A contextual analysis of time-limited psychodynamic psychotherapy with children, young people and parents
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Introduction and overview. Psychodynamic therapy and the changing emotional and social landscape of childhood and parenthood
The 21st century presents us with challenges with respect to the way in which we disseminate information, particularly in the area of mental health. A post-modern perspective asserts that we cannot isolate a particular treatment such as time-limited psychodynamic psychotherapy for children, young people and their parents, from a broader critical reflection and examination of professional practices concerned with child and family mental health. Our perspective of our practice can also not be separated from a values and ethically based position with which it must essentially be intertwined. In work with children and young people therefore, psychotherapy and advocacy become one.
This book builds on my earlier publications and research that take a critical view of the contemporary bio-medical approach to the construction of child and adolescent mental health, often to the exclusion of the relational, family and social context. The predominance of the bio-behavioural paradigm and the loss of a developmental understanding of children’s behaviour, constitute potential risk factors for children and young people, together with the increasingly reductionist approach to knowledge about childhood and parenting.
Given these challenges, what role can psychoanalysis or psychodynamic thinking play? Psychoanalysis has had to weather ongoing criticism for many years because of the apparent lack of a credible scientific evidence base for its practice. Cuts in public services have tended to push psychoanalytic treatments to the sidelines given that they have been viewed as synonymous with long-term treatment. The response from the psychoanalytic community not unreasonably, has been to attempt to justify its relevance and to expand its research and evidence base. In its eagerness to do so however, there is a risk that the very methodologies used such as outcome studies, manualisation of treatments, and the reaching after the holy grail of the randomised controlled trial, actually reinforce the de-contextualised problems for children and young people described above. These methodologies will not take us to the Promised Land as they are already out of date, encased as they are within the individual pathology focused discourse that is resonant with modernity biased practices.
In this book it is not suggested that we should not conduct research or examine our professional practice, but rather that we need to take a very different view of what constitutes health and wellbeing and positive outcomes for children and young people. This book on time- limited psychodynamic psychotherapy therefore takes as its starting point the recognition that we cannot change therapeutic practice without changing or recalibrating the way in which we construct the conceptual psychodynamic framework. The term psychodynamic is used throughout the book rather than psychoanalytic, which I believe is incorrectly used as a generic descriptor when it more appropriately refers to a specific treatment mode. The recalibration of the psychodynamic framework requires more than a tweaking of established psychotherapeutic practice with children and young people in order to accommodate a shorter time frame. The oft quoted statement that it is only through the practice of long-term psychotherapy that we can successfully carry out shorter-term work is also refuted. Instead, we are concerned with reconfiguring the way in which psychodynamic ideas can be applied in a new and different way to encompass the changing emotional and social landscapes of childhood, parenting and family life. This means that we must take a fresh stance with respect to the many articles of faith that surround traditional psychotherapeutic practice and that confine many training institutions to repeating theoretical doctrines when these may no longer be applicable. We need to open the windows and allow space for the development of fresh theory and practice to emerge that will be resonant with the needs of today’s child and today’s family.
The focus in time-limited psychodynamic psychotherapy with children, parents and young people thus requires a total review of who is there to be worked with/what is the primary task and how can one best go about it? These questions are all underpinned by the meaning of the symptom or behaviour that is presented. A core theme of the book is that by acknowledging that in the first instance, the therapeutic task is to uncover meaning rather than pathology, we begin to recognise the enormous value of the symptom. In other words the symptom is the opportunity that opens up a wider, richer way of working. Because of this, therapeutic work with parents, caregivers and the wider network has equal value to that of work solely with the child and young person.
By widening the therapeutic frame in therapeutic work with children, young people and their parents in this way, we reflect the world that they actually inhabit. This approach is the antithesis of a traditional therapeutic approach that is entirely focused on therapy with the child and young person, in which the role of parents and others is perceived as marginal and as primarily that of ‘supporting’ the child or young person’s therapy. One may argue that these rigidities and inward looking practices have, even more than the apparent lack of research rigour, served to undermine support for a psychodynamic way of working, particularly in the public services.
The integrated approach suggested in this book requires a high level of skill and experience as practitioners need to be equally adept at working with parents as well as with children and young people. This requires a change in the way in which training is offered and how students are selected. The approach described in this book is the opposite of single strand thinking and is reliant on a confluence of experiences and ideas. One of the often observed side-effects of traditional psychoanalytic and psychotherapeutic training is that the life of the student that has gone before is considered a mere stepping stone on the road to psychoanalytical enlightenment. One may have observed fellow students with previously rich and demanding careers that appear to have become negated with the taking on of the identity of psychotherapist or psychoanalyst. In recalibrating the psychodynamic approach we would want instead to integrate, encourage and use the previous experience of the practitioner as a powerful source of information, depth and diversity.
With respect to my own experience, the gestation for this book has in a sense taken all of my professional life and it may be said to represent a distillation of the experience I have had of working with children, parents, families and young people in a wide variety of settings and across three continents, the United Kingdom, South Africa and Australia. It has been clear to me in the course of writing this book how influential these different opportunities for learning have been and how they come together to inform my current practice. I commenced my career as a graduate of psychology, but continued to work for several years as a social worker initially in the field of child protection and subsequently as a psychiatric social worker in adult psychiatry and then in child and adolescent mental health services. My own personal analysis and training as a child psychotherapist opened up a world of knowledge and understanding. Finally, I have come full circle back to the field of psychology in which I carried out my PhD research. A substantial part of this professional experience put me in touch with children, young people and adults struggling with high levels of stress, abuse and chaos in their lives. This presented an enormous challenge in terms of being able to find ways of making even the slightest difference in the face of major intergenerational deprivation and trauma. It brought home to me that the individually lived life cannot be separated from the relational, family, systemic and wider organisational, social and political environment. It further brought home to me that the predominantly pathology-driven diagnoses associated with these problems have not led to the hoped-for outcomes with respect to improvements in child and family mental health. In fact it may be argued that narrow pathology-based diagnoses not only compromise the child and young person, but also the ability of professionals to offer meaningful treatment and support.
It is here of course, that psychodynamic understanding comes into its own. The paradox is that at a time when psychodynamic practices and services are coming under threat we need this wealth of understanding more than ever. Psychodynamic understanding predicated as it is on the meaning of behaviour, on observation and on lines of continuity, presents us with a highly contemporary and engaging method. This method as described in the book demonstrates the intersection between the intra-psychic, the inter-personal and the systemic, where none of these fields can be kept artificially separate from one another in the therapeutic encounter. It enables us to shift from a pre-ordained prescriptive diagnostic framework to one in which we validate and promote the inherent knowledge of the people we are trying to help. For children and young people in particular, the recognition of their inherent capacity for health and growth is intrinsic to the process. Professionals in turn are able to move from the servicing of deficit-focused stratagems that preclude critical judgement, to drawing on their deeper well of understanding, insight and skill.
Finally, where does this lead us in the future? Time-limited psychodynamic psychotherapy presents us with a different view not only of time, but also of what we mean by ‘illness’ and by ‘cure’. Time- limited psychodynamic psychotherapy is not in any way presented here as a cost-cutting measure. However, once we move away from a predominantly bio-medical framework, this opens up opportunities for a different way of engaging with research. How the research is carried out will also need to be recalibrated in a way that can include children, young people and their parents as active participants in the inquiry. For example, involving children, young people and their parents directly in research as contributors to the process, rather than as carriers of symptomatology, has the potential not only to deliver reliable information, but also to help shift the research paradigm into that of the important area of prevention.
A further major theme of the book is that practitioners in child and adolescent mental health have a special duty of care towards children and young people, and advocacy is intrinsic to the entire psychotherapeutic enterprise. Children and young people in need cannot wait, and it therefore behoves us as psychotherapists to be very clear about our professional and values-based position with respect to how we carry out research and who will ultimately benefit from it. It is hoped that by recognising the potential for time-limited psychodynamic psychotherapy with children, parents and young people, we shift the locus of control away from pathological constructions of individual behaviour to that of a more dynamic and contextual interchange. Hearing the voice of the child and young person with respect to their everyday lived experience within the family, school and important relationships is a critical part of this dynamic inquiry. It not only makes excellent use of the skills of child psychotherapists and other practitioners, but also enables us to use this information to provide the kinds of services for children, young people and their parents that will create a true engagement in the service of positive change.
The book is divided into two parts:
Part 1 addresses current concerns about child and adolescent mental health and the particular dilemmas presented by traditional psychoanalytical practice with children and young people. It goes on to provide an overview of the pioneering work of practitioners in time- limited psychodynamic psychotherapy with adults. This is followed by a critical assessment of contemporary developments with respect to research and outcome studies in time-limited psychodynamic psychotherapy with children and young people, with a particular focus on current research dilemmas within the post-modern age.
Part 2 presents a conceptual framework for practising time-limited psychodynamic psychotherapy with children, young people and their parents, which takes as its starting pointing the recalibration of the psychodynamic approach for current times. This is predicated on the need to attend simultaneously to the four interconnected domains of the intra-psychic, the inter-personal, the systemic and the environmental. An integrated perspective is proposed of the important findings concerning the primacy of the developmental task; understanding of attachment; the contribution of family therapy and the making of meaning and the unity of brain and mind. This framework is further underpinned by the recognition of the capacity for health and growth in children and young people. This is followed by a description of the clinical method and clinical technique in time-limited psychodynamic psychotherapy with children and young people, in which attention is paid to setting up the therapeutic frame in a way that encompasses the total field that surrounds the child and young person. The involvement of parents and caregivers is perceived as integral to this process. In the final chapter the implications are discussed for training, and for ways in which time-limited psychodynamic psychotherapy can contribute to changing the research paradigm from one of pathology, to that of prevention.