Psychotherapy with Children and Families in a Child Psychiatric Setting
The traditional model of child psychiatric clinics is that they are centres of ‘expertise’, whereby parents can bring their children to seek ‘expert’ advice on a whole wide range of childhood and family problems. The title Child Guidance Clinics which often describes these centres suggests this approach and creates certain expectations that children will be ‘guided’ in the right direction. However such a model can have serious draw backs in that it can deny parents’ and children’s own experience of their own lives and disempower them in finding long lasting solutions. This article examines an alternative approach as proposed by Solution Focused (de Shazer, 1988, 91, 94) and Narrative Therapies (White & Epston, 1990) whereby parents and children are seen as the ‘experts’ in their own lives. The role of the therapist becomes facilitative and the parents and children become the experts who are consulted about the problem they are experiencing and any solutions they wish to implement.
At the heart of the medical model is the notion of expert diagnosis. The idea is that certain specialists can categorise problems and people with certain diagnoses and labels. Once this has been done, treatment which matches the diagnosis can be selected and applied. This approach can work very well in physical medicine – many diseases when skillfully diagnosed can be cured with tried and tested treatments. However when we consider the psychological and interpersonal world, such a medical approach is not as easy to apply. Human problems are mediated by subjective meaning and interpretation. What is a problem for one person is not for another. In any resolution we cannot strictly apply objective criteria but must incorporate the subjective experience and interpretation of the individual.
Medical science isn’t the only culprit in the privileging of objective knowledge over subjective experience. Therapists and counsellors are often over informed by their own the oretical orientation about the nature of their client’s difficulties, which may prevent them from hearing their client’s unique experience and indeed miss the unique solution which may be outside the realm of the preferred theory. There is always the danger that we will impose our own description of the world onto that of the client in the name of therapy. We can see from many case studies in psychotherapy how the client’s experience, as described by the therapist, always follows the therapist’s theoretical orientation. Jungian clients all seem to have Jungian dreams to be analysed. Freudian clients always have Freudian dreams and Behaviourist clients don’t dream at all!
No model is all-inclusive. There are always inherent limits and cases to which it doesn’t apply. There are many descriptions and theories of problems and not only those generated by the psychological theory which inform the therapist. Yet it is the latter ones which are often given a privileged position causing us to overlook the ‘other knowledge’ (Foucault, 1979) and unique experience of the people closest to the problem – that is the experience and knowledge of our clients.
With collaborative models the description and assessment of the problem is negotiated with the client. There is no privileged knowledge and parents and children are encouraged to come up with their own descriptions and theories. The goal is to find descriptions which fit with the client’s experience and which are helpful to moving them towards their own solution. This is often described in Narrative therapy as a co-author ing process (White & Epston, 1990).
In traditional assessment, questions are often used to gather information which is then used by the therapist to come up with a diagnosis and treatment plan. This is often information well known to the client – that is the when, where and how of the problem saturated story which they may have told many people before. In Narrative and Solution Focused therapy, questions are not used to elicit information, but rather to generate expe rience (Freeman & Combs, 1996). The aim is to use questions which generate new expe rience about potential solutions and the strengths and capabilities of the client. Think of the difference between the following questions to illustrate this point:
How long have you been depressed? [Likely to be known to client]
What would your life be like if you weren’t depressed? [Possibly unknown or not focused on by client]
In the collaborative therapies there is an over-riding belief in the client’s own strengths skills and resources. The focus is on what’s right and not on what’s wrong, on strengths rather than deficits and on change rather than stuckness (George, Iveson & Ratner, 1990).
The shift is away from the therapist as being an expert in the client’s problem, but to being a facilitator to the client in solving their own problems. As Selekman (1997, p7) states, ‘Our main expertise as therapists should be eliciting patients’ expertise’. Our goal now becomes one of empowerment, aiming to find interventions and questions which help clients generate useful descriptions of their own lives and which help them move towards their own solutions. The expectation is that the people closest to the problem – those dealing with it on a daily basis – are in the best position to know about its resolu tion. Certainly no solution can be implemented without their co-operation. However in many instances children’s and even parent’s, views about the problem and treatment aren’t collected. Even in the case of long term problems when the family has attended professional services for years, sometimes the identified child is still not consulted about her view – whether she thinks there is a problem and whether she thinks it should be changed. (White, M., personal communication, 20th June 1997). Such lack of key consultalion prohibits the work from moving forward.
Within a collaborative model there is no prescriptive advice on how to solve problems. Human dilemmas are too subjective and unique to fall under a neat categorisation which matches objective problem with an objective solution. The emphasis is on finding an example of solution behaviour which already exists within the client’s experience, even though it may be only operating to a small extent or not noticed. This represents the con cept of an exception in Solution Focused thinking (de Shazer, 1988) and a unique outcome in Narrative Therapy (White & lipston, 1990). The argument is that there are always times when the problem is less strong or when it does not occur at all, even for a brief period. The emphasis is on finding out about these times, understanding them and expanding them – find out what works and do more of it. Because these exceptions are already occurring within the client’s life, they are more likely to form the basis of a broader solution which would fit with the client’s circumstances, rather than one matched from theory. These exceptions represent flaws in the hold the problem has over a client’s life, which when exploited and increased can lead to the problem’s total col lapse.
Who should he included?
Therapists often experience a dilemma as to who should be involved in therapeutic work with families. Different schools of thought propose different answers. Historically children tended to be seen alone for psychodynamic psychotherapy (Klein, 1957; Axline, 1971) almost to the exclusion of parents. With the advent of systems theory and family therapy, it was seen as crucial to involve the parents. Sometimes the focus within fami ly therapy approaches is mainly on parental concerns and goals. Quite often young children are excluded from sessions or at least included only if they are ‘seen and not heard’ (Selekman 1997). In wider systems (e.g. school and child protection services) the child’s voice can be lost and they can become the last person to be consulted, even about criti cal decisions affecting their lives.
Within Narrative approaches, both parents and children are considered clients. Both their goals, views and concerns are central. Even if priorities appear in conflict, it is not a case of promoting one interest over another, but rather looking for an inclusive common ground. When meeting families from a collaborative point of view it is important not to have a fixed rule coming from your theoretical position about which way is the best to Proceed but rather to negotiate this with the family and other concerned parties. As Freeman et al. (1997) state: ‘We are open to meeting parents and children in flexible con figurations. Frequent consultations with the family guide us in deciding which members or concerned others attend particular sessions.’
Inclusion and flexibility are important ideas in collaborative work with families. In my own work I always attempt to include all the key people involved in the child’s life. This is generally both parents and the child but could include other caregivers, siblings and possibly outside people such as teachers or other professionals. This is all negotiated with the parents and the children from the outset. Families can be asked to bring along whoever they think might be helpful in finding a solution to the problem.
A Case Example
The following case example illustrates some of the principles of consulting with children as experts in their own lives. It also shows the power of having parents present during the interview, giving special validation and audience to the views expressed by the child. The dialogues have been paraphrased and shortened to be included in this brief article.
Paul was a 11 year old only child with mild learning difficulties. He had been referred due to aggressive behaviour at school and was at the point of being excluded. He attended with his mother Lisa, a single parent.
Lisa started by describing in detail the problems she was having with Paul’s behaviour and how she found it difficult to control. I empathised with her. Her particular concern was that he would be expelled. Paul during this conversation seemed a little tuned out. I asked Lisa what things were going right in Paul’s life. She paused and thought and then described how he did some jobs with her brother (a carpenter) and he seemed to like this. I brought Paul into the conversation at this point asking him about his work with his Uncle [getting to know the child aside from problem]. He talked for some time about this. I then proceeded to consult him about the problem.
J: So Paul, why do you think you have come along here today? (He looks down and away.)
P: My behaviour? (He looks to his Lisa to confirm answer. She nods)
J: Is behaviour a problem for you? (He shrugs his shoulders, and looks to Lisa to answer)
L: You speak to John yourself, Paul.
P: I don’t know.
J: You’re not sure? (We go on to slowly explore how the behaviour affects his life. He describes how he hits boys who tease him, and that then he gets into trouble both at school and home.)
J: Is your Mum worried about your behaviour? (Paul nods.) Do you know why? (He shakes his head and looks to his mother.)
J: Would you like your Mum to explain? (Paul nods.)
Lisa goes on to describe how she is worried he will have to leave school and she does n’t know of another which will take him. She says she wants Paul to behave better in school.)
J: You want Paul to behave well in school so he will be able to stay there? Lisa nods in agreement.
J: What do you think Paul? Do you agree with your Mum that it is a good idea for you to get on well in school so you can stay there?
J: So why do you think its a good idea to get on well in school?
P: To get a good education? (He looks to Lisa who continues.)
L: That’s right, Paul, you need to learn at school. Also we’d be having no rows if you got on well…..
At this point we have the beginnings of an agreed goal about which both Lisa and Paul have been consulted. Paul has begun to make a decision about what he wants and why. We continue to explore this in the session and how ‘good behaviour’ is linked to less hassle at home.
The next sequence illustrates a time later in the session when we were beginning to talk about solutions. Lisa reported that the teacher said there had been a slight improvement in Paul’s behaviour in the last two days. I begin to explore this exception, consulting with Paul about how he managed to achieve it.
J: So Paul, the last two days the teacher thinks you behaved well in school? (Paul nods.) What happened?
P: I just kept out of trouble. (He shrugs his shoulders as if to belittle this.)
J: You just kept out of trouble?…How did you do that?
P: I didn’t want to upset my Mum.
J: So you were thinking of your Mum’s feelings? [Picking out positive intention.] What I am interested is how you managed to keep out of trouble. It’s quite an achievement. What did you do when the boys bothered you?
P: I just ignored them.
L: That’s what I told him to do.
J: So you listened to your Mum’s advice. What else did you do Paul?
P: I just walked away from them.
J: You just got up and walked away. That was a good idea.
This section illustrates the skills Paul used to keep out of trouble. It shows his develop ing expertise in behaving well which may not have been noticed or discussed before. The session ended with a plan: Paul was going to continue to use his skills and to notice further ones with Lisa’s support. Lisa was going to arrange for Paul to spend more time with his Uncle and to talk to him about what was going on. I agreed to contact the Paul’s teacher to tell him of Paul’s goal and attempts to stay out of trouble, and to ask him to support Paul in looking out for more improvements. When Lisa and Paul attended the clinic again in two weeks they described big improve ments and decided things were going well enough for them to end treatment.
The case illustrates the power of consulting with children about their own lives. Paul was given the opportunity to share his feelings and views about the problem. Though it took some time, he then took a position on the problem and established an agreed goal with his mother. So often professionals set up pieces of work with children without gaining the parent’s collaboration, let alone that of the child. Without this collaboration the work is completely handicapped and disempowered. Notice also how the above case also includes other closely involved people in the solution (the uncle and the teacher). Accessing the resources and supports families already have within the community often increases the effectiveness and brevity of therapeutic work.
Child guidance professionals are often perceived as experts in family and childhood problems. However it can be a refreshing alternative to reverse this view and consider those who are closest to the problem as the real experts – that is the children, the parents, extended family and community (teachers etc.) who deal with it and solve it on a daily basis. The new professional role is to consult with these real experts about the best way to go forward in each individual situation. It is interesting because this new approach, not only can find the best fitting and long lasting solutions, but also can be less stressful for the worker. Gone is the burden of being all knowing and responsible for other people’s lives. Instead we give this knowledge and responsibility back to the clients. We empower them as mastering their own lives.
John Sharry – is the Senior Social Worker at the Department of Child and Family Psychiatry at the Mater Hospital in north Dublin. He trained in Solution Focused Brief Therapy in London and Dublin and is a founding member of the Brief Therapy Group in Dublin who organise training and conferences within Ireland. He can be contacted at 01 853 2426.
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