Use of a reference group in researching children’s views of psychotherapy in Malta

This paper explores the process and outcomes of a children’s reference group within the context of child psychotherapy research in residential care. The reference group was set up to consult children about the design of a research project which seeks to evoke, represent and understand children’s views of psychotherapy. No work to date has explored the experience of reference groups in the context of child psychotherapy in residential care in Malta. The paper contextualises the research within the literature on reference groups in child research, which identifies the potential of reference groups as a participative and co-reflexive activity which can inform research design. The paper critically examines the nature and conduct of the reference group by acknowledging the specific context of this work rather than assuming this is necessarily positive. It does so by specifying and evaluating the outcomes of the reference group in line with its aims. The paper draws on the recordings of the reference group meetings and reference group field notes taken by the researcher as key data which were thematically analysed. The main outcomes of the reference group include children’s contribution to the design of data collection methods especially in terms of not relying only on words during data collection. Children also identified key ethical issues from the point of view of young psychotherapy service users, especially in relation to issues of trust within a residential care context. Children also reviewed and appraised research information material. The reference group process drew from the researcher’s and participants’ contexts and contributed significantly to the researcher’s reflexive process especially in terms of acknowledging his power and positioning as an adult and his dual role as a practitioner/researcher.     

Gender/ed identities: an overview of our current work as child psychotherapists in the Gender Identity Development Service

Abstract

This paper is adapted from a presentation first given at the 2017 Association of Child Psychotherapists (ACP) Conference. We hope to give a feel of our work as psychoanalytic child psychotherapists working in a Tier 4 national assessment service for gender variant children and connect with our colleagues working therapeutically with these families in Child and Adolescent Mental Health Services (CAMHS) and other settings. Gender variance does not have a single cause, or straightforward developmental pathway; rather it is a complex interplay of multiple factors, akin to sexuality in the diverse manifestations and ‘tributaries’ taken. This paper is given as a plea for complexity, to counter the current intense focus on gender identity and the consequent reductionism this can lead to. To this end, three case studies from the clinic, taken from Under Five, Latency and Adolescent phases of development, are explored. The complexity of the cases is then discussed, followed by parallel issues of development, divergence and difference. These three ‘average’ cases from the Gender Identity Development Services (GIDS) serve to demonstrate the need for child psychotherapy as part of multi-disciplinary thinking about gender variance and how attention must be maintained to each unique story and process of identity development; as well as our clinical task to establish and encourage depressive functioning and secondary processes where possible.     

‘Un-certainty’: working therapeutically with a transgender young person and learning to bear the unknown

Abstract

The rate of referrals to mental health services for children and young people for whom gender dysphoria is the identified clinical issue has increased significantly over the last ten years. Debates around the classifications of gender identity disorder, gender dysphoria or gender incongruence, as well as the involvement of child and adolescent mental health services with this group of children and young people seem to be re-enacting the societal gender binary world view where we see acceptance versus rejection, open-mindedness versus conservative, trans-phobic thinking. In this paper the author will attempt to shed some light on the work with these young people in a clinical setting by reflecting on a year of therapeutic work with a female to male young person. Through the therapist’s reflections upon these binary preconceptions, along with the use of developmental and object relations theory, an in-depth account of the work is given. It is suggested that in some cases the therapist’s capacity to bear the unknown, while gradually observing and mirroring the un-integrated inner self of the patient, can gradually bring the fragments together, even if not in a perfect fit, and that this in turn provides a sense of relief.     

Bridging the Theory-Practice Gap by Getting Even Bolder With the Boulder Model

Cognitive behavioral therapy is an effective treatment for virtually all psychiatric disorders. However, very few patients have access to it and few therapists are trained in the theory and practice of cognitive behavioral therapy. Based on the existing evidence and the articles of this series, the following recommendations are made: (a) all mental health care providers (including Psy.D. and social workers) need to be trained in the practice and theories of empirically supported treatments, specifically cognitive behavioral therapy; (b) clinical practice also needs to be based on theory, not just treatment manuals; and (c) psychological treatments have to move beyond the DSM boundaries.     

‘No entry’, an invitation to intrude,or both? Reflections on a group of anorexic patients

This paper describes the twice‐weekly psychoanalytic psychotherapy of a young woman who had undergone major bowel surgery in her early 20s, with no clear medical indication for the surgery. Whilst the concept of ‘No Entry’ described by Williams ( 1997a , b ) aptly describes many features of more ‘typical’ anorexic patients, this paper describes a particular group of anorexic patients, referred by their physicians for multiple medical procedures; and proposes there is a group of anorexic patients, repeatedly referred for medical investigations, into whom particular types of entries occur. These are entries into the body ‘legitimized’ as medical, with a trajectory towards multiple procedures, examinations and surgical operations. Other entries (outside the medical setting) may occur in a state of altered consciousness, under the influence of alcohol or drugs, such that any wish for intrusion is disowned and denied. In both sets of events, intrusion is both invited, and consciously denied. The case example illuminates some of these features, and aspects of the countertransference are also described. Attention is drawn to relevant research focusing on surgical intrusion. Finally, there is an exploration as to how such patients may invite intrusions into the body through surgery and medical procedures.     

The child's experience of Munchhausen syndrome by proxy

This paper examines the emotional impact of Munchhausen syndrome by proxy on a child aged 6 who had been poisoned by her mother. It describes her treatment in child psychotherapy over twenty months at the Cassel Hospital where the family worked towards her successful rehabilitation home. The work with her showed her experience of dangerous relationships in her family that left her distrustful of any new relationship, and doubtful of her capacity to be close without being destructive. Like her parents, she was terrified of facing the murderous feelings in the family, retreating into denial when life was too painful. The paper describes three phases of treatment: fear of separation and preoccupation with the trauma of poisoning, ambivalence about facing the destructiveness in the family and the move into more appropriate latency behaviour as she prepared to go home with her parents. It concludes with an overview of the impact of Munchhausen syndrome by proxy on the developing child, as shown in this treatment: the delay in emotional and cognitive development, the interference with the capacity to relate, the retreat into illness under stress, and the fear of permanent damage caused by the emotional and physical 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.     

Clinical encounters with children in the Trump era

There is an emerging research and conceptual literature on the impact of the 2016 United States election of Donald Trump on the psychoanalytic psychotherapy process; however, the focus of this growing body of literature has been primarily with adults. Issues related to the election of Donald Trump, and the current political climate, also continue to arise in clinical encounters with children. These moments highlight the complexities of intersectionality, intersubjectivity, power dynamics, and self-disclosure. This article describes several clinical scenarios with American youth – reports from the front lines of a new political reality – drawn from the perspectives of trainees learning psychodynamic therapy, a private practitioner conducting an assessment for a young asylum seeker, and a school psychologist working in a private school for children with learning disabilities. We consider the fears and preoccupations that arise among children and their caregivers and the feelings that are provoked in the clinician, both in response to their clients and to the election itself. Traditional psychoanalytic paradigms of limiting self-disclosure and maintaining the therapeutic frame are challenged by the intensely personal nature of contemporary politics. This paper explores a contemporary phenomenon – the tension between therapeutic attending to internal experience and symbolisation, repression, and integration, while also considering a harsh, political external reality – through the lens of centuries of psychoanalytic work conducted in the face of war, trauma, and oppression. Children and adolescents who present for treatment or other forms of clinical intervention require a flexible therapeutic approach that acknowledges their unique position in history and the ways in which their distress is exacerbated by real and perceived political threats.     

Book Reviews

BRUNO BETTELHEIM : The Empty Fortress: Infantile Autism and the Birth of the Self. The Free Press, New York. 1967. $9.95. (£4 in England).

GERALD O'GORMAN: The Nature of Childhood Autism. (Illustrated, 8 plates)

C. M. HEINICKE and I. J. WESTHEIMER: Brief Separations.     

The development of an evidence-based treatment: Regulation-Focused Psychotherapy for Children with externalising behaviours (RFP-C)

There is a critical need for the development, evaluation and implementation of evidence-based psychodynamic treatments for children and adolescents. Currently, there are no empirically supported, manualised psychodynamic treatments for children and adolescents with disruptive behaviour problems. The field of manualised psychodynamic treatments with measurable equivalence or superiority to other established forms of psychotherapy is in its nascent stage. This paper details a novel, manualised, time-limited psychodynamic treatment approach for children who manifest disruptive behaviours and emotional dysregulation. Regulation-Focused Psychotherapy for Children (RFP-C) conceptualises children’s disruptive and acting out behaviours as expressions of maladaptive emotion regulation. Externalising symptoms are conceptualised as attempts to defend against painful emotions and thus protect the child from disturbing feelings such as sadness, shame and guilt. This paper provides the theoretical basis for the treatment approach and through the use of a clinical example demonstrates the systematic application of RFP-C in a single case.