Counselling Children Adolescents and Families is an excellent textbook for all professionals who are seeking a respectful and effective way of engaging and helping children, adolescents and families. Drawing on the best in recent advances in solution-focused and resilience-oriented models of psychotherapy, the book will outline a collaborative approach to therapeutic work that builds on children and families own strengths and resources and that can establish cooperation in even the most difficult situations.
Divided into three parts, the book first takes the reader in a clear and straightforward manner through the background and basic principles of the approach, tackling thorny professional issues such as how and when to use diagnosis. Second, the book outlines creative applications such as groupwork with children and parents, using playful and creative activities and using new but highly effective approaches such as video based feedback. The last section, considers how the strengths-based approach applies to difficult contexts such as working with child abuse and suicidal teenagers and children.
Dr John Sharry is a social worker and psychotherapist and the author of six self-help books for parents and families, including Parenting Preschoolers and Young Children, Bringing Up Responsible Teenagers and When Parents Separate: Helping Your Children Cope (Veritas 2005, 2001, 2001). John is also is co-developer of the award winning Parents Plus Programmes Ã¢â‚¬â€œ dvd-based parenting courses Ã¢â‚¬â€œ which are used extensively in mental health services throughout Ireland and the UK.
- PART I:
BASICS AND PRINCIPLES
OF THE APPROACH
1 Establishing the Context
'For children, childhood is timeless. Its always the present. Today is what they
feel and when they say V[hen I will grow up...there is always an edge of
disbelief - how could they be other than what they are?'
- Ian McEwan
'There is always one moment in childhood when the door opens and lets in the
- Graham Greene
'Becoming a parent brought me the greatest joy in my life, but also the greatest
- A parent
'My life completely changed when I became a parent. It was so hard because I wanted
my old life back. It only became wonderful when I let go and went with the flow.'
- A parent
Working as a professional with families requires the ability to listen to and take on board different perspectives. The professional needs to be able to appreciate and see the world from a child or adolescents eyes as well as from those of their parents.
Childhood and adolescence are times of first encounters and intense experiences in the present. They are periods full of joy and sadness, excitement and fear as well as rapid growth and new learning. They are also critical times when certain events and relationships greatly impact individual lives and determine futures. To engage children and adolescents as professionals, we need to take time to appreciate their experience and to understand the world they move in, while recognising their relationships with their families.
When we engage with children we also engage with their parents and the other significant members of their families. To be effective we need to be sensitive to and appreciate the experience of being a parent in its ups and downs, its joys and sorrows. The lives of children and parents are so inextricably linked that we almost cannot help one without helping the other. Parents who bring their children to therapy also bring their own needs, concerns and wishes. If we help parents with their own concerns, then we also help their children, and if we help children to change positively, then we also help their parents who care for them. When therapy is well done, it is hopefully a moment in the life of a child and their family when the door opens and a positive future is let in that benefits each person in the family.
Working effectively with families also involves appreciating and understanding the professional context from which we operate. As professionals we bring our own perspective, and that of our profession, to the therapeutic process. This includes our personal style and beliefs as workers, the theoretical models we subscribe to, the standing and context of the agency we work for and the values and goals of our profession as a whole. The more self-aware and self-reflexive we can be of the theoretical models we bring to our work and the professional context from which we operate (both their strengths and their weaknesses), the better we can help our clients.
In this spirit of self-reflexivity and transparency, this chapter describes the guiding principles and theoretical context of this book, attempting to locate them within the context of professional knowledge (see Box 1.1). The chapter also describes how these principles can contribute to working with children and families, taking into to account the different and inter-connected perspectives of parents, children and significant others, including concerned professionals.
Box 1.1 Theoretical context and guiding principles
- Social constructionist framework.
- Developing strengths-based practice.
- Towards inclusive, multi-systemic practice.
- Appreciating the professional context. [end of Box 1.1]
Social constructionist framework
Truth is not what we discover but what we create
- Saint Exupery
Nothing is good or bad, but thinking makes it so.
Assumptions can be like blinkers on a horse - they keep us from straying from the
road, but they block our view of other routes and possibilities along the roadside.
- Armand Eisen
The underpinning philosophy to this book is social constructionism (Gergen, 1999; Gergen and McNamee, 1992; Hoyt, 1998): notably that people construct rather than uncover their psychological and social realities. Human knowledge and meaning is not absolute or universal, but evolves within specific contexts and communities of people. In human affairs there are many different systems of knowledge that could be derived to explain events and to guide meaning, that equally fit within the limits of the physical world and boundaries of historical facts and events. Taking the particular case of psychological knowledge, this implies that the ideas, theories and models that we as therapists, counsellors and other professionals hold about our work with families are not absolute, but rather social constructions that have evolved over time as discourses within certain communities of professionals. They may or may not be helpful in our work with the clients we might meet and could be in need of re-thinking and re-negotiation as we face the specific experience of an individual child or family. This means that guiding therapeutic principles, such as the medical principle that symptoms reveal underlying problems or the solution-focused therapy principle that solutions can be created independent of original problems, are not true or false, but rather may or may not be the most helpful in guiding the therapeutic experience towards a positive outcome. Similarly, therapeutic constructs such as the DSMIV (American Psychiatric Association, 1994) diagnostic category of attention deficit disorder or the solution-focused category of a visitor level of client motivation do not necessarily exist as entities, but simply are more or less helpful ways of describing common patterns across distinct clients and families.
Social constructionism is not a licence for anything goes, nor theoretical anarchy. All ideas are not of equal value, either in terms of effectiveness or ethical quality. As Alan Carr states:
Thus we can never ask if a particular diagnostic category (like DSM IV depression) or
construct (like Minuchins triangulation) is really true. All we can say is that for the time
being, distinctions entailed by these categories fit with observations made by communi-
ties of researchers and clinicians and are useful in understanding and managing particular
problems. The challenge is to develop integrative models or methods for conceptualising
clinical problems that closely fit with our scientist-practitioner communitys rigorous
observations and requirements for workable and ethical solutions. (1999: xx)
Thus from a social constructionist perspective, we have a collective professional responsibility to ensure that our models are ethical to use and to conduct research to make sure that they are indeed beneficial to our clients.
The implications of social constructionism on the individual practice of therapists are quite profound. It means that when we engage in conversation with clients, we should be aware of the limits of our theories and conceptions. We should be prepared to revise them or to co-create better conceptions, should our models of the theories not fit with the unique experience of the clients in front of us. Frequently stuckness in the therapeutic process stems from the therapist inadvertently holding on to a belief that is limiting progress or that does not fit with the client (see Case Example 6.4A in Chapter 6). Gillian Butler (1999) describes a systematic process whereby therapists, when faced by difficulty, can begin to deconstruct and analyse the therapeutic conversation to identify a disputed belief from their model that supports the difficulty, and then to be able to change this by drawing on another model. Social constructionism demands that we strive to be self-reflexive and self-critical. We are compelled to be theoretical-flexible and not to cling to pet or favourite theories. For example, though solution-focused therapy is my model of choice, I strive to be flexible enough to abandon this approach if it does not work for a certain client. I remember one teenager who teased me, Ah, dont ask me another miracle question (his previous social worker was also trained as a solution-focused therapist), to which I responded, What would you like me to ask about instead? He answered, I just want to talk about how bad things are at the moment, and so I followed his preferred direction.
Thus from a social constructionist perspective, the therapeutic relationship is a collaborative one in which therapist and client co-construct meanings, understandings, goals and treatment plans within the therapeutic conversation, operating from their respective knowledge bases, with the therapist cognisant of psychological models and best therapeutic practice research and the client as expert in the details of his life. The aim is to construct helpful understandings that fit both with the unique experience of clients lives and the best known psychological knowledge, and which satisfy ethical norms and broader societal expectations and which ultimately are of benefit to clients in achieving solutions to their problems.
Social constructionism and therapeutic conversation
Life should he more about holding questions than finding answers. The act of
seeking an answer comes from a wish to make life, which is basically fluid, into
something more certain and fixed. This often leads to rigidity, closed-mindedness,
and intolerance. On the other hand, holding a question - exploring its many
facets over time - puts us in touch with the mystery of life. Holding questions
accustoms us to the ungraspable nature of life and enables us to understand
things from a range of perspectives.
- Thubten Chodron - on Buddhism.
From a social constructionist perspective, beliefs and meaning are mediated by language and constructed and perpetuated by the ongoing communications between people, whether these are in the form of individual conversations or collective communications such as writing, television or other media. Rather than providing us with a neutral description of reality, language in part creates and shapes reality. Put simply, how we talk about things influences how we feel, how we think and how we might act. Our beliefs, meanings and ideas are determined by the stories we tell ourselves and each other.
In the context of therapy with families, this means that the stories (and the underpinning beliefs) that children, parents and families tell about the problems that afflict them and the solutions that might help them are not absolute accounts, but ones that have evolved over time in the family and wider system. Coming to therapy is often about retelling stories in a different way that provides new perspectives, ideas and meaning which are more helpful for the children and family concerned. Like Chodrons quote above, the therapeutic aim is to engage in a therapeutic dialogue that eschews prescribing rigid answers and beliefs, and instead holds questions in order to help clients understand things from different perspectives. This process helps clients generate new constructive meanings and beliefs that lead to action and change. The aim is to move from narrow stories of problems and oppression to empowering stories of strength and hope and liberation, that fit equally well with the evidence of the clients lives.
Let us consider a concrete example of this process in therapeutic practice, where the mother is helped to construct a new understanding of her son and develop a new self-construct about her ability as a parent. A mother brought her six-year-old son to a child mental health clinic, due to her sons behaviour problems. The mother believed that there was something wrong with her son, because he was so aggressive and that she must be a bad parent for not being able to manage him. Through careful dialogue with the therapist, who explored how the mother coped with the problem and also her positive influence on her son, different meanings and beliefs were negotiated. By the end of the therapy, she came to view her son differently, realising that he was a sensitive boy who needed extra attention and encouragement. This new understanding, and subsequent change, helped her evolve a more constructive self-belief about her parenting. As she explained it to me, When I first came I felt a complete failure with my son. I felt I was responsible for his problems. What helped was realising that I wasnt a bad parent, but a good parent trying to do my best, and to realise that I could help my son.
Sometimes the beliefs that limit and cause problems for clients are located in societys expectations that reflect a certain cultural and historical context. For example, 30 years ago a gay client presenting with depression at a psychiatric service would have been likely to experience a discourse that pathologised his lifestyle seeing it as a possible cause for his depression, whereas the same client presenting at a counselling service today would be more likely to have his lifestyle validated and affirmed. From a social constructionist perspective, the aim is to help clients understand the source of the ideas and beliefs that may define them as having a problem. For example, a teenager with eating problems may have a strong belief that she must be a certain weight or have a certain body shape. In therapeutic dialogue a strengths-based therapist may gently invite her to examine this belief and to consider its source in oppressive societal expectations. Through dialogue the therapist may help her to generate alternative beliefs and ideas (for example, that she can choose her own body image) that are more empowering to her to move forward. Groups can provide a powerful arena for this process to take place and this is the purpose of the Anti-Anorexia League (Grieves, 1998; Madigan, 1998). By bringing people affected by the same problems together, through sharing experience and strength, people can be assisted to generate new, more helpful ideas and beliefs, and then be empowered to challenge existing societal prejudices which reinforce the problems influence.
Social constructionism and multi-cultural practice
A social constructionist framework has much to contribute to non-discriminatory multi-cultural practice. The challenge is for therapists to understand and appreciate the cultural factors that shape the lives of the clients they meet, while being self-aware of their own personal cultural identity and how this impacts their therapeutic practice. In addition, therapists are obliged to be aware of the societal forces and prejudices that may contribute to clients problems as well as the specific cultural context of the therapeutic model which is inherent in their own professional practice. This may seem like a tall order, but is the mark of a self-critical reflexive professional. Indeed, this is the reason why the practice of regular supervision and consultation that provides an arena to tease out these issues is universally seen as central (across all accrediting bodies) to good professional practice.
Case Example 1.1 The soft western way
A five-year-old boy whose parents were refugees in lreland was referred to a child mental health service due to behaviour problems and a concern he was displaying autistic type behavior. During the first session the father reported his attempts to control his son using physical discipline. The therapist noticed her own feelings of unease at the fathers description, and wondered whether she should challenge the fathers use of physical discipline. When she began to raise other parenting strategies for managing behavior, the father described how in his country of origin he would be expected to take control and to use physical discipline. This opened a discussion about culture and parenting, and the therapist acknowledged the fathers positive intention to bring his son up in a responsible fashion and shared the ideas behind other strategies. Operating from a strengths-based paradigm the therapist asked, What are the good things about parenting in your culture that you would like to hold onto as you live here in Ireland? The father thought about this and said, Well I dont like how people want to find something wrong with my son here. In my country he would be looked after just the same as other children. This opened a discussion about whether it was needed to name his sons difficulties and the importance and value of a culture that accepted different children as they are.
Later in the session, the father said he was looking for support on how to manage his son and agreed to try out an early intervention parenting group (see Chapter 9). As he made progress, the father reflected in the parenting group, When I started this Course, I did not think that the soft western way would work with my son. It takes more time but I see that he needs it. When invited by the facilitator to say more about the soft western way, the father joked, But I also think you take things far too seriously here; you should relax more and take it easy. [end of Example 1.1]
In Case Example 1.1, what made the difference was the therapist being sensitive to cultural issues around parenting. Rather than imposing her own cultural values, she strove to understand the parents own cultural background and to appreciate its strengths and benefits. This helped build the therapeutic alliance and enough trust for the father to try out the parenting programme, which he interestingly dubbed the soft western way.
It is important to note that non-discriminatory or multi-cultural practice is not limited to working with clients from different ethnic groups. There are many other groups in society that have distinct sub-cultures which require understanding and appreciation. For example, though my own background is a middle-class culture in which parents are usually educated and married, choosing to have children later in their lives, this is very different from many of the single working-class parents I work with, who are more likely to have left formal education earlier and to have children younger. As a professional, I have to work hard to understand this cultural experience that is different from mine, appreciating both the challenges (dealing with discrimination) as well as some of the benefits (for example, many of these parents have the support of grandparents and wider communities). The challenge as a professional is not to assume that we know what it is like to live life within the culture and experience of our clients, but to respectfully listen to what they say and to let them tell us what is important and helpful. I find it helpful to conceive of being a therapist as much like being a visitor to another country for the first time. Rather than being a stereotypical tourist who travels in a foreign country without a sensitivity to the local culture and who even seeks out examples of his own culture (for example, looking for the local Irish pub in the Far East!), it is better to don the role of being a respectful traveller engaged in getting to know the local culture and customs, and letting the local people show you the way.
Developing strengths-based practice
Many of the ideas in this book are inspired by the solution-focused brief therapy model developed by de Shazer and others in the 1980s and 1990s (Berg, 1991; de Shazer, 1988, 1991; OHanlon and Weiner-Davies, 1989). In developing the model, the originators drew heavily on the innovative therapy of Milton Erickson (Haley, 1973; Zeig and Munion, 1999) and the work of the Mental Research Institute (MRI) in Palo Alto (Watzlawick et a1.., 1974; Weakland et al., 1974). Milton Erickson was a highly influential therapist who evolved a resource focused way of working with clients that used creative and individual strategies to help them reach their goals. Ericksons creative and idiosyncratic approach was in direct contrast to the dominant psychoanalytic and behaviourist approaches of the day and his work spawned the development of many different therapeutic approaches such as strategic therapy (Haley, 1963), neuro-linguistic programming (Bandler and Grinder, 1979; Grinder and Bandler, 1981) as well as the MRI brief therapy model and solution-focused therapy.
Focusing on understanding the interaction and communication patterns between people, the MRI team evolved a model of brief problem-solving therapy which essentially conceived of problems as failed solution attempts which were reinforced and maintained in patterns of family communications. For example, a mother in an effort to get close to her son may bombard him with questions when he comes in from school. But this approach may have the opposite effect and cause him to pull away. The aim of MRI therapy is to identify these patterns and to help the family do something different, even if it was simply the opposite of what was done before. In the last example, the mother may find a solution by waiting for her sons initiative to communicate and then listening, rather than bombarding him as before. In many ways the solution focused therapy model replicated that of the MRI team, but instead of identifying problem patterns the Milwuakee team looked to identify already existing solution patterns - that is, times when the family, even to a small degree, are finding a solution to the problem. (Interestingly, this technique was already described by the MRI team but not emphasised in the same way.) With this subtle change of focus the solution-focused brief therapy model was born. The Milwaukee team spent the next few years expanding and refining this approach (Berg, 1991; Berg and Miller, 1992; de Shazer, 1988, 1991, 1994) and the models popularity and appeal grew.
Part of solution focused therapys appeal is in how its principles stand in stark opposition to a number of the self-evident truths of many traditional and modernist therapies. For example, the approach questions the need to understand a problem before we find a solution, or the need to examine the past before building a future (see Table 1.1 [not available online.]) In fact, from its social constructionist perspective, solution-focused therapy does not contend that the self-evident truths of modernist (and largely problem focused) therapies should be replaced by the truer and opposite solution focused ones. Indeed, any rigidly held or unquestioned beliefs held by the therapist can impede progress when these do not fit with those of the client. Rather, the contention is that for brief and focused therapy the solution-focused schema of beliefs generally, though not absolutely, is a better starting point for the therapy. The appeal of the model is also explained by its simplicity. Unlike the work of Milton Erickson, which is highly individualised and very hard to systematise, de Shazer and his colleagues took pains to develop a step by step almost formulaic model of therapy that could be easily followed and implemented. This simplicity, however, is also the models weakness and can lead to it being misunderstood to be insensitively applied in some clinical contexts. For example, novice therapists can over-rely on the techniques or the questions in the model and miss the respectful listening and relationship skills that underpin the approach (and which are essential to all successful therapy). Also, the model has been criticised for its lack of focus on social forces on such as oppression, disadvantage, and social inequalities, which curtail clients freedom and their ability to make progress towards their goals.
Strengths based thinking
In my own view, the greatest contribution of the solution-focused therapy model is the strengths-based thinking that underpins the approach. We are invited to think in terms of resources, skills, competencies, goals and preferred futures about our clients, their lives, the communities they belong to, the therapeutic process itself and the professional context in which we find ourselves. We are invited to become detectives of strengths and solutions rather than detectives of pathology and problems, and to honour the clients expertise and capabilities as well as our own (Sharry et a1., 2001a). The model also provides us with a practical method (via new questions and techniques) to make the conversations we have both with our clients and colleagues more constructive and collaborative, and to orient the therapeutic process towards solutions. As we shall see in later chapters, this strengths-based thinking has much to contribute to our work in difficult and challenging contexts, where pathological thinking may be reinforcing the problem and increasing the sense of difficulty.
The reorientation towards strengths and resources is part of a wider cultural shift in psychotherapy and the helping professions (Hoyt, 1998; OHanlon and Weiner-Davies, 1989). This has included the emergence of new popular models of psychotherapy such as narrative therapy (White and Epston, 1990), motivational interviewing (Miller and Rollnick, 1991), resource-focused therapy (Ray and Keeney, 1993) and possibility therapy (OHanlon, 1998), all of which share a strengths-based orientation. This reorientation has also affected traditional models of professional practice, leading to a focus on resilience in family therapy (Walsh, 1996) and psychiatry (Haggerty et al., 1997), the emergence of strengths-based approaches in social work (Saleeby, 1996), and also the development of appreciative inquiry as a method of organisational consultancy (Hammond 1998).
Though the solution-focused model is located within a social constructionist philosophical paradigm, the ideas have a strong resonance in practice with many traditional psychological therapies. For example, the focus on goals measurable change, and helping clients think more constructively is shared by the cognitive behavioural traditions of therapy (Beck, 1976.; Ellis, 1998). In addition, the person-centred approach emphasizes the core therapeutic attitude of acceptance (or unconditional positive regard), whereby the therapist strives to hold on to a positive view of the client as a person of unconditional self-worth despite any negative behaviours or feelings the client may display (Rogers, 1961: 34). This notion of acceptance resonates strongly with the core values of a strengths-based approach. Indeed, as I shall explore in Chapter 2, a strengths-based approach can be conceived as building on the foundational work of the person-centred approach, offering set techniques and conversational strategies that can help cultivate and maintain the attitude of unconditional positive regard.
Evidence for a strengths-based approach (1)
Several research studies have shown that substantial numbers of clients who are awaiting psychotherapy or who receive minimal treatment (on average 43 per cent) experience spontaneous remission - that is, they overcome problems by their own resources without any formal professional help (Assay and Lambert, 1999; Lambert and Bergin, 1994). Other studies have shown that in the general population, many people overcome problems through their own efforts and resources, without coming into contact with professional services at all. For example, there is extensive research that many people with addiction problems (such as alcohol or smoking) recover by themseives without recourse to professional help (Prochaska et al., 1992). In addition, there is evidence that many children or young people who might have received a diagnostic label do, in fact, grow out of their problems without professional help. For example, Cohen et al. (1993) found that while as many is 17.1 per cent of children meet the criteria for Attention Deficit Hyperactivity disorder (ADHD) in childhood this has fallen to 11.4 percent in mid adolescence and 5.8 per cent in late adolescence.
The above studies suggest that many people overcome problems by their own strengths and resources. It is this self-healing process that a strengths-based approach to therapy aims to enhance. Even when people access professional support, there is evidence that it is their own actions and resources that make the vital difference, rather than those of the therapist. For example, in a comparative study of parents attending therapist-led group parenting sessions and parents working through the video-based material by themselves (completing exercises and suggested homework), both groups showed similar levels of positive change (Webster-Stratton et al., 1988), suggesting that the clients agency and actions, rather than those of the therapist, are the most significant contributor to success. In addition, many clients improve by increasing their access to social support. For example, Mallinckrodt (1996) found that the clients perceptions of increased social support outside of the psychotherapy was more important in terms of symptom reduction than growth in the strength of the therapeutic alliance. These studies lend evidence for strengths-based approaches to therapy that aim to build upon clients own actions, resources and social supports in the process of positive change.
There is also evidence that the reverse is true, that a focus on client deficits and highlighting problems in therapy can actually lead to poor outcome (Miller et al., 1997; Miller and Rollnick, 1991). For example, confrontational group therapy, focused on highlighting client deficits, has been shown to lead to poorer outcome and more harmful effects than other more supportive approaches (Lieberman et al., 1973) and that, alarmingly, such approaches may be particularly unsuccessful or damaging for clients with poor self-ego strength or self-esteem (Annis and Chan, 1983). Contrast this with the work of the Plumas project, which used a solution-focused group intervention (focused on helping participants identify personal goals and strengths) with 151 perpetrators of domestic violence (a client group that has high levels of poor self-esteem). On completion of the programme, only seven clients (4.6 per cent) had re-offended, and in a recent six-year follow-up which tracked 90 of the clients in the study, recidivism rates amounted to 16.7 per cent (Lee et al., 2003). These results are very impressive when compared to recidivism rates at five-year follow-up for traditional treatments, which are as high as 40 per cent (Shepard, 1992).
Underpinning a strengths-based approach to therapy is a belief that clients possess (either personally or within their social networks) most of the resources and strengths they need to change and reach their goals. This is consistent with belief within the person-centred approach in the existence of a self-healing potential in all people (Rogers, 1986). Psychotherapy is simply about providing the right conditions, notably an empathic and supportive therapeutic relationship, for this self-healing potential to be brought to the fore. Or as Prochaska et al. state: in fact, it can be argued that all change is self-change, and that therapy is simply professionally coached self-change (1994:17). Perhaps the best endorsement for a strengths-based approach is given by researchers Bergin and Garfield who, reflecting about the extensive research evidence compiled in their book, concluded that as therapists have depended more upon the clients resources, more change seems to occur (1994:826).
Towards inclusive, multi-systemic practice
It takes a village to raise a child.
- African Proverb
Professionals often experience a dilemma as to who should be involved in therapeutic work with families. Different schools of thought propose different answers. Historically, children tended to be seen alone for