Dr. Stephen Robinson

Therapy for kids, teens, and families

Dr. Stephen Robinson

Blue Wall 3: Crossing the Street: an Alternative Blue Wall Allegory

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In the previous two posts, I reflected first on the extremes and then on the mild to moderate end of the Blue Wall spectrum. In these posts I focused on the difficulties people have in asserting and holding onto their perceptual truths when doing so puts at risk their vitally important relationships, ones on which they depend for their safety and well-being. I pointed out that people’s perceptual truths are most vulnerable and threatened when the other person with whom they are in a relationship holds the lion’s share of the power. This is especially true for children, because of their necessary dependency on adults, especially parents.

In this third post, I consider three core qualities that promote the retention of perceptual truth while diminishing the toxicities of blue wall choices.

Begin with a second allegory, Crossing the Street. The second one starts just as the first did. Aiden insists that the wall is blue, while Zeke sees it is white. And as before Aiden digs in, threatening to end their friendship if Zeke refuses to see it his way. Then something dramatic happens.

Stung and infuriated at Aiden’s intransigence and without a word, Zeke abruptly stands up, walks out and crosses the street. Surprised at the intensity of Zeke’s reaction, Aiden is suddenly gripped with a fear of losing his friend. Jumping up, he rushes across the street in pursuit. Aiden exclaims, “Wait, wait, Zeke! How it is that you see the wall as white when I am certain that it is blue? How can it be that we view it so differently?” The two old friends, mutually relieved at avoiding a rupture, sit down to hash out their differences.

This allegory has two noteworthy characteristics. First, Zeke refuses to let go of his own perceptual truth: he won’t give up his power and let himself be bullied. Second, by relinquishing coercion in the interests of friendship, Aiden is spurred to make sense of their stark differences. By crossing the street he sets out to learn how they can see it so differently. They will work out their differences on a level playing field acknowledging that each of their perceptions has legitimacy.

In dropping his coercion and crossing the street, Aiden recognizes and accepts the simple and profound human truth that people have differing perceptual truths.

Real Life

In the Crossing the Street allegory, the conflict was easily resolved. In real life, not so easy! People have inevitable conflicts – contrasting interests, misunderstandings, opposing views, and combative struggles.

Getting along depends metaphorically on crossing the street, engaging others’ minds, working through conflicts and tensions, understanding and knowing their truths – in essence walking in their shoes.

We know that the Blue Wall choices in relationships occur when the other person, especially the person with power, fails to cross the street. The perpetrator who sexually molests a child cannot see the child’s mind. The mother who sees her son as monstrous and dangerous cannot cross the street to see that her little boy’s aggression is correctly attributed to his resentment of his baby sibling’s arrival – rather than mental illness or some innate trait. Peter’s wife fails in crossing the street to see her husband’s emotional reserve through any lens other than her own profound feelings of deprivation, these stemming from her own horrific experience of childhood abuse and neglect.

The Blue Wall dilemnas dissipate when people cross the street to practice and work diligently in understanding one another’s minds. Imagine a perpetrator stepping back to envision the effects of his violations on his victim’s mind – walking in the child’s shoes. Imagine Andrew’s mother putting her boy’s aggressions in its true perspective and relinquishing the monster demon attributions about her little boy’s behavior. Imagine Peter’s wife acknowledging the true nature of her husband’s reserve. The Blue Wall distortions would substantially fall away.

What psychological qualities undergird the capacity to cross the street? This is one of the most profound and complex questions that can be posed and has drawn endless attentions throughout history and into our scientific era from multiple disciplines – religion, philosophy, psychology, sociology, neuroscience to name some.

In pondering this, I am dauntingly aware that the question and the inquiries that follow from it lie at the core of our human social existence and are vast in their complexities. Any views that I put forward here can, at best, suggest skeletal ideas about the key mental constituents in the relational practice of crossing the street. Here are three of my thoughts about what counts in cultivating the practice of crossing the street.

The Capacity for Reflection. This capacity takes us beyond the day-to-day actions and steps of our concretely lived experience. Reflection consists of an abiding belief and deep interest in engaging one’s own and others’ minds. The reflective process recognizes that there are profound internal, often conflicting forces in the inner workings of our mental processes about which we are often only partially aware. Reflection compellingly takes us beneath the facing surface of our words and actions and into the inner landscapes and topographies of our feelings and mental constructions. I agree with Confuscius’s sixth century assertion that reflection is nobel: I believe that it underpins what is most uplifting in human social behavior.

Curiosity/Interest Directed towards Others. Another of the essential underpinnings of crossing the street, and a cousin of the capacity for reflection, is an attentive interest and invested curiosity in other people. It is the deeply felt sense that relationships matter, that others provide the connective tissue for what nurtures and sustains our lives. This is a key quality that activates and fuels vitality in the process of engaging the other person’s mind.

Ability to Go Back and Forth Across the Street. Relationships between people are vastly enriched and deepened when the participants can cross back and forth between each other’s minds. The process is infused with vitality if one partner engages and learns about the other’s mind and feelings and then additionally recognizes what the encounter evokes in his/her own mental process. Optimally this reflects a reciprocal exchange, with each person engaging the other’s mind but also encountering what gets stirred up in one’s own mind, on one’s own side of the street.

Blue Wall 2: The Milder, More Common End of the Blue Wall Spectrum

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In the previous post I considered transactions at the extreme end of the Blue Wall continuum and their effects on perceptual truth, exemplified by child sexual abuse.

In this post I consider mild to moderate forms of the Blue Wall dilemna, ones that are far less apparent and graphic, often even to those most directly involved. These insidious Blue Wall choices often stem from early life experiences and can lead to debilitating mental states – anxiety, depression, and obsessional patterns, behavioral enactments. Here are two illustrative case examples, one of a child and the other an adult.

Andrew

Andrew is three when his sibling is born. During those first three years Andrew and his anxious mother, Sarah, are inseparably bound together. With the baby’s arrival, Andrew suddenly finds himself in daycare. Stung by his fall from the grace of his mother’s constant attention and presence, Andrew responds angrily. He lashes out, hitting and pushing his mother and at times acts aggressively towards his sibling.

Deeply stung at what she experiences as the rejection of all her earlier attentions, Sarah reacts angrily to Andrew’s aggression, frequently shouting in outrage and inflicting harsh punishments. Sadly she takes personally his angry and retributive reactions to his sibling’s arrival. In Sarah’s mind Andrew inexplicably transforms into a “monster” posing “danger” and “threat” to herself, her infant, and their family.

The family believes Andrew is a disruptive and disturbed child. Children come to know and experience their senses of self in the reflective mirror of their parents’ representations of them. Andrew internalizes the vision of himself as a troublemaker and the source of his family’s distress.

How does Andrew’s story reflect the dilemna of the Blue Wall allegory? Like many older siblings, Andrew reacts angrily to the arrival of his sibling and its unwelcome impact on his little-boy life. Like Zeke’s white wall, this is his truth, his perceptual reality. However, in the context of his mother’s intense reactions and reflected representation of him, Andrew unconsciously concedes his sense of self to the reflected and toxic view of him as bad seed, the disruptor.

Acceding to his parents representation occurs entirely outside of Andrew’s conscious awareness. In 2005, David Foster Wallace opened his commencement address at Kenyon College with a parable about an older fish swimming past two young fish. In passing the older fish nods saying, “Morning, boys, how’s the water?” The two young fish swim on a bit, and then one turns to the other and asks, “What the hell is water?” Like the two young fish, little Andrew knows no other water but his family. And with his dependency and level of cognitive development, it would never of course occur to him to say to his parents like an adult might, “What the hell are you getting so angry at me about? I am just pissed off that I have to deal with an intrusive infant who takes you away from me. Cool your jets!”

Without conscious awareness, Andrew opts for the relationships that so centrally sustains him without in any way recognizing that it comes at the cost of his perceptual truth – the Blue Wall choice. One might say that he has no choice. What is so striking about Blue Wall choices is that they are most often initiated earlier in life and are then replayed repeatedly over time, often with damaging impacts on mental health, one’s sense of self and one’s relationships.

Peter

Peter is a highly accomplished married professional with two adult children. Early in his young life, his adored older sibling died suddenly. He and his family were plunged into grief, particularly his mother who withdrew into a depressed stoicism throughout his childhood. Not only did his beloved sibling die, but emotionally he lost his mother as well. No one in the family ever talked about what had happened.

As a youngster Peter soldiered on with hypervigilant concern for his mother’s state of mind. Fearing that she would worry about his safety, he repeatedly asked (the school secretary phones home) his mother to pick him up after school, claiming that his books were too heavy to carry alone.

Peter adapted, steeling himself to the relational leanness. He carefully, albeit unconsciously, avoided sticking his neck out emotionally, understandably fearing that whatever he had, could suddenly and without warning be ripped from beneath him and disappear. One might say that based on his experience, he comes by his emotional reserve honestly.

In his early twenties he met and fell in love with a young women, drawn to her lively warmth and kindness: there was a spark about her. Like standing in front of a crackling fire on cold winter’s day, he soaked in her warmth, but maintained his cool reserve. Over time and with children, she becomes increasingly disappointed, at times infuriated with the lean quality of his reserved presence, and she lashes out resentfully. Like her husband, she had had her own miserable experience of childhood neglect and deprivation and longs for deeper connection. It is a perfect storm.

He feels enormous guilt, like he is more of a taker than a giver, that he had somehow entered the relationship deceptively, not being honest either with her or himself. Her anger and resentment toward him are excruciatingly painful and awaken his massive latent fears of loss and abandonment.

What does this have to do with the Blue Wall allegory? With the tsunami of his wife’s recriminations slamming over his psychological shores, Peter is compelled to find his perceptual truth. Is he the failed and betraying husband? Or is he a devoted and loyal husband who keeps his feelings under wraps, holding himself back from demonstrations of affection? To preserve his marriage, is he obligated to accede to his wife’s insistence that he is overwhelmingly responsible for their disintegrating love, or do they both contribute and share responsibility? These are challenging questions, not easily answered or understood. However, as in the Blue Wall allegory, he is called on to find his own perceptual truth and vision of himself and his relationship with his wife. These are profound and profoundly difficult and important challenges.

Reflection

Finding and refusing to relinquish one’s own perceptual truths while resisting the pull of relational comforts and security requires an assertive process of determined courage and bold self-reflection. What is the true color of the wall of our minds? What is truly ours? And what can we agree on with others while keeping our truths?

A sixth century Confuscion aphorism is well-suited to this post.
By three methods we may learn wisdom: first, by reflection, which is noblest; second, by imitation, which is easiest; and third by experience, which is the bitterest.

In the next post I will offer some thoughts about navigating and resolving relational differences without having to relinquish one’s own perceptual truth.


Blue Wall 1: Two Friends and the Blue Wall: An Allegory

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Imagine two friends, Aiden and Zeke, sitting together. Aiden points to the wall, exclaiming, “Isn’t that a beautiful shade of blue!” Zeke replies, “It’s white.” Aiden claims that Zeke is wrong and insists that the wall is blue. “If you see white, your eyes are tricking you.” Further Adam aggressively asserts, “If you don’t see that it’s blue, as I do, our friendship is over.”

Aiden has thrust on Zeke a cruel choice. If Zeke adheres to his perceptual truth, i.e. what his own eyes tell him – that the wall is white, he loses a friend. For Zeke the contemplation of losing Aiden is devastating: Zeke has depended and counted on their friendship for years.

If Zeke chooses friendship with Aiden, he must in the same stroke negate the truth of his perceptions – what he sees – the wall is white.

So what does he do? What matters – the friendship or the integrity of his own perceptions? This the Blue Wall dilemma.

In the allegory Zeke’s choices are stark. In real life, the Blue Wall dilemma in relationships plays out on a spectrum from mild to extreme. In this first of three posts I take up the grimmest, most toxic extreme end of the Blue Wall continuum. At that end there are no shortages of horrifying relational patterns – bullying, spousal abuse, #MeToo, work place harassment, human trafficking. Specifically in this post I consider child sexual molestation as the exemplar of the crushing choices at the extreme end of the Blue Wall spectrum.

In the second post I will examine the exercise of power in relationships at the mild to moderate end of the continuum. Unfortunately the less extreme Blue Wall choices are often deeply toxic and harmful, and these play out all-too-frequently in people’s lives.

In the third post I will take up an alternative growth-promoting way of engaging conflict in relationships that I metaphorically label “crossing the street.”

The Dark End of the Blue Wall Spectrum – Child Sexual Molestation

Child sexual molestation darkly afflicts ours and many cultures: it leaves in its wake shattered lives. I consider it here, in part, because it exemplifies the grim but all-too-common choices at the darkest end of the Blue Wall spectrum. I will describe the pattern, comment on the perpetrator’s mind and then reflect on the child’s horrifying Blue Wall dilemma.

The Pattern

An adult (a father, priest, uncle) grooms and sexually molests a child thereby coercing the child into the service of the adult’s boundary violating yearnings and urgencies. The adult manipulates: 1) ours – the child and adult’s – relationship is loving and special; 2) if you disclose, no one will believe you; or 3) if you tell, you will hurt me and I will abandon or hurt you in kind. Children from toddlers, even babies, to teenagers fall victim and the abuses ranges in frequency, duration and the specificities of the encounters.

The Perpetrator’s Mind

At its psychological core, perpetrators who violate a child’s boundaries are blind to the sufferings of their young victims. A child’s feelings are invisible to the violator, because he is incapable of seeing that young person’s mind as anything other than an extension of his own yearnings and imperatives. In his mental process, outside of his conscious awareness, there are no boundaries, no separations between the child’s mind and his own mind. His yearnings are the child’s yearnings.

Despite the widely held revulsion at the perpetrator’s heinous victimization of children, his yearnings are rooted in his own unseen deprivations and often traumatic childhood relational sufferings. While his childhood sufferings may help to explain his assaults and could be explored, the primary focus of this post is on the terrifying Blue Wall choices of his victim.

The Child

For a child this extreme relational dilemma is layered with cruelties – the obvious lack of bio-sexual energies and interest, the stark prematurity of the experience, the developmentally determined absence of sexual agency and psychological preparedness.

And in the subjectivity of her response, she experiences this absence of boundaries as invisibility, a crushing annihilation of her separate being. She is made to not exist as a separate person with a different mental life as he imposes his physical will on her young life. As with Zeke in relation the Aiden, her perceptual truth has no value.

A child’s well-being and sense of self, even life itself, rest on adult s’ care and nurturance. Like Zeke in the allegory, a molested child is pressed to choose relationship over truth. Regardless of the magnitude of toxicities, the child’s necessity for emotional and relational connection frequently trump perceptual truth. The child pushes aside and quashes his/her own perceptions and most often buries them in shame. “What happened to me must have been my fault. If I had been a more worthy child, this would not have happened. Somehow I must have invited it.”

Cruelest of all is the disowning and disavowal of a child’s perceptual truth that “that person really did kiss,fondle and penetrate me.” The discounting blows up, annihilates and destroys perceptual truth and is crazy making. Without help, support and working through, the child can never thereafter claim the truth of her own perceptions and mind.

Mental health and well-being depend at their most basic level on the truth of one’s own experiences, the ability to share these and be believed/understood and the freedom to make choices.

Chilling Blue Wall relational interactions are tightly bound to a wide variety of brutalizing relational experiences such as those mentioned above: human trafficking, spousal abuse, #MeToo, bullying, workplace harassment, etc. At these Blue Wall extremes, victims’ lives depend entirely on the other: the victimizer has all the power.

Fortunately for civilization, the dark and graphic ends of the Blue Wall spectrum have captured wider cultural recognition and greater public redress in recent year. However, prosecutory focus and policy/legislative redress continue to fall grievously short of longed for justice and truth.

In the next post I consider the mild-to-moderate end of the Blue Wall spectrum of experiences that can also can cause long-term and harming effects on psychological well-being.

 

Parents’ Guide to the Therapeutic Process with Children – Part 7: What Happens in a Child Therapy Session?

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In Part 6 of a Parents’ Guide I commented on what to expect from a psychological evaluation of your child and how to consider the recommendations that follow from it. In this seventh post I am giving you a closer view of what actually happens in child therapy sessions.

I first review the guiding principles of the work, ones that I touched on in my fifth post about getting off to a good start with a child. Second, I share three vignettes intended to bring you into the playroom and reveal the therapeutic process at work.

Brief Review of the Guiding Principles

Children don’t talk about their troubling experiences, relationships and feelings like adults do. Play is their language, and children “talk” about themselves in their play. A child chooses and directs the play, and I follow his lead, playing my part as directed. I am at once an actor and an observer.

Wearing my observer’s hat, I have in mind the following questions. Of all the activities he can choose, why these? Why does he involve me in this particular way? What is he telling me about himself and his relationships? What is he feeling inside?

Play metaphors encrypt a child’s emotional and psychological concerns. My job is to “break” the code, figuring out what the play both expresses and hides.

At the beginning I most often don’t know what a child is “telling” me in the play. It takes time to figure it out. Most often a child settles on a play theme that is repeated over sessions and becomes further differentiated and elaborated. In the process I deepen my understandings of a child’s troubles as these are expressed in the play.

Adults talk. Children play. Therapy with adults requires discussion, self-reflection, recognizing and gaining insights regarding the sources of the underlying issues. But does this requirement hold for a child? How important is it for a child to become consciously aware of the conflicts and issues encrypted in his play?

Child therapists heatedly debate this question. One camp asserts that a therapist must offer interpretations that reveal the child’s underlying conflicts and struggles. In this view a child cannot develop self-reflective insights and understandings without the therapist, when the time is ripe, interpreting the play to the child. The other camp counters that interpretations, intended to bring out-of-awareness issues into the child’s conscious awareness, are not essential. From this perspective the conflicts can be worked through in the play without requiring the child’s becoming consciously aware of them.

Based my 35 years of practice, neither view can claim a monopoly on truth. Neither excludes the other and both have their place. It all depends on the child, the family and the circumstances.

Three Vignettes

David, a six year old boy, has great difficulty modulating his feelings. His anger boils into defiance and physical aggression towards family members, including his mother. Home is a war zone. I make a home visit. David crashes his toy trains into trucks and lego “people” lying on the tracks. At my office, we repeatedly hurl Match Box cars across the floor that crash violently into one another. At his request we watch YouTube videos of car, train and plane crashes. He is fascinated in rapt attention. Seemingly he can’t get enough: crashes pervade our sessions.

Several weeks into this drama, I comment that while the crashes are fascinating to watch, I have the idea that he is telling me about something more personal, closer to home – “people crashes.” David immediately and contemptuously dismisses my interpretation as “stupid” and ignores me as if I am a fool. I don’t force it. However, a month later he spontaneously describes conflicts at home labelling them “people crashes.” It appears that my interpretive remark implicitly resonates and takes up residence in his mental life, even though he emphatically denies knowing the source of the term he is using.

Bridgette, a seven year old girl is bossy, imperious and non-cooperative at home. She is intensely anxious, especially at school where she excitedly and rhythmically self-soothes flexing her legs together, becoming red-faced, oblivious that such a public display could embarrass her and result in peer exclusion.

In our first meeting she rummages through a bag of play clothes and puts on a blond wig and a cape, dramatically asserting that she is the Wicked Witch of the West. She then casts a spell on me, turning me into a port o’potty. Her mother agrees to be a vending machine. Me on the floor and mother on the couch, Bridgette races back and forth excitedly between the port o’potty and vending machine, imaginatively peeing and pooping repeatedly in the port o’ potty as she squats over me and moments later grabs candy from the vending machine.

Wow! What does this mean? Two ideas or conceptual lenses i.e., representations that focus and make meaning of the play themes, come to mind. First, with the port o’ potty I speculate that she is “telling me” that she can no longer hold back the pressures of feelings that have built up inside her. She must expel and express that gross and smelly stuff, hoping that the receptacle, i.e. me, will be accepting and safe. Second, I think of grabbing the candy from the vending machine as a representation of an equally urgent need to fill an emotional hunger for attention and succorance.

In many subsequent sessions she engages in imperious play demanding that I, her “servant”, cater to her power, whims and appetites. With a stop watch she times her servant as he frantically runs downstairs to fetch her ice water. He is always too slow, always falls short. I repeatedly disappoint her demands and urgencies, and in this game we have fun together.

Over the course of our work together her anxiety abates as do her imperious demands both in the my office and at home. I do not make interpretations. The play is the engine of her therapy, creating space for her to work through her conflicts, those burrs under the saddle of her young life.

Christopher, a remarkably considerate, engaging and friendly seven year old boy, is a natural and talented athlete. His parents enthusiastically enroll him in youth basketball and baseball. Although loving sports, he is gripped with anxiety, to the point of resisting attending practice and even games. For Christopher competing is aversive and unsettling. He can’t explain it and minimizes and avoids discussing his worries.

In our meetings Christopher creates elaborate and fun competitions. For example, he distributes objects on the floor from gable to gable of my attic playroom. We compete jumping from object to object without touching the floor. Whoever does it the fastest without falling off an object wins. Needless to say I almost always lose.

One competition in particular captures my attention. We stage a war between two armies with toy plastic soldiers, tanks, artillery pieces and bombs (foam balls). Unlike anything I have seen before with any child, he insists that each army must have a hospital equipped with beds for wounded soldiers. As the bombs explode, we carry our wounded to their respective hospitals for care. Plastic soldiers lies on beds(small wooden blocks) and are given time to recover as the war rages on.

Another Wow! What is this all about? I speculate that the play expresses Christopher’s anxieties about competition. By competing, he puts himself in harm’s way, just like the plastic soldiers. His fears of injury profoundly inhibit his participation in sports, and all of this is quite outside of his awareness.

In our two years together Christopher stages endless varieties of competitions as he works through his anxieties. He doesn’t injure me, and I don’t injure him. We are both safe and having fun. His worries dramatically lessen. One day his mother emails that Christopher believes he no longer needs to see me. We met one last time and together celebrate his liberation from those constraining worries.

I hope the seven posts of a Parents’s Guide have offered you a sense of my understandings of the psychotherapy of children. Please don’t hesitate to offer your views and ask me any questions that you may have about child psychotherapy.



*****

I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you?  What are your questions?  I will do my best to respond in a timely way.  Please don’t dismiss my requests. I really mean what I am saying!  Please offer your thoughts and questions.

Parents’ Guide to the Therapeutic Process with Children – Part 6: What Constitutes an Evaluation, and What Kinds of Recommendations Follow from It?

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In Part 5 of a Parents’ Guide, I addressed the question of how a therapist can get off to a good start with a child, and not scare him/her away. In this sixth post I consider the question of a psychological evaluation and the recommendations that follow from it.

Parents reach out asking for help with their child. They share their presenting concerns. I gather a careful history of the family and the child’s development. When relevant, I speak with the pediatrician, school staff and others. I meet with the child and usually with the child and her family.

Learning about a child and her family channels this process, and from it flows an evaluation, formally called a diagnostic evaluation. Usually after several meetings, I will meet with you to review the results of the assessment. But as a parent you wisely ask, “What does that really mean?”

In this post I will first respond to this excellent and thoughtful question with some clarifying perspectives about the differences between medical and psychological diagnoses. Second, I will offer some reflections on the range of treatment recommendations that may follow from such an evaluation.

Perspectives on the Evaluation

Parents are wisely advised to recognize the essential distinction between medical and psychological diagnostic evaluations. Suppose you have a sore, red and inflamed throat. Your PCP looks at your throat and tests for strep: the results come back positive, and you are prescribed antibiotics. In physical medicine diagnoses rely on recognizing and identifying illnesses based on symptom presentations and test results. Deductive reasoning informs a differential diagnosis, i.e. differentiating between two or more conditions that share similar signs or symptoms – in this case a sore throat. Bacterial or viral infections can both cause a sore throat. If a bacterial infection causes your sore throat, your PCP prescribes antibiotics: if it is viral, she won’t prescribe antibiotics and will suggest that you ride it out. In the case of a sore throat, as in many common medical conditions, the pathophysiology and treatment for your illness is well defined and understood.

There are no such understandings of the aetiological causes of mental health disorders (aetiology means finding the cause). In mental health the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-V) is widely recognized as the industry’s classificatory standard for mental health disorders. Each of the diagnostic classifications is based on symptom patterns for a particular state of mind and/or associated behaviors. For example, major depression is diagnosed based on showing five or more of the following symptoms:

  • depressed mood most of the day
  • markedly diminished interest or pleasure
  • loss or increased appetite with associated weight loss or gain
  • insomnia or hypersomnia
  • psychomotor agitation or retardation
  • fatigue or loss of energy nearly every day
  • feelings of worthlessness or excessive inappropriate guilt
  • diminished ability to think or concentrate, or indecisiveness
  • recurrent thoughts of death, recurrent suicidal ideation

In mental health a diagnosis of depression means identifying a cluster of descriptive symptoms that are associated with a depressed state of mind. These symptoms in themselves tell us nothing about the underlying aetiology or sources of the depression. Returning to the example of a sore throat, suppose that all you know is that a person’s throat is sore, red and inflamed, but there is no way of determining whether the cause is bacterial or viral. By analogy, that is where we are in mental health. Symptomatically we recognize depression, but the causes cannot be readily defined, and there are no sure fire treatments.

As parents you should not expect a diagnostic evaluation to explain the causes of your child’s psychological difficulties, but instead think of it as the beginning of a process, i.e that you and your child are setting out on a shared exploration with the mission of achieving reflective understandings and working through fraught and often unsettling conflicts and tensions. Here is what is reasonable to expect of a psychological diagnostic evaluation.

  • First, the evaluating therapist should offer insights and perspectives regarding the presenting concerns and your child’s state of mind that are clarifying and thoughtful and that ring true to you. If the process is meaningful, you might think to yourself, “Yes, that makes sense. I actually hadn’t thought of it quite that way.”
  • Second, you should have the sense that the perspectives offered are grounded in and grow out of shared exchanges that have unfolded between you and the therapist. You should come away with a feeling of resonance with the process and that the diagnostic representations make sense.
  • Third, you should feel completely free to ask a lot of questions and not feel constrained from challenging the perspectives that are offered.
  • Fourth, trusting your instincts is vitally important. If it doesn’t feel right, don’t discount your own views in deference to the so-called expert’s authority and status.

Reflections on Treatment Recommendations

There are several common recommendations that grow out of a diagnostic evaluation of your child’s mental health difficulties. But what does this mean practically? Here are the most likely types of recommendations.

  • Psychotherapy. The most common recommendation is ongoing psychotherapy. Once a week is a minimum frequency, because every other week dilutes the process. It becomes more like a check-in than an ongoing therapy. This is particularly so because of children’s sense of time: for a child a week can feel like a month. If the problems are more pressing and urgent, more frequent meetings may be in order. I have seen children more intensively up to 4 times a week. That may seem like an eye-rolling number, but for some children it is a game changer.
  • Meetings with you as parents. Initial meetings with you as parents are essential in the diagnostic process of getting to know a child and her family. Thereafter, the frequency of our meetings depends on the specific circumstances. When there are lots of tensions at home and you are struggling with how to respond, meeting at least once a week makes sense. These meetings are useful in exploring how to think about and respond to the challenges at home around things like compliance and relational conflicts. If there is less urgency, meeting with you can be less frequent (once every two weeks, once a month – it all depends). Sharing perspectives, brainstorming together – me learning what is going on at home, you hearing my reflections about your child – provide valuable opportunities in working together on our shared mission.
  • Family Meetings. Family meetings, of course including your child, can be of great value. This depends on what we together think will contribute most effectively to addressing the problems.
  • Psychotropic Medications. Unless there are pressing indications for medicating a child, it is far better to first give psychotherapy a chance to work. When a child has a place to express and focus her feelings and has the experience of being listened to and taken in, the turbulences at home and at school tend to become attenuated and lessen in frequency and intensity. However, if behaviors and conflicts reach a threshold of dysregulated intensity, the feelings are acute and there are rising levels of distress and psychological suffering, a psychopharm consultation may well be in order. Bottom line – it shouldn’t be the first step.
  • Neuropsychological Testing. Especially when a child is experiencing difficulties in school, testing may make sense. Typically issues of attention and impulsive behavior, avoiding school work, problems in processing certain kinds of information, difficulties with organizing and planning, problems in reading social cues, etc. – these kinds of presenting concerns may signal the need to have a thorough look at cognitive processing. Under these circumstances neuropsychological testing may be in order.
  • Other Kinds of Supports and Interventions. For some children, special additional interventions may be worthy of consideration – such as independent educational plans under Massachusetts Chapter 766 law, coaching, tutoring, exploring the possibility of a therapeutic residential and/or school placement, etc.

In the next post I am going to consider the actual meetings with children and the central role of play in the therapeutic process with children.

*****

I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you?  What are your questions?  I will do my best to respond in a timely way.  Please don’t dismiss my requests. I really mean what I am saying!  Please offer your thoughts and questions.

 

Parents’ Guide to the Therapeutic Process with Children – Part 5: What are keys to the therapist getting off to a good start with a child?

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In Part 4 of a Parents’ Guide, I considered what you as parents should expect of the relationship with your child’s therapist. In this fifth post I address the question of how a therapist can get off to a good start with a child, and not scare him/her away.

For most children initial meetings provoke anxiety. The therapist is after all a complete stranger. Not knowing what to expect, a child has all kinds of unspoken apprehensions. Will he give me a shot? Will he ask embarrassing questions? Will he judge me, criticize me, scold me? Will I feel uncomfortably exposed and want to flee? Or will I feel safe and comfortable?

In the context of these worries most children want the reassuring presence of one or both parents at least for the first meeting and even subsequent sessions until they feel at ease. And this is normal and to be expected.

In the first session(s), there is no need to focus directly on the problems that precipitated parents bringing their child to see me for two reasons. First, the child already implicitly knows why he is there, even if he were to maintain that he doesn’t. Second, focusing on the presenting problems risks the child’s feeling exposed, called out, embarrassed and made to feel ashamed, like he is the bad, crazy kid.

So what do I do instead? By being curious and interested in a child’s life, not just the problems, I implicitly state the terms that will govern our relationship going forward: 1) you are important and interesting to me; 2) you are much more than the problems that brought you here; 3) I want to learn and come to know the whole of you; 4) we will learn and share this journey together; and 5) along the way we will come to understand and work through the “problems” in your life.

These terms are not stated directly, but rather in the form of curiosity and interest. With more verbal and somewhat older children, I wonder about their lives. What is school like? What subjects do you like and don’t like? Who are your favorite and worst teachers? Who are your friends? What are their names? What do you like to do with them? Do you have a sport? Do you like music? What things do you do for fun? Curiosity and interest go a long way in starting to build our relationship.

Three to nine year olds typically prefer playing to talking. I show them around the playroom pointing out all that we can do and then follow the child’s lead. The child chooses the play, and I perform my part as directed. I am both a participant actor in and quiet observer of the child’s drama, whatever it may be.

In this process I keep in mind the central, core question: of all the possible play activities this child could have chosen, why did he choose this play and what does it mean? What is he telling me? In the metaphors of his play, I know that he is “talking” about himself, his mind, his conflicts, his concerns and his relationships with his family members.

Figuring out the meaning is challenging. Like decoding encrypted communications, the concerns that underlie the play are most often hidden and not readily apparent: deciphering the meanings takes time and repetition as play themes develop and become more defined and differentiated. Considering the range of possible meanings of the play’s content constitutes the art of therapy with children. Keep in mind that it is a shared undertaking, not just me as a therapist but the parents and me working together to make sense of the developmental issues and conflicts.

Some parents assume that their child will use therapy to talk about his problems, just like adults do and are disappointed when their child fails to discuss his anxiety, depression or difficulty getting along with his sister. Such expectations are ill-founded. Almost all children want to play, not talk. If pressed, a child will offer a few sparse sentences about his concerns and then want to get down to the business of playing. Some parents have complained to me that the play misses the point and is a waste of time. These judgments are various. “I didn’t bring my child here just to play. Of course he enjoys coming. Who wouldn’t want to play, but it doesn’t fix the problems.” From this perspective play is frivolous and indulgent waste of time that fails to address the problems.

This view represents a fundamental misunderstanding of the child therapy. When children play in therapy sessions, they are “talking” about themselves and their feelings. Play is the language of child therapy.

But why don’t children talk about their issues like adults do? It is primarily because children do not yet have the neurological equipment to think about their own minds in a reflective way, as we adults do. This capacity normatively emerges with the explosion of brain growth in adolescence, and these capabilities grow and strengthen as teenagers move towards their young adult lives. One of the great discoveries in child mental health care has been that children talk about and examine their world in medium of play. I will have a lot more to say about this subject in a later post.

In the next post I will consider what constitutes and psychological diagnostic evaluation and what recommendations would likely follow from an initial assessment.
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I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you?  What are your questions?  I will do my best to respond in a timely way.  Please don’t dismiss my requests. I really mean what I am saying!  Please offer your thoughts and questions.

Parents’ Guide to the Therapeutic Process with Children – Part 4: What should you expect of your relationship with your child’s therapist?

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In Part 3 of a Parents’ Guide, I characterized three core principles (working as a team, recognizing layers of complexity, and collectively joining in a reflective process of exploration and understanding) that govern the process of child psychotherapy. In this fourth post I consider what you as parents should expect of the relationship with your child’s therapist.

In my experience psychotherapy with children has a high likelihood of failing unless the parents and the therapist join and work well together.  What then nurtures a successful working relationship between you and your child’s therapist?

From the beginning you as parents should assume that you will have an ongoing relationship with your child’s therapist.  There are two main goals for the therapy. The first is to help your child with her difficulties. The second is to promote and strengthen the relationship between you and your child.

The particular characteristics of a parent-therapist relationship grow out of and are adapted to the child’s and family’s challenges and needs.  There is no one correct approach.  Instead there are a range of  possibilities that you as parents and your child’s therapist consider and together determine to be an approach that is most likely to be helpful.  Here are some examples, all of which have been part of my experiences as a therapist.

Some parents want and need help in figuring out how to make sense of and respond to their child’s problematic behaviors and troubled states of mind.  In such instances, I meet frequently with parents, and we brainstorm ways of thinking about what is going on and how best to understand and respond to the difficulties.

Sometimes parents ask for cookie cutter explanations/solutions, but this is seldom useful.  What works are back-and-forth exchanges that are both creative and collaborative.  And of course these exchanges should be laced with the therapist’s offering valuable insights and observations.

Other parents feel less of an imperative to meet frequently with their child’s therapist. In these instances we might get started meeting weekly and then taper to monthly meetings to keep one another up to speed. I would want to know how you are seeing your child and what is happening at home, in school, with peers, and you in turn want to know what I am seeing in my sessions with your child.

With more intermittent meetings, it is always helpful to learn from your texts, emails or phone calls about an incident or some unfolding events you think I should know about.  Since your child will seldom bring up a concerning event on her own, I take the lead. “Your mom mentioned that … What do you think that was all about? It will probably be useful for us to talk about it.  Are you OK with that?”

Regular family meetings,  attending school conferences with parents, speaking with the pediatrician and other providers – all are types of meetings that can be folded into your child’s care, again depending on the specific circumstances and what is needed.

On rare occasions, I have found myself deciding on limited contacts with parents – this because maintaining such involvements would significantly interfere with the child’s therapy. However, almost always there are clear benefits to parents being actively engaged in and aware of what is unfolding in the child’s therapy and for their child’s knowing that her parents are actively involved.

It is vital that your parent-therapist interactions are comfortable and safe, that you have the he-gets-me feeling, that you “feel felt” and not criticized or judged.  As parents you should resonate with the sense that your child’s therapist is invested not only your child’s growth and mental well-being, but also in facilitating and strengthening your relationship with your child.

I have found that I can be most helpful to a child and her family if I gather not only information about the presenting issues but also a thorough history.  How did you as parents meet and start your family? What was it like to be a child in your families of origin?  What is it like now that the roles are reversed – you are the parent, not the child?  What are the noteworthy events in your family’s history and your child’s developmental narrative?  Without this information, I always feel like I am flying blind without being sufficiently aware of the forces at play in your family members’ lives.

Some parents are susceptible to two misguided and excruciatingly painful and toxic ways of thinking about themselves as parents.  The first is, “I failed. It is my fault that my child is experiencing psychological distress. If we had just done a better job, our child wouldn’t  be struggling, and we would not have had to ask for help.”  The second is the vision that the present problems will remain static and persist unchanged. In this nightmare an aggressive six year old boy becomes a young adult criminal incarcerated for his violent acts.  If you are not so afflicted, you are fortunate, and you are exercising good judgment.

These kinds of negative feelings and thoughts are never helpful. Why? First, guilt and self-condemnation do not facilitate kindly self-regard and empathic understandings, either of yourselves or your child.  Instead they turn your reflections away from exploring the issues and from arriving at new insights and ways of engaging a child’s difficulties.  Second, the vision that nothing will change dramatically fails to consider the vast changes that unfold in a child’s developing mind.  There is no way that what you see at six will remain fixed and the same in your young adult offspring.  I have often found myself helping parents push back against these commonly held but deforming ideas.

Parents wanting to get their child into therapy often wonder how to introduce the idea.  They also frequently anticipate the child’s resistance.  So how do you broach the idea? And how do you as a parent respond to the resistance?

The first approach is to share with your child that you have seen her struggle with difficult feelings and behaviors.  You might say something along these lines, “As your parents who love you more than anything in the world, we want to see you gain some relief from your distress. We want you to see a ‘feelings doctor’ to help with the awful feelings.  And you are not alone. We are going to see him too, because this is a family thing.  We are all in this together. ”

I have found that a child resists seeing a ‘feelings doctor’ primarily when she feels blamed, like she is broken and the cause of the problems in the family.  She thinks she is being sent to a therapist to be fixed, like a broken clock.  And at an unconscious level the experience feels like proof that she is damaged or crazy.

There are two responses to this resistance.  First, to reiterate, it is not just you. It is us too. We are all in this together.  Second, seeing a “feelings doctor” shows strength, not weakness, because working on and thinking about difficult feelings is what strong people do.

In the next post I will take  up the question of how a therapist gets off to a good start with a child.

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I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you?  What are your questions?  I will do my best to respond in a timely way.  Please don’t dismiss my requests. I really mean what I am saying!  Please offer your thoughts and questions.

 

Parents’ Guide to the Therapeutic Process with Children – Part 3: What are the touchstone principles that guide the work?

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In Part 2 of a Parents’ Guide, I reflected on why parents call a child therapist. In this third post I offer three core principles that guide the work.

In the post’s title I chose the word touchstone for its meaning – “a standard or criterion by which something is judged or recognized.”  So what then are the touchstone principles that guide the work of child therapy?

The Team. The first is that you as parents, your child, the therapist, the teachers, your pediatrician and others who may be involved are a team, joining together in figuring it out and working it through.  Each person’s role is distinct and vitally necessary, and there must be ongoing communications as needed between team members. On the team, the therapist plays a central, guiding and partnering role in the psychological aspects of the work.

Layers. Presenting issues manifest themselves on the surface, covering and often disguising underlying influences/forces that mold what is most discernibly in sight.  The challenge is to peel back the layers, often one by one, to explore what is going on beneath the visible, often turbulent surface.

One significant and seductive risk for parents and providers alike is getting stuck on the surface, focusing primarily, even exclusively, on problematic behaviors without exploring what lies beneath. From this perspective what is going on below the surface is not held as central to the therapeutic process.

This view is particularly a hazard in our culture, primarily because of the longstanding, often entrenched perspectives born of learning theory in psychology (operant conditioning , a la B. F. Skinner). In this view all behaviors can be shaped into their preferred forms using well-engineered reinforcement schedules (roughly defined as rewards and punishments).  Whole schools of best parenting practices and treatment regimens have been built on the foundational principles of Skinnerian learning theory.

For me or anyone to assert that beneath-the-surface issues are all that matters would be naive and misguided. Problematic behaviors are problematic, and these must be engaged and addressed.  There are times when techniques from learning theory can be applied usefully in child therapy. However, the sources of behavioral problems are almost always rooted in misfiring relational patterns that constrain and interfere in kids getting along with family members, peers and others.  And these patterns while most often not immediately visible, nevertheless powerfully play out beneath the surface energizing problematic behavior.

Reflective Process.  An optometrist tests vision with lenses, evaluating  which lenses sharpen visual focus and clarity and which don’t.  By analogy we as a team try out different understandings, brainstorming and considering  possible ways of making sense of the difficulties, retaining some understandings, while discounting, even discarding others.  Successful outcomes in therapy depend on this kind of ongoing reflective process.

The reflective process recognizes complexity, that understandings require multiple perspectives and no one explanation is sufficient.  It resists simple explanations and snap categorizations that can constrain the process of developing deeper insights and that can interfere with understandings and working things through.  And it acknowledges that influences outside of conscious awareness contribute to the difficulties.

The concepts of the team, layers and reflective process are three foundational pillars that support and structure the work of child psychotherapy.

In the next post I am going offers a view of what parents can expect of their relationship with their child’s therapist.

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I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you?  What are your questions?  I will do my best to respond in a timely way.  Please don’t dismiss my requests. I really mean what I am saying!  Please offer your thoughts and questions.

Parents’ Guide to the Therapeutic Process with Children – Part 2: Why Call a Therapist?

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In the first post, I offered my rationale for writing a Parents’ Guide to the Therapeutic Process with Children.

In this second post I ask why would you as parents call a child therapist?  In my experience, it is because troubling behaviors/events reach a threshold of concern, alarm and worry.   You might say in essence, “There is a problem. We don’t know what to do. Our child needs help, and we need help helping our child.”

Calling a therapist is an impressive act, because realizing that there are problems takes courage as well the capacity for self-reflection.  And it demonstrates your strength of caring for the well-being of your child and your family to recognize that you may not be able to figure it all out on your own.

Why am I emphasizing that asking for help is a signature of strength?  Because in my experience, parents frequently don’t recognize and credit themselves with what they have already accomplished in calling attention to the problems and asking for help in addressing them.

Parents’ concerns typically coalesce around behaviors/events/circumstances that are bearing down on the child and the family.  Here are some common categories of concern:

  • within a family
    • a child’s resisting or refusing to comply with expectations  –  going to bed,  getting out of bed in the morning, hygiene, messy room, not doing homework, refusing to do chores, not joining the family at mealtimes, not participating in family activities, etc.
    • relational conflicts – with parents and/or siblings, at times conjoined with tensions and angry outburst/intemperate remarks
    • reactions to marital conflicts – parents fighting, signaled but unspoken tensions, separation or divorce
    • family illness – physical or psychological illness
    • death – grieving loss
    • economic stress – job loss or transfer, sudden drop in family income
  • with school
    • academic problems – poor grades, not doing homework
    • classroom inattention – not paying attention, talking out of turn, behaviors that distract classmates
    • breaking school rules – getting into trouble
  • with peers
    • limited friendships with peers – problematic social skills, not accurately reading social cues
    • aggressive, bullying behavior  towards other kids
    • being picked on – teased, made fun of
  • mental states and cognitive processing issues
    • anxiety – on edge, constantly worried that something  bad might happen
    • low self-esteem – feeling unworthy, less than adequate
    • sad, depressed feelings – at times expressing the wish not to be alive or having suicidal thoughts
    • problems regulating feelings – often expressed in outbursts of temper, being chronically irritable
    • cognitive processing issues – such as attention deficits, dyslexia, inefficiencies is executive processing

The presenting issues often fall into one or more of these categories.  However, every individual and family narrative is uniquely rich and complex with endless variations in specific circumstances and wide ranging experiences.  These complexities make it all the more fascinating and worthy of thoughtful attention and care.

Once the presenting concerns have been laid out, the journey begins – figuring out and making sense of what is going on, calming the waters and working  towards relief from distress and turbulence.

In the next post I am going to frame the core principles that guide the work with a child and the family.

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I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you?  What are your questions?  I will do my best to respond in a timely way.  Please don’t dismiss my requests. I really mean it! Please offer your thoughts and questions.

Parents’ Guide to the Therapeutic Process with Children – Part 1: The Rationale for this Guide

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Why write a series of posts about the psychotherapeutic process with children?

Most parents I meet have vitally important questions about psychotherapy with children and in particular their child.  What can they expect? How does the process work?  Why and in what ways does it help? When they consider entrusting their precious child to my care, they appropriately, responsibly want to know more about me in conjunction with how I understand the therapeutic process with their child and my role in it.

They have sensible and well-founded questions, in part, because providers who offer psychotherapeutic services to children often have a wide range of background experiences and understandings of child therapy, how it works and what matters.

This series of posts stems from my thought that parents who are interested may find it of value to hear from me as a practitioner:  how do I think about and answer the questions that they so rightfully ask?  My hope is that these posts may provide parents and others with some guideposts about what to expect and how to think about the process.

Here is a list of six post topics that I hope will shed light on the process of  the psychotherapy of children, each with a specific focus.

  • Why do parents call a therapist?
  • What are the touchstone principles that guide the work?
  • What should parents expect of their relationship with the therapist?
  • What are keys to getting off to a good start with a child?
  • What constitutes a psychological evaluation, and what are the range of  recommendations that would likely follow from an evaluation?
  • What happens in a child therapy session?

The work with children is so vitally important, and there is so much for us to think about together – like the role of play, making interpretive remarks to children, confidentiality in communications, evaluating suicide risk, issues about limit setting and discipline, TV and computer screens, learning problems and working with schools – the list goes on.  This series of posts will give you some sense of  how I view the therapeutic process with children and my role in it.

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I invite you not only to read my posts but to leave comments. Let me know what you think. Also what issues interest you?  What are your questions?  I will do my best to respond in a timely way.  Please don’t dismiss my requests. I really mean what I am saying!  Please offer your thoughts and questions.