First published 2010
by Routledge
27 Church Road, Hove, East Sussex BN3 2FA
Simultaneously published in the USA and Canada
by Routledge
270 Madison Avenue, New York, NY 10016
Routledge is an imprint of the Taylor & Francis Group, an Informa business
Ø 2010 Ruth Schmidt Neven
Typeset in Times by Gar®eld Morgan, Swansea, West Glamorgan
Printed and bound in Great Britain by TJ International Ltd, Padstow,
Cornwall
Paperback cover design by Andrew Ward
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
This publication has been produced with paper manufactured to strict
environmental standards and with pulp derived from sustainable forests.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Neven, Ruth Schmidt.
Core principles of assessment and therapeutic communication with
children, parents and families : towards the promotion of child and family
wellbeing / Ruth Schmidt Neven.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-415-55242-4 (hbk) ± ISBN 978-0-415-55243-1 (pbk) 1. Child
mental health. 2. Child psychotherapy. 3. Child psychotherapy±Parent
participation. 4. Child mental health services. I. Title.
RJ499.N43 2010
618.92©89±dc22
2009049527
ISBN: 978-0-415-55242-4 (hbk)
ISBN: 978-0-415-55243-1 (pbk)
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Contents
PART 1
Point of departure
1
2
1
Introduction: the rationale for the book ± a return to core
principles
3
Finding the meaning in communication: setting the scene for
work with children, young people and their parents ± how the
child `speaks' the family
7
Providing a developmental scaffold for effective practice:
understanding emotional milestones
21
PART 2
The clinical core
59
3
Practicalities of the assessment process: how to begin
61
4
Practicalities of therapeutic communication: how to continue
74
PART 3
Application of core principles of assessment and
therapeutic communication
5
Applying core principles of assessment and therapeutic
communication in schools, early childhood and health settings
6
Assessment and therapeutic communication in working with
separation, loss and trauma
97
99
121
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
viii
7
8
Contents
Towards an organizational understanding of assessment and
therapeutic communication: how professionals `speak' their
organizations
150
Toward the promotion of child and family wellbeing:
identifying the commonality of all experience for children,
parents and families
160
Bibliography
Index
171
179
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Chapter 1
Finding the meaning in
communication
Setting the scene for work with children, young
people and their parents ± how the child
`speaks' the family
Introduction
This ®rst chapter provides an introductory conceptual framework for
carrying out assessment and therapeutic communication with children,
parents and families. This work with children, parents and families should
not be perceived as con®ned solely to clinical settings, but can take place in
schools, social and community settings, hospitals, GP surgeries, health
visiting, kindergartens, nurseries, child-care centres, residential centres and
parent support services, as well as in many other places. The aim of this ®rst
chapter is to demonstrate that, in order to work effectively with children,
parents and families, whatever the setting, it is essential to combine two key
elements in our work; ®rst, to recognize the meaning of child and adolescent behaviour within an individual, family and social context; and
second, to advocate for the child within that family and social context. A
therapeutic approach based on understanding the emotional and social
world of the child, combined with child advocacy, is therefore perceived as
not only inextricably linked but also essential to good practice.
As a precursor to any consideration of assessment and therapeutic communication, it is important, in our work with children, adolescents and
their families, that we do not become blinded by the lights of our own
therapeutic orientation and treatment modality. Thus, we need to avoid a
schism in which, for example, children and young people become `divided
up' between proponents of a cognitive±behavioural approach versus a
psychoanalytical approach. Our focus at all times needs to be on what is in
the best interests of the child and young person. Regardless of our therapeutic orientation, the best interests of the child and young person are
always served by commencing with an understanding of the meaning of
their behaviour.
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
8
Core Principles
Linking understanding of the meaning of behaviour
with child advocacy
The validation of behaviour through understanding its meaning has a
strong advocacy function, because it enables us to view the child's and
young person's behaviour, however challenging and annoying, as more
than a noise in the system, something to be disposed of. Viewed as having
meaning, the child's and young person's behaviour presents us with an
important source of information that provides a pathway to understanding,
as well as identifying a solution to the problem. The reason for this is that
children and young people, through their behaviour, `speak their families'
and their important relationships. It is therefore part of the task of all
professionals who work with children and young people to be in a position
to understand and `decode' this meaning in order to be more effective in
their day-to-day work.
By recognizing that all behaviour has meaning, we respect the child and
young person through validating their experience, and go further in not
only listening to them but also learning from their communication.
The objective of this book, therefore, is to demonstrate how, regardless
of the therapeutic orientation or setting, effective work with children young
people and their parents is underpinned by creating linkages between the
experience of the individual child and adolescent, the family system in
which they operate, the organizational professional setting and the wider
social and cultural environment. Thus, in order to be effective as practitioners, we need to widen the ®eld of our inquiry rather than narrowing it
down. In this regard a psychodynamic framework within which to explore
assessment and therapeutic communication is particularly relevant, since it
encompasses individual, interpersonal, systemic and organizational elements. A psychodynamic approach, as its name suggests, is also concerned
with the underlying psychological and emotional aspects of behaviour,
which are never static but are dynamic and constantly changing. The key
elements of a psychodynamic approach may be described as follows:
·
·
·
·
·
·
·
All behaviour has meaning and is always a communication between
children and their parents and caregivers.
The events surrounding our infancy and early childhood shape our
future development.
The child exists in the parent and the parent exists in the child.
Behaviour is dynamic and changes all the time ± it is not static.
There is a constant tension and interplay between our inner world of
thought and fantasy and our outer world.
Our behaviour has covert as well as overt meaning.
Play and dreams have an important place for both children and
parents.
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Finding the meaning in communication
9
Behaviour as meaning making
For children and young people in particular, the meaning of their behaviour is closely linked to their developmental experience. Understanding
behaviour as a communication which has meaning helps us to reframe it
and avoid blame and recrimination. It also helps us to open up communication between children and parents, rather than close it down or take
an adversarial approach. We start from the assumption that the child±
parent dialogue is the fundamental dialogue of life, creating the potential
for mutuality, reciprocity and shared meaning. As we will see in the
following chapter, it is predicated on a healthy infant±parent interaction,
which is mutually transformative and promotes, simultaneously in the child
and the parent, the capacity to `give voice' and to `®nd one's own voice'.
That is why the most successful therapeutic outcomes in work with children
also create transformative experiences for parents. Thus, professionals, in
grasping the opportunity in the `here and now' to re¯ect on the meaning of
behaviour with both the children and their parents, help to promote insight
in leaps and bounds. This has the enormous advantage of being able to
actually in¯uence the course of development for the child.
Recognizing the importance of the meaning of behaviour in particular
enables us to move away from unhelpful foreclosing statements about
children. Even the earliest stage of child development is not immune from
this practice. The commonly used phrase `the terrible 2s' is one such
example. From this phrase we may deduce that the new-found independence
of the toddler is viewed as annoying and irksome. There is a suggestion
implied in the emphasis on `terrible', that the toddler was more acceptable
as an infant when they may have been more passive and dependent. From
our direct observation of 2 year-olds, however, we discover what delightful
people they actually are, engaged in their new and wondrous exploration of
the world whilst struggling with their attempts at mastery. Understanding
the comment `terrible 2s' in this context enables us to see that it is not only
denigrating of the child but also ignorant of their development. It is, in
effect, as useful or useless as referring to any other age group as the `terrible
35s' or the `terrible 28s'. Most signi®cantly, foreclosing summary statements
of this kind take the child's experience out of a relational context and close
down communication, rather than opening it up.
The place of child advocacy: challenging the view that
children `don't know what is going on'
A further example of how we cannot separate psychological understanding
from child advocacy is contained in the everyday statements made about
children, speci®cally with respect to not keeping them informed, particularly about signi®cant changes in the family. This is usually justi®ed by
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
10
Core Principles
the statement that children are `too young to know what is going on'.
However, from clinical experience we know that when parents and the
family are under stress, the child is fully aware of a disturbance in the
system. For example, parents who request information about how to tell
their children they are separating are surprised to learn that their children
already know about their plans from the verbal and non-verbal cues they
have communicated. Similarly, parents who are puzzled by their child's
anxiety about their angry relationship believe that the child could not have
been affected by their arguments because these always took place `not in
front of the children'. The idea of the child as an ignorant non-participant
who lives alongside family experience rather than within it is unhelpful for
the promotion of an open, trusting parent±child relationship. The persistence of the idea of the mind of the child as empty and uncomprehending is
a further example of this confusion. For example, some parents express
reluctance to discuss an ongoing and visible family traumatic experience
directly with the child, for fear that the very verbalizing of what is
happening will put the idea of trauma into the child's mind. They appear to
be unaware that the child already has the trauma literally `in mind' and
urgently needs the parent to help them make sense of it.
This view of children, as not knowing or not comprehending what is
going on around them, has its counterpart in the belief that the child cannot
be considered to be a reliable witness of his/her own experience. This is a
position that bedevils child protection and children's court proceedings,
where the evidence of the child is considered inadmissible or at the very
least is challenged as unreliable.
How the erosion of meaning compromises child
advocacy
In an increasingly technologically-driven, economically rationalist and
consumer-oriented society, the capacity to attribute meaning to the behaviour of children and young people has become further eroded. As professionals, we may feel under pressure to control, manage, diagnose or
eradicate what is seen as troublesome, de®ant or dif®cult behaviour in
children. It is sobering in this regard to consider the current language and
discourse of some parent and professionally oriented literature that is
resonant with terms such as `managing', `®xing' and `taming'. Equally
sobering are health and social service interventions that place children and
young people's developmental experience within the limited currency of
behavioural problems, disobedience and discipline, and attempts at social
control.
This tendency to reduce human growth, development and experience to
®xed instrumental and utilitarian outcomes is not in the best interests of
children, young people or their parents. The pitfalls of such a utilitarian
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Finding the meaning in communication
11
world view are many; in particular, it leads to the institutionalization of a
position that denies the intrinsic value of childhood and of parenthood and
excludes a notion of mutuality. This is re¯ected not only in the current
fragmentation of many professional services to children, parents and young
people, but also in the potential for fragmentation of the child±parent
relationship itself. The maintenance of an adversarial approach between
children and parents, and even in some cases their rivalry with each other
for scarce resources, whether of time or attention, are some unfortunate
examples.
Who is entitled to be understood?
A recurring justi®cation for favouring an instrumental approach to clients
or patients is that of categorizing many families as incapable of emotional
understanding, since they are deemed too ill-educated or inarticulate, or
will only respond to `quick-®x' solutions to their problems. These justi®cations and rationalizations relegate a whole class of people into a perpetual state of not being properly informed or listened to, which in turn
doubly deprives both the parents and their children and leads to the maintenance of a cycle of deprivation. It is more likely that the rationalization
inherent in this position emerges from the understandable need for professionals to protect themselves from what they perceive may be a deluge of
painful information and revelation from these families, who have experienced years of trauma and dif®culty. How professionals may be able to deal
differently with this will be discussed in later chapters in terms of managing
uncertainty and the limitations of what we can achieve.
Ultimately, the capacity to attribute meaning to behavour has little to do
with education or intellect. Rather, it is connected with the availability of
time and willingness to listen to children, parents and families. People who
live in deprived and dif®cult circumstances struggle to make sense of their
lives and hope to make things better for their children. Far from being
inarticulate, once listened to, they bring a powerful and moving account of
their lives.
How the past affects the present: growing into, not out
of, childhood
From a psychodynamic perspective, we recognize that the events surrounding our birth and early years inform the way we view the world. Thus,
as adults, we may refer to the `child part of ourselves', which may in¯uence
the way we act as adults and parents. The experience of childhood does
not end with childhood itself but remains within us all as a live and
informative experience that in¯uences our current and future relationships
and activities.
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
12
Core Principles
We have all had the experience, as children, of being irritated by hearing
our parents utter a particular word or phrase in response to our behaviour
or wishes. For example, our parents may have constantly admonished us to
`be careful' when we wanted to be out and about enjoying ourselves. Whilst
we may vow never to repeat these annoying words or phrases with our own
children, we may ®nd to our surprise that not only do we do so, but that we
utter these words and phrases in the same tone of voice (repeating the
process of irritation with our children). This has been described as an
experience whereby `you open your mouth and your mother jumps out' (A.
Cebon, personal communication). We may indeed add to this father and
other assorted relatives. This leads us to recognize the power of early
childhood experience and its impact on later childhood and adult life. In
other words, we discover that childhood is not something that we need to
`grow out of' but rather something that we need to `grow into' as part of a
healthy developmental experience that can be used in a constructive manner
in our relationship with our children. This recognition of the importance of
early childhood experience is not intended to be perceived as deterministic
and a counter to change; rather, this recognition enables us to make sense
of our experience, both positive and negative, and to integrate it as part of
who we really are, rather than denying the experience or wanting to edit
it away.
Behaviour is dynamic, not static ± it changes all the
time
The behaviour of children and young people is dynamic, constantly
changing and evolving as it re¯ects the thrust of growth and development.
Development in itself also contains within it the capacity for change,
although this is not the same as pronouncing all dif®cult behaviour as being
`only a phase'. An approach that takes into account the dynamic nature of
child and adolescent development, and the dynamic nature of the relationships with parents and family that this gives rise to, is intrinsically
different from a traditional medical model, with its emphasis on symptoms,
pathology and cure. For example, adolescents in the last years of secondary
school may arouse great consternation and anger in their families and in
their teachers when they fail their grades and do not ful®l their academic
potential. However trying this may be, the young person may for the ®rst
time be testing their independence of thought and action by resisting a
family plan for their future that is too prescriptive and that involves
following in the family's footsteps.
Behaviour can never be isolated and ®xed in time as though disconnected
from the family context. Thus, the tantrums of a child or sudden belligerence in an adolescent may be their understandable response to an intolerable situation in which there is no freedom to talk or act. Most importantly,
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Finding the meaning in communication
13
we need to keep in mind that, because behaviour is dynamic and evolving, a
tendency to give direct advice will have serious limitations. We may ®nd, in
fact, that the `use-by date' of the advice we give has already expired by the
time it leaves our lips.
The place of play: linking the inner world with the outer
world
We all dream and have fantasies, and when we observe children and their
play it is clear that they too are spontaneously involved in creating vivid
worlds of action and interaction that contain elements related to real
experience as well as to fantasy. The psychodynamic approach gives credence to our inner world or unconscious experience as a legitimate part of
our human experience. Sigmund Freud described dreams in adults as the
`royal road to the unconscious' and we may view play in children as its
counterpart. Of course, younger children in particular will be less guarded
than most adolescents in their play. In doll's house play, for example, we
may observe the intensity with which young children act out their family as
well as their hopes and fears; a child struggling to deal with the birth of a
sibling may cruelly discard the baby doll, whilst a child whose family life is
chaotic and unpredictable may spend all their time meticulously arranging
the doll's furniture and family dolls into an ideal family scene. Far from
being dismissed as a simplistic process, as in `just child's play', play for
children is in fact their everyday `work'. As such, it is a rich and complex
experience and a vital tool of communication. Operating, as it does, on the
boundary between the inner world of fantasy and imagination and the outer
world, play is a safe place of discovery and experimentation for the child, in
which experiences can be literally played out in order to be better understood. The child's capacity for play is always a sign of health and contributes
signi®cantly to how children learn, solve problems and negotiate their social
relationships. For young children as well as older children, it is mostly
through play, rather than in verbal discussion, that they are able to give us
an account of the most signi®cant aspects of their lives.
Attending to covert as well as overt communication
The psychodynamic approach considers the importance of our inner world
to be a legitimate source of observation and communication, since it affects
the way in which we make decisions and how we live in our families. It
enables us to understand how unconscious wishes, hopes and fears play
a role in in¯uencing apparently rational thought and action. In other
words, the psychodynamic method is concerned with widening, rather than
narrowing, the ®eld of inquiry surrounding a particular problem. This
approach differs from a behaviourally-oriented approach, where the focus
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
14
Core Principles
is on narrowing the ®eld in order to concentrate speci®cally on the presenting problem, with a view to providing relief from the annoying
symptom. Extensive attention to the origins of the problem is viewed as a
distraction from this central task. However, the notion that `what you see is
what you get' is not always borne out by everyday clinical experience.
Many professionals have described their baf¯ement, for example, about
clients who, having spent an hour talking about how well things are going,
reveal as they are going out of the door that they will be having an
operation the next day. This is generally described as the `door-handle
confession'. Here what concerns us is how and why the client was unable to
discuss the impending surgery in the course of the session, and how the
worker missed what was truly troubling the client.
Thus, the recognition of overt and covert processes in our work with
children, parents and families, and what may be described as manifest and
latent behaviour, is an essential part of the assessment process and enables
us to tease out where the `presenting problem' ends and the `real problem'
begins. We may also come to realize that the widening of the assessment
process, and a decision to offer behavioural therapy following a period of
assessment, are not necessarily mutually exclusive. The most important
factor to take into account is that this decision has been taken as a result of
a careful assessment. This will be discussed at greater length in the following chapters.
Providing containment: the cornerstone of all
assessment and therapeutic communication?
We may believe that the cornerstone of all assessment and therapeutic
communication is the identi®cation of a problem, or ®nding a diagnosis
that will somehow encapsulate what the child and family present us with, or
®nding an immediate answer to their problem. However, before we even
begin the process of trying to understand the problem, we need to create the
right environment in order to facilitate this ®rst stage of our inquiry. The
creation of this `right environment' emerges directly out of our capacity to
provide containment for the people we are trying to help. The provision of
containment is seen as the foundation for all therapeutic work. The idea of
containment has emerged from the seminal work of the psychoanalyst
Wilfrid Bion (1962, 1993) and his understanding of the infant±parent
relationship.
Bion coined the term `container and contained' to refer to the need of the
infant to be contained by the mother, who needs to be able to manage and
make sense of everything the baby produces ± bodily functions, hunger,
fear, tears, anxiety. Bion describes the process of containment as one in
which the mother is able to contain the negative and anxious communication of the child and, by so doing, is able to help the baby reintegrate
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Finding the meaning in communication
15
these communications as a tolerable experience. In order to do so, of
course, the mother must contain her own anxiety and so she needs the
presence of a thoughtful and supportive partner to help her with this task.
The parenting couple in turn also need to be supported and `held in mind'
by extended family and friends, and so we can see how the process of
containment operates at the level of an emotional ecology, through the
interdependence between the intrapsychic, the interpersonal, the familial
and the social.
Bion's model of containment can be applied not only to how we understand infant±parent interaction but also to how we as professionals conduct
ourselves in relation to the client or patient. We may therefore ask ourselves
how we contain our clients and patients and what is aroused in us by their
presenting problems. We may also ask ourselves how we contain our own
anxiety and who is available to contain us. The following chapters will
amplify in more detail the process of containment, which is at the heart of
all assessment and therapeutic communication.
Clinical case example
The following case example demonstrates a number of the key elements
related to assessment and therapeutic communication that have been
discussed thus far. These relate to:
·
·
·
·
·
Not foreclosing on a problem and not starting from a de®cit diagnosis
that closes down communication.
Acknowledging the role of past experience; understanding the problem
within the interpersonal and family context.
Validating the experience of the child and the parent, thereby
empowering both to be active in the solution of their problems.
Listening to the non-verbal as well as verbal experience of the child.
Providing containment in order to facilitate the joint therapeutic
endeavour.
Mrs C. contacted me about her concern for her 11 year-old daughter,
Heather, who was in Year 6 at a local school. Heather had had learning
dif®culties over the course of her schooling, was receiving special tuition
and there was increasing anxiety on the part of both the school staff and
Mrs C. about how she would manage the transition to secondary school.
On meeting Mrs C., initially on her own, she told me that Heather had
recently been diagnosed with `auditory processing disorder' and that she
was seeking my help in order to `manage' this disorder in her daughter. Mrs
C. further reported that at home her daughter's behaviour was dif®cult to
control; she was moody and had huge temper tantrums, when she would
¯ing herself down on the ¯oor and ¯ail about with her arms and legs. Mrs
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
16
Core Principles
C. had two older sons, who were described as very different and doing well
at school. Mrs C. had brought with her the report which described the
results of a number of tests related to hearing and comprehension, with
which Heather had clearly had dif®culty. It was striking that the report
made no mention of any aspect of Heather's life or the family background.
Over many years of practice, I have become aware of how diagnoses of this
kind, similarly to those of attention de®cit disorder (ADD) and attention
de®cit hyperactivity disorder (ADHD), have come to represent the increasingly narrow parameters within which children's problems are considered
and assessed. The transfer from the medical ®eld to the general population
of a language and discourse concerning speci®c de®cits in brain functioning
appears to have given these diagnoses particular acceptance and respectability. However, outside of the purely medical context from which it has
been transferred, a diagnosis of auditory processing disorder represents
something of a tautology; thus, if we cannot hear and take in information,
we cannot make sense of our experience, and we cannot make sense of our
experience if we cannot hear and take in information. On taking a history
from Mrs C. a different picture began to emerge, one which enabled us to
make sense of what Heather might not wish to hear or take in and why she
might be having trouble making sense of her experience. Shortly after
Heather's birth, Mrs C. was diagnosed with a serious life-threatening
illness, which necessitated long stays in hospital as well as demanding
postoperative treatment. Mrs C. had been told not to touch her children
following these treatments, so that Heather as a young baby was doubly
deprived, ®rst by not seeing her mother and then by being tantalized to see
her but not being able to be picked up and held by her. A further signi®cant
factor in the family was the longstanding marital dif®culties and apparent
lack of support of Mr C. in the family. Mr C. had ceased going to work
and was spending all his time on the computer, to the exclusion of any
involvement with the family. He had refused to join Mrs C. in attempting
to seek help.
Mrs C. came to the second session with Heather, who appeared a small,
slight, frightened-looking girl. It was dif®cult to imagine her as a preadolescent going to secondary school, and the idea of her coming to the end
of her primary schooling appeared painfully premature. The most striking
feature of her arrival was the way in which she clung to her mother as
though stuck to her, whilst they walked into the room. Heather refused to
sit on a separate chair and clung to her mother, making it dif®cult for her
mother to move her head and look at me and engage in conversation.
Heather refused to engage with me and looked away. Half-way through our
time together, she emitted a wail to her mother, `When are we going to go?'.
When we explained that we would be chatting for a while longer, Heather
threw herself onto the ground and began to kick and scream. Mrs C.
looked at her helplessly and said that this was the behaviour she had
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Finding the meaning in communication
17
described to me earlier. I told Heather that I was pleased that she could
bring to our session the behaviour she sometimes had at home, as it could
help us understand her and hopefully make things better. I went on to say
that I thought it was very hard for her to hear mum and me talk about her
problems at school, but we were also talking about what happened to her
when she was very young and a baby, when her mum had been ill. I said I
thought she was bringing the baby part of herself into the room for us to
know about, because that baby part felt very sad and angry. Heather
appeared to listen and calmed down and she left in an overall calmer state
at the end of the session.
At the second session, Heather did not appear as stuck to her mother as
on her ®rst visit and sat in a separate chair. She responded to questions
about how school was going and began to talk in a more age-appropriate
way about how annoying her brothers were. However, as we came towards
the end of the session, her tolerance appeared to run out and she emitted
the same wail of `When are we going to stop?', and with that threw herself
onto the ground in a similar manner to the ®rst session. When I started to
say that I thought the baby Heather had returned to the room, a remarkable thing occurred; Heather very quickly corrected me. `No', she said, `it's
not the baby Heather, it's the toddler Heather'. Why may this communication be considered remarkable? For a girl assessed as having an auditory
processing disorder, Heather displayed, in one, a sophisticated understanding of what lay beneath her tantrum, namely her need to regress (because of
her earlier deprivation) to an infantile state. By having this acknowledged,
she was able to let us know that, by the second session, she had already
moved on in her development to the toddler stage. She had also moved on
in being less stuck to her mother, sitting in her own chair and beginning to
hold a conversation.
Resisting the response to unquestionably accept a diagnosis that focuses
on a cognitive de®cit in the child, without giving us the context of the
diagnosis, enables us to open up a meaningful conversation with the people
themselves. In this case, it became clear that Heather's attachment to her
mother, and her mother's bonding with her, had become severely compromised through the early traumatic experience that they had shared. As
we will see in the following chapters, the capacity for attachment and
bonding is inextricably linked with the capacity for the child to make sense
of the world, to be open to hearing what is going on and to be able to
process their experience. I encouraged Mrs C. to talk with Heather about
what was, in effect, their shared trauma, namely Heather's birth occurring
at the same time as her illness. This had the effect of helping Heather begin
to piece together the various bits of this experience that had, over time,
become so dislocated. Within a short period of time, Mrs C. reported that
Heather's school work had improved to the extent that her teachers
considered that she no longer needed to attend the remedial classes and that
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
18
Core Principles
she could manage the transition to secondary school. Her intense anger and
tantrums at home had also abated.
This period of our work together took place over a period of approximately 3 months, which indicates how much change can be accomplished in
a relatively short space of time. The experience had also given Mrs C. a
sense of greater resolve with respect to how she managed personal aspects
of her life, particularly the longstanding marital problems with her
husband. As a result she had asked her husband to leave the family home,
which appeared to be a great source of relief to him as well as to the
children.
Summary of key points
This opening chapter highlights the essential tools and framework for all
assessment and therapeutic communication. These are primarily based on
the recognition that all behaviour has meaning and is never random; that
our past childhood and family history affects how we view and act in
relation to our present lives; that behaviour is dynamic and not static; that
fantasy, dreams and play constitute legitimate areas of our experience and
are therefore deserving of our attention; and that the provision of containment is the ®rst requirement for good professional practice.
These foundational assumptions can be summed up further as the
Four Cs:
·
·
·
·
Coherence ± behaviour having meaning.
Consistency ± the in¯uence of the family and social environment.
Continuity ± how the past affects the present; the impact of intergenerational experience.
Containment ± making it possible for us to re¯ect on and understand
the problem.
Putting the four Cs into practice
Asking `what', `why' and `how' questions
A way of ensuring that we put the Four C's into practice is to ask ourselves
some quite simple and straightforward questions when we work with our
clients and patients. These questions are: What is happening? Why is it
happening now? How do I feel about it? These simple questions are relevant
to all professionals who work with children, parents and families in any
setting, and are not speci®cally clinically focused.
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
Finding the meaning in communication
19
What is happening?
When we are faced with problems concerning a child or young person, or
an adult for that matter, asking the question `What is going on?' gives us
the space to take a step back to re¯ect and avoid a reactive response and
possible poor decision making. Once we ask this question, we are already
moving away from the limited presentation of `what you see is what you
get', because what you see, or what you are told initially, may not re¯ect
what is actually taking place. For example, parents may ask for our help for
what they describe as an `emergency', giving the impression that we are the
®rst person they have spoken to, or that no one previously has responded to
their requests for help with their child. Their agitation and sense of
desperation may tempt us into action but we may, if we take the time,
discover that in fact they have already received professional help or that
they are not prepared to follow the advice or treatment plan that has been
offered to them.
Another example may be that of parents complaining about their child
not sleeping, but our `what' question enables us to understand more about
the surrounding family circumstances that may be contributing to the
problem. Where parents present the problem in the child, the problem will
almost invariably be the child's way of `speaking the family'.
Why is it happening now?
'Why' questions are important because they give us an insight into why
problems are presented at one particular point in time and not another,
even though the problem may have persisted over many years. Often the
reason for people seeking help with a child or young person coincides with
developmental changes and transitions, such as starting school, starting
secondary school and changes in the family. Problems presented in adolescence are a good example. Parents may be outraged at the hostile behaviour of an adolescent whom they previously described as `angelic', or they
may suddenly become less tolerant of behaviour in their adolescent that
they had tolerated over the years when they were growing up. I have
likened this experience to that of parents going into their garden to discover
something horrible growing there, in the form of their adolescent, when in
fact they had nurtured this same behaviour over years. The question to ask
is, why has this behaviour suddenly become intolerable or unacceptable?
The issue of timing, or `Why now?', also comes to the fore when children
or young people may be challenged by external events, such as attending a
school camp. Often the external challenge or anxiety expressed by the child
or young person may be more connected to what is happening at home,
and problems that are unresolved there, than to a fear of the camp
experience itself.
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431
20
Core Principles
'How' questions
'How' questions relate to our own experience. I have discussed the need to
listen carefully to children, parents and families, but careful listening also
needs to extend to ourselves.
We may, for example, experience strong feelings both towards and about
the people we are trying to help. We may feel repulsion, fear and disgust at
what they are revealing about their lives; or we may ®nd ourselves identifying with their experience if it resonates with our own. This may lead us to
wish, in the ®rst example, to want to minimize contact, or in the second, to
do all we can for the client, perhaps to wish to rescue them from their
dif®cult situation. As will be discussed in the following chapters, these
powerful emotions and our responses are not irrelevant to the task of
assessment and therapeutic communication, but need to be recognized and
understood as meaningful experiences. As meaningful experiences, they give
us important insight into the dynamics of what is happening for the client
and patient, and how this connects with the dynamics of the helping
process, which includes the setting in which we work and the containment
that we can offer the client and that we can obtain for ourselves.
The following chapter will explore how we can connect our understanding of the meaning of behaviour with our understanding of early childhood
and past experience, through the creation of a developmental scaffold.
http://www.routledgementalhealth.com/core-principles-of-assessment-and-therapeutic-communication-with-children-parents-and-families-9780415552431