Emotional maltreatment

Nice to see the Government has released a paper on Emotional Maltreatment – What works. Except it doesn’t really prove anything. It does, however, assure me that the jury is still out and what I do is okay.

How do I know it’s okay? Well, the child improves no end and the foster carer, for example, says the client has become a child again (instead of a hyper-alert mini adult afraid or unable to play). Things like that, which warm the heart.

Sometimes I think this is all the evidence we need. And if we check up as we go, then we’d know when things needed adjusting.

I suppose shoving data onto CORE/SDQ forms makes us feel official and effective and conscientious and all the rest of it. But since every child and young person is different, it really isn’t achieving anything. As proved by the various inconclusive or slightly-less-than-thorough studies surveyed in the report above. Own goal, Mr Brown and/or DCSF.

I guess I’m feeling a bit rebellious today.

But I’ve also heard of a book that interests me, and may interest you. I was talking to someone yesterday and they mentioned The Emotional Experience of Teaching and Learning by Isca Salzberger-Wittenberg and her colleagues. It was written many moons ago (well, 1988, to be precise) and has been republished since. But it deals with some of the same important aspects of pupil emotional health in school, attachment and learning as do some very recent books. Some of the publisher blurb is:

“Based on the work done with groups of teachers attending the Tavistock Clinic, the book demonstrates how insights derived from the psychoanalytic study of the mind can heighten the understanding of the learning relationship.”

Sounds good stuff for a school counsellor to know, so I’ll be taking a look at it. Since it’s Tavistock in origin, it’s probably psychodynamic too – which is so useful as a way of understanding life in school.

Ephebiphobia outside the supermarket

I thought Tanya Byron was making up words back in the Guardian in March when she announced that we were suffering from ephebiphobia. Was that even a proper word?

I wasn’t too sure about the meaning she was getting at, either. Agreed, there is crass media emphasis on how young people are feral, violent, unmanageable etc. But I still expect to walk around seeing nice adults doing nice things to nice young people all the time. And mostly they do. We’re not all phobic of young people!

But the media creates and models another view, which adults often buy into. Try this:

A colleague’s son, who is 12 or 13, took his mum’s shopping list to the local supermarket after school and was barred from entry, with the rude demand that he go home, change out of his school uniform and then return, otherwise he could not go in.

The lad was petrified, showed his list but was given no explanation for the order, nor was he allowed to speak with the manager.

What kind of behaviour modelling is this?

So I looked up Tanya’s word and found: ephebe – “(In Ancient Greece) a young man of 18-20 years undergoing military training.”

Yes, well, someone taller and stronger, who knows tactics and bears arms – that could refer to gang members, I suppose. But a young lad in school uniform going shopping, not yet inside the shop, and putting up no argument… For god’s sake, what is going on?

We have a duty to model the behaviour society wants from its young. Assuming they’re criminal before they open their mouths is criminal in itself. As Tanya said: “Our distorted perception of young people creates a self-fulfilling prophecy: why bother to try when you are told that you are a failure? Why bother to strive when your existence is seen as a nuisance?”

I hear endlessly in sessions about teachers who have spoken rudely to young people, refused to hear their version, and talked disdainfully about them in their presence. I’m not gullible but I’ve heard it too often myself to totally disbelieve their account. I sometimes wonder whether it’s the child or the adult in need of therapy.

The mum in question got both explanation and atonement from the supermarket, but, as she told them, they needed to change their policy to something more acceptable. Where else are you guilty before being charged (pun not intended)? And, significantly, what damage are we doing to the mental health of young people or children treated in this way? A whole generation will grow up feeling they are tainted, unacceptable and unwanted. I wouldn’t like to be an OAP when such a damaged generation was deciding my fate. Would you?

A good book to recommend to struggling parents is Sura Hart’s Respectful Parents, Respectful Kids: 7 Keys to Turn Family Conflict into Cooperation, and a good organisation running decent family coaching that brings out the potential in kids and respects their contribution (Develop Your Child) is run by Alan Wilson and can be found here.

The brain in child therapy

It’s amazing to think how much we rely on our knowledge of what happens in the brain these days. Neurophysiology has considerably changed what we think and what we do as therapists. It’s noticeable in all models of working, and especially so in EFT and EMDR which pretty much rely on it (of which more later).

Whichever way we work, we can, for instance:

• explain to teenagers how the brain works when they are anxious or traumatised or acting precipitously
• have confidence that things can change, because the brain connections are constantly being reorganised, pruned or developed
• devise helping interventions that use what we know about neurology, whereas once we might not have.

I was thinking about this recently as I read the book Play Therapy for Very Young Children edited by Charles Schaefer and his colleagues, which I said I’d report back about.

I haven’t finished reading yet, and that’s mostly because the chapters are all by different contributors and so it’s a fresh start each time (and also because it stopped raining and the grass needed cutting).

But the chapters I’ve read so far have all stood out for me as “obvious”, as in “well, of course this is what we should do”. It wouldn’t have been so obvious a few years back, before we understood so much about the brain. But when a child is traumatised, unable to attach securely or is being neglected, then it makes sense to use the brain’s plasticity to re-do what has been missing developmentally. I love the comment in the preface – that we maintain that play is how children make sense of the world non-verbally, so why do we say play therapy is for 4s-12s? Why wait till they can speak? This book is about helping under-4s.

So – our knowledge of the brain is really important to us as therapists.

For those of you interested in EFT in particular, or as an adjunct to therapy with young people, Gwyneth Moss, an EFT UK Master, recently presented to the British Psychological Association on “Tapping, Trauma and the Brain” (see her news bulletin here – scroll down). You can access her slide presentation from that link too. This is the “brain background”, this is why it works. EFT with young people is currently being masterminded in the UK by Christine Moran at her site www.eftworld.co.uk, and I leave you with that, as I go to finish off the grass…

Violence and bribery

It makes sad reading to learn that so many under-4s are excluded from school for being violent (according to a report in The Times.

Are they modelling aggression from home? I know of many children whose parents still hit and slap them when they do something wrong. The scenario goes: “I can’t get from you what I want so I will hit you in the hopes of making you realise I want it now and mean what I say.” Is it any wonder the children copy?

Sometimes, though, it’s because the child has no negotiation skills. Yes, asking nicely, playing together, waiting for one’s turn are all expected to be learnt or reinforced in Reception, but older children also get aggressive or resort to bribery when they have no idea how to negotiate.

I have often worked with a child to help them negotiate for what they want within the family rather than erupt in unmanageable anger. (My belief is that putting sticking plaster on the anger does not offer skills for future.) But often, the child is expert at bribery not negotiation. They learnt it from home, and when it doesn’t work, violence follows.

That’s not to say stickers and small target rewards are not of value early on. But in general, what is modelled at home reproduces itself amazingly accurately in the child. Bribery being an obvious example: “I will bribe you with this expensive present to behave as I wish.” What next? Another bribe? If it fails, anger? Where does self-control and self-satisfaction come into the scheme of things?

Parents’ modelling aside, if very early violent behaviour is to be transformed in the right way, access to suitable counselling services is a priority. Charities such as ThePlace2Be are doing an excellent job but can only expand as the funding and counsellors become available.Their counsellors work voluntarily, as do many others. How soon before the Government capitulates and agrees to fund them for their very successful and much-needed early interventions?

If we want some guidance for work with even younger children, the ubiquitous Charles Schaefer has recently co-edited Play Therapy for Very Young Children, which I have just bought. I will read it and report back later.

When the client smells

When faced with a young client who smells, life becomes problematic for me. Not because I wish to magic them out of their awful situation (which of course I do want because I’m human) but because I’m never quite sure which way to jump and who should do the jumping.

I’m not talking about a child of four or five who smells of wee, nor a teenager who has yet to discover deodorant – though each of those will need dealing with by someone at some point. But when you are faced with a very smelly 14-year-old and the smell is all-encompassing, you know that something is going wrong at home. Cue, child protection considerations.

But wait, I hear you say. Isn’t this blog about mental health? Well, yes. But the ramifications for an unclean child are many:

Someone presumably isn’t providing care
The child must be struggling alone
Physical and mental health can become enmeshed
Friends either don’t exist or desert – at 14, that’s serious.

So what are my options?

School nurse? Not all schools have them. Social services? A possibility. Filling in a CAF seems overkill. A word with the parents (if I can contact them) often brings only temporary results, and school staff ditto.

But oh please, not the counsellor. Not me. How am I meant to be accepting and supportive, “on side” and a safe place, if I tell the young person they smell? (On the other hand, where does congruence fit in here?!)

At times like this, I become acutely aware of joined-up working with all the other professionals involved with young people. That way, while protecting my role (or fleeing the unthinkable), I can ensure the child’s needs are met.

One excellent book of case studies that makes for good and informative reading around these wider contexts is Case Studies in Child and Adolescent Mental Health.

This sounds a tad daunting so I’ll mention the contents:
Oppositional defiant behaviour
Adolescent depression
School refusal
Intellectual (learning) disability
Parental divorce and separation
Looked after child
Asperger’s syndrome
Anorexia nervosa
Hyperkinetic disorder
Obsessive compulsive disorder
Somatisation
Conduct disorder
Post traumatic stress disorder
Deliberate self-harm I: overdose
Deliberate self-harm II: self-injury
Schizophrenia

The author works in Walsall, UK, and there are references to smelly children, so I feel it is grounded in reality! It doesn’t solve my dilemma. Just eases my intermittent worry that I, alone, might be expected to sort out a child’s total problems. Which is how it can feel if we forget about joined-up working and a multi-agency approach.

What works in therapy part 2

The dice game

To play this game with a colleague, throw the dice three times on your turn to choose your client, the model and one of the two issues in the problem column (your choice!). Decide together how you would work with that scenario. Then it’s your colleague’s turn. Help each other out – but having a colleague to play with ensures you do actually think it through and toss ideas around that emerge during the process.

 

If you don’t work with that category of client or that model of therapy, do your best with the knowledge you have and then look up more information so that you either confirm your current way of working or learn something wider that will maybe throw light on how and why your current work differs – which, strangely, may strengthen it.

 

 

DICE	CLIENT	MODEL	PROBLEM
1	child of 10	cognitive behavioural	anger / behaviour issues
2	teenager 14	person centred	health issue / chronic illness
3	single mum	psychodynamic	eating disorder / OCD
4	family dad	solution focused	bereavement / loss
5	single man	multimodal	anxiety / phobia
6	older lady	Personal construct/EFT/NLP	alcohol abuse / domestic violence

 

For instance, I just threw a 4 for family dad; a 5 for multimodal; and another 4 for bereavement/loss (I’ll go with loss). Now I mostly work with under 18s and their carers but that means I should have an idea of what would be most helpful to this imaginary dad who has had a loss of some kind (child, spouse, job, future, health etc) and how it might affect his children.

 

I’d go with him on the detail, of course, but on the general theoretical underpinning of multimodal therapy, I’d be assuming – in this scenario – that we should address several aspects of his situation (Behaviour, Affect, Sensation, Imagery, Cognition, Interpersonal relationships, and Drugs/biology) and also consider what we know about the effects of loss in general. And it’s instantly reasonable to assume this model would address what needs addressing. 

 

Because I work with young people, I should be aware of how loss affects different members of the family and how this impinges on the young person’s own coping. And because my work with young people takes into account their various contexts, then all this should be pretty familiar territory. The multimodel aspect obviously contains a “specific” way of working and parameters – but it’s also completely understandable to a therapist trained differently.

 

How far can we remain pigeon-holed in the 21st century? I’m not saying we should necessarily change our way of working, just consider it in a wider context and be open to possibilities. The thought of being more effective surely underpins why we do this work in the first place. And that’s why I invented this game – to think around what I do!

What to do in therapy part 1

The news today that there are many more cases of autism disorders than currently diagnosed raises many questions (see here for the BBC story).

Not least is the one about how these children and young people should be given emotional support, and whether mental health interventions can essentially eradicate the problem. What works in theory may not work on the ground with an individual child.

I spend a good deal of driving time cogitating on my work.

The thing is, it won’t matter how many hours I claim for CPD: if none of them cover this “thinking” activity, I won’t improve/develop.

So, perhaps it’s age and a sense of responsibility kicking in, but I find myself continually questioning whether I have done the right thing, used the right kind of intervention, worked early enough, held back enough, taken too long, not taken enough time – well, that sort of thing, though I’m not as bad a therapist as it sounds!

What I came to thinking about is the difference between efficacy and effectiveness studies.

Since this is a blog not a treatise, I’ll omit the detail and simply point out that effectiveness studies assess whether my clients benefit from my interventions under the conditions that I work in. That is, in uncontrolled field settings.

This is important. We’re bombarded with advice and guidelines about what to do with what. And none of that necessarily relates to me and my settings.

Efficacy studies, on the other hand, omit a great deal of the reality in situ:

• We can’t run a parallel child because all are unique. Omit the trimmings of a particular child and you don’t have a “control”, merely another child.
• We can’t eliminate other factors that may be influencing a child’s progress at the same time as we work with them. Indeed, specifically with children and young people, we would expect them to improve over time as they continue to develop cognitively and emotionally.
• And we can’t be scientific in the tick-box sense because therapy is a flexible art, tweaked daily according to need.

Surely this means we should be seeking to provide a variety of therapies for all young people so that they have choice in what they can make use of to heal themselves. No one can dictate that. And I foresee a directive on recommended therapies for autistic disorders, and that won’t be perfectly suited to a particular child, either, any more than the depression and anxiety ones are!

But f you’re interested in the prevalence of autism and how diagnosis is now made, then do read Unstrange Minds by Roy Richard Grinker. It’s very good and most informative and demystifying.

Stripped of their masks

Very interesting that a group of teenagers has been bold enough to volunteer for an experiment in ditching their accessories – chiefly IT equipment and make-up. If you missed Make My Kids Happy on ITV1 tonight, you can catch up with the final part on Friday 15th at 8pm.

Several interesting things emerged as I listened to it from a therapist point of view (there was a child therapist on the programme but she hasn’t done or said much yet – merely taken the kids out to check if people preferred them with or without their make-up!).

1
Someone commented how good it feels to have iPod earphones in their ears. Sounded like a comforter or dummy. Not that I’m passing judgement – I feel good when I have favourite things around me or am lounging around in an old fleece. It’s just that my fleece and possessions aren’t “doing” anything to me in the way that constant melody, words and rhythms are. In that sense it’s more like a drug you rely on to feel okay.

2
Another thing was that the people in charge had run the Rosenberg Self-Esteem Scale before and after (though we have yet to see the results, of course). So they really did mean they were going to hypothesise about happiness and bling being negatively correlated.

3
What was third? Oh yes, the horror the girls felt at being deprived of their make-up. I think I can empathise with that. No one likes moving outside their comfort zone or doing things differently in public. The real issue was, I felt, that they had to be disguised in this way in the home, with their boyfriends, among their girlfriends. Surely there has to be somewhere where you can just be? It was therefore great that so many people assured them how lovely they were “in the nude”, so to speak. I mean, doing your hair and applying your make-up before a kick-around with a football is a bit extreme!

4
The last thing I noted was that they simply had to have music in their ears at school because that was how they had learnt to work at home – against a constant background noise. I know about comfortable routines and personal ways of working. That’s fine. But I got a weird feeling that the sound of silence bothered them. As if they might find themselves if they endured it for too long. As if anything were better than confronting their existential loneliness. Hence the various masks.

I still haven’t recovered from the hair extensions bit…

No quick fix for children

The Government seems hell bent on quick fixes these days. Maybe they sense time running out for them, but it has long been common sense that where a stitch in time saves nine, that one stitch needs to be long and strong, not frayed and misplaced.

Two things have cropped up recently to emphasise this. One is their determination to recruit and fast track social workers to fill the gaps left by those who have more sense than to stay on (The Times reports on this here). The other is Lord Layard’s request (made earlier but reported by the BBC here) that we train more child therapists quickly.

The idea that “the additional [children’s] workforce could be drawn from those who already have experience working with distressed children” sounds good, but I read somewhere that they would be drawn mostly from community mental health workers (CMHW) – and they do not often have the experience that many of us have after years of working at the, er, playground face.

The contrast between the values of “experience” and “tick-box assessing” is troublesome. Of course the assessment should be thorough, and you can train someone to do this reasonably fast, but there is so much more than simply assessing. Would these new workers have gut instinct about what is troubling a child? Skills to allow a child to feel safe enough to open up? Play skills to help with expression? A feel for what other creative input might be more use than the officially recommended “treatments”? A good intervention for a specific child on a specific day – which can only be decided then and there?

I do wonder, because I have heard of children being referred to CAMHS for help and the school nurse is sent to do a preliminary assessment (for mental health and dyslexia, for god’s sake) or a CMHW doing two-thirds of an assessment and then deciding the “diagnosis” before completing it. One even had a family therapy MA that he was keen to point out to me, yet had not considered bringing in the family for therapy, because his form-ticking indicated a problem within the child (and, as everyone knows, you get the answer your question seeks)…

So whereas the Government seems to be being pushed in the direction of non-stigmatising mental health interventions for children, it all sounds like a quick-fix, when what is needed is a thoroughly thought-out system of counselling services in every school, staffed by well-trained, all-round therapists (yes, with CBT skills and assessment skills too) who have years of experience with all kinds of children with all kinds of presenting issues.

If this takes a long time to structure, so be it. Work with children is not quick – though it can often seem so when the problem is caught in time – and the training can’t be either. But it is the only way through. A sound stitch, carefully planned and executed. Preferably, by those who already have the skills.

To change the topic: if you’re looking for something different to use, I came across Steven Richfield’s Parent Coaching Cards a few weeks ago. You can find the blurb and examples here, but I bought them in the UK from ADDISS at their bookstore.

Lament for finger paints

I am gutted today to discover that the finger paints I usually buy – which are such a basic part of my playroom’s equipment – have been altered in composition so that they now resemble runny custard rather than clumpy, granular stuff. To add insult to injury, the change has been brought about, the manufacturers tell me, on account of EU regulations regarding preservatives. (I won’t start on about the EU here!)

Before you think I’ve taken leave of my senses to be so upset about this event when there’s a recession and increasing child mental ill health to consider, let me point out that the original product by Scola was a fabulous means of children rediscovering a hands-on bodily connection. I have seen kids almost swoon as they absorb the feeling of mixing the colours with their palms; smile a small smile as they write messages they dare say out loud (“I need help”) because it can be rubbed out instantly; proclaim their boldness in finger-written graffiti (when their ego is fragile); and leave clunky chunks of carefully positioned paint to set in situ as a 3D residue. All this is totally impossible with the new custardy sort (all the other brands on the market, and home-made recipies, were always so). And my child clients hate them.

I am bereft. What’s more, I can feel once again what many of my small clients often feel for all sorts of other reasons: betrayed, powerless to change things, indignant at not being consulted, angry no one seems to care, furious on behalf of my clients.

And all over a set of finger paints that no longer serve my clients’ purposes. 

I fantasise over finding a long-lost reserve supply in some forgotten corner, but ultimately I have to mourn my loss and take up life again. If this sounds vaguely familiar to you all as therapists, well that’s hardly surprising. It sort of defines our work.