which was eroding such forms of practice. By the late 1970s, interest in internal aspects of relationship difficulties had waned and family therapy was the dominant therapeutic tool of interest to social workers. Child psychotherapists had to rethink how to approach work with parents.

The approach of child psychotherapists

This situation led to many of us seeing the way forward as one in which we would need to be able to support each other's cases. It was frequently noted that unless long-term work with parents was provided, the child's therapy was at risk of interruption, irregular attendance, and so on. Who better to provide the necessary input than one of our own colleagues? However, this development raised important questions of technique. We were very carefully trained in working within the psychoanalytic model of observation of transference and countertransference phenomena, and the interpretation of unconscious material, with insight as a primary goal of the work, but this kind of approach was by no means always appropriate or acceptable to parents. So we had to learn to use our observations of underlying patterns of object relations in different ways. We also found ourselves exposed to shaky marriages, borderline personalities, the risk of adult psychotic breakdown, perverse family structures, and so on; all of these, while they could be approached coherently on the basis of the training in work with children and adolescents, also took us into new territory. I do not think we have fully resolved the consequences of this either in terms of training or in thinking deeply enough about the clinical issues. Seminars in work with parents are a requirement in the Tavistock training, but often this work can be very difficult indeed. Does the absence of an expectation of individual supervision reduce the attention given to this work and its status? Is the work done of an adequate quality? Perhaps our anxieties on this score are one source of the tendency for child psychotherapists to go on to train as adult therapists or analysts. There are often excellent reasons for people seeking this extension of their professional capacities, but possibly some of the pressure to seek further training is a consequence of our not having solved the problem of how to train for the component of adult work within any child psychotherapist's practice.

A possible model

In reviewing the range of work undertaken with parents, I have come to think about four main categories. At one end of the spectrum are cases where gaining the support of parents to protect and sustain the child's therapy is the prime aim. The second group is where parents are looking for support in their parental functioning. The development of brief work with the parents of babies and small children is a specialization within this category (Daws, 1989; Miller, 1992). This group includes parents who feel they cannot make sense of a child's behaviour and relationships and who seek a better understanding of their children's problems, and parents who are struggling to cope with very difficult life circumstances—family illness, economic stress, disability, bereavement, and so on. These parents either see themselves as working in partnership with the professionals or feel in need of help themselves, but with the focus clearly on their role as parents. The third group is where the explicit aim of the work is change in family functioning, and this has been agreed by the parents as part of the treatment as a whole. There are different styles of work which may be appropriate, including marital therapy, individual work with a focus on the intra-family relationships, or family therapy as such. At the other end of the spectrum is individual psychotherapy for one or indeed both parents, to which the parents have committed themselves as patients in their own right, even if the issues that have brought them into contact with psychotherapists have started off as concern for a child. Both the therapies aimed at change within the family and psychoanalytic psychotherapy can function either alongside treatment of a child or on their own. I fully realize that these categories are schematic and that clinical cases often face us with work that veers between one or another type of work, but I think that it may be useful nonetheless to have the broad range subdivided. Sometimes the move from one position to another on this spectrum needs to be not only grasped by ourselves but also rendered explicit to patients. It is a bit like the transition from assessment into ongoing therapy. If work in progress makes it clear that a different aim from that originally intended is appropriate, signalling this can both give us real consent for a change in technique and enable us to free ourselves from confusion about what we are responsible for. My examples will address some of these points further.

First clinical example

Let me take first the support of a child's treatment, A recent example comes vividly to mind. An 8-year-old boy was about to begin three-times-weekly treatment. His evangelical Christian parents are separated. Both are closely involved with their two children. The boy had previously attended a one-year children's group therapy, and his mother had joined a parallel parental group of which she spoke with warmth. She then requested individual help for herself and had been offered weekly sessions. The father, Mr A, however, needed to be catered for in addition. The parents' relationship is stormy, full of writs and injunctions as well as real efforts to share out the care of the children. Mr A has a tendency to manic-depressive episodes and has made a serious suicidal attempt. He is under the care of a psychiatrist and also has had some counselling arranged as part of his psychiatric care. He has shown himself to be very touchy indeed about being treated as of equal importance to his wife in relation to his son. Faxes to the chief executive with complaints about clinic staff are part of the fat file that I inherited at the point where a tutee of mine was to take on the boy's therapy. What should we offer this father? Seeing the potential for trouble, I decided that a very clear-cut approach would be best. I offered Mr A an initial meeting in my role as Case Consultant—this is the title given at the Tavistock to the clinical manager of a case. In this I negotiated that I would be seeing him together with his son's therapist (a young man for whom this was a first intensive case) each term, to review the progress of the psychotherapy. If anything arose in between these meetings, Mr A was invited to get in contact with me. Despite the alarming tone of the threats that Mr A uttered in his initial meeting with me (he announced that he would not hesitate to consult his lawyer or to complain to all relevant authorities if he felt in any way left out of any decisions about his son's treatment, or indeed mistreated in any other way), Mr A has in fact been supportive of the boy's therapy overall and has taken a share in bringing him to sessions.

My feeling was that a number of factors had to be taken into account: first, this father needed to feel taken seriously as having parental responsibility and not dismissed as mentally ill; second, he needed the clinic to provide an absolutely clear account of who was responsible for what, particularly since the prior management of the case had been rather confused; third, the responsibility for containing Mr A had to lie with a senior member of staff who had the confidence to stand up to potential bullying and who would be seen as having authority both by the family and by the members of the clinical team. As psychotherapists, we usually veer away from taking an authoritative stance, but I think that there are circumstances where the assertion of professional authority is appropriate, when it is based on knowledge and a willingness to take responsibility. This can be the best containment of an unstable parent.

Parents who seek support

Now let us look at work with parents where they are openly seeking support. I would like to refer to two contrasting cases, both concerning the parents of autistic children. It should be mentioned that this group of parents is one with special needs, both because of the complexity of the network of services with which their child is likely to be involved and because of the peculiar loneliness often felt within these families (Klauber, 1998). Their children are so difficult to understand and to integrate into social life. One helpful approach tried out by Sue Reid and Trudy Klauber (colleagues at the Tavistock Clinic developing new approaches to work with families with an autistic child) was the establishment of a group for these parents, meeting once a term or so for an extended evening meeting, during which some of their shared concerns could be discussed. Parents felt helped by each other in coping with family and community issues. This group was in addition to the regular work undertaken with them on a case basis.

To undertake supportive work with parents, two possible models can be considered. The first is when the child's therapist also works with the parents. This can be seen as an extension of the termly review meetings, and is appropriate when the parents seem very reluctant to see anyone else. It may, of course, also be the only option available in the context of limited resources. When the referred child is psychotic or autistic, there can be good reasons for parents wishing to maintain a close contact with the child's therapist. She is often the person most able to help them understand the very puzzling character of their child's behaviour, and if some understanding of bizarre rituals or explosive tantrums can be achieved, it is easier for parents to sort out their response (Tischler, 1979).

Second clinical example

In my work with a psychotic girl, "Holly", whom I saw for psychotherapy for nine years, starting from when she was aged 13, I found that the work with her parents—which I had taken on reluctantly—was in fact fruitful, although I had started out by wishing that they would accept my offer to find them a colleague who would see them regularly. As they gained confidence in my commitment to working with this very ill girl, saw that I could make some sense of her behaviour and communications, and would take seriously how immensely burdensome her illness was to all the other members of the family, they began to give up some of their defensiveness. The mother in particular had told a tale of extensive prior contact with professionals, by whom she felt blamed for Holly's autism; in fact, in the early years she had been told that she was the one who needed psychiatric treatment, as it was her anxiety, not anything in her child, that was the problem. Her conviction that I recognized the agonies that Holly endured, and also appreciated how painful it was to be close to her and feel responsibility for her, was the basis of increasing trust in me.

I met these parents once or sometimes twice each term throughout Holly's treatment. Occasionally, these meetings also included at the parents' request another professional with responsibility for an aspect of Holly's life. For example, a local authority social worker who became involved in relation to possible residential placement when Holly was 18 joined us; later, when Holly moved to live in the community, the nun in charge of the institution that Holly joined, a woman with immense good sense and a capacity to enjoy the good qualities of damaged young people, also came from time to time. The parents saw me as Holly's interpreter on these occasions, with the task of making sure that other professionals had a proper grasp of what sort of person she was. They also valued my willingness to speak up for facing the realities: they often felt subjected to pressures to agree to what they felt was against Holly's interests—in particular, to deny the extent of her pain and her illness and to adopt a spurious cheerfulness about her future. In the work with the parents themselves, there were four major areas where useful work was done, and one where I felt defeated. This last was in my efforts to create space for consideration of Holly's younger sister, for whom I felt concerned, but I never succeeded in this.

The first matter we tackled was to explore what could be done about Holly's ruthless splitting of the parents. She rejected her mother systematically and indeed all things female, while idealizing her father, who was an art teacher. She spent hours entrancing him with what he saw initially as remarkable creativity. This consisted mostly in model-making, at which she was deft, the models being delusional penises (lighthouses, windmills, etc.) which she made by the dozen. These were felt by her to support her absolute denial of her own femininity. Her hatred and mistrust of her mother was painfully recognized by the mother as in part a response to the mother's hatred of her in her early years. This mother's sense of rejection, faced with an autistic baby, combined disastrously with fear rooted in the history of mental illness in her family of origin to create a pool of hatred, which she knew she had been unable to contain. But the vengefulness of Holly's refusal to recognize the loving and devoted side of her mother needed a change of stance from her father: he had to stand up to her distortions, as well as to challenge his own narcissistic pleasure in being the preferred parent. My involvement in the overall care of Holly resurrected respect for the maternal role, allowed the mother to regain some sense of her importance to Holly, and allowed the father to give back to her some of his ill-gotten gains and to share with her the heaviness of the task of confronting Holly at times. The reversal of roles had been at the expense of the mother's capacity for tenderness and of his capacity for firmness.

A second focus was on how Holly might be shifted from her defensive obsessional rituals. Over the years, as the family gained more confidence in me, they were able to turn to me for help in gathering courage to assert themselves against her deadening demand for sameness. They ultimately rebelled against the tyranny of having to go on the same bus ride, have the same meals on predictable days of the week, and answer the same questions for the thousandth time. Their conversations with each other and me enabled them to see that Holly's belief that she would fall to pieces if her will was challenged was unreal. Her tantrums had been so explosive and so overwhelming to them that they had boxed themselves into a shared phantasy about Holly's need to be treated as tenderly as an egg, as though her identity were a shell always at risk of shattering. Related to this process of becoming empowered as parents and escaping from Holly's rigid control was their struggle to assert themselves against the maternal grandmother, who had maintained a malignant idealization of Holly which overlooked her capacity to devastate others' lives as well as her own, Holly's mother found in me an ally to sustain her against the denigratory and envy-loaded projections of her own mother and against her daughter's projections of despair, meaninglessness, and unending guilt. Discussing the details of Holly's peculiar preoccupations sometimes enabled them to find meaning in what had become unthinkable about, because it was so strangely impenetrable. They became more able to distinguish between what had valuable meaning and was worth listening to and pondering and what was fundamentally an attack on meaningfulness and required parental limit-setting. Family life had been shaped by an anxiously compliant respect for Holly's problems, which needed to come into question. For example, when she asked for the hundredth time for reassurance that she would not have to share a room or a bed with her sister on the family holiday, was it constructive to answer as if this were a reasonable question, or was it reasonable to express irritation and refuse to go along with her claim not to know what had already been carefully explained to her?

A third important area was in helping them to take steps towards some separation. Holly had had a catastrophic early separation from home. When she was 4 years old, she had been placed in a psychiatric hospital at a distance from home for almost a year, spending only weekends with her family. Her mother understood deeply that this had been severely traumatic for Holly. In fact, ultimately the mother had refused to take her back because the weekly separations had been so unbearably painful. Her guilt about this enforced early separation made any move towards thinking of Holly leaving home very difficult. This arose first in discussion of schooling. When I first met her, Holly was going to a local school for learning-disabled children. This was profoundly unsuitable—she was driving the teachers crazy with her loud psychotic chatter throughout the day, and she was being actively abused by other children in the playground, who were frightened of her madness and dealt with this by exploiting and degrading her. A change of school meant a long journey and, ultimately, a weekly boarding arrangement, with weekends at home. Holly and her mother shared a sense of impending catastrophe about this—her mother felt that she would never be forgiven for a second separation, and Holly believed that she was being confined to a torture chamber for a second time. However, by moving a step at a time, each of them was released from their timeless convictions so that reality could impinge, and the shift took place. Later this had to be reworked when, at the age of 19, the only possible placement for further education and development acceptable to the parents involved Holly going to live in a community 40 miles away, where the expectation was that residents spent a good many weekends within the community. My capacity to defend the continuity of Holly's therapy over these changes seemed to help her m...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• ACKNOWLEDGEMENTS
• ABOUT THE AUTHORS
• Contents
• FOREWORD
• INTRODUCTION
• CHAPTER ONE Dialogues with parents
• CHAPTER TWO Therapeutic space for re-creating the child in the mind of the parents
• CHAPTER THREE Keeping the child in mind: thoughts on work with parents of children in therapy
• CHAPTER FOUR Parental therapy—in theory and practice
• CHAPTER FIVE Work with parents of psychotic children within a day-care therapeutic unit setting
• CHAPTER SIX Working with parents of autistic children
• CHAPTER SEVEN Helping children through treatment of parenting: the model of mother/infant psychotherapy
• CHAPTER EIGHT Working with parents of sexually abused children
• REFERENCES
• INDEX