Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. Through stories from my behavioral pediatrics practice (with details changed to protect privacy) I will show how contemporary research in child development can be applied to support parents in their efforts to facilitate their children’s healthy emotional development. I will address factors that converge to obstruct such support. These include limited access to quality mental health care, influences of a powerful health insurance industry and intensive marketing efforts by the pharmaceutical industry.

Saturday, September 25, 2010

Dyadic Therapy: Working with the Parent-Child Relationship

One of the things of which I am most certain, based on my years of practicing pediatrics together with my years of being a mother (and also just my experience as a human being) is that what children need most is for the people who love and care for them to understand them, and to be with them in a way that communicates that understanding.

For this reason, I have never understood why a young child would be ever seen in psychotherapy without his or her primary caregiver. Psychoanalytic theory contends that a young child has hidden conflict and fantasies that can be brought to light through imaginary play. This may well be true, but given the limited time and resources, is it really important?

This weekend I have begun what will be an intensive year long training in Infant-Parent Mental Health. Already I can see that perhaps the two most valuable piece of this experience will be one, to have this viewpoint validated by the world leaders in this newly emerging discipline and two, to be learning with a group of like minded clinicians from a wide range of disciplines, including social work, early intervention, infant massage, psychology, psychiatry and pediatrics.

This point was brought home for me yesterday when in our first full day we heard a case presentation and watched a video. Being ever mindful of confidentiality issues, I will describe only the basic points. The identified patient was a young child who had experienced significant neglect, with multiple losses and disruptions. This "dyadic therapy" we watched in the video was conducted with the child and adoptive parent together. The way in which both the setting and the therapist served to connect this mother with her very troubled child was magnificent.

Some of the most painful cases I have seen in my practice are those of children adopted out of situations of severe abuse and neglect. Parents come to me for medication when the children have been diagnosed with ADHD. When I hear these stories of terrible trauma, I work hard to convey to the parents that while medication may be helpful in controlling the symptoms, it is not sufficient.

Yet I immediately come up against intense resistance. The assumption is that I will recommend therapy. and the parents, for good reason, do not understand the purpose of individual therapy for such a young person. Yet a recommendation to work together with their child in therapy is also met with resistance. The difficult behavior is not their fault, and their loving and safe home should eventually cure the problems.

Here in lies the beauty of this program. My biggest challenge is a paucity of colleagues to refer to. In my community there is not only a shortage of child therapists, but even fewer who work from a conceptual framework that supports treatment of parent and child together.

My fantasy is that one day, when I see such a family, I will have a group of colleagues, all on the patient's insurance plan, who I trust to work to bring a parent and child together in the way I watched in that video yesterday. I know it's a dream, but at least as I sit with all of these colleagues who will one day be leaders in the field, I am hopeful that perhaps mental health care for children is moving in the right direction.

4 comments:

  1. You are so right! It is scandalous that child psychiatrists want to medicate children from traumatic circumstances and do nothing else.

    Play therapy, in my opinion, belongs with such discredited psychoanalytic ideas as "schizophrenogenic mothers" and "penis envy."

    Family systems therapy was big in the eighties but unfairly fell out of fashion due to a wide variety of disperate yet converging societal forces. (That is the subject of my new book).

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  2. Well said, Claudia! Working with parents and children together is crucial to making change happen and making it last. However, it's not always necessary to see them together. There are many factors that can contribute to why a therapist would choose to see a child alone and then have "parent guidance" sessions every other week, every month, or whatever. That being said, I think very young children (<3) would likely need a parent/caregiver present most, if not all, of the time.

    Like you, I'd like there to be a network of colleagues who work with very young children. However, I think the hope for those professionals being on insurance panels is wishful thinking. I have my own reasons for not being on any panels that I can share with you at our next IPMH session, but I almost always will accept a patient's specialist co-pay as if I were in-network.

    Lastly, I'd just like to take issue w/ Dr. Allen on his blast about play therapy. Everybody is entitled to their opinion, but to lump play therapy with schizophrenogenic mothers and penis envy is a bit beyond the pail. I think that's the kind of rhetoric people hear from trusted professionals, which then gets acted out in the form of resistance when a different professional is giving a recommendation for therapy. That's my $.02.

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  3. In response to the above comments, as well as those I've received privately, I wish to clarify my position that use of play therapy is only problematic when done in isolation from the parent-child relationship. Play therapy can be of great value, as play is a child's way of communicating.

    It In addition, there are some circumstances when seeing a young child(by which I mean under five) alone may be important, such as in cases of suspected abuse.

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  4. Claudia, I am right there with you about the need for a community of dyadic therapists. I believe the fundamental problem with insurance panels may not be resolve anytime soon. I believe we can create a network of therapists who develop a sliding scale payment system for families if only we have the vision to do it. Thank you for your insightful post.

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