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Healing the Hurt Child: A Developmental-Contextual Approach
BOOK REVI EWS
Healing the Hurt Child: A Developmental-Contextual Approach. Denis M. Donovan and Deborah Mcint yre. New York: Norton, 1990, 320 pp., $34.95 (hardcover).
In the Adolf Meyer Lecture at the annual meeting of the American Psychiatric Association in 1990, Melvin Sabshin traced the changing borders and boundaries of psychiatry in the 20th century, its demedicalization in the 1960s, and its remedicalization in the 1980s. He predicted that in the 21st century psychiatry will move toward "a new systemized psychobiology of coping, of adaptation, and of active efforts by persons to deal with multilevel stresses." Denis Donovan and Deborah McIntyre have antici pated that movement. They reveal a psychob iology of the hurt child seen to be repeatedly attempting to cope, adapt, and deal with extremely severe stresses. Their goal is to bring to child psychiatry a badly needed problem-solving approach. Their view is optimistic; the ir focus is on the child 's strivings and strengths. They explore puzzling behaviors and symptoms and find them to be understandable responses to conclusions that the developing child logically deduces from existential events and co ndi tio ns. Th eir approach is thu s development al- cont extu al. They demonstrate how suitably constructed therapeutic intervention can relieve disorders as dramatically as trauma can precipitate them. Their conceptualization of the " therapeutic space" takes theory into practice. The authors begin by stating their concern over the current trend to medicalize psychiatry on the one hand, and to continue to employ pessimistic and ineffective modes of psychotherapy on the other. They caution against three obstacles to the simple understanding of children. First, the Freudian therapist' s pursuit of conscious awareness and self-observation serves the therapists' needs and convictions but misapplies an adult model of thought to the child. Second, the demarcation of cognitive limitations according to Piagetian stages blinds the therapist to the child' s early developmental ability to generate hypotheses and arrive logically at conclusions regarding the cause of danger and injury. That such conclusions may be mistaken in no way denies the logic em ployed. Discovery of that log ic permits therapeutic change; failure to recognize it leads to the third obstacle, the categorization of dysfunction, with possibly false presumption by the therapist oflearning disability and psychiatric disturbance in the traumatized child. The authors elaborate how children are ' 'obligatory slaves of logic"; traumatized children ' s fantasies and daydreams, rather than solely expressing wishes, fears and conflicts, contain operational hypotheses and implicit beliefs. The authors refer to the verbalizations of the kidnapped, entrapped children described by Lenore Terr. Although called fantasies, they were in fact recognized by Terr as hypothetical beliefs about the nature of events experienced by the children, based on the children's available information and past exp erie nce. The authors ' developmental-cont extu al approach encompas ses such recognition, that statements, fantasies and behaviors are contextually related, are responses to beliefs, and are expressively communicated. The authors J. Am.Acad. Child Adolesc. Psychiatry , 31:3, May 1992
offer a striking example of a child whose behavior imitating a handicapped parent was misunderstood out of context. The pathological identification of the child, who had been declared mentally retarded with an IQ of 60, was recognized, and, with psychotherapeutic help, the child was returned to a normal classroom and did grade level work with average or above average ability. The authors emphasize the importance of the therapist being aware of the child' s past and present behavioral states of consciousness; they note specifically the state of normative dissociation. The developing child must learn how to modulate behavioral states, normally dissociati ve in infancy and early childhood. Modulation permits the child to create the consistency and continuity of experience required for the development of cognitive skills and accurate understanding. When a child cannot do this because of persistent dissociative responses to trauma, the child may appear to be severely cognitively impaired. The authors agree with Bessel van der Kolk' s concept of inescapable shock, which produces neurophysiological as well as psychological consequences in traumatized victims unable to escape from their abusive experiential world. When the therapist recognizes the child' s state of awareness and provides a restructuring of a disordered psychophysiological style, many of the psychological sequelae of trauma can be attenuated or reversed, including attention deficit disorders, hyperarousal to full-blown mania, intrusive reexperiencing with flashbacks , nightmares and night terrors, and repeated addiction to trauma. The authors refer to the occurrence of " behavioral memories," citing Terr ' s work regarding trauma very early in life later producing memories identifiable through behavior but completely inaccessible to verbal recall. Family secrets as well may not be consciously accessible but can emerge in the form of behavioral memory. From this foundation, the authors devote the largest part of their book to clinical application and operational practice made abundantly clear by case examples. They proceed to describe their method s of history taking, their use of the tools of logic, parent issues, their conceptualization and utilization of the "therapeutic space," and evaluation of the child's therapeut ic aptness. They take the reader step by step through very creative techniques and important guiding rules. Recapitulating theory and principles of understanding, the authors demonstrate their application to children suffering physical and sexual abuse, learning disabilities, attentional disorders, physical handicaps, seizures, and losses through adoption, foster care, and death of family members. Throughout, the authors contrast their developmental-contextual approach with approaches based on traditional style. They close by doing so, commenting in critical detail on the transference-focused psychoanalysis of a 4-year-old boy reported by James Anthony. They then offer an annotated transcript demonstrating their own intervention with a 6year-old boy. There is much to be learned from this book. It is more than a valuable manual of psychotherapy. The authors wish "to put the child, as it were, back into child psychiatry." I infer that they also wish to put the therapist back into the practice of effective psychotherapy. They maintain ' 'uncom571
BOOK REVIEWS
prom ising realism and equally uncompromising therapeutic optimi sm," recognizing that the child, even during maladaptation, is responsible for making choices. Their goal is for the child to make free and healthy ones. The author s thus reveal their values and themsel ves as determined healers, which I believe is what we, as psychotherapists, should offer our patients. This book should be read by all interested in children and serving children and their families. It should be read together with Lenore Terr ' s Too Scared to Cry: Psychic Trauma in Childhood, with Bessel van der Kolk' s Psychological Trauma, and with a delightful little book illustrating the young child's theory building ability, Gareth Matthews' Philosophy and the Young Child. Frank Putnam, in his beautifully written Forew ord concludes, " Donovan and McIntyre have carefully and lovingly integrated a wealth of recent information on linguistics, child cognition, behavioral states and dissociation into a realistic clinical approach that significantly advances our understanding of the cognitive-beha vioral sty les of childre n." Don ovan and McInt yr e, in addition, have given us an approach that significantly advances our understanding of our own styles as child psychiatrists. I recommend this book highly. Please read it. SILVIO J. ONESTI , M.D. Assistant Profes sor of Psychiatry Harvard Medical School
Of Human Bonding-Parent-Child Relations across the Life Course. By Alice S. Rossi and Peter H. Rossi. New York: Aldine de Gruyter, 1990, 542 pp., $62.95 (hardcover), $39.95 (softcover). Child psychiatrists will be drawn to the title of this book. Bonding and parent child relationships are of interest to all clinicians who evaluate and treat the disorders of early life. Thi s book is the summary of a research project, the first collaborative effort of the Rossis, a husband and wife team. Alice Rossi has worked and published extensively in the field of family sociology, and Peter Rossi has contributed to research methods in the area of opinion surveys. Their project was funded primarily by the National Institute on Aging. In this book, the Rossis have chronicled the development and findings of this project that attempted to answer how obligation, sentiment, and interaction between parents and adult children change across their life span. This study was retrospective, based on the self-report of respondents. Their basic method was to conduct personal interviews with a random probabil ity sample of 1,393 adults in the greater Boston area and to then ha ve self-administered vignette booklets and telephone interviews completed with a parent or an adult child of the Boston respondents. The goal of this book is to describe variation s in parent 572
child relation ships across the life cycle. The authors contend that the social sciences have neglected the parent-child relationship in the intervening years between childhood and when parents are aging. Their focus was to assess how sentiment, obligation and interaction change during these years. The book is organized into three main sections: the biopsychological and social structural dimen sions of aging, several chapters on normative obligations of kin and nonkin, and the analysis of the parent-child relationship regarding solidarity, affectional closeness, and social interaction. The issue of one ' s affiliative ties extending beyond one's death is also addressed in the chapter on inheritance and provisions for kin in actual or intended wills. We find especially noteworthy their comment s regarding kinship obligations, affectional closeness, family size, and the help offered from one generation to another. By interviewing adults, their children and their parent s, general comparisons were possible that shed light on issues such as the extent to which obligations are felt by one generation toward another generatio n. The Rossis assessed the affec tional closeness toward family members and the amount of help extended from one generation to another. They traced the current intimacy or strain in the parent-child relationship back to early family life to test whether or not certain family characteristics and earlier event s could bias current family relatedness. Their findings revealed that marital happines s of the parent was significantly related to the marital happiness of the adult children who had married. Although one may have suspected as much, the Rossis have quantified these pattern s. They also found that parental affection and family cohesion translated into warm, cooperative, and enduring families headed by happily married parents. Also, the children of such famil ies tended later to be more affectionately expressive, happil y married, and have cohesive families of their own. The impact of family size was also analyzed and the Rossis found that if the family of origin was large, this was associated with a lessening of the family' s sense of financial well-being and limited how far the children went in school. Large family size was related to lower parent investment in the children's training and social relatedness to the parents. For the Rossis, the implication is that a number of closelytimed pregnancies strains the parent, the marriage, and decreases parental time and energy available to an individual child. The Rossis have documented that the types of help between generation s are gender specific. Fathers are more likely to give advice, money, and employment direction to their children than are mother s. Sons are more likely to provide help in the form of personal effort such as yard work or othe r speci fic physical assistance. Moth er s and daughters are more likely to provide comfort, help with domestic matters, special gifts, and care during iIInesses. On the issue of gender-linked personal traits, the authors found that males stress conformity as a way to gain status, whereas, females stress that children should develop their own interests and talents. The style of this book is readable, but the necessary reflecJ. Am.Acad. ChildAdolesc. Psychiatry, 31:3, May 1992
Healing the Hurt Child: A Developmental-Contextual Approach. Denis M. Donovan and Deborah Mcint yre. New York: Norton, 1990, 320 pp., $34.95 (hardcover).
In the Adolf Meyer Lecture at the annual meeting of the American Psychiatric Association in 1990, Melvin Sabshin traced the changing borders and boundaries of psychiatry in the 20th century, its demedicalization in the 1960s, and its remedicalization in the 1980s. He predicted that in the 21st century psychiatry will move toward "a new systemized psychobiology of coping, of adaptation, and of active efforts by persons to deal with multilevel stresses." Denis Donovan and Deborah McIntyre have antici pated that movement. They reveal a psychob iology of the hurt child seen to be repeatedly attempting to cope, adapt, and deal with extremely severe stresses. Their goal is to bring to child psychiatry a badly needed problem-solving approach. Their view is optimistic; the ir focus is on the child 's strivings and strengths. They explore puzzling behaviors and symptoms and find them to be understandable responses to conclusions that the developing child logically deduces from existential events and co ndi tio ns. Th eir approach is thu s development al- cont extu al. They demonstrate how suitably constructed therapeutic intervention can relieve disorders as dramatically as trauma can precipitate them. Their conceptualization of the " therapeutic space" takes theory into practice. The authors begin by stating their concern over the current trend to medicalize psychiatry on the one hand, and to continue to employ pessimistic and ineffective modes of psychotherapy on the other. They caution against three obstacles to the simple understanding of children. First, the Freudian therapist' s pursuit of conscious awareness and self-observation serves the therapists' needs and convictions but misapplies an adult model of thought to the child. Second, the demarcation of cognitive limitations according to Piagetian stages blinds the therapist to the child' s early developmental ability to generate hypotheses and arrive logically at conclusions regarding the cause of danger and injury. That such conclusions may be mistaken in no way denies the logic em ployed. Discovery of that log ic permits therapeutic change; failure to recognize it leads to the third obstacle, the categorization of dysfunction, with possibly false presumption by the therapist oflearning disability and psychiatric disturbance in the traumatized child. The authors elaborate how children are ' 'obligatory slaves of logic"; traumatized children ' s fantasies and daydreams, rather than solely expressing wishes, fears and conflicts, contain operational hypotheses and implicit beliefs. The authors refer to the verbalizations of the kidnapped, entrapped children described by Lenore Terr. Although called fantasies, they were in fact recognized by Terr as hypothetical beliefs about the nature of events experienced by the children, based on the children's available information and past exp erie nce. The authors ' developmental-cont extu al approach encompas ses such recognition, that statements, fantasies and behaviors are contextually related, are responses to beliefs, and are expressively communicated. The authors J. Am.Acad. Child Adolesc. Psychiatry , 31:3, May 1992
offer a striking example of a child whose behavior imitating a handicapped parent was misunderstood out of context. The pathological identification of the child, who had been declared mentally retarded with an IQ of 60, was recognized, and, with psychotherapeutic help, the child was returned to a normal classroom and did grade level work with average or above average ability. The authors emphasize the importance of the therapist being aware of the child' s past and present behavioral states of consciousness; they note specifically the state of normative dissociation. The developing child must learn how to modulate behavioral states, normally dissociati ve in infancy and early childhood. Modulation permits the child to create the consistency and continuity of experience required for the development of cognitive skills and accurate understanding. When a child cannot do this because of persistent dissociative responses to trauma, the child may appear to be severely cognitively impaired. The authors agree with Bessel van der Kolk' s concept of inescapable shock, which produces neurophysiological as well as psychological consequences in traumatized victims unable to escape from their abusive experiential world. When the therapist recognizes the child' s state of awareness and provides a restructuring of a disordered psychophysiological style, many of the psychological sequelae of trauma can be attenuated or reversed, including attention deficit disorders, hyperarousal to full-blown mania, intrusive reexperiencing with flashbacks , nightmares and night terrors, and repeated addiction to trauma. The authors refer to the occurrence of " behavioral memories," citing Terr ' s work regarding trauma very early in life later producing memories identifiable through behavior but completely inaccessible to verbal recall. Family secrets as well may not be consciously accessible but can emerge in the form of behavioral memory. From this foundation, the authors devote the largest part of their book to clinical application and operational practice made abundantly clear by case examples. They proceed to describe their method s of history taking, their use of the tools of logic, parent issues, their conceptualization and utilization of the "therapeutic space," and evaluation of the child's therapeut ic aptness. They take the reader step by step through very creative techniques and important guiding rules. Recapitulating theory and principles of understanding, the authors demonstrate their application to children suffering physical and sexual abuse, learning disabilities, attentional disorders, physical handicaps, seizures, and losses through adoption, foster care, and death of family members. Throughout, the authors contrast their developmental-contextual approach with approaches based on traditional style. They close by doing so, commenting in critical detail on the transference-focused psychoanalysis of a 4-year-old boy reported by James Anthony. They then offer an annotated transcript demonstrating their own intervention with a 6year-old boy. There is much to be learned from this book. It is more than a valuable manual of psychotherapy. The authors wish "to put the child, as it were, back into child psychiatry." I infer that they also wish to put the therapist back into the practice of effective psychotherapy. They maintain ' 'uncom571
BOOK REVIEWS
prom ising realism and equally uncompromising therapeutic optimi sm," recognizing that the child, even during maladaptation, is responsible for making choices. Their goal is for the child to make free and healthy ones. The author s thus reveal their values and themsel ves as determined healers, which I believe is what we, as psychotherapists, should offer our patients. This book should be read by all interested in children and serving children and their families. It should be read together with Lenore Terr ' s Too Scared to Cry: Psychic Trauma in Childhood, with Bessel van der Kolk' s Psychological Trauma, and with a delightful little book illustrating the young child's theory building ability, Gareth Matthews' Philosophy and the Young Child. Frank Putnam, in his beautifully written Forew ord concludes, " Donovan and McIntyre have carefully and lovingly integrated a wealth of recent information on linguistics, child cognition, behavioral states and dissociation into a realistic clinical approach that significantly advances our understanding of the cognitive-beha vioral sty les of childre n." Don ovan and McInt yr e, in addition, have given us an approach that significantly advances our understanding of our own styles as child psychiatrists. I recommend this book highly. Please read it. SILVIO J. ONESTI , M.D. Assistant Profes sor of Psychiatry Harvard Medical School
Of Human Bonding-Parent-Child Relations across the Life Course. By Alice S. Rossi and Peter H. Rossi. New York: Aldine de Gruyter, 1990, 542 pp., $62.95 (hardcover), $39.95 (softcover). Child psychiatrists will be drawn to the title of this book. Bonding and parent child relationships are of interest to all clinicians who evaluate and treat the disorders of early life. Thi s book is the summary of a research project, the first collaborative effort of the Rossis, a husband and wife team. Alice Rossi has worked and published extensively in the field of family sociology, and Peter Rossi has contributed to research methods in the area of opinion surveys. Their project was funded primarily by the National Institute on Aging. In this book, the Rossis have chronicled the development and findings of this project that attempted to answer how obligation, sentiment, and interaction between parents and adult children change across their life span. This study was retrospective, based on the self-report of respondents. Their basic method was to conduct personal interviews with a random probabil ity sample of 1,393 adults in the greater Boston area and to then ha ve self-administered vignette booklets and telephone interviews completed with a parent or an adult child of the Boston respondents. The goal of this book is to describe variation s in parent 572
child relation ships across the life cycle. The authors contend that the social sciences have neglected the parent-child relationship in the intervening years between childhood and when parents are aging. Their focus was to assess how sentiment, obligation and interaction change during these years. The book is organized into three main sections: the biopsychological and social structural dimen sions of aging, several chapters on normative obligations of kin and nonkin, and the analysis of the parent-child relationship regarding solidarity, affectional closeness, and social interaction. The issue of one ' s affiliative ties extending beyond one's death is also addressed in the chapter on inheritance and provisions for kin in actual or intended wills. We find especially noteworthy their comment s regarding kinship obligations, affectional closeness, family size, and the help offered from one generation to another. By interviewing adults, their children and their parent s, general comparisons were possible that shed light on issues such as the extent to which obligations are felt by one generation toward another generatio n. The Rossis assessed the affec tional closeness toward family members and the amount of help extended from one generation to another. They traced the current intimacy or strain in the parent-child relationship back to early family life to test whether or not certain family characteristics and earlier event s could bias current family relatedness. Their findings revealed that marital happines s of the parent was significantly related to the marital happiness of the adult children who had married. Although one may have suspected as much, the Rossis have quantified these pattern s. They also found that parental affection and family cohesion translated into warm, cooperative, and enduring families headed by happily married parents. Also, the children of such famil ies tended later to be more affectionately expressive, happil y married, and have cohesive families of their own. The impact of family size was also analyzed and the Rossis found that if the family of origin was large, this was associated with a lessening of the family' s sense of financial well-being and limited how far the children went in school. Large family size was related to lower parent investment in the children's training and social relatedness to the parents. For the Rossis, the implication is that a number of closelytimed pregnancies strains the parent, the marriage, and decreases parental time and energy available to an individual child. The Rossis have documented that the types of help between generation s are gender specific. Fathers are more likely to give advice, money, and employment direction to their children than are mother s. Sons are more likely to provide help in the form of personal effort such as yard work or othe r speci fic physical assistance. Moth er s and daughters are more likely to provide comfort, help with domestic matters, special gifts, and care during iIInesses. On the issue of gender-linked personal traits, the authors found that males stress conformity as a way to gain status, whereas, females stress that children should develop their own interests and talents. The style of this book is readable, but the necessary reflecJ. Am.Acad. ChildAdolesc. Psychiatry, 31:3, May 1992