CHILD AND FAMILY THERAPIES
APPRAISAL OF CASE STUDY MATERIAL.
The two types of therapeutic approaches to be discussed will be the psychodynamic theory of Freud and the humanistic theory of Carl Rogers. These approaches will then be considered with respect to the designated case study material provided.
The psychodynamic approach developed from the work of Sigmund Freud. Freud believed that the human mind had both conscious and unconscious areas. The unconscious part of the mind was seen as being dominated by the id, a primitive part of the personality that pursues only pleasure and gratification. The id is not concerned with social rules but only with self-gratification. This disregard for the consequences of a behaviour is referred to as ‘primary process thinking’. The second area is the ego which dominated the conscious mind. This is the part of our mind that is in contact with the outside world, the part that considers the consequences of an action, and as such carries out ‘secondary process thinking’. The third part of the mind is the superego. This develops as we become more aware of the rules and conventions of society and specifically of our parents. It contains our social conscience, and through the experience of guilt and anxiety when we do something wrong, it guides us towards socially acceptable behaviour. According to Freud, the ego and the superego dwell largely in the conscious mind, while the id is in the unconscious area of our mind.(Cardwell (2000) ).
The theory of Freud is controversial in many ways but perhaps most because of his emphasis on the importance of sexual instincts. Freud proposed that people move through a series of five psychosexual stages in their early years of life. The way that the individual deals with each stage will determine the person’s personality. The first stage is the oral stage (birth to about 15 months). Only the id is developed at this time so the child requires immediate gratification usually by means of the mouth (i.e. Through feeding and crying). The second stage is the anal stage (15 months to about age 2 years) when the focus of gratification moves from the mouth to the anus. The id dictates random elimination of faeces which is in direct conflict with the demands of the parents. The resolution of this conflict requires the development of the ego and as such has important implications for personality in later life. The third stage is the phallic stage (3 years to about 5 years) where the focus of gratification is now on the genitals. Children take and increasing interest in their own genitals and show a curiosity about other peoples’ bodies. The major conflict faced during this stage is the Oedipal conflict, the resolution of which should result in the attachment to the parents, most notably the same sex parent and the development of the superego. The idea of Oedipal conflict is central to Freudian theory. The fourth stage is the latency stage (around 5 years until puberty). The drives which have been responsible for conflict during the previous stages appear relatively inactive. Repressed drives may be directed into formation of friendships, hobbies etc. The final stage is the genital stage (puberty onwards). There is a re-emergence of the earlier drives. The drive energy is focused on the genitals once more, but this time with an adult expression of sexuality.(Cardwell (2000)).
Freud insisted that problems in later life could be traced back to unresolved conflicts from childhood. These had been repressed because the immature ego was unable to deal with them at the time. The aims of psychoanalytic therapy are to create the right kind of conditions so that the patient is able to bring these conflicts into the conscious mind where they can be addressed and dealt with.
Humanistic therapy is based on the main premise of humanistic theory that people have a natural tendency towards growth and development (an ‘actualizing tendency’) and will themselves seek to resolve problems in their life, rather that succumbing to them. Humanistic therapy is better known as ‘person centred therapy’ and originated largely from the work of Carl Rogers (1951). Rogers did not hold with the interventionist techniques of the psychodynamic or behaviourist schools. They believed they created dependence upon the therapist. He introduced the term ‘person centred’ to underline the fact that this approach was first and foremost a means to access the personal power of an individual to become more autonomous, spontaneous and confident in himself. Like psychodynamic therapy, humanistic person centred therapy is an insight therapy in that it involves delving into deeper emotions. However, the therapy should focus on the present rather than past experiences because it is now that the person is having the problems.
Rogers proposes three key conditions – warmth, genuineness and empathy. Warmth means ‘unconditional positive regard whereby their should be respect between therapist and client. There should be a non-judgemental attitude. The therapist must show himself to be a ‘real’ person (genuineness) with thoughts and feelings, which would be expressed where appropriate. The therapist must also enter the clients inner world (empathy) and this is achieved through genuine, attentive listening and by restating what the client says in order to clarify its emotional significance.
The means of investigating conflicts can be varied and will be based on these pre-stated approaches. Play therapy is usually used with children ages 3 – 11 years. The therapy allows the child a means to express their experiences and feelings through a natural, self-guided, self-healing process. As children’s experience and knowledges are often communicated through play, it becomes an important way for them to know and accept themselves and others. This is humanistic in that it is a way of searching for self actualization and it is person centred.
Play therapy is often used as a tool of diagnosis. A play therapist observes a client playing with toys (play houses, pets, dolls, etc.) to determine the cause of the disturbed behaviour. The choice of appropriate toys or props is very important and should be carefully selected prior to any sessions. Older children will respond differently to toys specifically stereotypical of young children. It may be that the older child will still find them very therapeutic but they will be inhibited playing with them in case they are thought of as ‘childish’. Puppets are a good means of getting the child to express himself. ‘The child can use various puppets to work out conflict situations. The fight in which the puppets engage might be showing the hussle that is going on internally.’ ‘He may act out the same story time and again but may vary the outcome, again trying on for size ways of getting through dilemmas.’ ‘It is rehearsal for the real world conflicts that might occur in the future.’ (Hopper 2007 p.84,85). The case study of Polly shows the way in which the puppets allows her to gradually work through her experiences of sexual abuse and how she is now trying to build up trust in other again.
Prose and poetry also have a part to play. Fairy tales are valued by all children and adults. ‘They usually begin with the central character(s) being introduced, the scene set and a dilemma to be faced. As the story unfolds, difficulties and dangers are encountered, but through all the struggles, the hero or heroine comes through triumphant and life is changed from rage to riches, from despair to hope.’ (Hopper 2007, p.87). The case study of Felix shows how his love of poetry gave him a way of expression to his counsellor. In his sessions his poetic abilities were appreciated and treated positively.
Sand and water allow a child to recreate his world using small toys. This type of play can allow the individual to reach a deeper insight into and resolution of a range of issues in their lives such as deep anger, depression, abuse or grief. The child can choose to expose little toys or to keep them hidden depending on how he wants. This again is humanistic because it is only when he has reached the correct time for him will he begin to open up (person centred therapy again). Hopper gives the case studies of Kim, Philip, Penny and Valerie as examples of how the play therapy with sand and water helped each child despite very different circumstances.
According to the psychodynamic view, people (especially children) will engage in play behaviour in order to work through their anxieties. In this way play therapy can be used as a self-help mechanism, as long as children are allowed time for ‘free play’ or ‘unstructured play’. From a developmental point of view, play has been determined to be an essential component of healthy child development. Play has been directly linked to cognitive development.
Play therapists often use their methods when dealing with pre-verbal, non-verbal or verbally-impaired persons, such as slow-learners, brain-injured or drug-affected persons.
The article by Flitton and Buckroyd – Counselling children and young people who attend a school for children with complex needs: A Case Study, gives a good overall account of work with young student called Kemi, aged 11 years. This study was carried out by providing counselling for children with learning difficulties. This type of work is new and very limited. In mainstream schools, counselling is now widely available but the general opinion is held that ‘the general response to a young person with a learning disability who is presenting a mental health issue is ‘no response’. (Flitton & Buckroyd 2005p.131). There are many challenges of working with children with complex needs and finding respectful ways to overcome communication difficulties is important – these can include age appropriate toys and games. Because children and young people with communication difficulties may not be able to express themselves verbally, other ways have to be found to enable the communication process. This project made use of humanistic counselling techniques. It considered a quantitative element and also a qualitative element. In previous work ‘clinical case studies, especially in the psychoanalytic tradition, have been criticised:
- Failure to seek consent or ethical approval
- Practitioner bias: data is compiled from retrospective notes alone
- Lack of adequate data collection methods; data collection is begun after counselling begins or is written up retrospectively.
Case studies as a research method are more rigorously conducted; in this project:
- Consent from the participants, parents and the school was obtained prior to the study
- Ethical approval was also gained prior to the study
- Notes from the counselling sessions were supplemented by the recorded sessions, which reduced recollection bias. This data was in turn supplemented with interviews with the students and with the staff. (Flitton and Buckroyd 2005 p.133)
Throughout the sessions the counsellor’s way of being with Kemi was humanistic. Kemi was always the central focus of the sessions and the person centred approach was taken. Kemi has a global development delay and difficulties with spatial awareness. The staff found her very immature and Kemi found it hard to express herself directly to the interviewer. She started off by story telling and then went on to draw and write. By carefully allowing Kemi to build up a feeling of mutual respect (Rogers three core conditions of warmth, genuineness and empathy) with her counsellor it was possible to gradually get Kemi to show her feelings. It became obvious during the sessions that Kemi was keen to seek approval from her mother and she even was happy playing without dialogue as long as she was in the presence of a maternal figure. They also used role play during the sessions which allowed Kemi to act out how she perceived her parents. The art therapy had proved a valuable tool in building up the trust between Kemi and the counsellor and then things quickly moved on to her being able to ‘describe her emotional environment and to actively working on her responses and moving towards forgiveness and gratitude (Flitton & Buckroyd 2008 p.135).
In the article Working with the whole class in primary schools by Dean Reddick, it states that the therapeutic work carried out with ‘case material of work with two classes, a Year 1 class and a Year 6 class, which covers the ages and spectrum of the latency period’. He stresses the importance of the latency phase in terms of the Freudian theory. It is with the resolution of the Oedipal Complex that allows for ‘a move away from the intensity of the family and towards society.’ ‘Edwards (1999) sees Freud’s original formulation of the latency child as emphasising a defensive and disappointed turning away, a giving up of Oedipal love objects through the internalisation of the Oedipal prohibition and the development of the the superego (and the child’s interest in rules)’.
Dean Reddick used art therapy as a means of investigating the group. Art therapy is a form of expressive therapy that uses art materials, such as paints, chalk and markers. The process combines traditional psychotherapeutic theories and techniques with an understanding of the psychological aspects of the creative process, especially the affective properties of the different art materials. The American Art Therapy Association consider art therapy can address important issues and help individuals to increase insight and judgement, cope better with stress, work through traumatic experiences and increase cognitive abilities. This can be seen to be relevant from a humanistic perspective of helping to gain self-actualization and also from a Freudian perspective of allowing the individual to explore his unconscious.
Initially, Reddick asked the children to draw themselves as an animal. No suggestions were given to the children as to which animal to choose. Some found the task more difficult than others. Differences were obvious between boys and girls ‘several girls who sat together were particularly vocal and answered that boys were not confident in speaking about themselves but were confident about doing sports’. (Reddick 2008, p.91) It was noted that the ‘many of the girls seemed more mature than the boys. This was in part due to the unequal development of boys and girls at this age. Several of the girls in the class were already pubescent and therefore moving out of the latency period. The boys, in general, seemed smaller and younger. (Reddick 2008, p.91)
There were two children, Paul and Hamza who were two-thirds of a triumvirate. The third child was continually absent. Reddick saw this as part of the Freudian Oedipus Complex. ‘This suggests an unresolved Oedipal constellation: the three could not survive and had regressed further to a pair’ (Reddick 2008, p.92). The researcher represented himself as a dog fox which the boys found challenging. ‘The boys’ power, their use of aggression and derision, and their defiant attitude to authority, were linked to a need to protect their unresolved infantile needs. They had not achieved sexual latency and yet were on the point of entering adolescence and their infantile needs impacted on the whole class’. (Reddick 2008, p92.
During the third session, Paul and Hamza were ‘defiant and distracting’ and ‘the mood of the class became lethargic and unresponsive despite the first four presentations being eloquent and interesting’. During subsequent discussions it was discovered that ‘there was a lot of trust between this teacher and the class and this allowed for the expression of anger and loss about the forthcoming end (leaving the school). (Reddick 2008, p94). This source of expression allowed the pupils to voice their worries and anxieties about moving on to another school. Freud saw repression as a defense mechanism which allow an individual to shield himself from the distress of a situation or event.
There is obviously a need for art therapists to be trained to recognize the nonverbal symbols and metaphors that are communicated during the creative process. It was important therefore to help the children to discover the underlying feelings and emotions presented in the artwork. ‘Superheroes occur frequently in latency children’s play and art, mostly among boys, many latency concerns can be discerned in superheroes: issues of morality, strength, skill and often a stereotyped and split attitude to gender (e.g. Man of Steel). Superheroes, therefore, provide powerful representations for male latency children to identify with. (Reddich 2008, p96). Freud said that successful resolution of the Oedipus Complex results in the boy being able to move into the latent period having identified with the same sex parent. Reddick makes this observation ‘The link between loss and separation and the defensive formulation of a fantastic persona resonate with some latency boys’ struggle to negotiate the move away from the mother as an Oedipal partner and as an object to identify with. In this formulation the superhero is a symbol of the rescuing father who helps the mother and child to separate (Gerrard, 1992) (Reddick 2008, p 96)
Drama also has a place in therapeutic sessions. Clients do not need to have previous experience or skill in acting, theatre or drama. The clients can have a variety of different needs – children on the autistic spectrum, adolescents who self harm, people with history of sexual/emotional abuse. Vaughan (2007) gives accounts of various vignettes which can be acted out in family therapy sessions – Mountain climb expedition, Desert Journey and Prince in the Tower.
It can be seen from careful consideration of these case studies that the therapy process needs to be flexible and person centred while based on well documented theories. In many cases it is true to say that an eclective approach is decided on which will provide the client with the best type of care.
References:
Cardwell, K & Clark, L & Meldrum (2000) Psychology for A level (2nd edition) Collins, London
Flitton, B. and Buckroyd, J (2005) Counselling children and young people who attend a school for children with complex needs: A Case Study. Counselling and Psychotherapy Research , June 5 (2) 131-137
Hopper, L (2007) Using Creative Opportunities in Play Therapy. In Counselling and psychotherapy with children and adolescents, Basingstoke; Palgrave Macmillan
Jones, P (2007) Vignette : The Prince in the Tower. In Drama As Therapy: Theory Practice and Research (2nd edition) London: Routledge
Reddick, D (2008) Working with the whole class in school. In Case, C. and Dalley. T (Eds.)Art Therapy with Children, London: Routledge
Vaughan, J (2007) Research vignette: Mountain Climb Expedition, In Jones, P. Drama As Therapy: Theory Practice and Research (2nd edition)