Commencing with widening the field as part of the therapeutic endeavour
The point has been made earlier that the framework within which we currently conduct treatment for children and young people, as well as the accompanying research, is too narrowly circumscribed. In addition, when this framework is predicated on the identification of psychopathology then we have already foreclosed on the problem. By taking the four domains as a cornerstone of all clinical practice and intervention, we create a widening of the field of inquiry that will enable us to more accurately identify the problem and find more meaningful solutions. Further, by widening the field of inquiry and encompassing the total field that surrounds the child and young person, the therapeutic process is able to have a greater impact over a relatively shorter period of time. Thus the total field surrounding the child and young person is perceived as being part of a complex dynamic system of which the components may all require attention at various times.
Our work as psychotherapists is to address the tension and interplay between these different domains at different points or stages in the therapy. Therefore, we may at one point in the therapy address an internalised struggle for the child, and at another time communicate with parents, or with a teacher about the child. Underlying this process is the recognition that all of these interactions are perceived as having similar therapeutic ‘value’ in the service of helping the child and young person. An image that comes to mind is that of a glass prism which is made up of similar, equal and parallel ends. Different parts of the prism when held up to the light will reflect different colours of the rainbow.
Attending to the different elements of the field surrounding the child and young person, is best carried out by the same therapist rather than allocated to different people, because the therapist needs to be able to make it credible and workable. This resonates with the approach referred to earlier of Bevington et al. (2013). By widening the field of the total therapeutic enterprise, the therapist contains the function of case manager as well as that of therapist at various times. Both are perceived as having equal therapeutic value, and as complementing each other in attending to the needs of the child and young person.
This approach is illustrated in the following example. A therapist working with a young child in permanent foster care was aware of the impact of her early difficult experience, particularly with respect to her fear of loss and separation. The therapist was informed by the foster parents that she was having difficulties at her kindergarten, where the teacher continually complained about her challenging behaviour. Here, we might draw an initial conclusion that the child’s traumatic early history was a contributing factor to her behavioural problems. Whilst this was not incorrect, it only presented a partial picture. The therapist resolved to visit the kindergarten to speak to the teacher and suggest ways in which they could both work towards helping the child. At the visit, the therapist found an older, very harassed, woman in charge, who was clearly no longer enjoying the job of caring for any of the children, let alone the little girl in question. She was dismissive of the therapist, and reluctant to engage in any discussion about ways of helping the child, preferring to see her as ‘the problem’.
The accumulation of data as described in this example that follows from a widening of the field, and which accompanies the therapy of the child and parents, is of considerable benefit in helping us not to jump to conclusions about a problem. It also assists us with respect to not taking premature or incorrect action before we have more of the total picture. By the same token, a school or kindergarten visit can reveal supportive and engaged staff who bring their own insight to bear on the problem, and through this collaborative experience, contribute to the containing holding function that can be so critical for children and young people.
The issue of confidentiality when the therapy is contained within a single worker is often cited in these situations to justify why such an approach may not be appropriate. However, whilst we need to take a protective and confidential approach where required, we also need to be vigilant about a slavish adherence to confidentiality which may be used as a defence to justify a lack of communication with parents and caregivers, as well as with other professionals. In fact, clinical experience indicates that children and young people have a great longing to be understood by their parents; in many cases they want the psychotherapist to be able to ‘hold’ the whole picture of the important people in their lives.
The attention to the total field surrounding the child and young person inevitably changes, expands and contracts at different times depending on the presenting problem, and requires an evaluation of what may be the appropriate ‘leverage’ at any point in time to effect positive change. Encompassing the total field of the child and young person’s experience has the further function of reducing fragmentation. It also provides a model for a way of thinking about, and understanding of, the problem that can be readily accessed by parents and caregivers. In this sense the ability of the psychotherapist to hold in mind these different fields promotes both integration and containment. There may of course be occasions in clinical settings where it is strongly indicated that two practitioners work together, for example in high-risk situations.
When two practitioners work together, it is imperative that they share the same conceptual understanding and method of working. Where this does not take place and where the emphasis instead is on ‘dividing up’ the problem, or ‘dividing up’ the child, this will almost always result in a poor outcome.