Nonmentalizing States in Early-Childhood Survivors of the Holocaust: Developmental Considerations Regarding Treatment of Child Survivors of Genocidal Atrocities

This paper attempts to coalesce considerations of attachment processes, trauma, mentalization, and nonverbal behavior to underscore some of the developmental and therapeutic challenges demonstrated by older-adult child survivors of the Holocaust, and by implication, other child victims of similar genocidal and traumatic events. Young child survivors experienced not only their own traumatic exposure to violence, harm, and loss, but also the stress-transmission of the adult caregivers who raised them in the years that followed. For some, the horrendous losses, combined with impediments to organizing relationships, and to experiences of predictable and trusted continuities, negatively impact the development of the reflective function, and of interpretive skills basic to successful implicit relatedness and explicit exchanges. "Neutral flow" of bodily tension and shape often signals the freezing accompanying nonmentalizing states. Misalignments in individual personality structure and discordances in interpersonal exchange underscore the need to address fundamental building blocks of relatedness and mentalization in the therapeutic process.     

A family systems approach to child–parent separation: 'developmental closure'

This paper presents a family systems model for considering the interactive events that occur when a child and parent move towards closing their relationship and separating. This process typically involves the child being 'received into care' and is identified as developmental closure . Different stages of this process are exemplified clinically and the therapeutic principles that guide work with families struggling with such difficulties are outlined.     

Therapeutic assessment with children: intervening with parents "behind the mirror"

All the steps in the model of therapeutic assessment used with children (TA-C) are designed to involve and impact the child's parents. However, a distinctive process that parallels and accompanies the testing sessions with the child might be the most significant in helping parents shift their story of their child and family. In this process, parents are invited to observe their child's testing sessions (in an adjacent room through a live video feed, through a 1-way mirror, or in the corner of the testing room) and process the experience with the assessor (either simultaneously in the case of the 2-assessor model or after the fact in the 1-assessor model). We discuss the development and evolution of what we have come to call the "behind the mirror" method. We describe the therapeutic intent of the method and delineate 13 techniques utilized to enlist parents as active collaborators. We illustrate each technique using the case study of a 10-year-old boy where the 2-assessor model and live video feed method were used. We also provide research findings from the case study that address the parents' experience of the assessment and their changed view of their child.     

Systemic Family Therapy Competences in Child and Adolescent Mental Health Care

This article is based on a doctoral research project aiming to identify a comprehensive and detailed outline of the systemic therapist competences in child and adolescent mental health care in Norway. Because of the growing demands to offer specialized services within child and adolescent mental health care, I intended the identified competences to target the psychosocial difficulties that are categorized as associated abnormal psychosocial situations (axis 5) in the multiaxial diagnostic system (WHO, Multiaxial classification of child and adolescent psychiatric disorders. The ICD-10 classification of mental and behavioural disorders in children and adolescents. Cambridge University Press, Cambridge, 1996). The project is based on twelve qualitative in-depth interviews with six experienced systemic family therapists, and fieldwork observations of the therapists (participants) in practice. The qualitative methodology is based on Grounded Theory and five overarching categories were identified through the analysis: (1): the importance of ethical and contextual awareness in systemic therapy; (2) the systemic therapist’s stance; (3) therapeutic processes; (4) therapeutic practices; and (5) session-specific features. Challenges, such as limiting the systemic approach to five overarching competences, are discussed alongside this strengths and limitations of the study. The detailed outline of systemic therapist competences is intended to offer a framework for delivering flexible, yet specialized systemic therapy in the context of child and adolescent mental health care. This research may therefore facilitate a “bridge-building process” between mental health’s biomedical focus and postmodern systemic ideas.     

Further Labeling Within the Category of Disability Due to Chemical Dependency Disorder

This paper raises issues of validity and consequences of appending the label Borderline Personality Disorder to chemically dependent women who are adult survivors of child sexual abuse. Parallels between documented sequelae of childhood sexual abuse and DSM-III-R delineated characteristics of Borderline Personality Disorder are noted as is the DSM-III-R insertion of "No information" with respect to Predisposing factors. This clinician suggests that the label Borderline Personality Disorder and its accompanying assumptions function to generate negative expectations regarding both the course and direction of the therapy process. By failing to consider the impact of childhood abuse this label provides neither appropriate diagnosis nor therapeutic directionfor women with a diagnosis of chemical dependency who are adult survivors of childhood sexual abuse.     

Family Assisted Contingency Management within the Context of Evidence-Supported Treatment for Child Neglect and Drug Abuse

Contingency management (CM) has extensively been shown to be effective in reducing substance use disorders, but its effects in reducing child maltreatment have yet to be determined. The current study provides preliminary support for the utilization of an innovative family-assisted CM component in 18 mothers who were referred to an evidence-supported behavioral treatment for concurrent child neglect and drug abuse by Child Protective Service caseworkers. In the examined CM, participants were invited to indicate from a list of common actions incompatible with child neglect (i.e. positive parenting actions), the extent to which these actions had been experienced utilizing a 3-point scale (almost never, sometimes, almost always). For each item that was indicated to be almost never or sometimes experienced, the participants were queried to indicate if the neglect incompatible action should be targeted as a therapeutic goal. Contingencies were subsequently established in which the participants were rewarded by involved family members for their completion of therapeutic goals. At baseline, results indicated that there was a negative association between the number of neglect incompatible parenting actions that were infrequently experienced and child abuse potential. A hierarchical multiple regression analysis showed that the number of neglect incompatible actions targeted as therapeutic goals at baseline, but not the number of positive parenting actions experienced infrequently at baseline, predicted reduced child maltreatment potential following treatment. These findings suggest the examined CM may assist evidence supported behavioral treatment specific to child neglect and drug abuse.     

Sliding doors: some reflections on the parent–child–therapist triangle in parent work–child psychotherapy

The parental presence as therapy agents, namely as a medium and support for the therapeutic process, is one of the paradoxical parameters of working with children. Parental presence serves as a reminder of the need to find a balance between inner and outer reality. The door that is closed in the therapy room leaves a parent on the other side but at the same time provides the child’s inner world with more latitude to reveal itself. This paper examines the fabric of relations created in the therapeutic parent–child–therapist triangle (analogous to Britton’s conceptualisation of the parent–parent–child link). How does this triangular connection affect the ability to be with the silent self (Winnicott) when the parent remains (tangibly and symbolically) on the other side of the therapy door? This paper presents two clinical examples to illustrate the complex fabric of relations created in the therapeutic parent–child–therapist triangle and the interactions between the internal and external reality of the parent–child relationship.     

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.     

On the Role of Reparative Processes in Childhood: Pathological Development and Therapeutic Change

This article continues my discussion of the process of therapeutic change in psychodynamic child therapy. In a previous essay (Barish, 2004), I stressed the therapeutic benefit of enhancing the child's positive affects as well as developing his or her capacity to tolerate painful affects. I now propose an extension of these ideas, a perspective on the nature of psychopathology in childhood and the implications of this perspective for our understanding of the therapeutic process, based on the clinical concepts of emotional injury and normal reparative processes.

Every emotional injury evokes in the child a complex affective experience, comprised of painful emotions as well as an intensification of the child's instinctive self-protective responses—some form of withdrawal and/or retaliatory response. In normal psychological development, as in healthy biological systems, reparative processes function to heal injuries. Failure of these normal reparative processes sets in motion malignant psychological events in the mind of the child: painful affects and associated fantasies increasingly dominate the child's sense of self and others, leading to prolonged states of withdrawal and demoralization or defiant rage. The therapeutic process, especially the therapist's empathy, intervenes to arrest this malignant development, helping unlock the child's exuberant energies and restore in the child a more confident and joyful participation in life.     

Integrating Psychotherapeutic Processes with Cognitive Behavioral Procedures

There has been a recent focus on the processes that underlie intervention delivery for children and adolescents throughout the Cognitive-Behavioral Therapy (CBT) literature. Certain process variables have been associated with treatment outcome among youth receiving CBT. Data for these process variables including: the therapeutic alliance or therapeutic relationship, child and parent involvement, other child and therapist variables, and issues of diversity, are reviewed. Based on this data, specific clinical recommendations are made. The treatment relationship as a very important process (VIP), and the facilitation of CBT so that it is real and relevant to youth are emphatically discussed. Process issues in modular CBT are identified. Ultimately, genuine collaborative empiricism and guided discovery preserve the therapeutic relationship as a VIP, and foster the customization of therapeutic tools and the treatment trajectory.     

Sculpting Present and Future: A Systemic Intervention Model Applied to Psychosomatic Families

We present a therapeutic intervention model for use with psychosomatic families. This method, the result of our extensive research on various psychosomatic disorders, uses family sculptures of the "present" and "future": each family member is requested to represent the family as it now "is," and how it "will be" in the future. We discuss the theoretical reasons for our choice of this method: (a) the opportunity to use a therapeutic language that is similar to the nonverbal language of the psychosomatic symptom, and (b) the usefulness of reinserting temporal dimensions into family systems that seem to have lost their evolutionary potential and to be in a sort of "time lock." Two clinical cases are discussed (a child with chronic asthma and an anorexic adolescent); the use of sculptures in both cases revealed the underlying problems and made positive therapeutic interventions possible. Finally, we point out how the use of sculpture as a therapeutic technique enables therapists to deal with multiple systemic levels.     

Barriers to treatment participation and therapeutic change among children referred for conduct disorder.

Examined predictors of therapeutic change among children seen in outpatient therapy. Children (N = 200) referred for oppositional, aggressive, and antisocial behavior and their families participated. The major findings were that (a) socioeconomic disadvantage, parent psychopathology and stress, and child dysfunction predicted therapeutic change from pretreatment to posttreatment; (b) barriers to participation in treatment also were significantly associated with therapeutic change and this effect was not explained by the other family, parent, and child predictors; (c) as the level of perceived barriers to participation in treatment increased among families, the amount of therapeutic change decreased; and (d) among children at risk for relatively little therapeutic change, the perception of few barriers to treatment increased the degree of child improvement. The implications for further work on predictors of therapeutic change and the role of barriers in the treatment process are discussed.     

Transmission: From Experience to Awareness: Jewish Children Hidden in France and Their Children

The purpose of this research was to attempt to understand how the experience of having been a Jewish child hidden in France during the Occupation was transmitted to offspring. This analysis is based on research carried out among former hidden Jewish children, and the therapeutic follow-up provided in the setting of our clinical activities. The psychopathology of the first generation plays a role in the transmission process. The transmission of their history is also a source of ambivalence. This study shows how important it is to consider the complexity of personal histories and the distortions attendant on the transmission of these histories.     

Mindful Parenting: a group approach to enhancing reflective capacity in parents and infants

In this paper, the process of ending therapy is likened to the ordinary developmental task of ‘letting go’ that parents have to undertake, to help their child to grow up. ‘Letting go’ is contrasted with the process of ‘holding’ the child in mind that is so central to the therapeutic and parental task Following thoughts about some of the external issues that play a part in the decision to end a child's treatment, this developmental perspective of psychoanalytic psychotherapy is discussed through a clinical illustration of the ending of a 5-year-old boy's treatment. Different strands of the therapeutic relationship as highlighted during the ending phase of therapy are distinguished and attention is drawn to the role of the ‘new relationship’ between therapist and child and how this differs from the transference relationship. Countertransference issues in their broadest form are also considered.     

Early consequences of pre-Oedipal maternal deprivation

Abstract

The goal of this paper is to emphasize the early consequences of pre-Oedipal maternal deprivation, addressing the theories and techniques of the pioneers of child psychoanalysis. Even when these theories differ in their understanding and conceptualization of child psychopathology, their common denominator is that they believe in the importance of the infant’s early experiences of life and the necessary physical and emotional constancy of the mother–infant dyad. This paper approaches the different theories using three clinical vignettes. Through the synthesis of the psychoanalytic therapeutic process of a four-year-old boy, we can see how the conflicts and symptoms evolved and resolved in the course of five years of treatment, during which the boy’s behavior and productivity changed, allowing the treatment to come to an end. This boy was able to work through his traumatic separation experience in analysis, and to develop more mature defense mechanisms that led him toward a better adjustment to his environment. We can conclude that the early interruption of maternal care led to serious symptoms in this child’s behavior and mental organization. If these difficulties had not been addressed in time, the symptoms would have gone on to become severe.     

Family Unification with Reactive Attachment Disorder Children: A Brief Treatment

This is a case study of a family with a child (age eight) with reactive attachment disorder and the subsequent individual and family therapy. Treatment of choice for the child was Eye Movement Desensitization and Reprocessing (EMDR) and supportive educational counseling for the parents and family. Qualitative evaluation of the process demonstrated that the parents observed an instant change in the child's attitude. The child reported that she felt better about family, school, and truthfulness, and stated about the therapy: It opened a window for me. A 12-month evaluation demonstrated continued positive effects.     

Family process in the treatment of intrafamilial child sexual abuse

The paper describes the changes in family dynamics that occur throughout the process of family-orientated treatment of families where father–daughter incest or stepfatherr–stepdaughter child sexual abuse has occurred. A detailed step-by-step analysis of the developing family process in incest families during therapy is given. The analysis establishes the nature of the original pattern of family relationships, explores the impact made by crisis intervention on the family structure and then outlines therapy and termination of treatment. Characteristic mechanisms in the family process during therapy are described. A detailed clinical example demonstrates the basic therapeutic moves and the mechanisms involved.     

Intersubjectively oriented,time-limited psychotherapy with children: how does the therapist evaluate the therapeutic process and what are the therapist’s tasks?

Based on the therapist’s evaluations of three therapies, this research aims to study the therapeutic process in intersubjectively oriented, time-limited psychotherapy with children. A primary objective is to further develop the therapy method. The study comprises therapies with children 6–11 years of age, who had experienced difficult family situations. Each child received 12 therapy sessions. The number of therapy sessions with children and parents was agreed upon beforehand, and the therapeutic objectives were approved by the parents. Each of the therapy processes were evaluated by the therapist by answering three questions and filling in three forms after each therapy session. The forms were: The Feeling Word Checklist; an alliance form for the child; and a process form. The therapeutic alliance and the behaviour of the therapist during the therapy sessions are discussed on the basis of the total material. The following main tasks for the child therapist emerged: structuring the therapy sessions; following the child’s initiatives; participating and cooperating with the child; exploring the child’s expressions; and understanding and regulating emotions.