Child and Adolescent Psychotherapy

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In this book, Peter Blake articulates his clinical practice of child and adolescent psychotherapy. A clear conceptual framework and historical context is provided for the work. The book is then structured to follow the therapeutic process, from assessment (referral and initial interview, individual assessment, developmental considerations, assessment for therapy, working with parents) to therapy (physical and mental settings, interpretation, the role and challenges of play, transference and countertransference, termination). Drawing on the Winnicottian tradition, in which fun and humour have a place in child and adolescent work, Blake demonstrates how a therapist can be playful and less directly interpretative. How psychodynamic thinking can be applied in an effective yet time-limited manner is also demonstrated. The text is enlivened by many case studies and clinical anecdotes.For therapists who are new to child and adolescent psychotherapy, and who wish to take a psychodynamic approach, the book will provide a valuable introduction. For professionals who refer to or work with child and adolescent therapists, the book will provide insight into the field, dissipating much of the mystique and misunderstanding that surrounds this work. Experienced child and adolescent therapists will find of interest how Blake integrates a Kleinian, Object-Relations approach with more Interpersonal (now, Relational) thinking.

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1: The analytic legacy

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WHY HISTORY?

Rosa, a 17-year-old girl, has just thrown a brick through the window of a church. This is next to the clinic she attends for weekly psychotherapy.

Anne, her therapist, hears the breaking glass and rushes out of the clinic to see Rosa and a small group of girls running away. In this scene it is hard to see how Anne knowing about the history of psychoanalytic work with children could be of any relevance to helping her work with Rosa, yet it is. Anne must recover from the shock of this incident and begin to think about why Rosa is doing this. This thinking is crucial in determining what she will do. But she is not alone in this process. She has the benefit of over one hundred years of thinking and clinical experience of great minds to help her understand what may be going on for Rosa. The conceptual and technical tools used by current child therapists are the legacy of previous generations of therapists, who have shared their thoughts in publications and supervision. To understand, and more importantly, to challenge these historical wisdoms, it is imperative to know how they evolved and in what context they were formed.

 

2: Conceptual framework

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A clinician observes, thinks, and at some stage, intervenes. These three activities define the work. They are the basic building blocks of the clinical process. While they are all intimately connected, this chapter will isolate and focus on the task of ‘thinking’.

THE IMPORTANCE OF THINKING

Understanding arises from close observation. Our observations are the raw data that are held and shaped by the conceptual framework. Our sight, hearing, and feelings are the basic perceptual tools. In looking, listening, and feeling, we gather information that needs to be processed. Without this processing we can be overwhelmed by a mass of random impressions. To make sense of our observations we need to think about them: to gather, organise, and relate different sets of data to each other so they start to form a pattern. Only then can we begin to make sense of the data. This enables us to ‘do’ something with this information. Clinical intervention is the result of this interplay between observation and thought.

 

3: Psychoanalytic observation

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The task of observing would, on the surface, appear to be a fairly straightforward and simple process. You look at something and note your perception. However, it is the fact that we do this all the time in everyday life that makes it problematic.

To function as a human being we need structure and predictability. Our systems are not designed to cope with constant change and uncertainty. We need to organise and establish patterns in order to reduce uncertainty, to predict.

This need for certainty makes objective perception almost impossible. Fine details that do not conform are glossed over. However, from a psychoanalytic perspective, it is the fine detail that is of particular interest; that is, the unexpected. Such details can be important clues to understanding the inner world of the individual. They can be evidence of unconscious percolations. It is important for the analytic therapist to develop his or her perception so that it is as open and acute as possible. It is crucial to be able to tolerate an attitude of ‘nothing is irrelevant’, and also to be able to bear the chaos that arises from this attitude.

 

4: Referral and initial interview

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REFERRAL

Initial contact is often made by phone, and usually made by a parent. This is the first step in the assessment process. For the clinician, this is a time of little ‘memory or desire’, a period of first impressions. If one is open to receive these impressions, a great deal can be learnt.

In some clinics a receptionist takes down the details, while at other centres an intake officer may perform this task. In private practice, the usual procedure is for the practitioner to take the call. In most practices this would be in response to a phone message left on an answer machine. It is important that such messages are responded to within a 24-hour period. The making of a phone call about a child's emotional and/or behavioural difficulties, for a parent, can be the end result of weeks, months, or even years of worry. In reaching out for help, parents can be desperate and struggling with feelings of guilt, fears, and hopes. This cocktail of emotions makes them particularly vulnerable. How their concerns are received can significantly influence the outcome. An attitude of professional empathy and concern must be conveyed. While going into detail at this first contact is not advisable, it is important for the parent to feel you have time to listen. For this reason, ringing people in a ten-minute gap between appointments is not a good idea.

 

5: Individual assessment

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There are two broad ways of individually assessing a child. It can be done in a structured way, with formal testing and/or a particular set of questions. Alternatively, it can be unstructured, with no preconceived agenda. The unstructured approach entails careful and detailed observation of whatever is happening in the room, allowing the child to take the lead.

My first training was in clinical psychology, and I began assessing children by administering formal tests (such as projective cards and questionnaires). In my early days I was anxious when seeing children. I wasn't sure how to talk to them or what to do in the interview. I found these tests gave me some structure. This enabled me to be less anxious and more able to observe and think about their responses.

As my experience grew I felt more comfortable in doing away with this structure. I was becoming more interested in a psychoanalytic way of working. This meant allowing greater space or freedom to explore what the child was spontaneously giving me. In the interview this meant I had a rough idea of the areas I wanted to cover, but I was more relaxed to let the child wander off the topic and follow their lead. As my psychotherapy training developed, I found my anxiety lessened and my observational skills increased. This enabled me to let go of any kind of structure and to enter a session and to see what happens. This latter approach I am calling unstructured.

 

6: Developmental considerations

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Given that children and adolescents are works in progress, it is crucial to have an understanding of their developmental context. Assessing a three-year-old is different to seeing an 18-year-old. Child therapists need to have an appreciation of the emotional strengths and weaknesses that are expected at each stage of development. This enables them to be in a position to gauge whether a child's or adolescent's development is on track or derailed.

THE PRESCHOOL CHILD

Points to consider when assessing a preschool child include:

•  The material is generally raw and hectic

•  Feelings are very strong and powerful, and can suddenly overwhelm the child

•  The material can be erratic and contradictory

•  Anxieties are usually expressed in a primitive, nonverbal, gross manner

•  There is little direct response to interpretation

•  The speed and physicality of children make thinking diffcult

•  Listen to the verbs in the conversation, as subject and object can interchange suddenly

•  Assessment is often based on only a few examples

 

7: Assessment for therapy

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The role of assessment for the child therapist includes trying to understand the psychodynamics of a child, and applying this understanding in consultation with parents and other professionals. One of the more specific questions asked is whether this child should be offered analytic therapy. Klein felt that every child could benefit from psychoanalysis, the so-called prophylactic analysis, but the modern realities of time and money mean that some discrimination is necessary to determine who would benefit most. Decades of analytic child work have resulted in a greater sophistication of thought. We would now question the idea that every child could benefit from analytic therapy, and question whether ‘standard’ analytic therapy could actually harm a child. I am referring to an interpretative approach in which direct interpretation can shatter the child's or adolescent's fragile sense of self (Spiegel 1989).

If not all children are to be offered therapy, which children are suitable for this form of intervention? One way to approach this decision is to consider three basic questions:

 

8: Working with parents

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MEETING BACK WITH THE PARENTS

After a child or adolescent has been seen individually for three assessment sessions, I meet back with the parents to discuss my thoughts about the assessment. I talk about what I perceive to be their child's anxieties, how he or she is trying to manage these feelings, and how these emotions are influencing behaviour. The parents will also be expecting some discussion as to what is the best way to help the child and themselves with their presenting concerns. Although discussing the assessment, this meeting is also a therapeutic consultation.

CREATING A COLLEGIATE ATMOSPHERE

As noted earlier, when first meeting the parents, what is absolutely crucial is to create a collegiate atmosphere. This meeting needs to be conceptualised as three minds coming together, each with valuable but perhaps different perspectives, so an understanding and management plan can evolve.

There are technical issues that can help to engender this outcome. I usually start this interview by saying to the parents, ‘Before I start and give you my thoughts, I wonder if you could give me some feedback on how Joseph has been going since I saw you last. Also, could you give me some idea of how he has reacted to the sessions with me?’

 

9: The setting, physical and mental, and limits

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Therapy begins with the setting. This does not always have to be a consulting room. Analytic work with children began with Freud consulting to a father about his son's fears. Here there was no formal setting, but adults observing, thinking, and talking to the boy about the possible meaning of his behaviour. While Freud began this tradition he never worked directly with children, and therefore was never confronted with its clinical implications. Hermine Hug-Hellmuth, Melanie Klein, and Anna Freud undertook this task of applying psychoanalytic principles to the child in the formal setting of a consulting room. These early pioneers had differing thoughts, and this was reflected in the different clinical settings they provided.

THE IMPORTANCE OF THE SETTING

The setting is the physical and mental space within which psychoanalytic work occurs. It provides the backdrop to the clinical work, and helps to define it. Indeed, one can get a good idea of how a child therapist works by looking at the room and the sorts of toys he or she uses, as well as how the therapist dresses and presents him- or herself.

 

10: Interpretation

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From the beginning, interpretation has been central to psychoanalysis. For Sigmund Freud, Anna Freud, and Melanie Klein the analytic model was about analysing, and you analysed by interpreting to the person what was behind his or her behaviour. This early and rather crude view of interpretation has been refined over the years. The refinement has led to many different schools of thought as to how interpretation should be used in the therapeutic encounter. These differences involve the questions of what, how much, and when an interpretation should be given.

Before exploring these questions, it is important to understand why interpretation is central to analytic technique. In discussing its development, it can be shown how this centrality has inhibited the growth of more age-appropriate ways of working analytically with children.

THE HISTORY OF INTERPRETATION

In his earliest formulations, Freud believed that the patient's disturbed behaviour was the result of a traumatic event that was hidden from conscious awareness. The memory of this trauma was split off from consciousness, but the unreleased affect associated with it remained festering in the psychic system. The function of the physician was to lance this psychic sore by analysing the person's history, in an effort to reveal and release the hidden trauma. He also discovered that the patient's dreams were especially ripe for revealing these hidden events or desires.

 

11: The role of play

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ENGAGEMENT THROUGH PLAY

The move away from insight and direct interpretation in child analytic work has important implications for technique. The child therapist must look to play, not only as a means of understanding the child, but also as a technique of engagement. Play has many benefits over formal interpretations. It is devel-opmentally attuned. It allows anxieties to be displaced into the safer realm of pretend. It keeps things light and enjoyable. Children can retain their sense of personal security. Importantly, play is fun, a word not often used in analytic work. Fun and enjoyment bring interest and curiosity.

Play is the safe ‘in between’ area that Winnicott calls the transitional space. Play is like ‘a transitional interpretation’. It is in between reflective functioning and self-reflective functioning. From play, thoughts and feelings can be explored without the threat of the child feeling overwhelmed. As Joyce and Stoker (2000) note, play does not threaten the child's internal equilibrium, because it is not a direct reference to his or her internal experience.

 

12: The challenges of play

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There is no question as to the importance of play in child and adolescent work. However, play is only helpful, both as an assessment communication and a therapeutic endeavor, if it is real play.

REAL ALIVE PLAY

Real play is emotionally alive. A critical factor in play, from an emotional point of view, is whether it is spontaneous. Winnicott always stressed this feature. Real play is about discovery, of not knowing what is going to happen next. When it is present, the play flows, and as Winnicott states, if it is flowing then the most therapeutic thing you can do is to leave it alone (Winnicott 1971). However, there are children who cannot play at all, or the quality of their play is lacking this spontaneity. It has either dried up or it is seriously stuck.

Child therapists need to be aware of the different types of play, to know what is real play and what isn't, when to leave the play alone, or when the play, or what looks like play, needs some intervention. At a gross level it is not too difficult to make this distinction. Being in the presence of emotionally alive play is pleasant. It is interesting, engaging, at times exciting, and time flies by. Emotionally dead play feels distant. It is boring, often repetitive, and minutes turn into hours.

 

13: Transference and countertransference

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The third major component of child and adolescent psychotherapy, beside interpretation and play, is the use of the transference and countertransference. All analytic therapists, be they child or adult, are taught from the very beginning of their training about the importance of transference. Always thinking about and working with the transference is the one thing that differentiates an analytic therapist from any other form of therapist. What this means in practice is that you are always thinking about how the child is feeling towards you. What is happening between you, and what aspects of his or her behaviour in relation to you, are repeating earlier patterns in his or her life?

In the clinical situation this may manifest in numerous ways. For example, you are told by the parents that their daughter has always been a ferocious eater. She is demanding and insatiable. After several weeks of seeing the child you realise how difficult it is to finish a session. She wants more time. She is now starting to complain that there are not enough toys; she says she needs more Lego to build a bigger house. Or the parents may describe their eight-year-old as always being jealous of her six-year-old brother. As sessions proceed, this little girl starts to ask who else is seen in this room. ‘Do you see other children? How many? Do you have children of your own? What is your favourite colour?’ These ways of relating strongly suggest that earlier patterns of relating, or earlier concerns, are now starting to be repeated in the relationship with the therapist. These repetitions take these concerns out of the past and allow them to be known and examined in the here and now. Not only do you experience the child's behaviour, but also all the feelings and reactions around it.

 

14: Interpretation, play, and transference and countertransference in practice : Paul's story

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The following case material is presented to illustrate how the three components of the therapeutic process—interpretation, play, and transference and countertransference—are applied in the clinical situation. Paul was chosen because his material was very rich, and it was recorded in detail after every session. Also, while I have spoken about children for whom direct interpretation is too much, this was generally not the case with Paul. There were periods throughout the three years I saw him when he was resistant to the therapeutic process, and at these times I worked and stayed in the metaphor of the play. At other times I did use interpretation, and more specifically transference interpretations. Both of us were able to manage this.

Paul's story is told in an attempt to illustrate some of the concepts described throughout the book: splitting, projection, containment, and transference and countertransference. The varying types of anxiety described by Klein are also highlighted. Paul is interesting because he began therapy with a heavy use of play, but as he became older he became more verbal and presented much more like an adolescent.

 

15: Adolescents

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‘Only the most courageous, or perhaps the most foolish, therapists are willing to treat adolescents, for they are the most difficult group of children with whom to work’ (Spiegel 1989, p. 130). This age group is difficult because there are certain technical differences that arise from the developmental peculiarities of this period. Some time around the age of 12 years children begin to be confronted with changes that will shape them for the rest of their lives. As noted in chapter 6, the security of being identified with the family begins to lessen as the tasks of autonomy and identity come to the fore. The holding and containment of infancy and childhood are gradually reduced. The loss of this external holding now exposes the quality and nature of this previous containment, and how well it has been internalised and integrated into the young person's sense of self.

MEANINGFUL MOMENTS

The psychic system of the adolescent is placed under great strain, not only from the biological forces of puberty, but also from the social, cultural, and technological changes that are endemic in present-day life. In navigating through this sea of change, adolescents call upon their earlier role models for internal guidance. The child who has been surrounded by consistent, caring, and thoughtful others is well prepared for this period of emotional upheaval. Alternatively, a history of loss, neglect, trauma, inconsistency, and emotional insensitivity makes this developmental period a potential nightmare. The internal tools needed to build a secure, thoughtful, and cohesive sense of self will be painfully missing.

 

16: Endings

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How can you tell if therapy is effective and when it should stop?

The simple answer to this question is you never can be sure. If you have to have absolute certainty about the results of your work, then you will struggle with this model of understanding and therapy. To understand another human being in depth is an enormous, if not impossible task. It is even harder to be completely convinced that the person has changed, and to have a sense of certainty about the factors that produced that change.

Most child therapists see children once a week. Publicly they may be seen for a year; privately this can be longer. unless the therapist is in a special institute it is unlikely that he or she will see many children for more than 50 to 60 hours of therapy. While this may sound a huge amount of time from an administrator's point of view, it is a remarkably limited period to attempt to help a child discover who he or she really is.

The other problem of seeing a child over any length of time is that the child is still in a period of development. One can never be sure if things have changed because of the therapy or because the child has matured over a developmental period. Of course, it is not all guesswork. Child therapists, you would hope, have more chance of understanding change than someone on the street. But if you are going to use this model of therapy for any length of time, you must be prepared for periods of thinking that this is all a load of rubbish, alternating with a sense of conviction that this is one of the very few ways of truly understanding and influencing a child's development.

 

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