Working communicatively with children
by Constantinos Fissas
The aim of the essay is to give an account of my experience in working communicatively with children. I will present research findings in the area of unconscious perception and the communicative model of the mind. Issues of technique will be considered with emphasis on triggers and the nature of derivatives. Interpretations and validation will also be discussed. Since nothing has been published on working communicatively with children, my essay is based on my work with children and supervision.
The communicative model of the mind is based on the concept of unconscious perception. The mind is divided in two systems: the Conscious system and the Deep Unconscious Wisdom system. Both systems process emotional perception and information. The Conscious system is concerned with the superficial meaning of emotional events and it "processes information according to learned categories and is therefore tremendously affected by factors as social conditioning."(Smith, 1991:133) and it is able to report information directly. The Deep Unconscious Wisdom system is extremely sensitive to emotional reality. It reports its responses and contents indirectly, in the form of a derivative. Another property of the Deep Unconscious system is that it selects narratives which are related to the immediate situation. Because the role of the immediate situation is so important, it follows that the immediate therapeutic environment is important, for understanding unconscious communications in therapy.
Communicative research (Langs, e.g. 1975, 1976, 1978, 1979) concluded that patients unconsciously ask for a 'secure frame'. Communicative clinical research and observation have shown that patients react negatively to poor management of therapy by the therapist. When a therapist deviates from the 'secure frame' the patient will produce a derivative to express unconsciously his reaction. The components of the secure frame as outlined by Langs (1988) are:
- the use of the couch
- the patient free associates and the therapist listens with free
- floating attention
- the therapist is neutral
- absence of physical contact
- the therapist must maintain anonymity total privacy of the sessions
- total confidentiality
- consistency of the setting
- the patient must pay
- set frequency and duration of sessions
- the patient is responsible for termination
According to Langs:
"secure-frame psychotherapy provides the patient with a basic sense of holding, trust, and containment. It establishes appropriate interpersonal boundaries and provides the patient with an opportunity to support his or her capacity for reality testing. In other words, the therapist's management of the framework is consonant with his or her basic responsibilities and role requirements and with his or her interpretative efforts" (1992:447).
To summarise, Langs found that the behaviour of the therapist triggers memories, dreams and stories in the patient. These stories are encoded unconscious responses to triggers in the immediate therapeutic environment expressing valid perceptions of that environment. Langs believes that "the therapist should recognise that the analysis of the patient's reaction to the error must take precedence over all other therapeutic work, since it is essential to the restoration of a proper therapeutic alliance" (Langs, 1973:249). The task of the therapist is to decode derivatives in light of triggers.
Once the ground rules of therapy are established by the therapist, patients communicate their reactions in two ways. Sometimes they talk in an abstract and logical form, and at other times in very concrete and easy to picture images. An abstract and logical communication might be: "I find it difficult to take decisions in my life. I always spend a lot of time to balance the pros and cons of a decision. I worry about the consequences. I don't know what is best for me." This can be seen as very similar to the psychoanalytic defence mechanisms of rationalisation and intellectualisation. A communication which is visually concrete can take the form of a dream, a memory or a story and communicatively referred to as a 'derivative'. An example might be: "Yesterday I went out with a friend of mine. I went out with him because I had a problem, and he was not listening. He was talking about himself and he was ignoring me all the time. I was very angry."
According to communicative theory, people tell stories because they want to communicate their feelings about the immediate situation, in a disguised way. The premise is that something in the here-and-now has triggered a memory.
I work in a primary school in Peckam, London. The children are referred to me by their teachers, parents or some are self-referred. The name of the child and their teacher are given to me by the project co-ordinator. I pick up the child from his classroom. I knock on the door and say to the teacher: " Hello, my name is Constantinos. I 'm from Kid's Company and I want to see x." This is the first frame deviation intrinsic to this setting. By picking up the child from his classroom, therapy becomes public. By saying that I am from Kid's Company I identify myself as a part of a larger organisation that includes people who work with the same children but in a different capacity. This situation is very exposing not only for the child, but for the therapist as well.
Any frame deviation will have consequences in the way that the child engages with me. The frame deviation has also an impact upon the therapist. Very often teachers try to engage me in conversation. They say: "He was very disruptive today. I hope you can do something with him" or " Take him for the rest of the day." Sound communicative practice requires one to avoid participating in discussion with the teacher. In that way, I aim to demonstrate to the child the confidential nature of the therapy. Moreover, my unwillingness to talk to the teacher can be seen as an intervention to secure the frame.
After picking up the child, we walk together for about two to three minutes to the therapy room. The room is locked and I unlock the door that leads to the two therapy rooms. I open the door, to allow the child in and I close the door behind us. The unlocking of the door is another frame deviation, since the responsibility for starting the session lies on the therapist and not on the child. The room I work in is a big room (4x5m) containing a variety of toys and games including cars, dolls, puppets, houses, garages, space stations, castles, swords, boxing gloves, animals, paints and brushes, paper, board games, etc. There are also two small chairs and a desk. When I sit down, I explain the contract to the child by saying: " My name is Constantinos and we are going to meet every Thursday at 12:00 for 45 minutes in this room during term time. When you came in you can play with any toy you want and I will try to understand your game. We are not allowed to break toys or take them outside this room. I 'm not going to talk to your friends or teacher about you."
The aim of the contract is to establish the role of the two parties, the child and the therapist. The issue of fee is not raised in this setting, as there is no fee charged. This contract differs significantly from an adult contract. We ask adults to free associate in the same way that we say to child to play with any toy he wants. But with children we forbid them to destroy or take toys, something we not do with adults. We do not say, "you are not allowed to swear, you are not allowed to talk about your suicidal thoughts." Maybe not allowing the child to do something is a significant trigger for unconscious material, but on the basis my own experience I have not been able to reach can to a conclusion.
Children react in different ways after the contract is offered. Some children will start to play on their own, as though I am not present and others will invite me to their play. Those who play on their own can be divided into two categories. Those who play in front of me and those who play hidden from view. Children who invite me to play seem to produce more derivatives from the others in the form of play.
Playing with a child poses many questions. How do you play therapeutically with a child? Do you take on the role that the child assigns to you or do you decide what you want to be? I will use an example to illustrate this dilemma. The child picks up a lion and he asks me to pick up an animal. I am confronted with two options. I can ask the child "which animal do you want me to pick up?" or I make a decision (usually unconsciously) and I pick up an animal. My experience has shown me that when I feel upset or angry with a child I tend to pick up an animal without first asking the child, and most of the time, I express my frustration or anger through the choice of an aggressive animal such as a lion or a dinosaur. I think that asking the child offers some advantages. The child will unconsciously chose the animal that represents, at that given moment, the qualities of the therapists' intervention. If for example, I make an intervention that is not necessary, the child might ask me to be a chicken or an animal that is not very clever. If my interpretation is incomplete (missing trigger or indicator) then he might ask me to be an injured horse with three legs. The choice of the animal can be an indicator of the truth value of the interpretation.
How much physical contact can I have with the child? Should I initiate contact or wait for the child to engage me physical contact? I think that children are not as sensitive as adults are, regarding physical contact, providing that physical contact is gentle and not intrusive. Stories and games that follow physical contact do not seem to contain any thematic reference to contact.
After the establishment of the contract, the most common effect of the deviant frame (mainly third party involvement) is violence. The theme of third parties is expressed in a variety of ways, for instance some children with start playing with a castle. The castle is under attack and somebody must protect it. Other children may pick up two animals and a third one will try to attack them. Once a child said after I set out the contract: "There is man who came yesterday and kidnapped a child." The theme of exposure is expressed in games where the child dresses up naked dolls and the therapist must help (which can be regarded as a model of rectification). The term rectification model refers to suggestions, by the patient, on what the therapist should do.
Feeding and fixing are two themes that come up very often. In feeding and fixing me, the child is trying to help me. Very often children offer me a cup of tea or lunch in the beginning or the end of a session. If offered in the beginning, it usually appears to mean that the child feels that I need energy to conduct the session, and if offered at the end the child apparently feels that I deserve to eat. We should keep in mind that there are different ways of feeding. "Open your mouth and eat!" is a command that indicates forced feeding; "You will eat what I eat" is an indication that the therapist should offer interventions only when they are needed. There are different qualities and properties to the theme of feeding.
The theme of fixing often takes the form of the child being the doctor and the therapist being the patient, who does not hear very well, who is blind, who suffers from an infection in his throat or who needs brain surgery. The child picks up the medical kit and examines me. Doctor's kit, is usually a signal for me to organise the derivatives of the child around their triggers and offer an interpretation. The improvement of my condition depends on my interpretation. If I make a good intervention I get well, if not I die.
Working in a school setting, third parties are constant irritants in therapy. Third parties are triggers, around which the derivatives are organised. Triggers can be divided into chronic (picking up the child from his classroom, frequent short and long breaks) and acute (starting a session early or late, change of room, etc.)
The child's response to the trigger can be a verbal narrative or an enactment in the form of a game. Derivatives usually organise around relationship themes (a narrative about a friend at school or a family member) and around function themes (a narrative about a broken toy or missing parts of toys).
The indicator can be, as in adult therapy, a symptom or a resistance. Most often it is a symptom. The child might get very agitated and start smashing things in the room. He or she might start shouting and screaming. This kind of behaviour is normally provoked by i) a wrong or incomplete communicative intervention or ii) my failure to offer an interpretation when the child has unconsciously indicated that he wants one. The most common resistance, expressed by children, is the request to leave the room. On one occasion a child wanted to go to the toilet. His request might be a sign of resistance, but it must be understood in the context of other behaviours that indicate resistances. I remember a child who asked me to go to the toilet twice in a session. I interpreted his resistance as his response to my inability to understand his play. The child then asked me to help him paint. The theme of two people drawing together expresses the theme of creative co-operation, and it can be regarded as a form of validation.
The trigger, the narrative and the indicator and a model of rectification are usually necessary in order to formulate an interpretation. I say usually because there are occasions when interpretations are validated without my having made reference to a trigger.
The interpretations I offer follow the following form: "I (the therapist) did a, you (the patient) perceive it to mean x, and maybe that's why you (the patient) play this game. And maybe you (the patient) are saying to me that I should do y." When the child demonstrates signs of resistances, and I am unaware of the trigger I sometimes say: "You (the patient) are killing the soldiers, and maybe you want to say to me that I am hurting you and you want to kill me." This intervention does not allude to the trigger, but it conveys understanding or at least an effort to understand. Interventions of this kind are usually validated.
In communicative psychotherapy the use of silence as an intervention is one of the most difficult and probably the most significant elements of the technique because it conveys the holding capacities of the therapist.
"... the therapist who is appropriately silent in the absence of meaningful material from the patient and/or capable of validated interventions in the presence of such meaning is experienced unconsciously as relating significantly and affectively to the patient in a form that is appropriately nurturing and otherwise sufficient" (Langs, 1992:394).
In one session, 'John' picked up the swords, the breastplates, and the shields and we began to fight. He attacked me and killed me, and then he took the sword and chopped off my ears and my tongue. Then opened a hole in my chest and took out my heart. I could not identify a trigger or an indicator (he was not upset or agitated, on the contrary he was very relaxed). I remained silent. John then decided to draw. He drew himself and his father holding hands. He said: " I enjoy going out with my father. We have fun." Two people holding hands and having fun, is a positively-toned theme, and portrays the importance of the silent intervention. The positive properties of silence refer, of course, to appropriate silence in the absence of interpretable narratives or indicators.
An intervention that I consider very important when working with children is non-verbal interpretation which conveys understanding in action and not in words. By doing something or by refraining from doing something, I attempt to communicate to the child that I understood him. Consider the following example. In the session in question, I gave direct instructions to the child about how to assemble a toy house. I told him which part goes first and then I told him that he should follow the written instructions which were at the bottom of the box. After this, the child started playing with a baby doll. He ordered the doll to be quite and to stop crying and shouting. Meanwhile I was left on me own, trying to assemble the house (without much success, I have to admit). The intervention which I formulated in my mind was: " this child is ordering the baby in the same way that I was ordering him. I should stop "crying" and "shouting" and let the child play." My intervention was to stop assembling the house and to go back to my chair. The decision to stop playing and go back to my chair was an attempt to convey understanding through action. The baby doll then stopped crying and rested quietly in its cot while the child returned to assembling the house.
When working with adults we decode the unconscious material and we use a conscious language to communicate this to the patient. We undo the displacements, the symbolisations and the condensations and we relate the decoded material to ourselves. If, for example, I am late for a session and the patient remembers a story in which people were unreliable I postulate that the patient remembered this particular story because I was late and that he perceives me as unreliable. The interpretation would be something like: " Today I was late for the session and that made you think of this story were people were unreliable. And maybe you are saying to me that I am unreliable."
When working with children another possibly is available, which might also prove to be helpful with adults. Consider the following interaction. There was one minute left before the end of the session and the child was playing Subbuteo with me. The game was slow and without excitement. It was communicatively "flat". There was nothing to be interpreted since nothing was being narratively portrayed in the material. I decided to say: " the referee will bring the first half to an end. The second half will start next Monday at two o'clock." The child looked at me, put the game on the selves and left the session. As I have already said, the material was flat and according to communicative technique silence would be the appropriate intervention. Nevertheless, this intervention utilised the material without decoding it.
Communicative therapists who work with adults have observed that some patients exhibit claustrophobic reactions after an attempt by the therapist to secure the frame. Patients might remember, for example, a dream in which they were locked in room, or a film in which somebody was killed. According to communicative theory, these patients experience intense death anxiety when secure moments occur. They ask unconsciously for a secure frame and when it is offered they feel trapped. I have observed such phenomena towards the end of sessions with children. Normally after a validated intervention, they continue playing with the same game but the quality of the interaction changes (i.e. the warriors become friends) or they pick up a different toy that serves as the vehicle of validation. I venture to speculate that a correct intervention is not perceived as a threat as it is often perceived by adults but breaks and forced termination are often strong triggers for death related themes.
The aim of the essay was to give a brief account of my experience in working communicatively with children. I focused on the frame, on the nature of derivatives, on interpretations and validation. Interpretations that do not allude to triggers are often validated. Death anxiety reactions were not observed after the establishment of the contract. Those two areas require further research, in order to enable us to arrive at proper technical principles for working successfully with children, in particular, the relationship between death anxiety and the securing of the frame may help us to develop a developmental theory for communicative psychotherapy.
BIBLIOGRAPHY
Langs, R. (1973) ' The patient's view of the therapist: reality or fantasy?', International Journal of Psychoanalytic Psychotherapy 2: 411-31.
Langs, R. (1975) 'The patient's unconscious perceptions of the therapist's errors', in P. Giovaccini (ed.) Tactics and Techniques in Psychoanalytic Psychotherapy, Vol. 2: Countertransference, New York: Jason Aronson.
Langs, R. (1976) The Bipersonal Field, New York: Jason Aronson.
Langs, R. (1978) Technique in Transition, New York: Jason Aronson.
Langs, R. (1979) The Therapeutic Environment, New York: Jason Aronson.
Langs, R. (1992) A Clinical Workbook for Psychotherapists, London: Karnac Books.
Langs, R. (1997) Death Anxiety and Clinical Practice, London: Karnac Books.
Smith, D.L. (1991) Hidden Conversations. An introduction to communicative psychoanalysis, London: Routledge.
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