Family therapy and family therapy methods have been developed and spread successfully in Germany since the 1970s. They have their roots in different scientific disciplines, including psychoanalysis, communication psychology, systems theory and constructivism, to name just a few. The present talk will focus on whether a family therapy approach can be useful in child and adolescent psychotherapy and psychiatry and if so, how it can be professionally developed and expanded for use as an effective and successful treatment.
To explore this, it makes sense to begin with the question of etiology of these disorders and discuss models that focus on the dynamic and functional aspects of symptom development, instead of those of a purely nosological perspective.
In the field of child and adolescent mental disorders, a purely nosological orientation and symptom classification are not enough. The basic idea of "functional psychopathology" (Resch and Fegert 2012, Resch and Parzer 2014) is that symptoms are not simply an expression of disturbed brain functions, as often postulated by nosological oriented psychiatry. They instead represent the best fitting adaptation of an individual, chosen according to their developmental stage and the resources available (Resch and Parzer 2014). From this point of view, symptoms are never embedded randomly in their psychosocial contexts.
"The starting point of developmental psychopathology is an interactionist development theory, which assumes that an active, self-motivated individual driving their own development is in interaction with an equally demanding, active and influential receiving environment.” (Resch, F., Fegert, J.M. "Etiological models" p.124 in "Psychiatry and Psychotherapy of Children and Adolescents" Fegert, JM, Eggers, C .; Resch, F .; Eds, Springer Berlin Heidelberg 2012)This concept reflects the image of a child as an active subject with its own agenda, perceptions, individual motives and goals.
From this point of view, a family therapy approach can be considered as a treatment for an affected child or young person. Due to the development processes, development-related need circumstances and development-related skills involved, an affected child or young person, cannot be treated without their reference system, the family. Furthermore, they cannot be understood without considering the development of their symptoms. Therefore, a family therapy approach would be appropriate, with the focus placed on the child and on understanding their developmental psychology.
For this reason, the importance of attachment theory and the theory of mind on the development of affect regulation and relationship behaviour will first be explored, as according to Resch and Fergert (2012) any therapy should be based on both a pathogenetic understanding and a model of change
2. Attachment theory and theory of mind as clinical development theory
The development of emotional attachment to the primary caregiver is a prerequisite for the development of a baby. The goal of the attachment system is the attainment of a secure experience. Interactive experiences with caregivers are represented mentally, creating expectations on the part of the baby about the effects and consequences of their bonding behaviour. According to Bowlby (1976) these expectations, combined with the baby's behaviour, form the internal working model.
The internal working model dictates how to handle an important attachment figure to create the most secure attachment possible. The working model is adjusted to the individual social environment of the child and is designed to achieve a homeostatic goal: safety in a relationship characterised by the reduction of negative affect indicating insecurity. Attachment theory sees affect regulation as a product of early bonding yet the internal working model continues to shape human behaviour in relationships into adulthood (Collins & Read, 1994; Main 1997).
According to Fonagy’s mental theory (2008), in interpersonal relationships, emotions are regulated based on the ability to perceive a feeling, while also reflecting on it and talking about it. This "mentalized affectivity" is a kind of affect regulation that is encouraged as part of Feeling-Seen therapy for children, adolescents and their parents (Fonagy et al. 2008).
The goal of affect regulation is not the general suppression of emotional expression. It is about the gradual empowerment of people to discriminate between the inner experience and outer expression of emotion. Instead of impulsively expressing emotion, one can choose an expression that is appropriate to the relationship and the present situation. Choosing and expressing emotion appropriately then allows others to understand the emotion and to react compassionately.
Fonagy’s mental theory also states that in the first five years of a child's life they acquire a cognitive and emotive understanding of themselves and the world (Fonagy et al. 2008, p 254). At around four years, a child can create and correlate multiple representations of the world and the ‘self’, known as the fifth phase or "representational actor." From this age on, a child can create an infantile theory of mind, recognising that their behaviour and that of others arise by way of an intention; through emotions, thoughts, desires, goals and beliefs. This ability means that at this age a child can recognise the meaning behind other’s actions and predict the result of an interaction. Thus, “mentalization” is defined as the ability to perceive and understand the feelings, intentions and desires of oneself and others (Fonagy et al. 2004).
The mentalization ability of a child is related to the internal working model or attachment representation. Fonagy et al. suggest that children who have experienced early violent relationships, inhibit their mentalization as a protection, so they do not have to think about their tormentor on whom their existence depends (Fonagy et al. 2002). Accordingly Taubner (2010) concludes, "If the ability to mentalize is undermined by aversive early attachment experiences, therapies that seem to be useful are those that support both the development of mentalization and the modification of internal working models around bonding." As Kobak et. have shown the possibility of modifying attachment representations reduce over time, there are strong indications for conducting therapy during childhood and adolescence.
If in the first years of the life, the basic needs of the child, such as for security, stay unfulfilled, it can create permanent fears that influence cognitive and emotional development. Without the regulation of emotion, the development of more mature interpersonal cognitions in terms of a mental theory is not possible and there is an insufficient capacity for empathy. Instead, a rigid system of affective and cognitive evaluations and behavioural rules is created and fixed as a complex scheme, corresponding to the internal working model of Bowlby or as Sulz (2010) calls it "survival rule."
This fixed scheme does not usually allow sufficient defensive behaviour in difficult interpersonal situations. A hard to handle anger is constructed, which can only finally be repressed by the creation of symptoms due to failing emotion regulation. This process may result in a depressive or anxiety disorder, or if the “survival rule” is extremely rigid and maladaptive, it creates a personality disorder (Sulz 2010).
The function of a symptom and the individual development of psychopathology may only be ascertained heuristically in each individual case. Child-centered forms of interventions begin with the collection of biographical symptom information in collaboration with the child and in the presence of the parents. Involving the parent in the therapy allows them to finally recognise the functional aspect of their child’s symptoms and understand that, "irrational, emotionally-led and seemingly "illogical" behaviour … can be explained in a logical way, because the behaviour is not just based on the environment but internal objectives." (Resch and Parzer 2014)
3. Access to children and adolescents in a family therapy context
3.1. General information
The implementation of effective therapeutic family sessions requires a clear concept. For example, it is important to talk with the child and not to talk with the parents about the child. At first, it is likely that the parents will dominate the conversation. The therapist should take care that the complaints of the parents are not overrepresented and that the child can speak for themselves. For example, the therapist should ask the child for their point of view and support them in expressing it for themselves.
The therapist should also inquire about a child's affective reaction to their parents words. With this approach, it soon becomes clear that the parents perspective and the child’s perspective may be different. Thus demonstrating that perception is a subjective process, and that there can be more than one truth (something all spouses know quite well). By supporting the child’s perspective during therapy, the child is seen as a subject, which avoids them being considered an object in the process of diagnosis and treatment. Providing comfort to the parents can be achieved in the following meeting with the parents alone.
3.2. The emotive conversation with the child in Feeling-Seen
3.2.1. Words create pictures in the mind
When choosing a way of talking during the therapy, the therapist must be aware that words create images in the mind of both the speaker and the listener. Observe what happens when I say the word "Mother." You will probably see the image of your mother in your mind. Your mother's face may reflect joy, happiness or pride or even anger, anxiety, exhaustion, despair, stress or resignation. At the same moment, in which we see this remembered image in our minds, we react emotionally to that information and experience feelings such as gratitude, connectedness, happiness or compassion or fear, frustration, anger, indifference or even scorn and contempt. These are actualised feelings that relate to remembered contexts, for example, specific interactions with your mother or her behaviour in certain situations. These are precisely captured and recalled feelings that relate to remembered information and pictures and they create a real and experienced affective reaction in the present. This affective reaction is seen by the changes in our facial expressions and body language and heard in the altered sound of our voice.
3.2.2 Support of mentalized affectivity
Therapists can take advantage of the phenomenon of mental imagery by using micro tracking (Bachg 2006). In micro tracking, the therapist listens carefully to the client and allows images to appear in their own mind as evoked by the client’s words. For example, if the child says during the family therapy session, "… and then the dog came around the corner," the therapist, as a listener, sees in their minds a corner, perhaps of a house and a dog who runs around this corner and comes closer and closer. The meaning of this image and the evaluation of this information will be different for every individual, depending on their own experience with dogs and the kind of relationship they have with them.
This is also true of the inner image created by the child, the individual significance of which, we can understand or read from their voice and facial expressions. The child’s face may express enthusiasm because they anticipate the joy they felt during an earlier experience with a dog, how it feels to stroke its fur or to play with it. Their facial expression may also show fear and pre-motoric tension in the body, indicating an impulse to escape from a threat or to run somewhere, to find protection, maybe behind the body of an accompanying caregiver.
This moment can be seized for an intervention in which the therapist actively focuses on the link between the experienced affect and the triggering context. Instead of describing the child’s expression when expressing the emotion, for example, "I see how you open your eyes or how you wrinkle your forehead…", the therapist tries to translate how this affect is being experienced as a subjective emotion. They select a word that renames the emotional experience as specific feeling, fitting for the child, and put it into context, for example, "how scared, or how worried are you/do you feel when you remember how the dog came around the corner". Note that it is important to name the feeling in the present tense, to create a connection between the past and the here and now.
If the intervention succeeds, the child will feel understood and confirms this immediately with their reaction, perhaps with a strong nod or a clear "yes". They will feel seen and understood, which increases their motivation to cooperate with the therapist. An absence of this reaction indicates that the therapist did not name the right emotion, or the triggering context is not accurate. In this case, the joint search process continues until the child shows they have been understood.
With this theoretical and methodological background, interview sequences with children and young people can be situationally based and more profound. This approach brings up important information and also helps the child in the mentalization of information and experiences. These feelings and evaluations influence the process of reflexive consciousness. Instead of just experiencing a feeling, a child can learn to see itself as a subject that is experiencing a feeling. These representations will be the object of their mental processes.
3.3. From the right questions to the right answer
3.3.1 Antidote Development with children and adolescents in the presence of their parents
The mutual coordination of interpersonal processes between a newborn and their attachment figures represents the evolutionarily acquired skills and newborn’s organismic potential to perform appropriately within its social environment. To understand and fulfill the child's emotional needs, the attachment figure must be sufficiently empathic towards the child. As Buber's key humanistic sentence states: "Only on you I will be I" Thus from evolutionary point of view comes a broader therapeutic context. (Kriz 2014)
With this background, it is obvious when bonding experiences have not brought a reduction of negative emotions in a child and have increased them instead. The therapeutic procedure for alleviating these negative emotions borrows from Pesso’s concept of antidotes (2008). The aim of which is to reduce negative emotions and to develop new representatives of attachment figures. Together with the child an ideal mother, father or caregiver, is symbolically constructed via dramaturgical means in a scene. This ideal caregiver shows a bonding behaviour that responds to the needs of the child so that those needs that were not met in the past can now be experienced and satisfied.
From this satisfaction, the regulation of affect is also be supported, the internal working model on the base of this experience is modified and the ability of mentalization will be strengthened. This process aims to improve the relationship behaviour and is based on the awareness that humans do not need reality for a new experience, an image of reality is enough.
3.2. Integration of parents: support parental empathy ability
The ability of parents to recognise the motives and emotions of their child may be limited for various reasons. Unprocessed childhood conflicts or traumas may influence the parental representations of the child and distort the perception and interpretation of the child’s signals like a filter. (Fraiberg et al. 1975, Quitmann et al. 2010). Negative parental attributions also prevent the process of mentalization and lead to inefficient parental behaviour. This behaviour then negatively effects the child's development and behaviour.
In their concept of parental reflexive empathy ability, Oppenheim and Koren-Karie (2009) accentuate that parents can only react sensitively to the signals of their child if they are able on a mental level to empathise with them and perceive the world through their child’s eyes. The parents’ reflexive empathy is often restricted through their own burdens, such as problems at work, problems in the partnership, care of family members and time pressures. These kinds of burdens restrict the parents’ ability to consider the different motives or explanations for the child's behaviour and to realise how important it is to name them. In order to work on the disappointed expectations of both the child and the parents, it is proposed not to search solutions directly in the current frame of reference of those involved, but at first, as described above, on the symbolic level of ideal caregivers.
As the parents recognise that their child can be reached through this approach, it creates trust in the process. Experiencing a suitable and proper reaction in the child produces an immediate sense of relief for all involved, which often changes even quicker into sadness. This occurs when the child in their relief, recognises what they missing and lacking in reality. This process is regularly observed and is called the Relief-Grieve-Cycle (Pesso 2008).
To be witness to this process makes it easier for parents to see what their child is missing and needs. By listening and going along, parents can feel empathy for their child. Often they have not been able to feel anything for a long time, at least not in the presence of their child.
Sometimes it is the first time in years in which the parents can really empathise with their child. This is an invaluable first step out of the family entanglement with the past and represents a deep common emotional experience with their child. For the parents, it is now easier to take a new perspective on their child, and on their experiences and behaviour, because the functional aspect of the symptom is easily identifiable. Through the family therapy approach described, the parents understand their child’s mental disorder in a developing psychopathological context and recognise that they played a role in its development. Often this realisation is accompanied by regret and sympathy for their child. Thus, the child feels really understood, by their parents which can cause the described Relief-Grief-Cycle again.
Using methods other than the family therapeutic approach, this final soulful and emotional encounter, where parents give their hearts fully to their child, would not be possible at such depth and sustainability.
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Published online: 4 January 2016.
Copyright: © 2016 Michael Bachg. This is an open-access article distributed under the terms of the Creative Commons Attribution License. The use, distribution and reproduction of this article is permitted, provided the original authors and licensor are credited and that the original publication in E-Journal of Psychotherapy Research is cited in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.