Work with Parents: Psychoanalytic Psychotherapy with Children and Adolescents

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Drawing on the rich range and depth of the clinical experience of the contributors, this welcome volume will be a valuable tool for clinicians and trainees. The authors share a powerful commitment to the relevance and value of psychoanalytically based work with parents - an area all too often inadequately provided for - and provide heartening evidence of the resilience and intellectual vitality of the various strands within this tradition.Part of the EFPP Monograph Series.

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CHAPTER ONE Dialogues with parents

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Margaret Rustin

This chapter is intended as an overview of current practice at the Tavistock Clinic. The approach described also represents a significant strand within child, adolescent, and family mental health services of the British National Health Service. I shall sketch a map of some varieties of approach, provide clinical examples, raise some ethical concerns, and explore how work with parents is encompassed within the identity of the child psychotherapist.

History of work with parents within child guidance

Perhaps it would be useful to start with some historical background. The early generations of child psychotherapists could rely on close working partnerships with experienced social workers (Harris, 1968). The postwar child guidance clinics were fortunate in their genuine multidisciplinary ethos and particularly in their social workers, who usually had a commitment to a psychoanalyti-cally based understanding of human development and family relationships. Much of Winnicott’s writing about his hospital work is imbued with his sense of the multidisciplinary teams within which his creative potential developed and standards of good practice were established. This was a very particular culture of care.

 

CHAPTER TWO Therapeutic space for re-creating the child in the mind of the parents

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Viviane Green

At The Anna Freud Centre, work with parents takes place in many different ways and in many different contexts. Outside the immediate classical therapeutic context, parents can be seen in educational or health settings, as, for example, the nursery setting at The Anna Freud Centre. Work with parents is also carried out in the Parent Infant Project and the Parent Support Project. This chapter does not represent the entire range of work carried out at the Centre. For the purposes of this chapter, which is based on group discussions at the Centre, I have focused on work with parents in conjunction with a child’s therapy or as a prelude to therapy.

Parents can be seen primarily to support and hold a child’s analysis. Sometimes the child is worked with through the parents. At other times, parents work actively with a therapist in parallel with their child’s treatment. Through accident rather than design, the vignettes selected were all of cases where the child’s therapist also worked with the parents; usually, however, the parents will be seen by a social worker or another therapist. In this chapter, I hope to show that, whilst there may be several themes that arise commonly in work with many parents, ultimately the clinical starting point for the worker is defined by the locus of the parent.

 

CHAPTER THREE Keeping the child in mind: thoughts on work with parents of children in therapy

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Ann Home

There is, amongst child psychotherapists, great flexibility in the kind of work undertaken with parents. Furman (1991) describes long-term careful work via the parent, enhancing understanding and offering support on an ego level to the mother of a bereaved boy, typical of the skills developed in her setting at the Hannah Perkins Nursery in Cleveland, Ohio. Winnicott, throughout his writings, gives rather bravura demonstrations of consultations to parents with amazing impact (e.g. Winnicott, 1971). The development of parent/infant work around the world has allowed early, brief intervention enhancing the attachment process (e.g. Daws, 1989; Hopkins, 1992; Stern, 1995). It is not the intention in this chapter to cover such multiple and developing applications of psychoanalytic understanding. Rather, the simple process of the child psychotherapist working with the parent or significant carers of children in therapy is addressed.

It is part of the training requirements of child psychotherapists in the United Kingdom that trainees work regularly, under supervision, with the parent(s)/carer of a child who is in therapy with a colleague. This requirement has not arisen inconsequentially. To some it might appear as one response to changes in social work training in the 1980s, which gave rise, on the one hand, to an emphasis on cognitive/behavioural therapies more readily open to research and, on the other, to a preoccupation with child-protection work of a more managerial, coordinating nature—to the detriment of the capacity to undertake psychodynamic parent work. The economics of the time also led to serious difficulties in multi-professional staffing for many child and family mental health settings, psychiatric social workers especially being casualties of cuts in local authority funding.

 

CHAPTER FOUR Parental therapy—in theory and practice

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Marianne Engelse Frick

The theme of this monograph—working with parents of children and adolescents who are in psychoanalytic psychotherapy—describes a form of treatment that has developed together with the ongoing specialization of individual child psychotherapy. When we choose this parallel form of parental treatment, our task is defined by the structure of the latter. The term “parental therapy” encompasses many types of treatment, which may appear in very different forms. However, the task field is always the same: to improve the situation of the child, we should not only ensure the prerequisites of child psychotherapy, but also help parents to start or restart a positive parenting process in order to accept and support the results of child psychotherapy.

In this chapter, I concentrate on therapeutic aspects of paren-tal treatment, as described below under “Psychotherapeutic Interventions within Parental Treatment” and “Individual Psychotherapy with the Parents”, aiming to help parents to start or restart a positive parenting process. This requires the parental therapist to know typical elements in this sort of psychotherapeutic intervention— that is, to be conscious of the therapeutic role to be performed, the tools to use, and the problems to expect. I illustrate this with some case examples. First, however, I present a survey of the different areas and levels in parental therapy which may become actualized in this type of treatment before the therapist may concentrate on the inner problems of the parents (for a comprehensive overview of the different aspects of parental therapy, see, for example, Armbruster, Dobuler, Fischer, & Grigsby, 1996).

 

CHAPTER FIVE Work with parents of psychotic children within a day-care therapeutic unit setting

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Olga Maratos & Athanassios Alexandridis

The focus of this chapter is on work with parents of children with severe psychopathology, diagnosed between 3 and 4 years of age, within an institutional setting. The setting is the PERIVOLAKI [“small garden”] therapeutic unit, which was founded in 1983, initially only for pre-school children; it was eventually developed into a day-care unit for autistic and psychotic children aged 3 to 14 years.

Central to our approach are the following considerations: (1) Autism and early childhood psychoses (symbiotic, confusional, etc.) may have some characteristic features in common, but they also present important differences in mental functioning, affect expression, social responsiveness, and modes of relating to persons and inanimate objects. These differences should be taken into account when working with parents. (2) We are not concerned in our clinical practice with the aetiology of the particular pathology, as the emphasis is put on understanding the mental states, mental functioning, expression of affect, and the ways these children relate to their social environment as well as to physical objects. We believe that the meaning of the child’s symptoms should be the primary preoccupation for both the parents and the therapists. Parents’ understanding of the ways their children feel and behave is extremely important for the development of their children and for the cooperation needed between the child’s therapists and themselves (therapeutic alliance).

 

CHAPTER SIX Working with parents of autistic children

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Didier Houzel

Over the years since psychoanalytic treatment of early in fantile autism was first attempted, a rift has opened between the parents of autistic children and psychoanalysis. There are many reasons for this, but I believe that the principal factor is the misuse of psychoanalysis in this area, together with a lack of conceptual and methodological rigour. I would argue that it is necessary to reflect on these points if we are to establish a new kind of productive dialogue between parents and therapists. It seems paradoxical that psychoanalysis, with its emphasis on understanding and help, should be experienced as a threat and set aside as a heavy and useless encumbrance. This paradox, it seems to me, has many lessons for us, in the same way that other theoretical or technical stumbling-blocks mark the frontiers of our present knowledge yet may also herald new advances.

I think that, up to a point, the situation of infantile autism over the last thirty years can be compared to the predicament that medical science found itself in at the end of the last century with respect to hysteria and the adult neuroses in general. At that time, neurology, with its emphasis on the systematic study of nerve paths and on an ever more thorough knowledge of the anatomy of the central nervous system, was faced with an enigma: the symptoms of hysterical conversion. Brain lesions could explain observed symptomatology by means of the anatomical and functional mapping between nerve lesion and peripheral manifestation, but hysterical symptoms did not lend themselves to any kind of comprehensible systematization. Thus hysteria was a challenge to the medical practitioners of the time—it was all Greek to them— and as a result they were quickly to become exasperated by these unclassifiable and baffling patients. From then on, there has been a kind of permanent divorce between somatic medicine and the patient who suffers from hysteria.

 

CHAPTER SEVEN Helping children through treatment of parenting: the model of mother/infant psychotherapy

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Bertrand Cramer

It is well known that treating children often means treating parents. This empirical finding, made by many clinicians (Anna Freud, Fraiberg, Katan, Winnicott) has brought about original forms of treatments: family or systemic therapies and parent/child treatments, among which the best known are Mahler’s tripartite treatment (with psychotic children: Mahler et al., 1975) and Fraiberg’s mother/infant therapies (Fraiberg, 1980). Several therapists have refined parent/infant therapies, each bringing his or her contributions (Cramer, 1995; Hopkins, 1992; Lebovici, 1983; Lieberman, Weston, & Pawl, 1991). In all these approaches, a major focus of therapy is the complex constellation of conflicts, anxieties, defences, ideals, and relationship modes (both internal and externalized) that produce what is often referred to as parenting. Parenting is a way of describing both how parents actually enact their relational and educational competencies with their children, and how they represent and experience the fantasies, conflicts, and object relationships that are the unconscious underpinnings of parental behaviours.

 

CHAPTER EIGHT Working with parents of sexually abused children

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Gillian Miles

Child sexual abuse is damaging and traumatic both for children and for their families. It often occurs alongside other forms of abuse—neglect, emotional abuse, physical abuse—but sexual abuse has its own particular emotional impact for the entire family.

When it occurs within the family, sexual abuse is secret and insidious, and the first impact of disclosure that the abuse has happened is a profound shock, which in itself is traumatic. Families are confronted with actions that cut across all taboos, as sexual abuse offends against the proper place of sexuality, which belongs in relationships between adults. There is total disbelief at what is emerging, because where the father or stepfather is the abuser,* there are profound implications for the adult partnership and for

The research referred to in this chapter was funded by the Department of Health and the Mental Health Foundation. his continuing role within the family. His partner feels irrevocably hurt. The children are considered unsafe with him, and either he or the child may have to leave the family. Where he denies the charge of abuse, his partner has to decide, in the absence of clear evidence, whether or not to believe the child, with the very possible implication that she will lose her partner. Almost more distressing, when there are allegations of sexual abuse between siblings, parents may have to decide which child to believe. The child alleging abuse may not be believed and may be forced to leave the family; alternatively, it could be that the abusing child is disowned and excluded from the family.

 

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