Child Psychotherapist and Problems of Young People

Mary Boston, Dilys Daws, Mary Boston, Dilys Daws

• Publisher: Routledge
• Year: 2018
• ISBN:
  9780429911811
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Many parents at some time dread that a child of theirs may be mentally ill or disturbed. But even after a generation of child psychology, psychiatry and psychotherapy, they still frequently fear to admit their fears, and fear the mystery of the remedy as much as the mystery of the problem. It is therefore important that parents should come to easy terms with the work of the psychotherapist, and be reassured that it is based on sympathetic understanding, not mysteries. It was to explain themselves to parents and others who work with other young people that sixteen psychotherapists and analysts (mostly following the principles of Anna Freud or Melanie Klein and largely drawn from the Hampstead Child Therapy and the Tavistock clinics in London) decided to collaborate in the preparation of this book. In it they set out to describe their work in schools, hospitals, clinics, day centres, etc and to discuss their fundamental approach to the treatment of the disturbed child.

Chapter One
The Contribution of
the Child Psychotherapist

by Mary Boston

This chapter takes a first look at the incidence and causation of emotional disturbance in children. It highlights the importance of the pre-school years and the desirability of increased social and emotional support for parents together with their young infants. The need for social and economic change and for further research into environmental factors is considered, joined with the specific contribution of the child psychotherapist in effecting changes in the inner world of the growing child. The psychotherapist’s basic methods are outlined.

M.B., D.D.

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Child psychotherapists are concerned primarily with the treatment of emotional disturbance in children and young people, although they also work in a consultative capacity in a variety of settings which touch the growing individual. The wide range of maladjustment which comes within the psychotherapist’s province will be clearly illustrated in the chapters which follow. When carrying out individual treatment the analytic child psychotherapist attempts to help the patient to understand his or her own situation and, in particular, any unconscious factors which may be contributing to current difficulties. The therapist is, in other words, concerned with the patient’s ‘inner world’ - the subjective picture of people and things we all carry around within us, sometimes without even being aware of it, and which may or may not adequately correspond to outward reality.

The last comment is significant. Whatever the part played by unconscious determinants of behaviour, the importance of the outer world is in no way to be discounted or neglected. It is clear that socio-economic factors operate on everyone. They can be a contributory, and sometimes a main cause of the kinds of problems discussed in the next chapter. There we shall find children from a large urban area suffering considerable deprivation in their home backgrounds, where the school classes are too large for teachers to give disturbed children the concerned attention they so badly need.

Social Disadvantage

There is ample evidence in surveys such as The National Survey of Health and Development, a long-term follow-up of four thousand boys and girls born in 1946 (Douglas, 1964), of consistent associations between maladjustment, poor educational progress and social disadvantage. Such associations are also demonstrated in the reports of the National Child Development Study (Pringle, Butler and Davie, 1966; Davie, Butler and Goldstein, 1972). These studies found particular categories of children to be disadvantaged from birth onwards.

Clearly, socio-political change and augmented social and educational services form one of the possible approaches to the problem of maladjustment in children. The elimination of poverty, bad housing, general overcrowding and too large classes in schools would be an important step forward. We are sure of this in general terms. But we still need precise research data on such matters as the effects on development of familiar old-style overcrowding and of new-style high-rise tower blocks.

Incidence of Maladjustment

Despite the emphasis of the previous paragraph, it is a disappointing and paradoxical fact that an evident increase in national prosperity since the Second World War has led to no reduction in the incidence of maladjustment. On the contrary, delinquency rates have increased, and this despite growth in the social services, the helping agencies and increased educational opportunity. Some of the apparent rise in delinquency may be spurious, a result in fact of society’s increasing awareness of the problem and altered methods of ascertainment. Some part of the rise, however, is probably genuine. For its explanation many point to the still evident contrast between the prosperous and the poor (one child in sixteen in Britain is socially disadvantaged [Wedge and Prosser, 1973]) and to the accelerating growth of our dehumanized cities.

It is not at all easy to assess the incidence of maladjustment in the general population. In large-scale surveys, of which there have been in any case few, assessments of disturbance have of necessity had to be made mainly on the basis of teachers’ rating scales or parents’ reports. The validity and reliability of these is open to some question, although in fact such ratings are likely to underestimate rather than overestimate maladjustment. Professional estimates of the general prevalence of psychiatric disorder have varied considerably, probably as the result of differing methods of assessment (Rutter and Graham, 1970). The Underwood Committee (1955) and the Scottish Education Department Committee on the Ascertainment of Maladjusted Children (1964) were unable to offer an estimate of the prevalence of maladjustment in school children. Much earlier, however, Burt (1933) had judged the incidence of neurotic disturbance among school children to be five to six per cent. Rutter and Graham (1967), employing psychiatric interviews with parents and children after initial screening with parent and teacher questionnaires, reported an incidence rate of 6.8 per cent for clinically important psychiatric disorder in a population of ten- to eleven-year-old children in the Isle of Wight. The same authors later reported a considerably greater incidence in the same population, using the same criteria, when the subjects had reached fourteen to fifteen years. Reviewing studies in infant schools, Chazan and Jackson (1974) reported twelve to fourteen per cent of such children to be either somewhat or very disturbed. Still higher figures are suggested by long-term follow-up studies. Rutter (1973) reports the prevalence of psychiatric disorder in eleven-year-olds in an Inner London borough to be double that in the Isle of Wight - as might perhaps be expected. Richman et al. (1974) in a survey of three-year-olds, again in a London borough, noted seven to fourteen per cent as having significant problems.

CP—B

The Pre-School Years

An important fact which emerges from long-term studies is the overriding importance of the pre-school years. Douglas (1968) attributes major differences in educational performance to environmental influences acting during that period. Patterns of adjustment and educational attainment show relatively little change once a child has left infant school.

It is not surprising that it seems to be the pre-school years which are so important. We know that personality begins to form from earliest infancy and that by the time the child reaches school age, or even earlier, he or she is already a well-developed personality. The most important of all environmental influences on the young child are family relationships. In first place for the very young infant is his relationship with his mother and father. The father is especially important in terms of the support he gives, or does not give, the child’s mother. The parents together mediate the events and circumstances of the outside world to the infant. Adverse conditions such as bad housing and overcrowding affect the infant primarily through their impact on the parents.

It was Freud who first drew public attention to the fact that personality has its roots in early childhood. Child analysts such as Anna Freud and Melanie Klein have since demonstrated that these roots go back to very earliest infancy. A great deal of recent research, initiated mainly by John Bowlby (1951), has consistently shown the importance of a continuous, loving relationship between mother and baby in the satisfactory development of personality. Although some workers such as Rutter (1972) and the Robertsons (1972) have queried the necessarily devastating effects of early separation from the mother which Bowlby originally postulated, a good deal of current research on child development continues to support the view that an early, continuous and meaningful interaction between mother and baby is crucial for the child’s subsequent emotional and intellectual development (Newson, 1974; Foss, 1974). Ainsworth (1974) describes investigations which suggest that babies who have sensitive mothers, who respond adequately to their infants’ signals in the first three months of life, cry less and are more ‘socially competent’ at one year than babies who have not established such primal communication.

The Vicious Cycle

This fact of the crucial importance for subsequent development of early infantile experience throws some light on what has long been a stumbling block for those attempting to understand the problem of maladjustment in environmental terms alone: the fact that difficulties tend to recur from generation to generation in a family, despite change in external circumstances. Research is suggesting that cyclical processes are at work - for example, in baby battering. Parents who ill-treat their children are found often to be those who were ill-treated themselves. Bentovim (1975) also observed that as many as thirty per cent of battered babies in a hospital series have spent a period in hospital at or soon after birth, so that the vital link between mother and baby seems not to have been satisfactorily established. In this way the problems can be self-perpetuating. Lastly, a good deal of clinical work suggests that mothers who have not experienced in infancy adequate relationships with their own mothers, for whatever reason, themselves find it much more difficult to provide satisfactory mothering for their youngsters. This particular difficulty cuts across social classes, and is found as much amid prosperity as amid poverty.

Factors Within the Child

The problems, however, do not necessarily reside in the mother or the family alone. There can be a variety of factors in the infant himself which make the mother and father less able to respond to and interact with the child. Here we learn much from detailed observation of infants, which incidentally forms an important part of the psychotherapist’s training (see Chapter 14). Recent research (Foss, 1974) suggests that babies already differ considerably at birth. They are not merely ‘lumps of clay’ on which environmental influences get to work, as has been proposed by many schools of psychological and philosophical thought. Babies differ in general personality, in activity, irritability, ‘drive’ and many other qualities which are probably innate. In addition babies may be born with specific defects, minor or major, which inevitably affect not only the baby’s development, but the mother’s interaction with him. This modified interaction itself then affects development. Numerous other physical and psychological handicaps also affect the baby’s development and the responses of the parents (Bentovim, 1972). As Rutter (1974) puts it, ‘Differences in nature may lead to differences in nurture.’ Babies can further differ markedly in their manner of coping with environmental difficulties. Joyce Robertson (1965) has described the different ways in which two infant boys reacted to their respective mothers’ temporary withdrawal and depression during a family crisis - a differing response which of course itself may have arisen partly from the mothers’ individual ways of interacting with their children.

We draw the conclusion, therefore, that personality development proceeds as the result of a very complex interaction of factors, some of which are innate, some environmental. The infant’s very early experience is, however, always a crucial factor in development.

The Need for Support of the Mother-Infant Couple

The above conclusion, on the importance of early experience, has two major implications for child-care work. The first is that in our attempts to alter the social circumstances which produce maladjustment, we must pay much more attention than in the past to the pre-school period. Here we are thinking not only of the provision of nursery schools and play groups, but of support for mother and infant in the first year of life, as well as for the family as a whole.

There are many pressures in contemporary society which run counter to the findings of research into child development (Menzies, 1975). The devaluing of the mother’s (and the father’s) role is one example. The pressures on mothers of young babies to go out to work, either from economic necessity or to contribute in a supposedly more important way to society, are another. To the list can be added the enforced separation of mothers and babies in many of our hospitals during the neo-natal period. Such separation is likely to make more difficult the establishment of the vital mother-and-baby link (Richards, 1974; Bentovim, 1975). Not least are the enormous stresses placed on many mothers by financial hardship, poor housing and isolation from the extended family and from other mothers, particularly in new housing developments and high-rise blocks. All these factors together produce a very high rate of depression in mothers of young children. In the already mentioned survey of three-year-old children in a London borough, Richman (1976) established for such mothers rates of ten per cent severely depressed and forty per cent mildly so.

It would seem that social help must be directed particularly towards supporting the mother-infant pair in a wide variety of ways, if we are to make any appreciable attempt to reduce the amount of emotional disturbance currently observed.

The Inner World of the Child

The second implication of our understanding of the complex aetiology of emotional disturbance, and most notably the importance of the early years of life, is that once disturbance has arisen, further and beneficial change seems not so easy to effect. Some children seem to have constitutional strengths which enable them to overcome environmental deprivation or difficult early circumstances, or subsequently to make use of a variety of kinds of help. In other cases the experience of attempting to solve children’s emotional problems through improved environmental provision alone has made it increasingly clear that there are sometimes factors operating within the child himself which make change difficult. Some children, then, seem unable to utilize the help that is offered, perhaps because their view of the world has become significantly distorted in some way. These children cannot respond sufficiently, or even at all, to improvements in the environment or to concerned care. The feelings and attitudes built up from past experience go on resisting change. So the child with a chip on his shoulder who has been badly let down many times, or at any rate feels he has, may continue indefinitely to resist the friendly overtures of well-intentioned people. Most teachers have had this experience of the child who does not respond whatever one does. For such children simple modifications in their ‘outside world’ are not enough. Some deeper change has to be effected in the structure or style of their ‘inner world’ - in their feelings and attitudes and ways of looking at life - before they can utilize what the various helping agencies have to offer them.

The Contribution of the Child Psychotherapist

It is in trying to reach and effect changes in the child’s inner world that the specific contribution of the child psychotherapist is made. This is not to say that once a child psychotherapist is involved the effects of external influences are either ignored or underestimated. The therapist usually works as one member of a team, alongside other workers and agencies. In this way an attempt is made on the total problem. Chapter 3 will be specifically concerned with this team work.

The psychotherapist however is directly concerned with external factors only from the way in which these affect the child’s inner experience. For it is only internal reality that we are able to influence in psychotherapy (Boston, 1967). We cannot undo events that have actually happened in the past, nor is it as a rule helpful to patients to dwell on the past, even though we understand this to be important in the aetiology of the problem. Rather, we try to help the patient to come to terms with past experience, and with his own present personality characteristics, in the hope that changes in his feelings and attitudes will make him more able to benefit by what is offered by his environment.

How exactly does the child psychotherapist set about this difficult task? To answer that question is precisely the aim of this book. The chapters which follow give some detailed accounts of actual procedure in a variety of settings. It needs to be borne in mind, inciden...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Contributor
• Preface and Acknowledgments
• Revised Foreword
• Introduction
• Chapter One The Contribution of the Child Psychotherapist
• Chapter Two Working with Small Groups of Children in Primary Schools
• Chapter Three The Child Guidance Clinic
• Chapter Four Child Psychotherapy in a Day Unit
• Chapter Five The Child Psychotherapist in a Day Centre for Young Children and Parents
• Chapter Six Working in a Hospital
• Chapter Seven Counselling Young People
• Chapter Eight A Study of an Elective Mute
• Chapter Nine Beginnings in Communication
• Chapter Ten Play and Communication
• Chapter Eleven Psychotherapy with Psychotic Children
• Chapter Twelve Freud and Child Psychotherapy
• Chapter Thirteen Some Comments on Clinical Casework
• Chapter Fourteen The Tavistock Training and Philosophy
• Appendix Doubly Deprived
• References and Further Reading
• Index