There are a wide variety of therapies that attempt to help patients and families improve their emotional health and well-being. We know from evidence that the most important factor effecting therapeutic outcomes is the quality of the relationship with the therapist. It is easy to become overly attached to one model, particularly if it fits the therapist’s way of thinking and has helped them personally. An overly confident or rigid belief in one’s own model may serve as an omnipotent defence against the anxiety we face acknowledging the limitations both individually and within each model. Finding the right ‘fit’ of treatment for each patient and family is essential. The models of mind I gravitate towards are grounded in psychoanalytic theory, particularly in its current developments linked to research and neuroscience. I also practice mindfulness based cognitive therapy, which despite its name, dove tails well with psychoanalytic ideas. Mentalisation based therapy which has a psychoanalytic foundation is another useful model I commonly use. While these are the main framework for how I formulate clinical problems, I have also used behavioural techniques, seen CBT cases and worked alongside family therapists. I appreciate how easily all of these different terms and therapies can leave patients and families feeling lost. I will explain how I have used some of these approaches to assess and treat children in Kolkata, and in doing this explain some of these therapies more fully. I will begin with the behavioural techniques.
All pictures provided by Martha Swann
Behavioural models of therapy focus on learned behaviours with a detailed analysis of how environmental factors shape them. There are a number of parenting courses based on this model and these teach parents practical tips on how to improve their relationship with their child and how to introduce appropriate and effective boundaries. Parenting courses such as these have excellent evidence for treatment of childhood disorders such as ADHD. I have previously attended a course on the ‘the incredible years’ strategies and some of these techniques have proven very useful when working with the parents at Calcutta Rescue. This method provides a hierarchy of interventions for parents to manage problematic behaviour. It also instructs parents on how to take part in non directive creative play, with evidence on how this can reduce difficult behaviours and strengthen child-parent bonds.
I have now worked with approximately 40 children and families at CR schools and found only 1-2 examples of parents playing with their children. Only a few more praise their children or demonstrate an ability to vocalise positive characteristics. The majority unfortunately neither played or praised. It was also common for parents to label their children as ‘bad’ or having no positive attributes , a painful disclosure to hear. The absence of play or praise in relationships appears to be partly cultural and partly a result of the harsh socio-economic circumstances they live in. It was common for parents to describe what I would consider to be quite normal care and attention, as the child being ‘pampered’ and a concern that this may adversely affect their development. This fits with the cultural practice of encouraging interdependence and obedience over individuality and autonomy seen in western cultures. At other times however, it was clear that abject poverty, or drug and alcohol abuse in the families had led to the cycle previously described in my blogs, with little positive emotions and experiences being shared and nurtured. The behavioural techniques I found to be most effective, were those I used to address cases of physical punishment. In these families I began by being as direct as possible in educating the parents on the negative effect of violence on the emotional development of their child. Parents frequently admitted how this form of punishment was rarely successful in the longer term, with children becoming ‘more stubborn’. Interestingly these parents were often unaware of how to set boundaries for their child. In the incredible years, the second tier of intervention is to encourage desirable behaviours through a system of rewards. These rewards do not have to be material and can be things such as time spent with a parent. Introducing concepts such as play, listening, praise and reward systems were normally only possible in a wider a context of working on the relationships and dynamics within the family which I will cover later. Given the time restraints and the seriousness of the violent behaviours, I focused on trying to swap the violent strategies with the highest tier of intervention- that being ‘consequences’. Consequences need to be immediate, age-appropriate and if possible, given with advance warning. Parents were able to identify appropriate alternative sanctions, such as taking away certain privileges and it was common for my suggestions to appear as a completely novel concepts. Striking a balance between making clear to the parents how harmful physical punishment is and preventing the parents from becoming excessively guilty and withdrawing from treatment, was a difficult line to tread. Many of these techniques come naturally to the majority of parents in the UK, although there are still many lessons that all parents may find valuable, such as the difference between rewards and bribes, and the importance of certain techniques such as ‘time out’ being used in a thoughtful and calm manner.
Motivational interviewing was another behavioural technique I found useful. This is a method for ‘facilitating and engaging intrinsic motivation within the client in order to change behaviour’. I most commonly used this to help adolescents at Calcutta Rescue’s schools to think through their hopes and plans for the future. Nearly all students initially stated hopes and aspirations for the future which were unrealistic. For example, older students would speak about wanting to be a government official or doctor when their grades were consistently poor. Others would talk of wanting to own a tea stall, while at the same time speaking about how they hoped to move out of their slum accommodation to secure a better quality of life. Motivational interviewing recognises that telling an individual to change a behaviour that you believe is harmful or unhelpful, may only serve to increase resistance if the patient is not in a position to change. As such, it is more effective to help a patient reflect on their current situation and highlight both the positive and negative aspects of their current position, while ‘rolling with resistance’. You then work on helping the patient to face these areas of conflict and find solutions themselves, so for example, I would encourage adolescents who spoke of wanting to own a tea stall to consider their prospective earnings and and contrast this with their other aim to improve their living standards.
These two behavioural approaches are examples of fairly straight forward techniques that were useful for many of the children and families at CR. You did not have to look far into a child’s family life to frequently find complex and unresolved trauma however. A common example of this was the loss of a key family member through sudden death. In my next blog I will discuss how more complex models and approaches were needed for such cases.