Starting Treatment With Children and Adolescents

A Process-Oriented Guide for Therapists

Steven Tuber, Jane Caflisch

• Publisher: Routledge
• Year: 2011
• Print ISBN: 9780415885584
• eBook ISBN: 9781136884382
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Starting Treatment With Children and Adolescents provides therapists with a time-tested framework for treatment and a moment-by-moment guide to the first few sessions with a new patient. In twelve remarkable case studies, verbatim transcripts of individual play-therapy sessions are brought to life through running commentary on techniques and theory and a fine-grained analysis of what worked, what didn't, and what else the clinician could have done to make the session as productive as possible.

Clinicians will come away from the book with a unique window into how other therapists actually work as well as new tools for engaging children and adolescents in process-oriented treatment. They'll also be guided through an exploration of common questions such as how else could I have handled that situation? What other paths could I have tried? Where might those other paths have led? What treatment strategies are most advantageous to my patients' growth – and to my own?

1	Setting the Frame for Psychologically Minded Treatment

INTRODUCTION

A Chinese proverb inspired the basic premise for this book: “Give someone a fish, they eat for a day. Teach someone to fish, they eat for a lifetime.” At the risk of sounding facetious, for the purposes of this work the proverb can be rephrased as “Give a child* an interpretation, he feels good for a day. Teach a child to feel comfortable with the mindset that allows him to make his own interpretations, he can feel good for a lifetime.”

SETTING THE FRAME

Upholding the idea of being psychologically minded (a perhaps less-unwieldy term than mentalization, which is employed interchangeably) as a goal of therapy has a powerful and obvious implication that somehow being psychologically minded is better than not being psychologically minded. That is a remarkably 21st century thing to say as the notion of a young child even having a mind, much less a mind that could be very much affected by its psychological milieu, has only had a history of roughly 100 years. It has only been in the last 15 or 20 years, moreover, that there has been heuristically vital thinking about when and how this capacity for reflective functioning (RF) and “mentalizing” evolves (Fonagy, 1991; Fonagy, Gergely, Jurist, & Target, 2002). Linking recent advances in attachment theory with the advent of RF has placed the ability to put yourself in the role of the other as an essential state of being, one that allows for enhancements in the capacity to be a better parent, friend, spouse, and colleague. If these enhancements are real, which I believe they are, then enacting a process by which you serve as a catalyst toward your child patient's growing capacity to look reflectively at his or her own mind and the minds of others becomes a most worthwhile therapeutic endeavor.

The potential value of this mind-set for the child is enormous. If a child can be helped to think about experience as a process and not simply as content, the child remarkably enhances his or her problem-solving capabilities. It allows the child not to be drowned in the bath of immediate affective experience, in the tension and the awfulness of an abrupt dysregulation. It puts affective intensity into perspective and creates a way to regulate and balance affective life. As Bucci (1997) put it in a different context, the process of verbalization, while retaining a connection to bodily and affective experience, allows for the potential transformation of that experience. At the least, this enhanced affective balance increases the likelihood that the child is going to behave better in the world, and this behaving better in the world in most circumstances winds up causing other people to behave better toward the child. Even at a basic behavioral level, therefore, enhanced reflectivity often creates a bidirectional, cyclical pattern between child and parent or child and teacher that can make a child's life so much easier and more benign.

From a teaching perspective, there is a most useful corollary to psychologically minded child clinical work: It puts less pressure on you, the beginning child therapist. One of the most difficult burdens about being a child therapist is a feeling, “This poor child is in pain; the family is disrupted. How am I going to make this better?” This state of mind is particularly challenging because, unlike most adults, young children are not able to come in and say, “ I'm really having trouble with X,” or “I don't quite understand why I do Y.” Yet, young children will symbolically enact a broad range of difficulties right in front of you. Since you often have little idea what to make of this symbolizing, what to make of this re-creation of deeply personal events, if you do get caught up in, “I have to make sense of this content, I have to interpret this particular content,” you will find yourself feeling remarkably inadequate most of the time. Even if you “figure out” the content and can make some interpretation that sounds reasonably correct, most of the time the child will not know what to do with your response or will not have any useful way to place it in his or her cognitive framework in a manner that would allow the child a true accommodation (in the Piagetian sense of a discernible shift in the structure of the child's thinking). The child may indeed assimilate your remarks because he or she feels that you are trying to be kind and the child has come to trust you as a benevolent person, but the child is not going to be able to apply it to the rest of his or her life outside the therapy room. By contrast, this notion of creating a child clinician, of nourishing a state of psychological mindedness that allows the child to make his or her own interpretations, takes you “off the hook” of having to come up with an exact interpretation that not only fits the moment but also is useful long afterward.

Of equal importance, this reflectively minded stance is inherently respectful of the child's inner life and of his or her potential for broadening and deepening this inner life. This framework is about helping the child to make sense of personal experience rather than you making sense of this experience for the child. It stresses children's humanity, it views them as capable of problem solving, and it accentuates your role as a catalyst. In Winnicottian terms, it turns the therapeutic endeavor largely into the creation of a holding environment, a potential space for the child to explore. That exploratory process and your honoring of that exploratory process are exactly the means by which the child becomes psychologically minded. You say to the child, “This space, this child therapy room, is really a place where you can let your mind go—to sort out, to make sense out of, to get rid of, to interpret, to externalize, to come to grips with a whole variety of inner experiences.” Your role as a therapist is now to help contain that experience by pointing out in a variety of ways what it means to be thinking about thinking and helping the child to articulate what it feels like to be thinking and feeling. So, the notion that the child can expand his or her way of feeling about him- or herself, can become more aware of him- or herself as a feeling person, and can begin to put words to what that experience is like is actually the “royal road” toward helping the child develop a richer and more differentiated internal life. To say this in another way, these are the two fundamental jobs of a child clinician: psychological tool creation and tool enhancement.

This tool creation/enhancement process occurs in several ways. One way is through simple modeling. Say, for example, a 7-year-old begins treatment by asking you, “Is this your job? Do you see a lot of kids? Do you just play with kids all the time?” You can answer that in a way that is self-reflective: “I wonder what it'd be like to have a job where you played with kids all the time, where you talked with kids about their worries all the time. What do you think that'd be like?” You formulate it as a question that asks the child to comment on the process, and you do it in a self-reflective mode, reflecting out loud, that shows that you are comfortable thinking about questions and questioning. You do not have to rush to an answer, you do not even have to answer the question, but you are comfortable articulating that this is a worthwhile, valid question. The process that you model ideally allows the child to say, “When I think of a question, when I'm curious about something, it's okay to be curious, and I can actually think about that, and I can imagine that process.” If you ask that question and the child says, “I think it'd be so weird, ’cause kids can do crazy things,” then you can say, “Crazy? What would crazy feel like?” “Well, crazy feels like when I get mad at my sister, and I have all these punching, biting feelings, I just so want to do something terrible to her.” What might in other contexts be seen as the child being “bad” is now placed in a context of “crazy.” In other words, the feeling is still being disowned but is less dominated by superego-fueled prohibitions, making it more open to exploration. This allows you to respond: “A lot of brothers have those kicking and biting feelings about their little sisters. It's very hard to have a little sister.” You have now validated the child's statement, you are validating the child's experience, and again, depending on where the child goes with that, you can further expand on it. But, it comes from your initiation of the process by asking a question out loud and serving as a model of what it is like to reflect on an inner experience.

In the vernacular of this chapter, you are trying to set a frame, and the frame is that this room and this time in many ways are a unique time and a sanctuary of space. You and your patient can talk about things and feel things and wonder about things in a way that we often do not have the time to do anyplace else. So, wondering about where feelings come from, wondering about what a feeling feels like, wondering about what to do with ideas, and keeping that sense of wonder and curiosity at the forefront of the process can come to be experienced by the child as an antidote to feelings of shame and guilt. Indeed, these can come to serve as an antidote to the entire family of superego prohibitions that so often dominate the reasons children believe they are entering treatment in the first place. In this sense, a reflectively minded model is very much an ego psychology model in that it is all about enhancing and vitalizing one's ego strength. Creating or elaborating on a child's dance of curiosity and competence is at the heart of what it means to enhance ego resources and therefore at the heart of what it means to have an ego-oriented approach to experience. Creating a child clinician thus by definition creates a more emotionally resourceful child. It is in this context that the first conceptual frame I described, that of the heuristic value of core psychoanalytic concepts, meets with the third conceptual frame I described, mentalization, so that “tool enhancements” (i.e., ego resources) are placed in the context of greater psychological mindedness (i.e., mentalization).

Crucially, the fact that you are going to take this “ego” approach does not mean that the child's clinical picture is not dominated by vindictive, rigid, superego-based feelings that can be horrifyingly cruel and malevolent. It does not negate that there are powerfully aggressive, sexual, and amorous feelings in a young child. But, part of what you are doing by focusing on curiosity, by focusing on wonder, by modeling a self-reflective process is essentially saying that every affective experience is worthy of being wonder producing. Indeed, the way that you use your psychological ego strength is in no way to deny these sorts of experiences but in fact to accommodate those superego-generated and id-generated experiences within this ego-based, curiosity-driven, resourceful context. The more we can bring terrifying feelings within the domain of one's flexible ego resources, the less terrifying they become. In turn, the less primitive one's id experiences become, the more those aspects of life can be integrated into the self. As we set the frame for self-reflection, we are saying to the child that these affects are not forbidden to talk about. They are not so overpowering and terrifying to both of us that they can never be mentioned. Rather, they are things that we can wonder about and try to make sense of because they have meaning. The very process by which we go about trying to make meaning out of these incredibly scary feelings and ideas makes them less scary. All of that is built into this notion of setting up the frame of therapy as a self-reflective process.

If by the end of such a treatment approach you have set a frame within which, when your patient experiences an intense feeling, the patient can (a) be unafraid of it, (b) find words to articulate it, and (c) if necessary, try to find someone who can help the patient try to make sense of it, you have helped that patient to build the bedrock of how every one of us copes every day. That process is what grounds us. That process is what takes a harsh, awful feeling of disappointment, shame, or incompetence or an incredibly infuriating aggressive or sexual experience and tames it somewhat, links it, binds it to something you can make sense of and for which you can feel some degree of mastery. Isn't that what we would want to enhance in our patients of any age? But, particularly in treatment with young children who are just beginning the process of learning how to do that, working to enhance that capability seems to be a valid and timely approach to psychotherapy.

THE ROLE OF CONFLICT AND THE ROLE
OF ANXIETY IN THE THERAPIST

Now, part of why this approach is particularly useful is because a child does not come into therapy just by chance. The child comes into therapy because there are a series of conflictual experiences that are making it hard for the child at this moment in time to do three things: to articulate a problem, to bind that affective experience to ideas, or to go to other people and derive clear reassurance of support and help in problem solving. The child is overwhelmed by a particular series of events, whether these events are internally derived or externally created by people around her. Thus, the child is particularly hungry for, is particularly in need of, this kind of reflectively minded resource enhancement. Therefore, the more you make therapy about creating an environment in which you can enhance those capabilities, the more useful you will be to your child patient.

Having said all that, there is a great difficulty. The great difficulty is that you are anxious. As beginning therapists, it is hard to sit in the room and just be there, to do what Winnicott called “going on being,” by which you are able to listen in a way that allows you both to go with the child and be very present and at the same time to be reflective enough so that you are able to ask: “What is this child communicating to me? To what extent is the child clear about what he or she is communicating to me? How can I get the child to be clearer about what he or she is communicating and how he or she is communicating it? How can I get the child to be more sophisticated about this communication process, in particular about this communication process as related to the conflicts and the struggles and the symptoms that the child came in with in the first place?”

Attempting to overcome this anxiety begins with the first things you say to the child. When I first meet a patient, I will say: “Do you know why you're here today?” Most of the time children will say no to your question, even if they “know” exactly why they are there. Or, they will make up something like, “My mommy says that I have to stop biting my nails,” or “My mommy says that I have to stop being mean to my sister.” We are all on routine ground here. I then ask the question, “Well, do you know what I am, and what I do?” Usually, they say no, and I describe myself as “a feelings doctor or a worry doctor.” I explain, “Kids have lots of different feelings inside, and lots of worries, and I'm really good at being able to listen to and play with kids and help them figure out where these feelings come from. If we can figure out where these feelings come from, we can sometimes make those feelings a lot easier and a lot safer.” That is my introduction to therapy. I do it that way because I want to let the child know that, whatever the reason that he or she is coming, for me the child's behavior is not that important. It is much more the child's inner state of mind that is important, and I am interested in the child making sense of this state of mind.

So, as early in the treatment as I can, I want to put out there that this is my approach; this is how I am viewing the patient. I am hoping that in time what is called the treatment alliance will be built on an agreement to make sense of feelings. This is not about the child liking me or me liking the child, although that is going to be important. It is about exploring and honoring the fact that the child has a mind, a mind that is full of feelings and ideas that can become jumbled and at war with one another. My job is to help the child figure out the source of this jumble and what the child can do to feel less jumbled and less at war.

That leads to the next problem, which is that if the child was already reasonably capable of figuring out this jumble, the child would not be in therapy. So, we are setting as a goal something that is difficult. There may be in the first session or two a kind of willingness to take a look at him- or herself in this new way because it is different and sort of tantalizing. But, relatively soon after that, once therapy loses its novelty and habitual or transferential paradigms come to the fore, a whole slew of states of mind and feeling states will conspire to prevent you from helping the child become more mindful. In other words, the child will develop resistance, and a variety of defenses will be mobilized not to let you help the child think as a clinician because thinking like a clinician at this point is terrifying.

RESPONDING TO CHALLENGES TO THE FRAME

If the first part of your job is articulating a frame, articulating a method, articulating a hypothesis about the notion of where feelings come from and about this notion of being psychologically minded, the nitty-gritty becomes how you respond to challenges to that frame. For example, you may find yourself saying something like, “I see that dragon looks very strong. I wonder what it would feel like to be that little boy when that dragon is towering over him?” “ Let's go play with Legos” may be a common reply, with a rupture in the play indicating that your attempt at creating a reflective stance completely backfired. You make an attempt to help your patient reflect, and the child shows you by literally going someplace else that he or she cannot reflect at that moment. Perhaps what you can do then is to say, “Hmm, sounds like it's time to have some Legos feelings instead of dragon feelings. I don't know what happened to make those dragon feelings go to Legos, … but we can go play with Legos.” You allow the shift to happen, but you acknowledge the shift by creating a process that says, “Something happened here.” Maybe the child cannot think about that for even a second and will make a Legos model for another 30 minutes. It is even probable that this is what will happen at first. But, little by little, you are suggesting that there is a reason why the child has shifted to Legos instead of just sitting with a feeling or an idea. Over time, what you are hoping is that the percentage of time during which the child can reflect develops from near zero at the beginning of treatment to a significant percentage of the time as the treatment progresses. Indeed, a measure of treatment progress can be the degree to which such reflective capacity increases.

THE ROLE OF CHRONOLOGICAL AND
DEVELOPMENTAL AGE IN FRAME SETTING

Now, you need to keep in mind that this shift is very much affected by the age and the developmental capacity and level of the child. If I were to have one thing to say to you, one incredibly concrete thing you can do as you start out as a child therapist, it would be to read developmental psychology textbooks, and then reread them, so that you have developmental milestones in your bones, as Winnicott put it. It is essential when you are sitting with a patient to know, “This is what typical 7-year-old patients are like. This is what their cognitive capabilities are, this is what they tend to think and not be capable of thinking.” When your goal is to want this child to be more psychologically minded, that is relative to what is capable for a 7-year-old. We cannot expect the child to have the abstract thinking of a 15-year-old because if the child is 7, no matter how sophisticated and wonderful the child is, the child cannot do it. So, if you set up the frame that way, the 15-year-old model, by definition you are setting up a treatment that is going to fail because you are expecting your patient to do something the child is not capable of doing, and the child is going to hear your sense of disappointment that he or she is not being sufficiently sophisticated. So, everything I have been saying about creating psychological mindedness is bounded by age and development. If your patient is under 6 years old and thereby still dominated by preoperational thinking, there will be limitations to how much the patient can “get” the concept of thinking about him- or herself as having feelings because a preoperational child is almost by definition without a sustainable capacity to maintain a reflective stance. So, sometimes you are going to have development as your worst enemy because it is going...

Table of contents

• Frontcover
• Title Page
• Copyright
• Contents
• The Process of Writing This Book
• Acknowledgments
• About the Authors
• Chapter 1 Setting the Frame for Psychologically Minded Treatment
• SECTION I Setting the Frame
• SECTION II Responding to challenges to the Frame
• SECTION III Broadening the Frame
• References
• Index