Therapy for children and adolescents: Does it do any good?

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Every decade, or so, a major worldwide review of psychotherapy is conducted by leading researchers in their fields and published as ‘Bergin and Garfield’s Handbook of Psychotherapy and Behaviour Change’. The most recent, sixth edition, was published in 2013 and edited by Professor Michael Lambert.

Within Bergin and Garfield’s Handbook, the chapter on psychotherapy for children and adolescents was written by John Weisz and collaborators. Reviewing the evidence these authors found the effect sizes for outcomes with children and adolescents were comparable with those of adults. On average, adults benefit from therapy, and on average children and adolescents find therapy as helpful as adults do.

Yet there are challenges in providing effective therapy for children and adolescents.

Yesterday I attended a training course for ‘Supervising Professionals Who Work With Young People’. The course was put on by Cambridge Supervision Training, with whom I did my Supervision Certificate (2010-11) and Supervision Diploma (2011-12). The course was led by Nick Luxmoore at Thriplow Village Hall.

Amongst many other attributes, Nick Luxmoore is a teacher, counsellor, clinical supervisor, trainer and writer. As an author, Nick has written a number of books including Practical supervision for counsellors who work with young people (2017), Horny and hormonal: Young people, sex and the anxieties of sexuality (2016) and Working with anger and young people (2006).

Nick was keen to stress the importance of defining the therapeutic task in counselling with young people. It can be too easy to resort to platitudes about ‘giving space to talk’ rather than encouraging the counsellor, and in turn their client, the young person, to focus on ‘what difference are we hoping to make’: What are we working to achieve here?

If we’re not clear on what we’re seeking to achieve, we may not achieve it.

Nick points out therapy and therapists need to be held accountable for the resources they are using (time, money and so on) and the outcomes they are achieving.

When I’m working with clients and supervisees my own case formulation approach centres around three questions:

  1. What is going on here? What problems/ symptoms is the client experiencing.
  2. What should be going on here? How would the client like their life to be like.
  3. How are we going to make that change happen? What is it that the client/ counsellor/ supervisor can do to make change happen.

In their 2013 review, Weisz and colleagues pointed out, often it is not the young person themselves who initiates therapy. Even when they do, their concerns may not agree with those of their parents and other adults.

One of my interests in attending the course was because of my work as Group Clinical Supervisor at a therapeutic community where I provide supervision to a group of therapists working with young people who are 15 to 18 years of age. Typically, in this setting, the young people are mandated to receive therapy.

Weisz and colleagues suggested a key challenge with therapy for children and adolescents is that of establishing engagement. If a person is mandated to receive therapy, it is important to build rapport and motivation in order to achieve the goals of therapy.

An area discussed by Nick that I particularly enjoyed was ‘On not being weird’.

Often as part of their training, counsellors will have learnt particular ways of being and behaving that somehow fit the theories they have learnt. Too often these result in the counsellor coming across as someone who is a bit weird. It’s difficult to build rapport with (young) people when you come across as weird.

Nick gave a particular example of ‘being weird’. Not unreasonably a new client asks their counsellor, ‘have you got kids?’.

Rather than simply answering the question, the counsellor replies ‘Hmm… I’m interested that you’re wondering whether or not I’ve got kids?’. This kind of response, while logical to the therapist, is weird! And it puts young people off.

Therapy for children and adolescents can be effective and what helps in being effective is being clear about goals, progression and engagement.

Clinical supervisors play an important role in holding the client’s counsellor to account in terms of ensuring goals have been established and the counsellor is working towards these in ways that maintain the engagement of the young person. Within the context of the scientific literature, the training course delivered by Nick Luxmoore on ‘supervising professionals who work with young people’ made a valuable contribution to my understanding of the importance of the role of the clinical supervisor and how to fulfil that role.

References:

Lambert, M. J. (Ed.). (2013). Bergin and Garfield’s handbook of psychotherapy and behaviour change (6th ed.). Hoboken, NJ: Wiley.

Weisz, J. R., Ng, M. Y., Rutt, C., Lau, N., and Masland, S. (2013). Psychotherapy for children and adolescents. In M. J. Lambert, (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavioural change (6th ed., pp. 343-392). Hoboken, NJ: Wiley.

I’ve been Educated

Tara signature.pngOn Sunday I met with Tara Westover and heard her talk at the Cambridge Literary Festival about her life and recent memoir Educated.

Educated tells Tara’s story of growing up in rural Idaho without formal education and her journey from there to being awarded a PhD in History from Cambridge University. She describes themes of what many would call neglect and abuse in her childhood.

Having previously read Educated, one of the things that struck upon hearing Tara speak was that her childhood was also an important part of her education, her childhood was not simply something to survive or overcome.

Perhaps because of what might be considered a non-traditional route to studying at University (she has also studied at Brigham Young and Harvard) Tara pointed out the ideological consensus that can exist in formal education. That unknowingly many of us can end up believing similar things, without having this questioned. And that bringing things into question, through differing views and experiences, can be healthy.

Tara’s story highlights the intergenerational effects of mental illness, in her book and in person. Tara describes her belief that her father was suffering with bipolar or similar that made him paranoid about others trying to control him, such as formal healthcare and education. Consequently, her father refused to allow his children access to healthcare and education. Father’s difficulties in turn having effects upon his children, and so on.

Seeing Tara talk, meeting with her one-to-one and reading about her life I am reminded of Carl Rogers’ thoughts about what he called ‘the actualising tendency‘. The idea that people (organisms) will struggle with adversity to become who they are capable of becoming. Tara Westover’s life and memoir ‘Educated’ is an inspiration.

  1. Westover, T. (2018). Educated. London: Hutchinson.
  2. Rogers, C. R. (1963). Actualizing tendency in relation to “Motives” and to consciousness. In M. R. Jones (Ed.), Nebraska symposium on motivation (pp. 1-24). Oxford, England: U. Nebraska Press.

 

The three conflicts.

Researchers have identified three patterns of conflict in human interactions.

Illustrating the first of these, Abi and Byron (names and identifying details removed) are discussing how they should spend Saturday evening. Suddenly the situation becomes tense.

‘You always get what you want!’

‘No. I don’t. You’re always the one who gets what you want!’

‘You got to do exactly what you wanted last week. And what about the week before. And you spent all that money when you were away with your friends last month.’

‘Well if we’re going to talk about money, look at how much you spent last weekend.’

These kinds of conflicts are called Negative Interaction Cycles and it is these that cause the harm in human relationships. Harm in couple relationships, family relationships, friendships and with people we work with.

Blame/Blame

blame_blame

The first of these Negative Interaction Cycles (NICs) is called Blame/Blame. In the example given by Abi and Byron, above, there is no need to indicate which partner is speaking, whatever is said brings about another attack. The unconscious pattern being played out is ‘if you’re going to attack me, then I’m going to attack you’.

Researchers refer to this as a Negative Interaction Cycle because of its cyclical nature, it goes around and around, each time deepening the hurt. It is interactive because each person plays a part. And negative because it is creating more and more so-called negative feelings.

The problems with this kind of interaction include:

  • Escalation, as feelings intensify the attacks become bigger and more hurtful
  • Destruction, the attacks destroy the sense of attachment in the relationship and cause hurt to each person
  • Lasting damage, the greater the hurt the more memorable the interaction, the more the conflict escalates and the more long-lasting the injury

Unconstrained conflict of this kind can lead to abuse, violence and what researchers term ‘attachment injury’; the previously secure attachment between partners becomes injured. The more this type of injury, the less emotionally safe the relationship feels.

Whilst referred to as a Blame/Blame conflict, to signify this is what both partners are doing to each other, the conflict may contain the whole lexicon of conflict behaviours: attack, blame, criticise and so on.

Blame/Withdraw

blame_withdraw

The second of these Negative Interaction Cycles (NICs) is known as a Blame/Withdraw. In this NIC one of the people in the conflict has less appetite for the conflict, there can be a number of reasons for this. Instead of responding to Blame with Blame, in this NIC the response is to Withdraw. One person is continuing with Blame, whilst one is Withdrawing.

Withdrawal can include a range of different behaviours including getting up and walking off, emotionally withdrawing, going silent, changing the subject and so on. The point is that the conflict is continuing and unresolved.

For the Blamer this can be infuriating, and they might say things like:

‘That’s right, do what you always do and just walk off.’

‘Come here I haven’t finished with you.’

‘I don’t really matter to you, do I.’

Whilst for the Withdrawer, they might be thinking things like:

‘Can’t you see how much this hurts me.’ 

‘I just want a simple life.’

‘I just need some space away from all of this.’

In this interaction it looks like the problem of escalation has been avoided, at least for now. A risk is that with unresolved conflicts of this kind, future conflicts may escalate more quickly because of the lingering bad feelings. Problems with this kind of interaction also include, for both people, emotional destruction and lasting damage.

Withdraw/Withdraw

withdraw_withdraw

The third of the three conflicts is known as Withdraw/Withdraw. Whilst on the surface it might appear there is little conflict between the people in this relationship, this NIC is the most fragile and usually marks the final phase of the relationship. In this NIC conflicts remain unexpressed. Both are withdrawn. In effect both have emotionally withdrawn from the relationship, given up, and there is now a fragile ceasefire.

Most of therapy is about relationships, either about one’s relationship with one-self or about relationships with others. In talking about relationships with others, in individual therapy, couples/family therapy or work-based relationship coaching there are a number of tasks and these can include:

  1. Understanding what Negative Interaction Cycle(s) are playing out. Usually one of the three conflicts described above is prevalent.
  2. The shift from seeing the other person(s) as the problem to seeing the NIC as the problem. ‘It’s not you or me, it’s what we do to each other.’
  3. Seeing that people make sense and they take up the position they do in the NIC(s) for good reason, usually to do with their experience of human relationships, especially interpersonal traumas.
  4. Putting something better in place than the NIC(s). Learning to resolve conflict without recourse to the NIC(s).
  5. Stepping away from thinking about short-term crises and investing in the relationship for the good long-term health of the relationship, so the relationship is more resilient to short-term crises and these can be more readily withstood.

Taking all of these tasks together, the overall change is one from Negative Interaction Cycles to Positive Interaction Cycles (PIC).

Positive Interaction Cycles

In a Positive Interaction Cycle, two people seeing things differently is an opportunity for a discussion. An opportunity to listen, understand and accept the experience of each other; an interaction with each person playing a part. This kind of interaction creates more intimacy and closeness; hence it gives rise positive feelings of connectedness between people. When a conversation goes this well, who doesn’t want more of it, so it becomes cyclical in nature; listen, understand, accept one another’s experience and arrive at a joint solution to a shared problem.

Abi and Byron are discussing how they should spend Saturday night:

‘You think I always get what I want. I’d really like to understand your perspective on this. I love you very much and I can see this is causing you a lot of hurt and upset. I’m ready to listen to you so we can see how we can sort this out.’

Suddenly the tension eases, there is an air of loving concern and an intimate conversation ensues.

Three conflicts. One heart-felt conversation: prizing relationships ahead of shared problems.

 

Selected sources:

Johnson, S. M., & Greenberg, L. S. (1985). Differential effects of experiential and problem-solving interventions in resolving marital conflict. Journal of Consulting and Clinical Psychology, 53(2), 175-184. http://dx.doi.org/10.1037/0022-006X.53.2.175

Lee, N. A., Spengler, P. M., Mitchell, A. M., Spengler, E. S., & Spiker, D. A. (2017). Facilitating withdrawer re-engagement in emotionally focused couple therapy: A modified task analysis. Couple and Family Psychology: Research and Practice, 6(3), 205-225. http://dx.doi.org/10.1037/cfp0000084

Makinen, J. A., & Johnson, S. M. (2006). Resolving attachment injuries in couples using emotionally focused therapy: Steps toward forgiveness and reconciliation. Journal of Consulting and Clinical Psychology, 74(6), 1055-1064. http://dx.doi.org/10.1037/0022-006X.74.6.1055

Vanhee, G., Lemmens, G. M. D., Moors, A., Hinnekens, C., & Verhofstadt, L. L. (2018). EFT-C’s understanding of couple distress: An overview of evidence from couple and emotion research. Journal of Family Therapy, 40(Suppl 1), S24-S44. http://dx.doi.org/10.1111/1467-6427.12128

Criticism: Why name-calling is more painful than a broken bone.

knight

The adverse effects of criticism on people is a huge area of psychotherapeutic endeavour. The effects of criticism frequently arise in individual therapy, couples counselling and family therapy.

For individuals, the effects of criticism from others are associated with a number of different psychological problems, including and not limited to:

  • Difficulties in psychological coping1
  • Psychological distress2
  • Depression3, 4, 5, 6
  • Anxiety5
  • Social anxiety7
  • Panic disorder8
  • Eating disorders9
  • Some personality processes, so-called ‘personality disorders’10
  • Difficulties in romantic relationships11, 12
  • Difficulties with child-rearing4

Sometimes the effects of criticism from others become internalised13, an ‘internalised critic’, a part of a person’s psyche that turns against themselves. This self-criticism is a well-recognised pathway to a range of psychological problems, including distress2, depression4, 5, 6, anxiety5, eating disorders9, personality processes10 and difficulties in romantic relationships11,12.

The evidence is that it isn’t just what happens to us but also how we criticise ourselves for what happened to us that leads to adverse psychological effects2, 5, 11, 12.

Becoming less self-critical and more self-compassionate are associated with:

  • Greater perceived ability to cope with life1
  • Improvement in distress2
  • Improvement in wellbeing and reduced psychological distress3
  • Improvement in depression6
  • Improvement in social anxiety8
  • Improvement in panic disorder9

Furthermore, some research has shown that it is the reduction in self-criticism that predict the improvements in distress2 and improvement in personality-process symptoms10.

For couples, criticism of one another ‘if you’re going to criticise me, then I’m going to criticise you back’, is technically known as a Negative Interaction Cycle and destroys the secure attachment both are seeking14.

This also plays out in families too, eroding the attachments between family members. As described above, criticism from family members, especially parents, can lead to psychological problems as a child, teen and later in life, even after having left home. Leaving home doesn’t necessarily mean the internalised critic is left behind.

In couple and family relationships criticism of one another destroys intimacy, attachment and emotional safety.

Googling ‘criticism’ yields two related definitions:

  1. Expression of disapproval on the basis of perceived faults or mistakes
  2. Analysis and judgement of the merits and faults

Seemingly the word ‘criticism’ comes from the Latin word Criticus, for ‘a judger’ or ‘decider’. This in turn is believed to arise from the Greek Krites, meaning ‘judge’.

In his Seven Habits of Highly Effective People series, Stephen Covey wrote how in his view judgement and understanding were opposites; understanding someone removes judgement of them and judging them shows a lack of understanding.

People like to be understood. People don’t like unfair judgements being made of them. Being judged unfairly by self and others leads to a wide range of psychological problems.

Clinical experience is that harsh criticism by parent(s) and other caregivers when young can lead to a harsh internalised critic in later life. Internalising the critic can serve to bring some predictability to being criticised; and maybe a way of avoiding being criticised by the other. The cost can be a lifetime of self-criticism and risk of a wide range of psychological difficulties.

Some ‘high intensity’ criticism can be easy to spot. This is the kind of criticism that observers might think of as abuse. Even so, to the person receiving this kind of criticism, it may not appear to be abuse or even criticism. It might just be what we are used to. Familiar. Just how life is.

Criticism of a ‘lower intensity’ might be more difficult to spot, even to an observer. Telling people what to do and giving advice when not requested are both subtle forms of criticism. It can tell the recipient ‘you don’t know, I know better than you’.

At an even lower level, some forms of praise can even constitute a form of criticism. Telling a child, the painting they have done at school shows they are a wonderful artist can set up what psychologists’ call ‘conditions of worth’16. This can tell the child ‘I’ll love you provided you produce what I deem to be ‘the works of a wonderful artist’. Anything less means you are unlovable.

Some of the antidotes to criticism can include trying to listen to, understand and accept the other person. Not name calling. Not belittling. Not setting up conditions of worth that create fear of failure in the other person. As much as possible providing a secure and unconditional attachment free from the threat of being ignored, rejected or abandoned.

Sticks and stones is an English children’s rhyme that tries to persuade that: ‘sticks and stones can break my bones, but words will never harm me’.

The research is in. It’s just not true. Criticism, including name calling, is hugely harmful and detrimental to lifetime psychological wellbeing.

Sources:

Keng, S.-L., Choo, X., & Tong, E. M. W. (2018). Association between trait mindfulness and variability of coping strategies: A diary study. Mindfulness. Advance online publication. http://dx.doi.org/10.1007/s12671-018-0885-4

Campos, R. C., Holden, R. R., Caçador, B., Fragata, A. S., & Baleizão, C. (2018). Self-criticism, intensity of perceived negative life events, and distress: Results from a two-wave study. Personality and Individual Differences, 124, 145-149. http://dx.doi.org/10.1016/j.paid.2017.12.004

Sommers-Spijkerman, M. P. J., Trompetter, H. R., Schreurs, K. M. G., & Bohlmeijer, E. T. (2018). Compassion-focused therapy as guided self-help for enhancing public mental health: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 86(2), 101-115. http://dx.doi.org/10.1037/ccp0000268

Shimizu, M., & Teti, D. M. (2018). Infant sleeping arrangements, social criticim, and maternal distress in the first year. Infant and Child Development. Advance online publication. http://dx.doi.org/10.1002/icd.2080

Kopala-Sibley, D. C., Klein, D. N., Perlman, G., & Kotov, R. (2017). Self-criticism and dependency in female adolescents: Prediction of first onsets and disentangling the relationships between personality, stressful life events, and internalizing psychopathology. Journal of Abnormal Psychology, 126(8), 1029-1043. http://dx.doi.org/10.1037/abn0000297

Chui, H., Zilcha-Mano, S., Dinger, U., Barrett, M. S., & Barber, J. P. (2016). Dependency and self-criticism in treatments for depression. Journal of Counseling Psychology, 63(4), 452-459. http://dx.doi.org/10.1037/cou0000142

Rose, A. V., & Rimes, K. A. (2018). Self‐criticism self‐report measures: Systematic review. Psychology and Psychotherapy: Theory, Research and Practice. Advance online publication. http://dx.doi.org/10.1111/papt.12171

Shahar, B., Bar-Kalifa, E., & Alon, E. (2017). Emotion-focused therapy for social anxiety disorder: Results from a multiple-baseline study. Journal of Consulting and Clinical Psychology, 85(3), 238-249. http://dx.doi.org/10.1037/ccp0000166

Chambless, D. L., Allred, K. M., Chen, F. F., McCarthy, K. S., Milrod, B., & Barber, J. P. (2017). Perceived criticism predicts outcome of psychotherapy for panic disorder: Replication and extension. Journal of Consulting and Clinical Psychology, 85(1), 37-44. http://dx.doi.org/10.1037/ccp0000161

Lowyck, B., Luyten, P., Vermote, R., Verhaest, Y., & Vansteelandt, K. (2017). Self-critical perfectionism, dependency, and symptomatic distress in patients with personality disorder during hospitalization-based psychodynamic treatment: A parallel process growth modeling approach. Personality Disorders: Theory, Research, and Treatment, 8(3), 268-274. http://dx.doi.org/10.1037/per0000189

Lassri, D., Luyten, P., Cohen, G., & Shahar, G. (2016). The effect of childhood emotional maltreatment on romantic relationships in young adulthood: A double mediation model involving self-criticism and attachment. Psychological Trauma: Theory, Research, Practice, and Policy, 8(4), 504-511. http://dx.doi.org/10.1037/tra0000134

Lassri, D., Luyten, P., Fonagy, P., & Shahar, G. (2018). Undetected scars? Self-criticism, attachment, and romantic relationships among otherwise well-functioning childhood sexual abuse survivors. Psychological Trauma: Theory, Research, Practice, and Policy, 10(1), 121-129. http://dx.doi.org/10.1037/tra0000271

Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused theapy: The process-experiential approach to change. Washington, DC, US: American Psychological Association. http://dx.doi.org/10.1037/10725-000

Fraser, J. S. (2018). Couple problems. In J. S. Fraser, Unifying effective psychotherapies: Tracing the process of change (pp. 191-222). Washington, DC, US: American Psychological Association. http://dx.doi.org/10.1037/0000078-010

Covey, S. R. (1989). The seven habits of highly effective people: Powerful lessons in personal change. New York, NY, US: Free Press.  ISBN 0-7432-6951-9OCLC 56413718

Rogers, C. R. (1959). A theory of therapy, personality and interpersonal relationships as developed in the client-centred framework. In (Ed.) S. Koch, Psychology: A study of a science. Vol 3: Formulations of the person and the social context. New York: McGraw Hill.

Daffodils and psychological wellbeing

 

two daffodils

Sunny weather this weekend gives a sense winter will come to an end. In the garden daffodils are starting to open.

Daffodils belong to the plant genus Narcissus, with about fifty different species.

The Roman, Pliny the Elder, claimed the Greeks named Narcissus for the effect of the plants’ fragrance on anyone smelling them, narkao is Greek for ‘I grow numb’; from which we also get the word narcotics.

In Greek mythology Narcissus is a young male hunter who seeing his own reflection in a pool of water falls in love with his own good looks, passes out and ultimately dies. According to myth Narcissus grows into the plant of that name next to the pool.

At the start of the 1900s, around the time of Freud, psychoanalysts began using the term ‘narcissism’, derived from the myth of Narcissus, to describe someone filled with self-admiration. This term continues to be used to describe someone who has a need to be admired by others.

There can be down-sides to having too much ego (ego is Latin for ‘I’). The idea of a ‘shrink’ is someone who helps us ‘shrink our ego back down to size’.

Yet there is also a need for sufficient ego (sense of self) to be able to take care of oneself, to tolerate difficult feelings such as hurt, sadness and disappointment. And to work towards important goals over a period of time, to take care of loved ones and to have a sense of meaning in one’s life.

Around the start of the 2000s psychologists began to consider what they called ‘the psychological immune system’. The physical immune system is what helps our body fight off infection. Similarly, the idea of a psychological immune system is a sufficiently strong ego or sense of self, helps us overcome adversity and keep on going in pursuit of what is important to us.

In addition to the idea a ‘shrink’ helps us get our ego back down to size, a therapist can also help us develop a robust and realistic ego that helps us get things done.

Somewhat like Goldilocks, of Three Bears fame, when it comes to ego, too much ego is problematic and too little ego is also problematic. Ideally, we could do with just the right amount of ego to help us stay in touch with reality and get important things done.