The Internal and External Worlds of Children and Adolescents

Collaborative Therapeutic Care

Lesley Day, Denis Flynn, Lesley Day, Denis Flynn

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429921100
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The field of child and adolescent psychotherapy is still relatively young and its short history has resulted in a paucity of mental health services for this neglected group. There is a distinct lack of research, evidence and treatment facilities, and yet in order to produce mentally healthy, undamaged adults of the future, this must surely be one area to concentrate resources on. The Cassel Hospital, and this book in particular, seek to redress the balance, and consequently, the chapters in this book follow a diverse path, on subjects ranging from Munchhausen Syndrome by proxy, to abuse within the home, relations within families and borderline adolescents. Various clinical cases are described in this much-needed volume that invites the reader to experience and learn from the life in a hospital that is often seen as the "last resort" of treatment for many children and adolescents. The Internal and External Worlds of Children and Adolescents provides a thoughtful perspective on mental health services for one of the most neglected groups in society - our children and adolescents.

CHAPTER ONE
Introduction: public and private dimensions of therapeutic work with children and adolescents

Lesley Day

This monograph brings together a collection of papers about inpatient therapeutic work with children, adolescents, and their families at the Cassel Hospital. The Cassel is one of a small number of national specialist services for people with a severe personality disorder. The treatment offered is psychosocial nursing and psychoanalytic psychotherapy within the therapeutic milieu of the inpatient hospital community.

The intensive and specialist nature of the assessment and treatment that is undertaken with these multi-problem families is described in a detailed exploration of the clinical work with children and their parents in the Families Service. Very often the situation involves a child who has been living in an abusive family; the work is about reaching a decision on the best interests of the child and assessing and working with the potential for parents to care for their child and provide a safe environment. In the Adolescent Service, young people aged 16 to 20 years come to the Cassel for intensive residential psychotherapeutic treatment. This is a Tier-4 service for adolescents with severe disturbance who have often previously accessed other child and adolescent mental health services.

What binds these children, adolescents, and families together, despite their different biographies and mental health problems, is that the Cassel may be a psychotherapeutic place of "last resort" for referrers and patients. As this Monograph documents, the Cassel offers a very different kind of treatment from that provided by "traditional" psychiatry. The stakes are high, and this can create anxiety and ambivalence about the work in staff and feelings of anger, hope, and hopelessness in the patients. The chapters in this Monograph give testimony to these feelings and also explore how they can be worked with and contained in the hospital community structures.

What we also know is that we are working in a child and adolescent mental health service that is itself relatively young and has a chequered history. Notions of childhood and adolescence are relatively modern concepts in Western societies (Aries, 1985; Kroger, 1996), and it is only with the prolonged economic dependence of what we now term "adolescence" that social scientists and clinicians became interested in the emotional and social lives of young people. Psychodynamic theories of adolescence have developed alongside these societal changes (Anderson & Dartington, 1998; Flynn, 2000). Separate mental health services for adolescents were not established until the late 1940s, and Children's Departments came into being after the Second World War dedicated to provide preventative and caring services for children deprived of a "normal home life" (Parton, 1991). Subsequent government reports, audits, and research have, however, documented that there is a wide variation in mental health services provided for children and young people and that the expenditure and provision of services does not correspond to need (Audit Commission, 1999). It appears that despite developments in provision, child and adolescent mental health services remain a Cinderella service. The Audit Commission (1999) found that health authority spending on child and adolescent mental health services accounted, on average, for about 5% of the total amount of spending oh mental health services.

This needs to be set against the fact that recent epidemiological studies suggest a prevalence rate of diagnosable disorder of 20% in children and adolescents in the United Kingdom and that approximately 10-15% of these will be offered treatment by specialist mental health professionals (Audit Commission, 1999; Target & Fonagy, 1996). The Audit Commission found that over one-third of the trusts they audited reported that they could "not respond effectively to young people presenting in crisis" (1999, p. 47) and that often the clinical staffing of services was the result of "historical service patterns" rather than an assessment of need. Furthermore, the absence of specialized treatment programmes for post-16-year-old adolescents continues to result in the inappropriate placement of older adolescents in adult mental health services (Audit Commission, 1999).

The paucity of mental health services means that many children, adolescents, and their families do not receive the psychotherapeutic treatment that they need. The consequence of this may be mental illness in adulthood and generational cycles of psychological disturbance and abuse. If ignored, these social and psychological problems do not simply go away. Indeed, they are likely to increase the demands on adult mental health services. Target and Fonagy (1996), for example, point out that children who have symptoms of depression and anxiety are referred less frequently to mental health services than those who are diagnosed as having disruptive disorders. Yet we know that children and adolescents with symptoms of depression are three times more likely, as adults, to make a suicide attempt or be hospitalized than matched non-depressed children in the mental health system (Target & Fonagy, 1996).

This suggests that what is seen as disturbing about children and adolescents' mental health may be focused more on their behaviour and conduct than on their emotional and inner worlds. Children and adolescents are dependent on parents—and on other adults with whom they come into regular contact—to be aware of their psychological needs and difficulties, but it may be the caregivers' needs rather than the child's that is the spur to seeking help. If the parents themselves have mental health problems, awareness of the child or adolescent's state of mind or well being may be limited or distorted. The discussion in this Monograph of the work with children whose parents have been diagnosed with the Munchhausen syndrome by proxy demonstrates a particularly perverse way in which parents attempt to meet their own needs through the fabricated, or induced, physical illness of their children.

Gender may also influence the way in which the child or young person communicates his or her psychological distress and affect what is perceived to be a mental health problem. This is evidenced by the fact that boys are more likely than girls to be referred for conduct and attention-deficit disorders (Target & Fonagy, 1996). Furthermore_, it seems that the deviant behaviour of young men may mask mental health problems, with some being detained inappropriately in the criminal justice system. Their depression or suicidal ideation may be hidden, the consequence of which can be tragic deaths in custody and in the community (Anderson & Dartington, 1998; Dwivedi & Varma, 1997). This may go some way to making sense of the high suicidal rates for boys (Shaffer & Piancentini, 1994). This suggests that adolescent psychiatric and psychotherapy services may neglect to meet the needs of young men who are psychologically distressed. Certainly the experience of the Cassel Adolescent Service is that young men with severe psychological difficulties are referred less often than are young women.

The dearth of appropriate mental health services for children and adolescents is also mirrored by the limited amount of research that has been undertaken on the effectiveness of different kinds of therapeutic work for this group. In the mid-1980s, the NHS Advisory Service investigated services for 12- to 19-year-olds and commented on the relative absence of evidence both of the incidence of psychological disturbance or of the effectiveness of treatment for adolescents (HAS, 1986). It seems that, almost twenty years on, this remains an underdeveloped area of research. Outcome studies on the effectiveness of psychotherapeutic treatment for children and adolescents are limited in comparison to the research that has been undertaken for adult patients. The case material presented in this monograph on the inpatient psychoanalytic treatment of children and adolescents may usefully add to this picture. The evidence that is available, however, appears to show that children and young people demonstrate clinical improvement with psychoanalytic psychotherapy in a range of contexts, and that this may be more acceptable to them than a cognitive-behavioural approach (Target & Fonagy, 1996).

Also, overall, there is little research on the treatment outcomes of different models of intensive family-based hospital treatment for children with severe emotional disturbance currently provided within the NHS. There is a paucity of systematically collected information about the clinical characteristics of these families, in terms of the range of social and psychological problems they bring to treatment and of data on the long-term outcome of different forms of treatment. Such research is complicated by the fact that there is a lack of agreement about what a "good" outcome might be for these families, and service providers differ considerably in terms of their implicit and explicit treatment objectives.

It is in light of this absence of outcome research that the Cassel Hospital is currently collaborating in a multi-centre evaluation study of hospital-based treatment of families and their children. The intention is that the data provided by this study will be useful to clinicians seeking to develop their treatment programmes and to referrers and commissioners who have to identify and purchase specialist services that will be most successful in their therapeutic work with these children.

While we know that children from very different social and cultural backgrounds can suffer from psychological distress, there are a number of risk factors that make some children and adolescents more vulnerable to mental health problems. In terms of their socio-economic background, those children and adolescents who are referred to mental health services are more likely to come from lone-parent households or reconstituted families, to live in poverty, and to be educationally disadvantaged (Audit Commission, 1999; Meltzer & Gatward, 1999). They are also likely to have a history of severe neglect, physical, sexual, or emotional abuse, and multi-agency involvement over a long period of time. This certainly accords with the family and social backgrounds of many of the children and some of the adolescents that we work with at the Cassel. The social and psychological experiences of these patients, and how they can be worked with therapeutically, is reflected in a treatment programme that focuses upon both the internal and the external worlds of the children or adolescents and their families. As the chapters in this monograph illustrate, collaborative working relationships between the psychosocial nurse, the psychoanalytic psychotherapist, and the teacher in the therapeutic community milieu of the hospital are important. They enable clinicians to be mindful of the relationship between the external social and emotional functioning of the patient and his or her psychic world.

The importance of the multidisciplinary team, and the need for the child and parent to have their own psychotherapy, is discussed by Paul Coombe in chapter two and Deirdre Dowling in chapter three. Coombe details the psychoanalytic psychotherapy with a mother who had poisoned her two children and was diagnosed with Munchhausen syndrome by proxy. This shows, in a landmark case, the possibility of personality shifts in a parent with this diagnosis, which had previously been deemed "untreatable". Dowling discusses the psychotherapeutic work with a child, from a different family, who had been poisoned by her mother. Both authors demonstrate the importance of providing a therapeutic space in which the child and the parent can give voice to their experiences of being the abused or the abuser. Dowling argues that it is particularly important to enable the child to give expression to the emotional impact of the abuse. Coombe points out that joint supervision with the psychosocial nurse of the mother enabled him to be aware of how he might "annihilate the child from his awareness", a possible countertransferential response to the mother's hostility towards the child. It was also important to be aware of how the psychosocial nurse and adult therapist might form a couple and exclude the child psychotherapist, with the consequence that the child is no longer kept in mind. Dowling similarly charts how the dynamics of the treatment team can reflect the dynamics of the family being worked with.

As Dowling points out, much of the literature on Munchhausen syndrome by proxy itself excludes an exploration of the emotional impact on the child, focusing more on the abusing parent's own emotional and social deprivation in childhood. As was argued earlier, children's distress can often be rendered invisible or be overlooked by public services. Dowling argues that this covert act of abuse, which is carried out in the public arena, makes the failure to identify it even more distressing for the child who is being both cared for, but not cared for, by health professionals.

Dowling also notes that a central feature of Munchhausen syndrome by proxy is the lack of emotional containment in the family, with the consequence that feelings of need and hatred are acted out on the body of a child. This relationship between the mind and body is a clear theme running through the chapters in this Monograph, in terms of the child's or adolescent's emotional experience and of his or her behaviour.

In chapter four, Denis Flynn articulates the relationship between the various aspects of the inpatient treatment of children and their parents. He describes how the patient is held in treatment by the mutually cooperative effort of nurse and therapist and by the sustained involvement of patients and staff together in the therapeutic community. While the therapist and nurse each have their own roles and tasks, they can think and work together to provide some containment for each other. If conflict between workers occurs, a reflective staff process can help to turn it to therapeutic effect.

Flynn describes the therapeutic work with two severe child abuse family cases. In the first example, he examines the mother-infant sessions with the patient discussed in chapter two. The interactions between mother and child in the therapy sessions, and the observation and psychoanalytic understanding of the everyday interactions between the family, the nursing staff, and other patients in the community, were drawn together. This enabled the possible risks to the child, the effects on her development, and the nature and progress of the mother-child relationship to be assessed. Flynn shows that even with good motivation, negative and abusive patterns—repetitions of the core situations of abuse—become manifest within the treatment. Addressing key features of aggression and hatred towards the child actually contributes to therapeutic progress and, in particular, strengthens and makes more real the relationship between mother and child.

In the second example, Flynn focuses on the therapeutic work with a mother and her daughter, aged 2 years. In this family, a baby sibling had been killed by non-accidental injuries inflicted by the stepfather. Flynn shows how the trauma of early abusive events left their damaging mark on the surviving daughter and how the pain of still-current patterns of abusive relationships were experienced by the child. This case material demonstrates how multi-layered treatment that offers mother-child psychotherapy, individual child psychotherapy, and adult psychotherapy, together with intensive work in the hospital therapeutic community, can provide a crucible for the development of mother-child relationships.

In other cases, however, rehabilitation may not be possible or may be assessed as not in the best interests of the child. Throughout the assessment period, or intensive inpatient treatment of children and their families, keeping the emotional and physical safety of the child in mind is crucial. Child protection cases and formal inquiries have alerted us to the fact that practitioners may defend against the awfulness of child abuse, and the unconscious anxiety this produces, by engaging in what has been termed the "rule of optimism" (Dingwall, Eeklaar, & Murray, 1983); they focus on the positive aspects of parenting and deny the negative and harmful. Investing so much emotional and practical energy into the work can leave clinicians feeling emptied out when rehabilitation has not been possible. It may also put other patients in the community in touch with their own feelings of loss and abandonment. Making sense of these feelings, and working with them in the multidisciplinary team and the whole community, is vital to the collaborative nature of the relationships between staff and nurses working alongside patients.

Lee Marsden, in chapter five, provides a different but complementary perspective on the therapeutic work with children in the Cassel, reaffirming the importance of collaborative working. As we saw earlier, children referred to the mental health system may well be educationally disadvantaged. The Children's Centre provides education for children who are resident at the Cassel, and whose parents are inpatients in the Families Unit. Marsden articulates a particular way of working with these children that is both educational and therapeutic, and one that takes account of their emotional difficulties and learning needs. Drawing upon her work with two siblings, she describes the importance of the relationship between the emotional experience of the child and his or her capacity to learn. A balance needs to be struck between the learning task as defined by the curriculum arid the need to adapt to the child's preoccupations and what they might be communicating, perhaps unconsciously, about the child's feelings.

This educational therapeutic work is provided in a protected space for the school-age children at the Cassel. In many ways it mirrors the "work of the day" in the more public areas of the therapeutic community environment, as the emphasis is on both playing and learning. What is particularly distinctive, however, is the attention devoted to the rhythm of the day for these children, and their attachments to parents, other patients, the staff in the centre, and the nurses and therapists in the wider hospital community. The detail of these relationships provides a rich source of material to make sense of the family dynamics and of the emotional life of the child, which itself aids the learning process. As we know, some children who have been emotionally, physically, or sexually abused may experience difficulties at school that may be defined as learning deficits, and their emotional needs are ignored or misunderstood. Marsden points out that by adopting an integrative perspective, learning can be both therapeutic and educational.

Many of the concepts that Marsden draws upon to articulate the therapeutic educational work with children at the Cassel are taken up in chapter six by Kevin Healy. These are the notions of transition, play, attachment, separation, dependency, and independence. Adolescence is a period of transition between childhood and adulthood and is a second phase of separation-individuation. It is a time fraught with different and transient emotions and states of mind, offering a particular kind of freedom to have new ideas and explore one's identity, as well as being marked by loss and grief and by defiance and dependence on parental figures. The shifting backwards and forwards between dependence and independence requires containing parental adults who can withstand this external and internal struggle, retain responsibility, and yet not impose a "false maturity" on their adolescent offspring.

Adolescence is likely to be a turbulent but normal phase of development that can be worked through when parents are themselves sufficiently contained and cared for. However, when the adolescent is exposed to a set of disturbed familial relationships and a social environment that do not provide sufficient containmerit, this transitional phase of life can become problematic. Just as the young person may fall between childhood and adulthood into a disturbed and frightening adolescence, he or she may also fall between the boundaries of child and adult mental health services and receive inappropriate or no therapeutic support.

Healy documents the kind of therapeutic inpatient work at the Cassel that is offered to older adolescents, aged 16 to 20 years, who have been identified as needing a particular kind of inpatient treatment, often when other kinds of support have failed. The different aspects of the treatment offer these young persons a new kind of milieu within which to explore their identity and their relationships with peers, substitute parental figures, and children younger than themselves, within the containing therapeutic structures of the hospital. They are given some responsibilities within the hospital to begin to develop a new separate identity, rather than the "false self" solutions described by Winnicott (1968b).

Healy, referring to Winnicott, points out that in adolescence identification with parents is rendered problematic as it is experienced a...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• ACKNOWLEDGEMENTS
• CONTRIBUTORS
• CHAPTER ONE Introduction: public and private dimensions of therapeutic work with children and adolescents
• CHAPTER TWO The inpatient psychotherapy of a mother and child at the Cassel Hospital: a case of Munchhausen syndrome by proxy
• CHAPTER THREE Poison glue: the child's experience of Munchhausen syndrome by proxy
• CHAPTER FOUR Psychoanalytic aspects of inpatient treatment of abused children
• CHAPTER FIVE School children in the Cassel community: discovering a place in which to live and learn
• CHAPTER SIX Adolescence; a transitory world
• CHAPTER SEVEN The darkling plain: the inpatient treatment of a severely disturbed borderline adolescent
• CHAPTER EIGHT The containment of borderline adolescents
• REFERENCES
• INDEX