Through Assessment to Consultation

Independent Psychoanalytic Approaches with Children and Adolescents

Ann Horne, Monica Lanyado, Ann Horne, Monica Lanyado

• Publisher: Routledge
• Year: 2009
• Print ISBN: 9780415462891
• eBook ISBN: 9781134041756
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Winnicott's description of "doing something else" or "working as a psychoanalyst" when not engaged in the actual analysis of his patients resonates with the child psychotherapist today. Individual psychotherapy is certainly a valuable part of the work but much of the time the CPT is "doing something appropriate to the occasion". Some of this time is spent in assessment work – for therapy, for the multi-professional team and for other agencies – and some in consultation to colleagues and other professional staff or in a combination of the two.

Drawing from the Independent tradition in psychoanalysis, Through Assessment to Consultation explores the application of psychoanalytic thinking to this daily work, reflecting on what is actually done and why. Contributors to the three sections – 'Assessment', 'Overlaps', 'Consultation and Beyond' – provide a variety of clinical illustrations as they describe a range of approaches and settings in the tasks of both assessment and consultation, ranging from the light impact of the analyst's presence in the grief of post-9/11 New York to the call to political potency of 'beyond consultation.'

This book will help both new and experienced Child and Adolescent Psychotherapists re-examine their role and function in the team and in the outside world, and will also be of interest to specialist health workers, educational psychologists and those wanting to explore more Winnicottian approaches to therapeutic work.

1
Introduction

‘Appropriate to the occasion’

Ann Horne and Monica Lanyado

If our aim continues to be to verbalise the nascent conscious in terms of the transference, then we are practising analysis; if not, then we are analysts practising something else that we deem to be appropriate to the occasion. And why not?

(Winnicott 1962:170)

I am not like what I was twenty or thirty years ago.

(Winnicott 1962:169)

‘Practising something else’ and ‘doing something else’ will be familiar phrases to the reader versed in Winnicott. In ‘The Aims of Psychoanalytical Treatment’ he explores ideas about the appropriateness or otherwise of analysis in certain circumstances and at times will ‘find myself working as a psychoanalyst rather than doing standard analysis’ (Winnicott 1962:168). Yet one might question whether this should, indeed, be called ‘doing something else’. This volume explores some of the work undertaken by child psychotherapists that is not standard individual psychotherapy or psychoanalysis. In its chapters, there is a recurrent theme: that appreciation and use of transference and countertransference phenomena is always part of what we do. The unconscious or ‘nascent conscious’ process intrigues us and we look assiduously to discern its workings. At times, however, we do not articulate this—or we find ways in which to express our understanding that do not involve offering interpretation. It may not be the one to one of the consulting room, the hurly burly of the chaise longue indeed, but it is just as passionate and just as psychoanalytic.

This book grew from discussions between the editors as to the nature of assessment. Paradoxically, it is not a handbook on assessment—was neither envisaged as such nor bears any pretence of being so. We concluded that assessment both continues throughout any work (it is always therefore ‘an assessment in progress’ even when we call it therapeutic or analytic treatment) and that it is also important to reach a formulation, a working diagnosis that one holds in mind and that has a dynamic life. As Winnicott wrote: ‘The essential thing is I do base my work on diagnosis’ (Winnicott 1962:169). We also noted that a request for an assessment invariably involves something additional—often a follow-up consultation. Yet we frequently speak of these two—assessment and consultation—as totally separate tasks. To consider a continuum, therefore, where much of what we undertake as child psychotherapists is located not at either end, in hypothesized ‘pure’ forms of assessing or consulting, but is more central, leaning in either or both polar directions and usually overlapping, seemed useful. And the title, of course, resonates with our Independent and Winnicottian identity.

This book is also about diversity. It demonstrates many of the ways in which child psychotherapists are currently helpful to children and their families by being involved in their internal and external realities other than in individual psychoanalytic work. In this, we hope to give pause to those who, in management, commissioning or other agencies, have a simplistic ‘take’ on what child psychotherapists do.

We have chosen to start the volume with an overview of assessment in the multiprofessional Child and Adolescent Mental Health Service (CAMHS) team. In Chapter 2, Mary Walker provides a measured and thoughtful ‘setting of the scene’: even here the role of the child psychotherapist is enormously varied in demands and practice.

In Chapter 3, Deirdre Dowling describes inpatient work with families who are being assessed for the court to see if the children are safe in parental care. In this anxiety-provoking situation the child psychotherapist’s skill enables the child and parent/s realistically to face and work on the problems in their relationships, whilst keeping the primary task of assessing the risk to the child in the centre of the frame. The necessarily protracted assessment is reported back to the court and is crucial to the life-changing decisions that need to be made.

Issues of risk also inform Chapter 4 by Parsons and Horne. They follow the course of the request for an assessment of risk, commenting on the stimuli that lead to the need for this being experienced in the referring agency, and offering considered thought and advice on the process at all levels.

In Chapter 5, Joelle Alfillé-Cook gives a specific focus on the problems of assessing adolescent patients, locating it in both a developmental and a clinical context, and exploring the clinician’s experience when engaging in adolescent work in a school setting.

Two of the chapters propound an overtly political agenda and urge us to look more widely than our clinical roles—indeed, wider than the family or team or Trust environment that normally preoccupies us. In Chapter 6, Caryn Onions interviews Dilys Daws about her pioneering work in parentinfant psychotherapy as well as her vigorous campaigning for child psychotherapy and infant mental health, through the founding of the Child Psychotherapy Trust and the Association of Infant Mental Health (UK). This delightful interview gives a vivid account of Dilys Daws ‘doing something else’ in her unique, modest but always powerful way. By becoming active in setting up organizations that further the well-being of vulnerable children and being prepared to fight for their needs, politically and in the media, she has convincingly drawn attention to their plight, as well as how they can be helped. The core understanding of the infant and child’s inner world is always evident and is what gives her message its power.

Being prepared to get involved in the fray of organizations, government committees and the media is also Peter Wilson’s passion (Chapter 13). The conviction with which he has argued for a better understanding of child and adolescent mental health and mental health needs, culminating in co-founding YoungMinds, is also given authenticity by being steeped in his clinical practice as a child psychotherapist. His progress is very straightforwardly described, but the impact of a committed and experienced clinician being prepared to challenge the often inward gaze of the profession and seek remedy and progress outside has been dramatic. Daws and Wilson illustrate how vital it is to be able to move creatively between the intimacy of what is observed, felt and understood in the consulting room, to the external environment, so that necessary change can be brought about in the external as well as the internal world.

It is not surprising that Part II—Overlaps—involves at times more personal description. Indeed, the whole process of moving to ‘do something else’ necessitates a personal shift in clinical approach—as we noted in Winnicott’s words at the start of this Introduction: ‘I am not like what I was twenty or thirty years ago’ (Winnicott 1962:169).

A different personal account, equally of finding an intervention ‘appropriate to the occasion’, is contained in a short memoir by Victoria Hamilton (Chapter 8) of a practical and humane response to the human tragedy of 9/ 11. Living and working in New York at the time of the bombings, she and Susan Coates offered their help at Pier 94 through their capacity to be ‘real objects’ who simply listened to the family experience of multiple trauma. This is a delicate and almost imperceptible approach to brief consultation and crisis intervention where, without any analytic explanation, a therapeutic encounter of the most profound kind can take place.

Iris Gibbs (Chapter 7) has long been called on to offer knowledge and support to colleagues in a wide range of organizations and her reflections on race and culture in both assessment and consultation are timely in a society that once again has resorted to the expression of anxiety through racial polarizations. This should be a known current in all our work and should inform all practice.

Although the risk presented by an apparently unpredictably violent and dangerous teenage boy who had admitted to several serious counts of arson is the frame of Ann Horne’s ‘From Intimacy to Acting Out’ (Chapter 9), the author reflects on the countertransference experience in such encounters and gently urges that omnipotence is not a helpful attribute in the child psychotherapist. The case involves the unintended psychoanalytic assessment of the boy, thoughts on its usefulness, and the necessity of follow-up feedback and consultation to the staff of his secure unit.

The theme of ‘listening’ is the cornerstone of Monica Lanyado’s chapter about consultation to staff in specialized therapeutic units working with severely sexually abused and traumatized children (Chapter 11) The ‘impact on the listener’ of truly listening to and hearing about what these children have suffered—verbally, through play and particularly through nonverbal projections which must be processed in the countertransference—can become cumulatively traumatizing for the staff. The child psychotherapist’s experience of struggling to process her countertransference when working individually with these children is extremely valuable in helping her to recognize and work with these anxieties and defences—personal and organizational—when consulting to therapeutic unit staff groups. This kind of psychoanalytically informed consultation is seen as essential for the well-being and ‘health and safety’ of the staff.

‘Listening’ is also part of Sophie Robson’s chapter where the reader encounters the child psychotherapist as a part of a multidisciplinary team working with the under fives—seeing the families as well as facilitating a valued reflective meeting in which painful and difficult countertransference issues can be talked and thought about (Chapter 10). Again, the capacity to move from ‘sleeves rolled up’ participation in the team to reflective consultant is an important feature.

One could view Gethsimani Vastardis’s chapter (Chapter 12) as just as political as those describing the passions of Dilys Daws and Peter Wilson. It is. It is also a profoundly thought-provoking reflection on roles, groups and context—and one which all child psychotherapists (especially those in managerial posts) should find enlightening. Child psychotherapists have grown almost happenstance into management: organizations eventually require someone to take on the function. The author’s capacity to retain thought and to seek integration and joint ownership of issues is an exhortation to the profession.

The organization of the book into three parts, Assessment, Consultation and Beyond and, in true Winncottian fashion, what we have called Over-laps—a kind of transitional section which bridges what is often taken to be the gap between the two—may strike some as contrived. Forgive us if it does. The continuum is neither static nor rigid and we move about it as we hope we have shown.

I aim at being myself and behaving myself (Winnicott 1962:166)

Winnicott’s influence is more subtly present in the current volume than in A Question of Technique, the first book in the series. It is taken as a basic axiom of this Independent approach that the environment has an impact on the internalizations and psychological structure of the child. We therefore consider and work with and in the environment that a child is trying to grow and recover within. This is intrinsic to the total therapeutic approach, be it with the legal system, secure unit, inpatient hospital setting, CAMHS team, education—and with the greater political world outside. More than that, there is a pragmatism and practicality about the chapters which illustrate a ‘have a go’ attitude—but in a thoughtful, responsible and disciplined way. We behave ourselves. This is an attitude which Kohon captures succinctly when he writes: ‘The Independent position is characterised by a reluctance to be restricted by theoretical or hierarchical constraints’ (Kohon 1986:50).

Like Winnicott, as Independents we aim at being ourselves—and as true psychoanalytic practitioners we also include behaving ourselves, keeping a compassionate ethical sense that does not abuse the analytic method even while we explore extensions of our technique and understanding to a wide range of settings. The framework of the psychoanalytic approach is not rigid: it gives us a sure foundation and encourages us as individuals to find creative pathways in the variety of encounters that form our working days. We hope that this sample, this selection of ‘what else we do’, engages the reader.

References

Kohon, G. (ed.) (1986) The British School of Psychoanalysis: the Independent Tradition, London: Free Association Books.

Winnicott, D.W. (1962) ‘The aims of psychoanalytical treatment’, in D.W. Winnicott (1965) The Maturational Processes and the Facilitating Environment, London: Hogarth Press.

Part I
Assessment

2
Every assessment matters

The child psychotherapist’s role in assessment in child and adolescent mental health settings

Mary Walker

Introduction

It is a common experience for all of us that entry into a treatment setting of any kind requires initial screening and assessment for complexity, severity and appropriateness. This is certainly true for child and adolescent services where there are a number of gateways to pass through before specialist treatment can be offered. Consequently, assessment procedures...

Table of contents

• Independent Psychoanalytic Approaches with Children and Adolescents series
• Contents
• Contributors
• Acknowledgements
• 1 Introduction
• Part I Assessment
• Part II Overlaps
• Part III Consultation and beyond
• Index