TRENDS IN THERAPY

VI. INTER-RELATED MOVEMENT OF PARENT ANDCHILD IN THERAPY WITH CHILDREN

ALMENA DAWLEYPhiladelphia Child Guidance Clinic

I N THIS paper I present briefly one emphasis in therapy with children thatrequires greater consideration. That is, the inter-relationship of the shift

and change in parent and child as each of them separately is a part of a newprocess of self reorganization. In this inter-relationship of movement lies a mosteffective, yet little explored basis of therapy.

Our discussion deals with trends in therapy. I would like to comment in asentence or two on those trends in Child Guidance Clinics in the last 15 yearsas they are related to the subject of this paper. In the earlier days of workingwith either neurotic or delinquent children of any age, the assumption, as carriedout in practice, was that outer life forces in the way of parents' greater under­standing of the child's problem, change in attitudes of the school, added recrea­tion, etc., would provide the external impetus for growth and change. There wasusually only a diagnostic examination of the child and repeated contacts withparents. Our operation was based on a faith that the life process and normalliving would affect psychological change in the difficult child. In some instancesit did, but more often the root of the difficulty remained untouched.

Out of the failure to reach neurotic problems by these external means, theredeveloped a need to understand and to work with the child's own mental forces.Gradually, as a new psychology of his emotional life was growing up, new skillin understanding and in helping him developed. Soon that became the majoremphasis in working with children. Direct therapy with the child was the purposeof clinical organization. Much of it was patterned after adult psychoanalysis orpsychological treatment. Contacts with parents and schools were supplementaryto and not an inherent, vital part of the child's reorganization.

As the child's relationship to the therapeutic situation was allowed to developand to take its form, rather than being blocked by the therapist's attempt tofit him into a particular theory, it appeared that the process was accelerated anddeepened as it had its roots in a significant part of his external life which was atthe same time shifting and changing in relation to his new development. It alsoappeared that the child's self was actually a composite of his inner forces andthose external elements that make up his life, to a degree not found in the adultwith a well-developed ego. It is this present emphasis on the inter-relationshipof the child's movement at the same time that the parent has put himself intothe experience, that I want to discuss. I will not attempt to discuss the thera­peutic or case work processes as such, but to emphasize them as they overlap.

A parent first comes to a Child Guidance Clinic when he is ready to do some­thing about his child's difficulty and the closeness of the struggle in which they

748

VI. INTER-RELATIONS: DAWLEY 749

are engaged. For a child's behavior and personality is indisputably related invarying degrees to the situation in which he lives. Parent and child are united inthis struggle and it is out of this close conflict that the parent has the impulse togo outside in an attempt to change his situation. In so doing he is beginning tobreak up their undifferentiated unity because he is including in it something out­side, in the form of the clinic. As I see it, there are two important elements inthis. First, the parent's coming to the clinic is a new living impulse rising out ofan impasse with a child. Therapists have mistakenly emphasized, I believe, thata parent's seeking help is synonymous with, "I am no good and a failure." Onthe contrary, his first relation to the clinic is the new and positive shift in him."I said to myoId father last night," one mother said, "It is a disgrace to go tothe clinic tomorrow to see about Tom." "Not a disgrace," he said, "It is an honor.It is an honor for you to find such a place and an honor for Tom to find newways." Secondly, this new impulse is directed toward an outer experience. Theparent does not seek to solve the difficulty by himself or with the child directly,but goes outside. By that very step he breaks up the negative unity with thechild by including someone outside of it.

A mother said to me recently in referring her I4-year-old boy to the clinic,"You know, a family has to have privacy and keep its troubles and intimatethings to itself. Well, a year ago I was so worried about John's becoming sounruly that I told his uncle about it. I let him in on our family privacy." In amoment she made the connection of telling the uncle as the first step in takingthis problem completely outside to the clinic a year later. She added that whenthey had finished with the clinic they might find "another kind of privacy."

This inclusion of a person outside of the problem as a means of modifying it,is of extreme significance in understanding how the parent may use later steps intreatment. The inclusion of another person, in going for help, is the basis of thewhole experience. The inner blockage has yielded to an outer area around whichthe conflict may be worked out. And yet, in a Child Guidance Clinic this is notso simple, because it is not a question of one adult going to another. There isa child in it, who is the particular reason for the dilemma and for seeking help.

I will give a brief factual statement of the way the clinic with which I am famil­iar operates. After the first interview, if the parent is ready to continue and ifthe situation is a suitable one for clinic treatment, there are regular-usuallyweekly or semi-weekly-appointments with both parent and child.* The childusually sees a therapist while, at the same time, the parent, either mother, fatheror both, work with a case worker. These interviews consider not only what thechild is doing in the clinic with the therapist and in his life in general, but theirmain purpose is to work on the problem the parent has in his relation to thechild. In other words, the structure of this clinic approaches the difficulty throughwork with both the child's problem and the parent's relation to it.

How then, does the child find himself in this new experience which has been

• This discussion pertains only to those cases where both parent and child come to the clinic.Other cases are carried in other ways.

75° TRENDS IN THERAPY

arranged by the parent and in which usually he has had little or no part? He isin difficulty, blocked in his normal growth and stuck in a relationship with aparent where neither of them can move on. As' the parent seeks psychologicalhelp for the situation, this is a profound experience for the child also. Some outerforce has entered into their relationship and has changed it in the very act oftheir going to the clinic. With some children there is an immediate shift in symp­tom or behavior, occasionally after the mother's first interview and before he hasever been in the clinic. If anything is to be done, he will do it himself! In anyevent, the fact that the parent seemingly gives him up to the therapist has in itan element of enforced separation. The child's leaving a mother to go with thetherapist has, therefore, significance not only as the beginning of a new experiencewith the therapist, but also as a rebalance in his relation to his parent. These twodirections, I believe, must be kept in mind and must be an integral part of atherapeutic procedure. What is happening in the child's progress in therapy?What is happening in the parent's shift in attitudes? And what is happening inthe balance and rebalance between parent and child as they are both a part ofthis experience?

If one may generalize, it is found that in most instances this running start isnot maintained. The start is a forerunner of what may eventuate but it is a longway from actual accomplishment. A parent has let into the closeness of his re­lationship to his child, a little of the outside, in coming to the clinic. He hastaken a new kind of responsibility for coming to grips with the problem. Thisputs an emphasis and responsibility in the first interview to maintain it andstrengthen it as time goes on, until he is able once again to live a more satisfactorylife with his child. The case work process with a parent, then, in a Child GuidanceClinic is that new impulse to make himself and his situation more livable whichis constantly strengthened and developed, by struggle and fight, guilt and fear,as well as in more positive ways until the parent is ready to give up the propwhich the clinic represents and to become responsible again, but differently, forhis relationship to his child.

This progress does not continue in an even, unbroken way. It is inevitable thatthere should be withdrawal from the directness of that first effort to change hissituation. One frequent attempt at withdrawal is to put the area of difficulty inanother place than in the relationship to the child. It is difficult to let anythingtouch the closeness of that relationship, even if, at the same time one wishes it.A mother, for example, may choose to use a Child Guidance Clinic and, as soonas she has actually let Jim go with the therapist, retreat to less immediate andpainful ground by talking about her relationship to her husband, annoyed anddisturbed when Jim is mentioned.

The case work process with a parent in a Child Guidance Clinic is quite dif­ferent from adult therapy because it originates and has its center in 'a realityproblem, namely, the relationship to his child. For that reason the parenthas sought this type of clinic which, in turn, is equipped to help with thisparticular difficulty. Adult therapy, on the other hand, approaches the reality

VI. INTER-RELATIONS: DAWLEY 751

problem as a manifestation of the whole self and its essential core is the re­organization of the self. In making this distinction I am not belittling the im­portance o'f case work. Recent developments in this field have established notonly the soundness of the case worker's being and representing the particularfunction for which her agency is equipped, but also demonstrates the value ofthis to the client. There is a more powerful impetus toward growth and develop­ment than has been generally recognized in an individual's working consciouslyand directly on the specific problem that brings him to a social agency.

A case worker's skilful use of and belief in the purpose of a Child GuidanceClinic is a most important element in keeping the direction the parent haschosen toward self-responsibility. Not in any rigid sense but in general outline,the focus of the parent's contacts continues where he has put it in the first place:on the child's difficulty and his relation to it. This, too, is where the clinic isprepared to help him. There is often great determination in a parent to make theclinic meet all needs and serve all purposes. The case worker's capacity to beoriented primarily to what is implicit in a Child Guidance Clinic, is the way inwhich she may most effectively keep the groundwork for the parent's finding hisway through this particular problem in his reality. Exploration of all otherphases in a parent's life only confuses the purpose for which he has come andoften makes it possible for him to evade that new shift in himself which has ledhim to seek help with a child. In other words, the surest way for a case worker tofunction meaningfully in a clinic is to help the parent keep the focus of hiscontact limited primarily to that area in which he has himself put it. His prog­ress then revolves around whether or not and to what extent he accepts hisimpulse toward change. Within this particular dilemma of his relationship tothe child, the clinic serves as the testing ground on which he advances and re­treats and makes a new move in taking himself out of his struggle with his childand in letting or helping the child develop in his own right. The means by whichhe achieves this, I see as the process of his change. That process is determinedby the worker and her identification with the Child tiuidance Clinic to which theparent has come.

But if one believes in the value of a Child Guidance Clinic for a parent, hemust then accept the child as a problem, as indeed he is, and understand theway he comes to this new experience. As I have said, the very fact that theparent takes him to a therapist has in it an element of enforced separationfrom their struggle. How can he give up enough of the conflict with a parentto get into a new relationship with the therapist? This makes the beginning taskof therapy with children a doubly difficult one. The child has made no move, ashis parent has, to change himself and his situation. The parent carries the im­pulse for change and the child gets into therapy in relation to the parent, oftenagainst that impulse. It is, then, the job of the clinical setup to help the parentmaintain his readiness for change, not only because of himself, but because it ispartly through this that the child will be able to relate himself to the therapist.For children accept a parent's decision when it is sure and firm. A child does not

752 TRENDS IN THERAPY

need to carry the responsibility for a decision about going to a Child GuidanceClinic when the parent will do so. In other words, the child's best preparation fortherapy is the parent's readiness to continue with it. He comes because he mustand accepts it. The continuing therapeutic experience maintains and developsthe differentiation from the parent implied in the very act of coming and as,little by little, he finds new forces in himself. Through the development of thenew expression of the child's individuality he will, in turn, be able to differentiatehimself from the therapist, give up this relationship which has served his pur­pose, and find himself in a new balance of relationship with his parent.

It is right here that the parent and his relation to the child is of the utmostimportance. For the most part, they have been engaged in a struggle that hastoo little recognition of each other or of themselves, so closely are they boundtogether. Coming to the clinic is a break in unity for both of them. How may itbe maintained? The most effective procedure we have found is to provide away in which both find themselves in the new experience which a Child Guid­ance Clinic offers. The parent has sought the new experience. The child has per­mission, so to speak, from the parent to get into this new relationship. As soonas each of them is engaged in a new situation the tension between them haslessened. Here it is that the interaction between them is a vital part of the thera­peutic process. As the child has begun to make a move with the therapist, howwill the parent react to what may be important psychologically, but unpleasantsocially? A deeply neurotic, withdrawn child, for example, may be learning toassert himself gradually during his relationship with the therapist. The extent towhich this necessary assertion may develop, modify and find itself in a more realexpression of self, is dependent upon the changing capacity of the parent toaccept, to limit and to deal with his child's new use of himself. The parent doesnot have this changing capacity merely by virtue of bringing the child. It comesthrough his own experience in the clinic, through his own change and his readi­ness to meet this new relationship more adequately because he too is different.

A woman physician brought her girl of six to the clinic because of excessivefears and her withdrawal from all other children. This mother preferred not totalk with a staff member at the same time. The child was taken on for her ownappointments and months later when she was a rollicking, boisterous girl, thedifficulty with the mother began. She had had no part in the change, this wasreally not her child, and she could not tolerate this difference in behavior. Itwas at that point that she could turn again to the clinic, outraged. From thenon, it was her child coming to the clinic and she was coming, too. As the motherwas a part of this experience the child gradually became softer and more lovable.A controlled testing out of reality with each other was taking place duringtherapy rather than after the contacts were terminated.

Mikey, a boy of six, on the other hand, was fearful, always putting himselfinto the background. He and his mother took going to the clinic as a joint ad­venture and Mikey blossomed out steadily into a humorous, delightful child.In the tenth interview Mikey's mother said to the case worker, chuckling, "The

VI. INTER-RELATIONS: DAWLEY 753

other children say we should begin to put Mikey in reverse. Some folks maycall it brazen but I call it swell."

Therapy with foster children brought to a clinic by a child placing agency, orinstitution children brought by a worker, illustrates this point in a different way.The child is brought by a worker who is not a part of this experience throughher own need. As a consequence, the child is carrying the experience in the clinicvery much alone. A premium is put upon most of the change taking place in hisinner mental forces, even though in his stage of development there is not thatdifferentiation between himself and his surroundings that characterizes an olderperson. As the child develops in his contacts with the therapist, he must makethe adaptation largely by himself to an environment that remains much the same.Partly because of the deprivation of his past life, but largely because he is carry­ing this inner experience so much alone, the therapeutic process is alwaysdifferent and usually longer than with those children whose parents are a partof it.

The most important part of this type of therapy with children, is in the com­pletion of this experience. The purpose of therapy is that the parent and childmay live together more happily as each has a fuller realization of himself. It isrelatively simple to help a child separate himself from the entanglements in hislife and develop more fully. It is far more difficult to help a child in his growthand inner development and, at the same time, help toward a new relationshipwith his family and life in general. In other words, a new and growing ego forma­tion may be going on without the child's making himself an accepted and re­sponsive member of a family group.

This new relatedness to his family certainly cannot be achieved by thetherapist's bringing it into his contacts with a child. Neither can the parent takethis directly from his interviews with a case worker. It must come as a part ofthe process itself. Here is where the joint experience is of such special significance.The parent has come with his child, to be rid of their impasse. What the parentgives up to the therapist is the struggling, neurotic part of his child. What hegradually builds into a new relationship is that developing part of the child thatemerges as therapy proceeds, and as he is ready to accept it himself. The child,too, is through with that part of himself which the clinic represents. "This placefor sale" painted on a sign or "I dreamed this old building burned down lastnight" is one way to express it. "We are all going off on a vacation together" isanother. He is going off with his parent because they have both left behind anold way of relationship as they have found a new way of being together.

Anna Freud requires that the parents of a child who is brought for analysis,should themselves have been analyzed. Important as understanding of themselvesand of the therapeutic experience may be, I believe it is of far greater importancein the meaning and depth of this experience for both child and parent, if theyare both an integral part of the process. For in this lies the greatest assurance ofself-development having an integral relation to essential life relationships.

Marietta, for example, was a five-year-old illegitimate girl. She had lived for

754 TRENDS IN THERAPY

all but the last three months of her life in a small institution. Then her mothermarried and took Marietta to live with her. A. new marriage, a difficult childconstantly wetting herself and flying into tantrums, and a pretty unstablemother at best, had more in it than the traffic would bear. The mother broughtMarietta to the clinic regularly while she herself talked with me. From a loud­voiced, cursing woman who threatened to "kill that brat" or to "maim her forlife" she became related to me, was interested in knowing what I thought aboutthings and grew soft and loving as Marietta also changed. Toward the last ofour interviews, Mr. Pinto also came in every time and was deeply interested.Mrs. Pinto said one day near the end; "You know, when people see me on thestreet with Marietta they say, 'Where did you get that beautiful little doll?'""And what do you say, Mrs. Pinto?" "Me? Why I say, 'Jeez, I borned hermyself'."

I should like to conclude by saying that I think there is a new chapter aheadin therapy with children. None of us has made great headway with it because wehave at various periods been interested in the type of problem the child presents,its etiology, and the technical ways of meeting it in direct therapy. A betterbalance between inner and outer forces which comprise the child's life has, untilrecently, been approached largely through emphasis on his inner reorganizationand development, with too little recognition of the fact that there is no completedifferentiation between these forces in a child. That is one reason why it is oftensuch a long and upsetting process. How outer forces may be utilized to get morequickly at the heart of the problem and strengthen the process of the child'sreorganization, is little known. One way that has proved to be most meaningfulis to utilize fully what naturally comes to the clinic as a parent refers his child,and himself becomes a part of the same experience.