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Editorial: The helping alliance in work with families where children have been abused or neglected
Child Abuse & Neglect. Vol. 20, No. 4, pp. 345-347. 1996 Copyright ~ 1996 Elsevier Science Ltd Printed in the USA. All rights reserved 0145-2134/96 $15.00 + ,00
Pergamon
Pll S0145-2134(96) 00003-8
SPOTLIGHT ON PRACTICE
EDITORIAL: THE HELPING ALLIANCE IN WORK WITH FAMILIES WHERE CHILDREN HAVE BEEN ABUSED OR NEGLECTED DAVID P. H. JONES Park Hospital for Children, Oxford, UK
THE REVIEW BY Morrison-Dore (this issue) emphasizes the quality of the alliance between practitioner and client/patient as a key factor in relation to outcome, when working with families where there has been child abuse or neglect. As Morrison-Dore emphasizes, abusive and neglectful parents disproportionately have difficulty in sustaining good quality relationships in the first place. Such parents have special problems trusting others, because their experience of life so often tells them that to trust is unsafe. Therefore the helping alliance is a special challenge in this field, and perhaps for that reason should achieve an even higher place in our concerns than it has to date. We hope that this review will draw welcome attention to this gap. In the UK, there has been special concern with the outcome of the helping alliance between practitioner and client--namely the establishment of a partnership between the two (Dartington Social Research Unit, 1995). The Dartington summary of government funded research projects in the UK has drawn attention to the complexities of partnership between parents and to a lesser extent, children and practitioners in the field of child abuse and neglect. However, the helping alliance is at the core of such partnerships, as Morrison-Dore emphasizes in the following article. It can be argued that the child abuse field has suffered from a degree of separatism from the main stream of concern in the psychological and social work practice fields. Morrison-Dore reviews mainstream research related to the helping alliance in order to inform our practice in this field better. She first turns to psychotherapy outcome research. This is an excellent source for insights into the helping alliance, as it has long been a special area of concern within psychotherapy. Some may argue that psychotherapy is a long way removed from the practical settings and context of work in the child abuse and neglect field. However, as Morrison-Dore stresses, most of the work on the helping alliance within psychotherapy has been undertaken within the context of short-term work, and in that regard is comparable with interventions by child welfare agencies in the wake of discovery of abuse and neglect. The author then reviews work on the helping alliance within difficult populations, including Requests for reprints should be sent to Dr. David P. H. Jones, Park Hospital for Children, Old Road, Headington, Oxford OX3 7LQ, UK. 345
346
D . P . H . Jones
those with chemical dependency problems and personality difficulties, before reviewing the helping alliance in relation to family and group work. All these areas are of special relevance to those working in child welfare agencies and initiating treatment work with clients who can be particularly difficult to engage with. The author relates this body of research interest in the helping alliance to family preservation services, before discussing some of the implications of this work for improving child welfare practice. She stresses that different approaches to alliance formation than are currently emphasized in the family preservation literature may be required. For example, relatively short-term intensive interventions may be inappropriate in some high-risk families, where a longer-term model may be necessary in order to develop a helping alliance in the first place. Equally, it is suggested that specific work of a cognitive or behavioral type may need to be placed in abeyance while the primary focus is on developing a relationship with the client. However, this clinician would suggest that it is just here that the practitioner's skill and sense of timing is likely to be most critical. For example, there may be some families where a demonstration to the parent that the practitioner does have some approaches which can help. This can be one of the turning points in establishing a longer term engagement with families who might otherwise refuse help (Jones & Verduyn, 1983). Similarly, for some parents, an indication that the practitioner is capable of seeing the world from their perspective, while avoiding unhelpful collusion, can be beneficial. Reframing points of interminable conflict between practitioners and clients/ patients can enable situations which were previously stuck to move ahead, opening up the prospect that a helping alliance can be established. For example, professional and parent may be deadlocked over the question of whether a specific act of maltreatment has occurred. Sometimes it can be possible to reframe this area of conflict, placing it into a broader context of parenting failure, and establishing an agreement between practitioner and parent that there was indeed a breakdown of parenting capacity and ability, within which certain acts occurred which led to the child protection response. In this way, the focus can change from a specific episode over which an alliance cannot be formed, to a more general agreement which may be a basis for change in certain high risk families. This example is outlined here to underline the principle that process research which examines the many different ways in which alliance formation can become achieved with high risk families, should be a central concern for practitioners and researchers now. Morrison-Dore stresses that alliances with parents with borderline personality disorder takes much longer and requires "more active attention by the clinician to maintain," than can be possibly established through existing approaches. The review contains many other helpful suggestions for both practitioners and for future researchers. Polansky and colleagues have done much to counter the charge that although neglect is one of the most common reasons for the reception of children into alternative care, it has received disproportionately less attention than acts of abuse. In this study, they examine the family functioning of neglectful families (Gaudin, Polansky, Kilpatrick & Shilton, this issue), comparing 103 neglectful families with 102 non-neglectful, but similarly deprived families. For the study, they have combined self report and observational measures, which is a great strength, in addition to the large number studied. They have demonstrated that neglect families were not as organized, were more chaotic, less verbally expressive, and showed more negative emotions to one another, combined with less positive ones, than did the comparison families. Interestingly, their method of observation of family interactions was similar to that used by Madonna, Van Scoyk, and Jones (1991), who found somewhat similar distinctions between families in which there was sexual abuse of a child, compared with similar, but nonabusive families who were presenting with a child mental health problem. Gaudin and colleagues (this issue), suggest that there are three types of neglectful family functioning, which might imply different types of interventions by practitioners.
Editorial: Spotlight on Practice
347
Once again, some of these findings echo those from the recent UK studies which have emphasized the importance of families characterized by low warmth and high criticism (Dartington Social Research Unit, 1995 ). Equally, there are important links, in terms of the implications for practitioners, between the work of Gaudin and colleagues and the review of the therapeutic or helping alliance by Morrison-Dore (this issue). One linking feature is that for helping alliances and subsequent partnerships to become established, the practitioner needs to assess and evaluate the full nature of the problem. Gaudin and colleagues provide us with a useful way of understanding neglectful families in greater detail, which should permit a helping alliance to develop. A further welcome feature of both of the articles in this month's Spotlight is surely the implication that the quality of practitioners' work is all important--emphasizing the skill base which is required in order to establish good working partnerships with neglectful and abusive families.
REFERENCES Dartington Social Research Unit. ( 1995 ). Child protection and child abuse: Messages.from research. London: HMSO. Jones, D. P. H., & Verduyn, C. ( 1983 ). Behavioral management of sleep problems. Archives of Disease in Childhood, 58,442-444. Madonna, P., Van Scoyk, S., & Jones, D.P.H. (1991). Family interactions within incest and nonincest families. American Journal of Psychiatry, 148, 46-48.
Pergamon
Pll S0145-2134(96) 00003-8
SPOTLIGHT ON PRACTICE
EDITORIAL: THE HELPING ALLIANCE IN WORK WITH FAMILIES WHERE CHILDREN HAVE BEEN ABUSED OR NEGLECTED DAVID P. H. JONES Park Hospital for Children, Oxford, UK
THE REVIEW BY Morrison-Dore (this issue) emphasizes the quality of the alliance between practitioner and client/patient as a key factor in relation to outcome, when working with families where there has been child abuse or neglect. As Morrison-Dore emphasizes, abusive and neglectful parents disproportionately have difficulty in sustaining good quality relationships in the first place. Such parents have special problems trusting others, because their experience of life so often tells them that to trust is unsafe. Therefore the helping alliance is a special challenge in this field, and perhaps for that reason should achieve an even higher place in our concerns than it has to date. We hope that this review will draw welcome attention to this gap. In the UK, there has been special concern with the outcome of the helping alliance between practitioner and client--namely the establishment of a partnership between the two (Dartington Social Research Unit, 1995). The Dartington summary of government funded research projects in the UK has drawn attention to the complexities of partnership between parents and to a lesser extent, children and practitioners in the field of child abuse and neglect. However, the helping alliance is at the core of such partnerships, as Morrison-Dore emphasizes in the following article. It can be argued that the child abuse field has suffered from a degree of separatism from the main stream of concern in the psychological and social work practice fields. Morrison-Dore reviews mainstream research related to the helping alliance in order to inform our practice in this field better. She first turns to psychotherapy outcome research. This is an excellent source for insights into the helping alliance, as it has long been a special area of concern within psychotherapy. Some may argue that psychotherapy is a long way removed from the practical settings and context of work in the child abuse and neglect field. However, as Morrison-Dore stresses, most of the work on the helping alliance within psychotherapy has been undertaken within the context of short-term work, and in that regard is comparable with interventions by child welfare agencies in the wake of discovery of abuse and neglect. The author then reviews work on the helping alliance within difficult populations, including Requests for reprints should be sent to Dr. David P. H. Jones, Park Hospital for Children, Old Road, Headington, Oxford OX3 7LQ, UK. 345
346
D . P . H . Jones
those with chemical dependency problems and personality difficulties, before reviewing the helping alliance in relation to family and group work. All these areas are of special relevance to those working in child welfare agencies and initiating treatment work with clients who can be particularly difficult to engage with. The author relates this body of research interest in the helping alliance to family preservation services, before discussing some of the implications of this work for improving child welfare practice. She stresses that different approaches to alliance formation than are currently emphasized in the family preservation literature may be required. For example, relatively short-term intensive interventions may be inappropriate in some high-risk families, where a longer-term model may be necessary in order to develop a helping alliance in the first place. Equally, it is suggested that specific work of a cognitive or behavioral type may need to be placed in abeyance while the primary focus is on developing a relationship with the client. However, this clinician would suggest that it is just here that the practitioner's skill and sense of timing is likely to be most critical. For example, there may be some families where a demonstration to the parent that the practitioner does have some approaches which can help. This can be one of the turning points in establishing a longer term engagement with families who might otherwise refuse help (Jones & Verduyn, 1983). Similarly, for some parents, an indication that the practitioner is capable of seeing the world from their perspective, while avoiding unhelpful collusion, can be beneficial. Reframing points of interminable conflict between practitioners and clients/ patients can enable situations which were previously stuck to move ahead, opening up the prospect that a helping alliance can be established. For example, professional and parent may be deadlocked over the question of whether a specific act of maltreatment has occurred. Sometimes it can be possible to reframe this area of conflict, placing it into a broader context of parenting failure, and establishing an agreement between practitioner and parent that there was indeed a breakdown of parenting capacity and ability, within which certain acts occurred which led to the child protection response. In this way, the focus can change from a specific episode over which an alliance cannot be formed, to a more general agreement which may be a basis for change in certain high risk families. This example is outlined here to underline the principle that process research which examines the many different ways in which alliance formation can become achieved with high risk families, should be a central concern for practitioners and researchers now. Morrison-Dore stresses that alliances with parents with borderline personality disorder takes much longer and requires "more active attention by the clinician to maintain," than can be possibly established through existing approaches. The review contains many other helpful suggestions for both practitioners and for future researchers. Polansky and colleagues have done much to counter the charge that although neglect is one of the most common reasons for the reception of children into alternative care, it has received disproportionately less attention than acts of abuse. In this study, they examine the family functioning of neglectful families (Gaudin, Polansky, Kilpatrick & Shilton, this issue), comparing 103 neglectful families with 102 non-neglectful, but similarly deprived families. For the study, they have combined self report and observational measures, which is a great strength, in addition to the large number studied. They have demonstrated that neglect families were not as organized, were more chaotic, less verbally expressive, and showed more negative emotions to one another, combined with less positive ones, than did the comparison families. Interestingly, their method of observation of family interactions was similar to that used by Madonna, Van Scoyk, and Jones (1991), who found somewhat similar distinctions between families in which there was sexual abuse of a child, compared with similar, but nonabusive families who were presenting with a child mental health problem. Gaudin and colleagues (this issue), suggest that there are three types of neglectful family functioning, which might imply different types of interventions by practitioners.
Editorial: Spotlight on Practice
347
Once again, some of these findings echo those from the recent UK studies which have emphasized the importance of families characterized by low warmth and high criticism (Dartington Social Research Unit, 1995 ). Equally, there are important links, in terms of the implications for practitioners, between the work of Gaudin and colleagues and the review of the therapeutic or helping alliance by Morrison-Dore (this issue). One linking feature is that for helping alliances and subsequent partnerships to become established, the practitioner needs to assess and evaluate the full nature of the problem. Gaudin and colleagues provide us with a useful way of understanding neglectful families in greater detail, which should permit a helping alliance to develop. A further welcome feature of both of the articles in this month's Spotlight is surely the implication that the quality of practitioners' work is all important--emphasizing the skill base which is required in order to establish good working partnerships with neglectful and abusive families.
REFERENCES Dartington Social Research Unit. ( 1995 ). Child protection and child abuse: Messages.from research. London: HMSO. Jones, D. P. H., & Verduyn, C. ( 1983 ). Behavioral management of sleep problems. Archives of Disease in Childhood, 58,442-444. Madonna, P., Van Scoyk, S., & Jones, D.P.H. (1991). Family interactions within incest and nonincest families. American Journal of Psychiatry, 148, 46-48.