Nurturing Children
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Nurturing Children

From Trauma to Growth Using Attachment Theory, Psychoanalysis and Neurobiology

Graham Music

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eBook - ePub

Nurturing Children

From Trauma to Growth Using Attachment Theory, Psychoanalysis and Neurobiology

Graham Music

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About This Book

Nurturing Children describes children's lives transformed through therapy.

Drawing on decades of experience, internationally respected clinician and trainer Graham Music tackles major issues affecting troubled children, including trauma, neglect, depression and violence. Using psychoanalysis alongside modern developmental thinking from neurobiology, attachment and trauma theory and mindfulness, Music creates his own distinctive blend of approaches to help even the most traumatised of children.

A mix of personal accounts and therapeutic riches, Nurturing Children will appeal to anyone helping children, young people and families to lead fuller lives.

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Information

Publisher
Routledge
Year
2018
ISBN
9780429794353
Edition
1
Chapter 1

Introduction

This book distils key ingredients needed to help emotionally troubled children and young people. Growth, change, well-being and a Good Life spring from having our feelings understood, from experiencing rewarding human relationships and being held in the minds and hearts of others. The stories in this volume make the case for the curative potential of growth-inducing human relationships.
This might sound obvious, but is counter-cultural in a climate emphasising short-term treatments, evidence-based practice and quick-fix ideologies. The evidence for so-called evidenced-based treatment is at best shaky (Shedler, 2018). Most such modalities eschew a commitment to deep interpersonal meetings, to the bearing of difficult thoughts and feelings and to biding one’s time. The latest developmental, neurobiological and attachment research, the riches from psychoanalysis and systemic thinking, alongside decades of clinical experience, suggest another, more relationship-based explanation of how change takes place. This is seen in forthcoming chapters where real stories of children and young people take centre stage.
I have worked as a psychotherapist for over three decades with children, young people, families, parents and adults. In such work our learning never ends, even if yesterday’s and today’s certainty become tomorrow’s naive belief. I have often witnessed how psychological shifts take root and how, despite unexpected twists and turns, the capacity to heal and grow can be tapped into. I hope the stories in this book illustrate this.
In my therapeutic life, an extraordinary group of teachers, supervisors and therapists have helped me to find my own way to be a therapist. I have worked in internationally renowned institutions, such as the Tavistock Centre, the Anna Freud Centre, the Portman Clinic and the Centre for Child Mental Health, and have trained with and worked alongside some of the most eminent in the business. More importantly, I have plied my trade for years in an ordinary way, in community child mental health services, schools, GP practices, specialist adolescent therapy teams and many other settings. Here is where the real learning takes place, via being immersed over time in the lives of those we work with.
I am continually excited about the possibilities that this work affords. We have unendingly interesting ways of understanding children’s development, what goes awry, how and why resilience and hope grow, what we can and can’t do to restore more positive life trajectories. When my work goes well it is minimally due to my theories and learning, but mainly due to making meaningful, compassionate emotional contact with complex states of mind and feelings in myself and others.
Like anyone trying to help troubled kids, I often feel despondent about what is possible. The unthinkable experiences of some children, their awful life circumstances, the ways we as professionals and society have let them down, can be unbearably painful to face. It is often agonising to confront the horrors of their minds, often filled with aggressive, destructive and nihilistic thoughts and wishes. Perhaps worse, it is excruciating when traumatic experiences lead to self-destructive patterns, lives lived in distrust, hopelessness, rancour and bitterness, with too little self-belief, hope or pleasure.
I believe we are on the cusp of a paradigm shift in therapeutic work, one requiring an integration of multiple orientations, from neurobiology, attachment theory, psychoanalysis, systemic thinking and more. The result of such integration is a fascinating if constantly developing set of new insights. Being open to new ideas requires courage and humility, alongside interest and curiosity. Above all, our work demands a passion, a sense of vocation, and a wish to continually learn, about ourselves, about those who come through our door, new scientific and clinical findings and indeed about life. The fourteenth-century Persian Sufi poet, Hafiz, cautioned against the small-minded building of cages that restrict thinking and urged that we should drop keys to free ‘the beautiful rowdy prisoners’. I too want to pass around some of the keys that my heroes of yesteryear generously dropped for us, keys that can unlock the doors to growth and freedom, for both ourselves and those we work with.

Empathy and feeling understood

I try in this book to return to the basics of therapeutic work, what really makes a difference to those in distress. Evidence suggests that the therapeutic alliance is the sine qua non of successful therapy, and I unpick some of what this means. Central to transformative relationships are empathy and compassion, making emotional contact with another, showing that we are prepared to join them on a journey, but not as too distant an expert, nor as a fellow traveller lost without a map.
I learnt important lessons about this from delivering non-directive play therapy over 30 years ago, for an organisation called the Children’s Hours Trust. Despite the official sounding name, the work took place in the unkempt dilapidated local authority flat of an 80-year-old maverick pioneer, Rachel Pinney (Pinney et al., 1983), who did extraordinary work with autistic children. Rachel’s living room was the playroom, her kitchen the staffroom and no one had police checks. These were heady innovative days, too unlicensed for today, but life-changing work was done. Rachel’s level of empathy with the children was profound, children changed dramatically, but her tough training required dispensing with much that felt natural. She taught us to really stay with a child’s actual immediate experience, to follow their play, reflect their actions and feeling back to them, never direct, interpret or explain, just stay true to their emotional and bodily experience.
Rachel was a tough taskmaster. We trainees paired up, did role plays, exposed our feelings and learnt how our own preoccupations and ‘issues’ could play havoc with the seemingly simple act of empathy. Co-counselling was the rage back then, and we gained a deep experience of being genuinely listened to and understood. This was new in my life and soon took me back into my own therapy several times a week. I felt deep relief, especially from allowing parts of me that I had hidden from myself and others to come into the light, breathe, be seen and accepted. This was where I learnt deeply of the benefits of empathy and compassion, and there has been no looking back.
In the playroom, time and again children calmed down when receiving such attuned attention. They then started to play imaginatively, working through central life issues with a fierce, intensity, often leading to symptoms abating. Yet it was easy to disrupt this flow. Their play faltered if my attention wandered, if I miscued, or my empathy was not on the button. For example, Joey, a deprived all-over-the-place 8-year-old dramatically calmed down when his play was followed and he could trust in my benign attention. Yet the moment my mind tensed, even though I retained the same external physical stance, he became dysregulated, even aggressive. As Donald Winnicott (1971) taught us long ago, being held in mind gives rise to a deep sense of ease. However, sadly, feeling held in the mind (and heart) of another is often a new and hard-to-trust experience for deprived children.
Rachel’s philosophy had a profound influence on me. Early in my therapy training I was earning money working in a parent-run nursery. A little boy, who I call Ethan, was crying and shouting. The other workers were getting desperate, as we had a long walk to navigate to make the lunch we were late for. Attempts to cajole Ethan simply exacerbated his entrenched crying, protesting and shouting. One parent-worker tried to persuade him, another tried telling him off, and another to yank him along the road. It all made it worse. I decided to see if the Rachel Pinney method could help. Self-consciously I sidled up to Ethan. He looked at me and winced. I said clearly, while keeping my distance, ‘Oh no, you are not sure what this other grown-up will want.’ Ethan calmed a little. I said with some force, ‘You are so so angry about having to go.’ The tension in his jaw softened slightly. ‘It’s just not fair is it? He looked at me long and hard. ‘I wonder what is most unfair?’ His lips quivered slightly, I said aloud quietly to myself, ‘Yes I wonder, I really want to know, if Ethan wants to tell me.’ After what seemed an eternity he whispered, looking down and away, ‘My horsey’. ‘Your horsey, goodness, what happened?’ ‘Susan.’ ‘What, Susan … (I guessed) has your horsey?’ He looked down. I said tentatively, ‘The horsey you had?’ He nodded mournfully. ‘Oh how really upsetting. Shall I speak to Susan?’ He nodded again, slightly glancing at me. ‘Shall we do this together after lunch?’ He nodded. ‘Ok, perhaps you can come with me now,’ I said, holding out my hand, and along he came. I had feared egg on my face and suddenly I felt like I possessed some magic. Just the act of bearing and staying with his feelings allowed him to soften and become trusting.
This was no miracle, just a basic life skill, but one that felt revelatory to me, possibly because I had received little of such attention myself. Often, I wish all trainee therapists learnt basic non-directive counselling before using more complex depth psychology thinking with children.

My perspectives

However, therapeutic alliances are about more than empathy, attunement or Carl Roger’s (1957) ‘unconditional positive regard’. Empathy and compassion are multi-facetted and complex and certainly not just sweetly ‘nicey-nice’. They require courage and the ability to escort people into dark, uncomfortable places. Good therapeutic work also requires thorough trainings, including an in-depth knowledge of theories. Knowing how to speak to and be with another in helpful ways, while being present with ourselves, come from personal and professional experience, training, personal therapy, aptitude, being well supervised and importantly, from not being too certain, and being prepared to learn from mistakes.
In Nurturing Natures (Music, 2016) I used the classical metaphor of the blind man and the elephant. Here, each blind man has a definite yet limited perspective on a single part of an elephant, but each adamantly insists that their perspective is what the elephant ‘really is’. To understand emotional development, we need knowledge from many disciplines, such as attachment theory, neurobiology, systemic thinking, anthropology, psychoanalysis, behavioural theory, evolutionary psychology and more. While lurching between a cocktail of eclectic influences is unlikely to help anyone, especially if it unsteadies a practitioner, we need to be open to new ideas, and integrate them into our practice, into our philosophy and, most importantly, into our very beings.
The lives of those we work with are too precious and developmental opportunities too few to waste time trying to prove what we already believe. As Einstein is reported to have said, ‘it is not sane to keep doing the same things again and again yet expect different results’. We can all be guilty of repeating our favourite habits, and avoiding feeling uncertain. Worst of all is repeating old habits and, when they are not effective, blaming the recipient for being resistant!
Therapeutically my most profound influence has been, and I suspect always will be, psychoanalysis, with its emphasis on non-conscious and unconscious processes, its ability to bear the harshest of realities, its capacity to understand defensive coping mechanisms, so-called defences originally erected as adaptive strategies but that since have become maladaptive.
Psychoanalysis is my bedrock, an anchor to return to, a secure base from where I explore. From psychoanalysis, I gain deep relief in knowing that the most unbearable and unthinkable experiences can be borne and thought about. There are no shortcuts to staying with the darkest of experiences, those aspects of human nature we might prefer to disavow. Psychoanalysis teaches us how our minds play tricks, keeping us ignorant of our deepest motivations, denying realities we don’t want to face.
From psychoanalysis, I learnt an ingredient missing from my somewhat naïve Rachel Pinney days, the importance of projection. The feelings stirred up in us when with disturbed children, whether anger, frustration, inadequacy, are often feelings that the child or young person has known all too well but cannot yet process. Oftentimes they are desperate to be rid of such feelings, including by ‘evacuation’, that is, getting another to feel them instead, rather like kicking the cat after a bad day.
Ryan, for example, often tried to denigrate and humiliate me, making me feel stupid. I often dreaded our sessions. He stated with cold venom that I was an idiot therapist, incapable of helping anyone. Some years back I might have become defensive, or worse, allowed his statements to trigger my own shame. In time, I learnt that kids like Ryan had themselves been humiliated and ridiculed and part of my role was to process in myself feelings that he knew all too well. I needed to know from the inside what he had suffered, before I could help him manage such excruciating experiences. Many stories that follow have similar examples.
Other influences on my work include attachment theory, which has provided huge understanding of troubled children and adults. Alongside it, developmental science as pioneered by the likes of Daniel Stern (1985) has greatly enriched my work, teaching us about the importance of attunement, empathy, mismatches and repairs, and intersubjective potential. Such developmental understandings provide vital lessons for therapeutic and other relationships (Boston Process of Change Group, 2010).
Alongside attachment theory, evolutionary psychology teaches how our traits, whether anxious, reactive, calm or trusting, start as adaptive responses to early environments, but can backfire later in life. As trauma therapist and neuroscientist Bruce Perry (Perry et al., 1995) stated, our early ‘states’ become ‘traits’. In a violent home where survival depends on being distrustful, vigilant and reactive, it makes no sense to be calmly easeful. Such initial ‘adaptations’ can though become problems later, in school, work or relationships.
Thus, people’s presentations are best understood via current and early environments. Donald Winnicott (1965) famously stated that there is no such thing as a baby, only an infant in relationship with significant others. Systemic thinking adds a vital ingredient by emphasising how we are all living in and influenced by contexts, embedded in cultures, ecological systems (Bronfenbrenner, 2004) and power relations (Foucault, 2002).
In stories that follow I describe balancing the capacity of psychoanalysis to bear the darkest in human experience with new understandings of how we help grow positive emotions, such as hope and resilience. The positive psychology movement (Goleman, 2006), mindfulness and Gilbert’s (2014) compassion-focused therapy are but three of many therapeutic modalities that balance hope and pain. We meet many in these pages who have never dared embrace hope, trust, enjoyment or safeness. For those with pessimistic ‘Eeyore-ish’ bents, and I include myself in that group, embracing hope or pleasure can be daunting.
Eastern thought and mindfulness infuse my every session, teaching so much about attending to whatever is present in our moment-to-moment experience, rather than being aversive to it. As mindfulness suggests, it requires ‘effortful effortlessness’ to non-judgementally attend to both another human being and one’s own feeling and body states, with interest and compassion. Mindfulness includes both a concentrated form of attention, such as on one’s breath, as well as the ability to use a more open-focused form of awareness, such as on sounds or body-states generally. Attending to another human being requires similar skills, being able to hone in on states of mind, to have insights, while retaining the open, wide form of attention that psychoanalysts call ‘free-floating’.
Neurobiology, while still in its infancy, has opened new vistas on body states, brains and nervous systems and how these are affected by trauma, changing how we work with maltreatment, abuse and neglect. Traumatised children are living with troubled minds and feelings, their traumas generally carried non-consciously in their bodies (van der Kolk, 2014). We are learning to work with body states as a site of intervention, to become body aware of both those we work with and ourselves. Personally I rely a lot on my own mindfulness and yoga practices, alongside supervision, to develop such capacities.

Evidence base?

Child mental health services are increasingly dominated by ‘evidence-based practice’ agendas and ‘quick-fix’ protocol-based treatments. With limited therapeutic resources, we should of course employ the best treatments, but there are downsides. Pressure from waiting lists has led to tighter top-down management, huge stress in systems (Armstrong and Rustin, 2014), and both risk-averse and fear-driven cultures. Management-driven auditing, data collection and treatment targets can be used defensively, forcing pressures onto front-line staff (Cooper and Lousada, 2005).
Being in touch with emotional pain stirs up feelings that few of us want. Institutions can defend against such discomfort with various mechanisms. People referred for treatment, who need support and understanding, can be too quickly labelled as bearers of symptoms to which we apply a specific treatment protocol. Sometimes this helps, but often it is a way of not bearing the realities of someone’s life. Isobel Menzies Lyth (1988) long ago described such a culture in hospitals where nurses referred, for example, to ‘the liver in bed 12’ as opposed to being present to a real, suffering human being.
Few of the children and young people populating these pages have a simple ‘disorder’ that can be ‘treated’ with a specific protocol. Many are ‘co-morbid’, with multiple diagnoses, such as ADHD, autistic spectrum disorders, conduct disorders and more. I suggest that what such children really need is ongoing relationships where they feel understood and can develop faith in their ability to grow, to love and be loved, to begin to heal from trauma.
Perhaps the biggest problem with the evidence-based practice agenda is that, when you drill down, the real evidence for what is effective seems to be less about the treatment modality and more about the quality of the therapeutic relationship. Many researchers have carefully examined what are called the ‘common factors’ (Lambert, 2005) that make for a successful outcome. The actual modality we employ, whether cognitive behavioural therapy, mentalisation, systemic family therapy, or another, often comes out as a low contributor to success. More important are human factors such...

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