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A CLASSIC REVISITED: Therapeutic Consultations in Child Psychiatry
B O O K
REVIEWS
A C L A S S I C REVISITED
Thisfedture of the Book Review section presents current reviews of classic books that have provided fundamental knowledge for child and adolescent psychiatry. Therapeutic Consultations in Child Psychiatry. By Donald W: Winnicott. New York: Basic Books, 1371, 410pp., $15.00
(hardcover). If a pessimistic colleague ever doubts that some children can be helped in 1 to 3 sessions, or that a therapist’s spontaneous play with children is “mere child’s play” with no lasting effect, suggest this book. First published in 1971, the year of Dr. Winnicott’s death and about the time I first read it, the book is both an unapproachable ideal and a source of much practical wisdom, especially about the first interview or two. Winnicott cannot be copied, but he can be learned from. He is always a source of inspiration. In the introduction he states, “. . . the work cannot be copied because the therapist is involved in every case as a person, and therefore no two interviews could be alike as they would be carried through by two psychiatrists” (p. 9). Spontaneous responsiveness was the essence of how he played squiggle (the famous game in which the child and therapist alternate offering each other a “squiggle,” or spontaneous curved line, which the other finishes into a recognizable object such as a face, a snake, or whatever). The doctor who considered the spontaneous gesture the mark of a true self, as opposed to a false or compliant self, naturally liked a game emphasizing mutual spontaneity. Yet ironically the “game with no rules” has quite a few. First, from the introduction, “In order to use the mutual experience one must have in one’s bones a theory of the emotional development of the child and of the relationship of the child to the environmental factors.” Winnicott wrote 7 books about this very subject, so few would question his credentials to play. Second, the pace of revelation must never be intrusive because pressure only creates defiance or, worse, compliance from a self that lacks true spontaneity. He also advises against brief consultation in the presence of continuing adverse external factors. Brief consultation only loosens a knot so the child can again find a healthy developmental path in a responsive enough environment. In assessing the environment, he shows faith in the child‘s view: “. . . it may be the child who best puts us in touch with the principal defect in the environment” (p. 8).
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : i , J A N U A R Y 2nnn
Assistant Editor: Dean X Parmelee, M.D.
The aim of the book is “. . . to report examples of communication with children” (p. 8; italics are his), not symptomatic cure. The capacity to reach deep into the child‘s inner world while simultaneously totally respecting the child’s need for being unknown is a part of what is sophisticated about these interviews. Winnicott uses small clues to sense when the child is signaling a readiness to go deeper, often citing the child’s choice of a larger sheet of paper. (I am now careful to offer children varied sizes of paper on which to draw. Here is a simple idea that can be easily stolen, “stolen” itself being one of Winnicott’s favorite words. He never borrows anything.) He compares himself to a cellist who has technique but is playing music. Often these clues of readiness to communicate more deeply lead Winnicott to ask about dreams. The child then draws a dream sequence. Yet he emphasizes, “. . . interpretation of the unconscious is not the main feature [of squiggle]” (p. 9). Communication with the child is the main feature. Allowing the child to make use of him as a “subjectiveobject” (his phrase for how the child initially perceives the therapist he has never met before), Winnicott says that the first interviews with a child are a unique opportunity to let the child see him as whoever he needs to be within the child: own subjective realiy. After several interviews, things are more complicated. The reality of who he is has intervened. Despite Winnicott’s professed disinterest in outcome, he cures. After only one interview, all but 1 of the 8 children aged 5 to 13 he sees for stealing report no stealing even years or decades later. He recommends residential treatment for one. In another case he even mentions in passing that after the first consultation, “The father also said that Jason was no longer smoking (p. 368). Take that, Zyban. Can the “modern” child psychiatrist, encumbered and enriched with CDIs, CBCLs, and DSM-Nand anticipating a call from a managed care reviewer, make use of this book? Unequivocally yes. First, Winnicott’s system of diagnosis is to ask something like this: Where, when, and in what way during development did the environment fail the emotional needs of this child as assessed by what he communicates in spontaneous free play?This is a useful frame for a first interview. Second, as our field increasingly moves toward structured manuals, he reminds us of the value of spontaneity. His own personal example of playful spontaneity within the context of deep commitment to the study of development embodies both discipline and spontaneity. Finally, he reminds us that a deep need to communicate coexists in the child with a need to be unknown, or even what he calls unfound, and that the right
123
BOOK REVIEWS
intervention with the right child can make a big difference quickly. What a comforting thought. John Hamilton, M.D. Clinical Faculty, University of California, Davis Senior Physician Permanente Medical Group of Northern California
Treating the Tough Adolescent: A Family-Based, Step-byStep Guide. By Scott I? Sells. New York: The Gui@rd Press, 1998, 320pp., $35.00 (hardcover). Parents increasingly seek outside help to deal with their adolescent children’s behavior problems. From time to time, books have appeared that deal specifically with family interventions for adolescents with behavior disorders, and in a recent addition to this literature, Dr. Sells details a treatment model based on principles derived from structural and strategic paradigms of family therapy. As the subtitle suggests, this book is intended to be a step-by-step manual to help clinicians deal with “tough” adolescents with behaviors such as hostility, threats of violence, theft, destruction of property, vandalism, lying, firesetting, truancy, threats of suicide, and running away. The question arises: Is this manual appropriate for use in a child and adolescent psychiatry training program? Dr. Sells lays out the basic assumptions and outlines the 15 steps of treatment. It is assumed that difficult teenagers maintain more powerful positions in the hierarchy than their parents. The outlined model of treatment seeks to help parents reverse this hierarchical assumption to regain control. The chapter “Neutralizing the Adolescent‘s Five Aces” describes behaviors that difficult adolescents use to undermine their parents’ attempts to reestablish parental authority: running away, truancy/poor school performance, suicidal threats or behaviors, threats or acts of violence, and disrespect. Dr. Sells then discusses strategies to restore nurturing behaviors in the parent-teen relationship. Clinical examples and clips from session transcripts explicate opportunities to build trust and to help parents deal with criticism, offer praise, listen attentively, use physical touch as an expression of tenderness, and plan special family outings. Part 3 deals with issues such as working with other health care and educational providers, understanding problems peculiar to single-parent fimilies and divorced parents, and approaching teenage alcohol and drug use problems. The final section details the process-outcome research used in developing this treatment model. The how-to style makes for easy reading. Child and adolescent psychiatry trainees looking for practical suggestionsfor clinical situations will find numerous guidelines for dealing with escalating situations such as a teenager threatening to leave home when grounded, i.e., parents will try to physically stop the teen-
124
ager, will call police and press assault charges if the teenager strikes the parents, will file a missing person report if the teenager leaves. Parent handouts summarize these and other strategies to deal with a runaway teenager, including confiscatingor pawning prized possessions, instituting a 24-hour watch, time-out in the bathroom, and even physical restraint using the “takedown” procedure, which is suggested as a last resort. The possibility that a teenager may use these interventions as a weapon against the parents by calling Child Protective Services is discussed. To help the parents be prepared for such an inquiry, the author suggests providing a printed rationale for each intervention. For those interested in the derivation of the treatment model, the last section lends credibility to the entire work, describing the elaborate process of reviewing previous clinical practice casesand analyzing videotapes of expert clinicians. The treatment model was field-tested on more than 80 adolescents, most of whom were males (average age 15).The clinical samplewas &rly diverse; 68% were European-American and about half the group had family annual income of less than $20,000. The study sample consisted of adolescents with severe behavior disorders, as evidenced by an average of 2 stays at residential facilities and 3 arrests. The manual was field-tested by 3 MAW. counselors and a Ph.D. supervisor with 3 or more years of clinical experience. The average length of treatment was 10 sessions, the minimum being 5 sessions. Because trainees frequently must work with outside providers, Dr. Sells offers concrete suggestions on how to deal with contradictory advice given by other providers. A good case example (p. 214) describes a plausible scenario (a school counselor undermines the family therapist‘s expertise) and a reasonable response (calmly acknowledging differences of opinion between professionals, pointing out past success in treatment, and negotiating with parents for some time to allow for therapy to work). Another case example (p. 215) describes a counselor who took a stance opposite to the psychiatrist‘s recommendation to hospitalize the teenager. Awareness of alternative conceptualizations could help child and adolescent psychiatry trainees work better with other mental health providers. One of the author‘s assumptions is that a behavior problem diagnosed as a chemical imbalance is more difficult to solve than one diagnosed as a family systems problem. Dr. Sells addresses this complex and controversial issue with finesse, suggesting that hospitalization falsely allows adolescents to hear a message that they are not responsible for their actions. He asserts that involving the police and pressing charges for property damage and physical violence is a more appropriate consequence than hospitalization. Some interventions he describes are very intense and appear to involve a level of commitment from parents and counselors that may be unrealistic, including the suggestion that parents should take a day off from work to go to school with the teenager, keep a 24-hour watch, sit in the living room with the teenager all day, and enlist the support of the community to
J . AM. A C A D . C H I L D A D O L E S C . PSYCHIATRY, 39:1, JANUARY 2 0 0 0
REVIEWS
A C L A S S I C REVISITED
Thisfedture of the Book Review section presents current reviews of classic books that have provided fundamental knowledge for child and adolescent psychiatry. Therapeutic Consultations in Child Psychiatry. By Donald W: Winnicott. New York: Basic Books, 1371, 410pp., $15.00
(hardcover). If a pessimistic colleague ever doubts that some children can be helped in 1 to 3 sessions, or that a therapist’s spontaneous play with children is “mere child’s play” with no lasting effect, suggest this book. First published in 1971, the year of Dr. Winnicott’s death and about the time I first read it, the book is both an unapproachable ideal and a source of much practical wisdom, especially about the first interview or two. Winnicott cannot be copied, but he can be learned from. He is always a source of inspiration. In the introduction he states, “. . . the work cannot be copied because the therapist is involved in every case as a person, and therefore no two interviews could be alike as they would be carried through by two psychiatrists” (p. 9). Spontaneous responsiveness was the essence of how he played squiggle (the famous game in which the child and therapist alternate offering each other a “squiggle,” or spontaneous curved line, which the other finishes into a recognizable object such as a face, a snake, or whatever). The doctor who considered the spontaneous gesture the mark of a true self, as opposed to a false or compliant self, naturally liked a game emphasizing mutual spontaneity. Yet ironically the “game with no rules” has quite a few. First, from the introduction, “In order to use the mutual experience one must have in one’s bones a theory of the emotional development of the child and of the relationship of the child to the environmental factors.” Winnicott wrote 7 books about this very subject, so few would question his credentials to play. Second, the pace of revelation must never be intrusive because pressure only creates defiance or, worse, compliance from a self that lacks true spontaneity. He also advises against brief consultation in the presence of continuing adverse external factors. Brief consultation only loosens a knot so the child can again find a healthy developmental path in a responsive enough environment. In assessing the environment, he shows faith in the child‘s view: “. . . it may be the child who best puts us in touch with the principal defect in the environment” (p. 8).
J . A M . ACAD. C H I L D A D O L E S C . PSYCHIATRY, 3 9 : i , J A N U A R Y 2nnn
Assistant Editor: Dean X Parmelee, M.D.
The aim of the book is “. . . to report examples of communication with children” (p. 8; italics are his), not symptomatic cure. The capacity to reach deep into the child‘s inner world while simultaneously totally respecting the child’s need for being unknown is a part of what is sophisticated about these interviews. Winnicott uses small clues to sense when the child is signaling a readiness to go deeper, often citing the child’s choice of a larger sheet of paper. (I am now careful to offer children varied sizes of paper on which to draw. Here is a simple idea that can be easily stolen, “stolen” itself being one of Winnicott’s favorite words. He never borrows anything.) He compares himself to a cellist who has technique but is playing music. Often these clues of readiness to communicate more deeply lead Winnicott to ask about dreams. The child then draws a dream sequence. Yet he emphasizes, “. . . interpretation of the unconscious is not the main feature [of squiggle]” (p. 9). Communication with the child is the main feature. Allowing the child to make use of him as a “subjectiveobject” (his phrase for how the child initially perceives the therapist he has never met before), Winnicott says that the first interviews with a child are a unique opportunity to let the child see him as whoever he needs to be within the child: own subjective realiy. After several interviews, things are more complicated. The reality of who he is has intervened. Despite Winnicott’s professed disinterest in outcome, he cures. After only one interview, all but 1 of the 8 children aged 5 to 13 he sees for stealing report no stealing even years or decades later. He recommends residential treatment for one. In another case he even mentions in passing that after the first consultation, “The father also said that Jason was no longer smoking (p. 368). Take that, Zyban. Can the “modern” child psychiatrist, encumbered and enriched with CDIs, CBCLs, and DSM-Nand anticipating a call from a managed care reviewer, make use of this book? Unequivocally yes. First, Winnicott’s system of diagnosis is to ask something like this: Where, when, and in what way during development did the environment fail the emotional needs of this child as assessed by what he communicates in spontaneous free play?This is a useful frame for a first interview. Second, as our field increasingly moves toward structured manuals, he reminds us of the value of spontaneity. His own personal example of playful spontaneity within the context of deep commitment to the study of development embodies both discipline and spontaneity. Finally, he reminds us that a deep need to communicate coexists in the child with a need to be unknown, or even what he calls unfound, and that the right
123
BOOK REVIEWS
intervention with the right child can make a big difference quickly. What a comforting thought. John Hamilton, M.D. Clinical Faculty, University of California, Davis Senior Physician Permanente Medical Group of Northern California
Treating the Tough Adolescent: A Family-Based, Step-byStep Guide. By Scott I? Sells. New York: The Gui@rd Press, 1998, 320pp., $35.00 (hardcover). Parents increasingly seek outside help to deal with their adolescent children’s behavior problems. From time to time, books have appeared that deal specifically with family interventions for adolescents with behavior disorders, and in a recent addition to this literature, Dr. Sells details a treatment model based on principles derived from structural and strategic paradigms of family therapy. As the subtitle suggests, this book is intended to be a step-by-step manual to help clinicians deal with “tough” adolescents with behaviors such as hostility, threats of violence, theft, destruction of property, vandalism, lying, firesetting, truancy, threats of suicide, and running away. The question arises: Is this manual appropriate for use in a child and adolescent psychiatry training program? Dr. Sells lays out the basic assumptions and outlines the 15 steps of treatment. It is assumed that difficult teenagers maintain more powerful positions in the hierarchy than their parents. The outlined model of treatment seeks to help parents reverse this hierarchical assumption to regain control. The chapter “Neutralizing the Adolescent‘s Five Aces” describes behaviors that difficult adolescents use to undermine their parents’ attempts to reestablish parental authority: running away, truancy/poor school performance, suicidal threats or behaviors, threats or acts of violence, and disrespect. Dr. Sells then discusses strategies to restore nurturing behaviors in the parent-teen relationship. Clinical examples and clips from session transcripts explicate opportunities to build trust and to help parents deal with criticism, offer praise, listen attentively, use physical touch as an expression of tenderness, and plan special family outings. Part 3 deals with issues such as working with other health care and educational providers, understanding problems peculiar to single-parent fimilies and divorced parents, and approaching teenage alcohol and drug use problems. The final section details the process-outcome research used in developing this treatment model. The how-to style makes for easy reading. Child and adolescent psychiatry trainees looking for practical suggestionsfor clinical situations will find numerous guidelines for dealing with escalating situations such as a teenager threatening to leave home when grounded, i.e., parents will try to physically stop the teen-
124
ager, will call police and press assault charges if the teenager strikes the parents, will file a missing person report if the teenager leaves. Parent handouts summarize these and other strategies to deal with a runaway teenager, including confiscatingor pawning prized possessions, instituting a 24-hour watch, time-out in the bathroom, and even physical restraint using the “takedown” procedure, which is suggested as a last resort. The possibility that a teenager may use these interventions as a weapon against the parents by calling Child Protective Services is discussed. To help the parents be prepared for such an inquiry, the author suggests providing a printed rationale for each intervention. For those interested in the derivation of the treatment model, the last section lends credibility to the entire work, describing the elaborate process of reviewing previous clinical practice casesand analyzing videotapes of expert clinicians. The treatment model was field-tested on more than 80 adolescents, most of whom were males (average age 15).The clinical samplewas &rly diverse; 68% were European-American and about half the group had family annual income of less than $20,000. The study sample consisted of adolescents with severe behavior disorders, as evidenced by an average of 2 stays at residential facilities and 3 arrests. The manual was field-tested by 3 MAW. counselors and a Ph.D. supervisor with 3 or more years of clinical experience. The average length of treatment was 10 sessions, the minimum being 5 sessions. Because trainees frequently must work with outside providers, Dr. Sells offers concrete suggestions on how to deal with contradictory advice given by other providers. A good case example (p. 214) describes a plausible scenario (a school counselor undermines the family therapist‘s expertise) and a reasonable response (calmly acknowledging differences of opinion between professionals, pointing out past success in treatment, and negotiating with parents for some time to allow for therapy to work). Another case example (p. 215) describes a counselor who took a stance opposite to the psychiatrist‘s recommendation to hospitalize the teenager. Awareness of alternative conceptualizations could help child and adolescent psychiatry trainees work better with other mental health providers. One of the author‘s assumptions is that a behavior problem diagnosed as a chemical imbalance is more difficult to solve than one diagnosed as a family systems problem. Dr. Sells addresses this complex and controversial issue with finesse, suggesting that hospitalization falsely allows adolescents to hear a message that they are not responsible for their actions. He asserts that involving the police and pressing charges for property damage and physical violence is a more appropriate consequence than hospitalization. Some interventions he describes are very intense and appear to involve a level of commitment from parents and counselors that may be unrealistic, including the suggestion that parents should take a day off from work to go to school with the teenager, keep a 24-hour watch, sit in the living room with the teenager all day, and enlist the support of the community to
J . AM. A C A D . C H I L D A D O L E S C . PSYCHIATRY, 39:1, JANUARY 2 0 0 0