Preventive work in a toddler group and nursery

This paper is about the sort of preventive work which can be carried out in early child care settings where incipient disturbance can be picked up and worked with promptly and effectively. It shows how toddler groups and nurseries can offer relationships and experiences which encourage mutuality and progressive development, while at the same time addressing difficulties before they have become fully internalized. It gives a detailed account of work with a single mother and her son who attended first a toddler group run by a child psychotherapist and her trainee assistant, and then a nursery where staff were in regular consultation with the child psychotherapist who also worked individually with the mother. It argues that the effectiveness of such early interventions can be conceptualized in terms of supplying maternal and paternal functioning at a time when children and parents alike are particularly needful of and responsive to this sort of help.     

Light and movement: making contact with a traumatised and embattled latency girl

This paper shows a child psychotherapist learning and developing her technique as she attempts to make contact with a child who is extremely hard to reach. It is based on the first two years of three-times-weekly intensive psychotherapy of a latency girl who had little faith in a helpful therapeutic relationship. Her defences against such a relationship were entrenched and hard to shift. In this clinical work, the psychotherapist relies on close observation and her countertransference to develop a relationship with the child, in order to begin to make sense of her non-verbal emotional experience and communication.     

Psychoanalytic psychotherapy in paediatric liaison: a diagnostic and therapeutic tool

Paediatric liaison work requires an appreciation of the interweaving of the different factors involved when a child has physical symptoms. Psychoanalytic psychotherapy is usually viewed simply as a potential treatment option. This paper argues that its use is both therapeutic and diagnostic and that it should be valued for this breadth of contribution. The therapeutic process is conducted in a way that can promote an understanding of the child and their context and thus enhance the ability 9 to meet the child's needs by all involved in their care. This can be achieved without sacrificing the degree of privacy that the psychotherapist/patient relationship requires. Material is presented from the psychotherapy of a child who had an hereditary condition which moved unexpectedly into a terminal 2 phase after psychotherapy was started. Examples are given to illustrate the importance of the understanding gained from therapy and how, through an integrative process, it was used to assist the overall 4 care. The material also describes the potential diagnostic use of information from psychotherapy when this is formulated by consideration of conscious and unconscious mechanisms alongside mental state phenomenology. This has implications for the relationships between disciplines and for their training requirements.     

Combined therapy with borderline and narcissistic inpatients at the cassel hospital

An account is given here of a rather unorthodox approach to psychodynamic therapy with Borderline patients in part of the therapeutic community at the Cassel Hospital. ‘Combined therapy’ here refers to the setting in which one therapist sees patients in groups and individual sessions concurrently. The paper demonstrates the manner in which this approach brings to the fore the massive destructiveness and rage which so often lies at the core of these patients' difficulties. This is done by describing the development of the group over its first nine months. The therapist comes to be split in the patient's perception, the group sessions representing separation in all its most hated aspects rather than as a prerequisite for differentiation and growth. The resultant rage and destructiveness threaten to render the group unworkable and dangerous. The individual sessions, by contrast, represent a fantasy of being regressed and at one with the ideal mother. It is my belief that these difficulties can be contained only within a therapeutic community. The strength of this approach lies in the vivid reconstruction of a central conflict for these patients and corresponding potential for working through difficulties in the area of separation and individuation. It is also particularly effective in bringing the therapeutic community alive within the therapy. The discussion attempts to address some of the complex theoretical issues raised by the transformation of the transference in both settings which occurs when they are used together and with the same therapist.     

‘Only connect’ – a sexually abused girl's rediscovery of memory and meaning as she works towards the transition from a therapeutic community to a foster-family

This paper looks at the role of individual psychotherapy with a severely sexually abused girl in a therapeutic community, and the place of this work as she makes the transition into foster-care. It emphasizes the importance, not only of the individual work, but also of the drawing together of the work around the child, particularly at such a critical time. There is discussion of the ideas of ‘deadness’ versus ‘aliveness’ in the therapy, and detailed case material is used.     

A child psychotherapist’s way of engaging in assessments for the courts

This paper focuses on assessments to guide decisions made by the courts about placements for children rather than any risk they may pose. The child psychotherapist’s specific skills and training which equip them to carry out this work in a distinctive way are described. The paper demonstrates how a child psychotherapist thinks about the material such an assessment might provide and describes the translation work required to provide a meaningful report for the court.     

The conceptual distinction between projective identification (Klein) and container-contained (Bion)

This paper describes the use of play in the psychotherapy of a latency child from a severely traumatised background. It considers the meaning of play in relation to the role of the psychotherapist and to psychotherapeutic technique and explores its functions in terms of the child's development. The paper documents the psychotherapist's learning experience about the difficulty of trying to make the ‘right’ interpretations and her consequent realisation of the intrinsic value of play in psychotherapy. In considering these themes, the author explores how, by placing interpretation secondary to play, the therapy enabled the development of the child's creativity and self-agency, facilitating a movement from primarily paranoid–schizoid defences towards the beginnings of a depressive position.     

The Co-Construction of New Meanings in Couple Relationships

SUMMARY

The gender informed psychotherapist has Ihc challenge of addressing power issues in couple relationships in a manner that is both gender sensitive and blame free. The Relationship Enhancement model of couple therapy (Guerney, 1977) is particularly suitable for doing this. The model integrates the qualities of empathy and autonomy that are culturally considered feminine and masculine respectively. It systematically teaches couples how to interact with each other in a non-blaming way that is deeply empathic, rationally assertive, and sensitive to how meanings can be both de-constructed and co-constructed in dialogue. The model also permits the integration of relevant techniques from other therapeutic approaches.     

Mindfulness: A Proposed Common Factor

Mindfulness is proposed as a core psychotherapy process. It is defined as a state of psychological freedom that occurs when attention remains quiet and limber, without attachment to any particular point of view. It can be shown that this process is collaborativefy employed by psychotherapist and patient within all psychotherapy orientations, and also by the integrative psychotherapist when making optimal choices among orientations. This article addresses (1) the defining attributes of mindfulness, (2) relevant conceptual approaches that lend theoretical support for a mindfulness factor, (3) two attentional forms of mindfulness that seem to have particular correspondence with either psychodynamic or cognitive-behavioral therapy, (4) clinical applications, and (5) the role of mindfulness for the integrative decision-making process.     

How much is too much? Understanding the role and function of violence and its manifestation in the consulting room: intensive psychotherapy with a latency-aged boy

The aim of this article is to explore and lend meaning to the role and function of violence in children, in particular boys, who have had disturbing and traumatic early experiences. Psychoanalytic thinking about the role and function of violence, as well as its impact and management in the consulting room, will be central features of this exploration. In a research project involving a single case study, a number of clinical concepts emerged that have potential ramifications for child psychotherapists working with children exhibiting violent and challenging behaviour. The clinical concepts emerged via the application of grounded theory research methodology to clinical data and contribute to the thinking and theory of Meltzer’s use of ‘temperature and distance’ as a means of understanding and regulating emotional states in the therapeutic setting. ‘Time’ and ‘space’ were additional clinical concepts that emerged. These four concepts are considered crucial elements in providing the child psychotherapist with the means to apply transformative and modifying processes to the un-processed and raw externalisation of primitive, violent impulses.     

Expanding community psychology's domain

Community psychology's twin goals of prevention and empowerment are ill-served when researchers and practitioners restrict their activities to traditional mental health settings. This paper echoes the call of the Swampscott conference for expanding community psychology's domain of inquiry and action. It reviews examples from the research literature of efforts at prevention and empowerment in five classes of behavior settings identified by Barker (1968), namely, schools, work sites, religious settings, voluntary associations, and government, and suggests additional roles community psychologists might play.     

Urban School-Based Family Counseling: Role Definition,Practice Applications,and Training Implications

The authors describe an expanded role for counselors in urban school settings that can improve the linkages among families, schools, and communities: school-based family counseling. The focus of this process is to assist children in becoming more successful in the classroom by increasing family and community involvement in addressing specific barriers to learning. The function of school-based family counseling, strategies, and challenges for implementation of this process; a case study of a school-based family counseling intervention; and implications for counselor training are presented. Benefits of the school-based family counseling model for diverse students, parents, schools, and communities also are discussed.     

Increasing the prevalence of successful children: The case for community intervention research

This paper makes a case for research on community interventions on child rearing. Sufficient evidence has accumulated about the development of children's problem behavior to justify evaluating efforts to reduce the prevalence of these problems in whole communities. The contextual risk factors for diverse child behavior problems are well understood, and interventions to ameliorate individual risk factors have been developed and evaluated. Because interventions with individual children have proven to be efficacious, it is now appropriate to direct energy toward reducing the prevalence of children with behavior problems. At the same time, existing interventions have limitations. Community interventions may be needed to modify the larger social context for families. This paper enumerates possible components of a community intervention to improve child-rearing outcomes. Existing evidence indicates that communities would benefit from making parent training and family support programs available to parents. Validated methods of identifying and remediating academic and behavioral problems in schools are available, but influencing schools to adopt them remains a problem. Community organizing could mobilize communities to allocate the resources necessary to support such parenting and schooling programs as well as encourage their adoption. Media campaigns could foster community support and directly influence parenting practices. Efforts to modify peer influences to use illicit substances have received empirical support; similar efforts may be relevant to preventing other problems. The development of a science of community interventions on child rearing is hampered by overreliance on randomized control trials. For this reason, two examples of time-series experimental evaluations of community intervention components are described here.     

Let’s play at the park! family pathways promoting spiritual resources to inspire nature,pretend play,storytelling, intergenerational play and celebrations

Contemporary interest from scholars examining spirituality have suggested that young children have an innately rich spiritual dimension that can be nurtured when they are given opportunities to express it or when such expressions are recognised. Based on direct observations in natural settings, this article addresses the importance of children’s spirituality and how outdoor play spaces, especially community parks, can contribute to a child’s spiritual development through enriching activities in nature, pretend play, storytelling and intergenerational play. The article also aims to encourage consideration of a variety of strategies that can be used to support the holistic development of a young child and nurture children’s spirituality. Supporting a child’s spiritual development with playful activities in outdoor spaces can help to identify the child’s interests, strengths and creativity through relationships that shape bonds with both families and community.     

The Association Between Therapeutic Alliance and Treatment Outcomes in a Group Triple P Intervention

A growing literature has examined the association between therapeutic alliance and treatment outcomes in child therapy. Few studies, however, have specifically investigated the role of therapeutic alliance within evidence-based parenting programs for children with externalizing behavioural difficulties. The current study prospectively collected measures of therapeutic alliance for 117 families completing a Triple P parenting program in a community children’s mental health center. Higher levels of mother and father rated therapeutic alliance were associated with greater gains in parenting skills and parental sense of competence. Parental rated therapeutic alliance was also associated with greater improvements in child conduct problems for mothers, but not fathers. However, therapist ratings of therapeutic alliance had limited associations with treatment improvement. The implications of the findings for clinical practice are discussed.     

From Dyad to Triad: On Psychodynamic Meanings of Psychiatric Treatment

The professions of psychiatry and psychotherapy are both complementary and competitive. This paper examines the dialectic tension between the two. It observes the complexity in having psychiatric evaluation and treatment in the context of ongoing psychotherapy. A referral to a psychiatrist is a meaningful, and a charged intrapsychic and interpsychic event for the patient as well as for the two therapists involved. The nature of the triangle is affected by the inner worlds of the three participants; therefore, the more awareness to the shared work, the better the communication between the three sides of this triangle. The referral to a psychiatrist by a psychotherapist is described as a specific type of an enactment in which the therapeutic dyad is becoming a tirade with all the implications attached. As opposed to the dichotomous perception of the psychiatric intervention as a temporary interruption and reduction of the therapy, this paper offers a model of cooperation between professions that will create a wider and deeper therapeutic space.     

Clinical commentary by David Trevatt,Clinical Manager of ‘Hear and Now’ Adolescent Counselling Service,Redbridge and Manager of Open Door's Parenting Teenagers Project,Haringey

Leading the charge to link intervention research with clinical practice is the development of process research, which involves a detailed analysis of specific therapeutic processes over the course of treatment. The delineation of interaction structures – repetitive patterns of interactions between patient and therapist over the course of treatment – can inform therapists of what may be expected from patients with particular patterns of symptoms or behaviours in their clinical practice and how interactions change over time. Using the Child Psychotherapy Q-Set, this study aims to compare the different interaction structures that emerged in the two-year psychotherapy of a six-year-old child conducted, for one year each, by two doctoral-student therapists in a university-based community mental health clinic. The study allows for exploration of the independent role of the therapist in the psychodynamic therapy of a child diagnosed with Asperger's disorder. The results suggest that four distinct interaction structures between child and therapist could be identified in this psychotherapy and that the interaction structures differed between the two therapists and also differed over time within each treatment. The implications of these findings for training and clinical practice are discussed.     

Psychoanalytic aspects of inpatient treatment

This paper looks at the experience of inpatient hospital treatment at the Cassel Hospital and how formal psychoanalytic psychotherapy, with its emphasis on the transference and the inner world, fits into that context and orientates itself to some of the realities of the setting. It outlines how psychotherapy and nursing can work to inform and enrich each other, and what is psychoanalytic about the overall work. A bridge of understanding is built using the patients' perceptions of, adjustment to and conflict about the inpatient setting, and the affective impact of the processes on patients and staff alike. Two clinical examples of severe child abuse family cases are given, the first of Munchhausen syndrome by proxy, the second in which a baby sibling had been killed. They show how in-depth psychoanalytic work with mother and child and individual psychotherapy of the child can be combined with psychotherapy of the parents and intensive work in the therapeutic community. Such a combination can contribute, even in cases of severe pathology, to the development of the relationship between mother and child and promote successful rehabilitation in the outside community.