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From Inside The Consulting Room. When Therapy Is Not Enough · Inside The Consulting Room - Understanding the Child Behind the Behaviour

• 0:00
  SPEAKER_00: And I am offering a two-part podcast piece from the series Inside the Consulting Room.
• 0:10
  SPEAKER_00: Most of my podcasts talk about how we as clinicians endeavor to help situations change.
• 0:21
  SPEAKER_00: So there's something about that that's hopeful.
• 0:24
  SPEAKER_00: I also talk a lot about how to help parents who I see as a really important part of the therapeutic process for reasons that I've mentioned before, and that has to do with children being the products of their environments.
• 0:43
  SPEAKER_00: So most of that has a kind of optimistic theme.
• 0:49
  SPEAKER_00: So I thought that for the sake of balance, I would write something and present it that doesn't have to do with hopefulness.
• 1:02
  SPEAKER_00: It's more to do with when hope evaporates.
• 1:07
  SPEAKER_00: And this two-part series is entitled When Psychotherapy Just Isn't Enough.
• 1:16
  SPEAKER_00: It would be so good to think that all cases ended well, but in reality, unfortunately, they don't.
• 1:26
  SPEAKER_00: So in this first of the two episodes, I want to just talk about when psychotherapy just isn't enough.
• 1:38
  SPEAKER_00: You see, the thing is there are some cases in my work that you just can't forget, they stay with you.
• 1:45
  SPEAKER_00: And they stay with you not because you remember the details, but because you remember the unfairness, particularly when you later discovered that the things that you predicted would happen if certain actions weren't taken actually do happen.
• 2:05
  SPEAKER_00: And as you'll appreciate, we clinicians are not allowed to say, I told you this would happen, which didn't listen.
• 2:12
  SPEAKER_00: We're not allowed to do that.
• 2:16
  SPEAKER_00: When psychotherapy isn't enough, it suggests that other things are required.
• 2:24
  SPEAKER_00: Now that's perfectly reasonable in my work because we are not the be all and end all of um of therapeutic work.
• 2:33
  SPEAKER_00: We work alongside and within other services.
• 2:37
  SPEAKER_00: Some cases really require that.
• 2:40
  SPEAKER_00: This boy was fourteen, and by the time he was referred, there had already been multiple concerns.
• 2:51
  SPEAKER_00: There was drug use and there was alcohol use.
• 2:57
  SPEAKER_00: There was volatile behavior within the home, within the school, and in public.
• 3:06
  SPEAKER_00: He was rapidly becoming something of a risk.
• 3:13
  SPEAKER_00: He was excluded from a number of schools for the sorts of things I've just mentioned.
• 3:21
  SPEAKER_00: An incredibly bright boy, a talented boy, but one whose circumstances so typically sabotaged his progress.
• 3:34
  SPEAKER_00: And I'm going to talk a little bit about that from a statistical point of view shortly.
• 3:39
  SPEAKER_00: But first, uh it should be said there was involvement from CAMS, that's child and adolescent mental health services, MASH multi-agency service hub, the police and educational services.
• 3:55
  SPEAKER_00: Now, there were plans in place and meetings were held, and there was certainly no absence of concern.
• 4:02
  SPEAKER_00: Everybody was really very concerned about this boy, partly because there's a very volatile cocktail called adolescence, drugs, alcohol, and volatility underpinned by acrimonious parents.
• 4:17
  SPEAKER_00: That's a bomb that's always going to go off at some point.
• 4:22
  SPEAKER_00: And the thing that was missing was an awareness of how those ingredients would come together.
• 4:33
  SPEAKER_00: And inevitably they did come together.
• 4:38
  SPEAKER_00: When I first met him, he didn't present as defiant or all of the things that people had described him as being, he just presented as unreachable.
• 4:48
  SPEAKER_00: He would sit, sometimes speak, and then disengage.
• 4:54
  SPEAKER_00: But when he spoke, it was almost as if I got this sense of you're overdue because there was just this kind of flurry of expression and descriptions about things.
• 5:06
  SPEAKER_00: And then he would disengage.
• 5:09
  SPEAKER_00: And there were times when something came through, but they disappeared again.
• 5:18
  SPEAKER_00: But the core problem wasn't so much engagement, his capacity to engage, it was the continuity.
• 5:27
  SPEAKER_00: Now, at the center of this case was a family system that was organized around conflict.
• 5:34
  SPEAKER_00: Now, by which I don't mean occasional disagreement, but sustained acrimony, where the parents were attacking each other and sometimes doing that in front of the children or with the children being not very far away and could hear.
• 5:54
  SPEAKER_00: Sometimes the children were used as tools of attack against the other parent.
• 6:01
  SPEAKER_00: There was frequent insulting in front of the children and disempowering of the other parent.
• 6:11
  SPEAKER_00: It was horrific.
• 6:14
  SPEAKER_00: And in spite of everything, each parent held the position that they'd taken, and this boy was caught between them.
• 6:25
  SPEAKER_00: The other child aligned herself with her mother and became something of a confident and a confidant, sorry, and someone who was in a sense beginning to parent the parent.
• 6:45
  SPEAKER_00: She became adaptive, compliant, but in my view, another ticking time bomb.
• 6:54
  SPEAKER_00: Now this situation creates an impossible position because children who can't attach securely are very often those who live in a system that is divided against itself.
• 7:10
  SPEAKER_00: So we see this horrific splitting, this division in the family.
• 7:16
  SPEAKER_00: And of course, children internalize that division.
• 7:19
  SPEAKER_00: And despite efforts to try and explain to the parents what was going on, nothing changed apart from a bit of awareness that the situation needed dealing with, although it never was.
• 7:33
  SPEAKER_00: So the child's internal world becomes organized around instability and predictability and the absence of unified unified holding environment.
• 7:45
  SPEAKER_00: Now failing to provide that has consequences because the child must try and organize themselves alone.
• 7:55
  SPEAKER_00: When I worked with this boy, when I spoke with him, there were there were moments where he could speak about one parent in one way and then completely differently in the next session.
• 8:06
  SPEAKER_00: And this kind of this poor boy didn't know who to align himself to.
• 8:12
  SPEAKER_00: It was like he was caught in a blender, and emotionally he had he had nowhere to go in terms of secure holding.
• 8:23
  SPEAKER_00: Inevitably, he found another family to inhabit, and they were all the same age or slightly older, and they were involved in drugs and alcohol and the sorts of things you might expect to see.
• 8:39
  SPEAKER_00: And they were all disenfranchised.
• 8:43
  SPEAKER_00: This boy wasn't holding two parents, he was endeavoring to survive between two worlds.
• 8:51
  SPEAKER_00: And in that space, something begins to organize.
• 8:57
  SPEAKER_00: So we see substance use, criminal association, risk taking, not simply as rebellion, but as an orientation.
• 9:07
  SPEAKER_00: Because when the family system can't provide structure, the young person will just find it somewhere else.
• 9:13
  SPEAKER_00: And this isn't uncommon.
• 9:15
  SPEAKER_00: Now the research into this is pretty harrowing because it demonstrates that poor family relationships and parental conflict are strongly associated with self-harm, substance misuse, and behavioral disorders.
• 9:31
  SPEAKER_00: That information comes from Science Direct.
• 9:36
  SPEAKER_00: Now, family dysfunction is a significant precursor to suicidality in children and adolescents.
• 9:45
  SPEAKER_00: That information comes from the Lancet.
• 9:49
  SPEAKER_00: Around one in six young people in the UK now have a problem with a mental health disorder, and that comes from the UK Parliament website.
• 10:02
  SPEAKER_00: The educational impact is clear.
• 10:05
  SPEAKER_00: Children in high conflict families are much more likely to experience poor attendance, reduced attainment, emotional and behavioral difficulties within school environments.
• 10:17
  SPEAKER_00: Then addiction and risk, because substance use in particular is closely linked to trauma, emotional dysregulation, and attempts to manage internal states.
• 10:28
  SPEAKER_00: Self-harm and suicide are the most concerning, but nearly half of young people who die by suicide have a history of self-harm.
• 10:40
  SPEAKER_00: That information comes from Cambridge University Press and Assessment.
• 10:46
  SPEAKER_00: Now, self-harm, trauma, and substance misuse frequently cluster together in high-risk adolescents, and that information comes from the same source.
• 10:58
  SPEAKER_00: So what we begin to see is not separate problems, but a system of interconnected risk raising levels of bad uh the probability of bad outcomes.
• 11:11
  SPEAKER_00: Now there were moments in the work where he engaged and something real began to emerge, but it couldn't hold.
• 11:19
  SPEAKER_00: Because he returned each week to the same environment, by which I mean to the same family home.
• 11:26
  SPEAKER_00: Although by this time we have two parents in two households.
• 11:31
  SPEAKER_00: So we have another factor.
• 11:34
  SPEAKER_00: But essentially the same conflict and division remained, and the same absence of containment remained.
• 11:45
  SPEAKER_00: The system itself, the family system, was unable to contain the child's emotional experience.
• 11:52
  SPEAKER_00: And so the work of therapy had nowhere to land.
• 11:55
  SPEAKER_00: And despite my continued efforts to try and influence the backdrop, to try and influence the system, it that the system just maintained.
• 12:06
  SPEAKER_00: There was something of an ostrich naivety about this, by which I think that both parents maintained keeping their heads firmly in the sand.
• 12:16
  SPEAKER_00: And I suspect that was because there, whenever they came together to talk about this boy, or whenever they talked about things in general, it would it would act, it would end up as an acrimonious episode.
• 12:31
  SPEAKER_00: Consequence, the boy is once again stuck where he's stuck.
• 12:35
  SPEAKER_00: And surprise, surprise, he was regarded as the problem, which I think is under the circumstances quite an insult to the child.
• 12:47
  SPEAKER_00: So this is the point at which we must say something really clearly.
• 12:51
  SPEAKER_00: Psychotherapy does not exist in isolation.
• 12:55
  SPEAKER_00: I've said a number of times I'm a clinician, not a magician.
• 13:01
  SPEAKER_00: And sadly, that means that at times, despite my best efforts, it's not going to work.
• 13:11
  SPEAKER_00: A child can't internalize what's not present in their environment.
• 13:16
  SPEAKER_00: What was missing, what was required here, was not only therapeutic work with the young person, but alignment between parents, reduction in conflict, a shared understanding and a shared approach, and a system capable of holding him consistently.
• 13:37
  SPEAKER_00: Because without that, the young person is left to manage and they can't.
• 13:43
  SPEAKER_00: And when they are left, they organize themselves alone, and they will always find something that holds them, even if that something places them at risk.
• 13:54
  SPEAKER_00: Because sometimes it's not the psychotherapy that's missing, it's an environment that can use it.
• 14:04
  SPEAKER_00: Psychotherapy in this case was deemed as not working, and so the boy was withdrawn.
• 14:12
  SPEAKER_00: In situations like that, it tells me a great deal.
• 14:17
  SPEAKER_00: I don't know, maybe psychotherapy was beginning to work, and the parents couldn't handle it.
• 14:23
  SPEAKER_00: They couldn't handle the fact that he was a boy who was maybe saying it's not me that's the problem.
• 14:29
  SPEAKER_00: I don't know.
• 14:31
  SPEAKER_00: But sometimes when kids start to get well, parents pull the plug.
• 14:35
  SPEAKER_00: Doesn't happen often, but sometimes it does.
• 14:40
  SPEAKER_00: And all of which, you know, we can theorize about we can make judgments about.
• 14:50
  SPEAKER_00: But the bottom line is that this boy was arrested for actual bodily harm, being in possession of drugs, and was subsequently expelled from another school.
• 15:06
  SPEAKER_00: His fate looks fairly clear.
• 15:13
  SPEAKER_00: I have a mixture of feelings of enormous frustration and some negativity towards the absence of awareness and the neglect that this family system lived by.
• 15:37
  SPEAKER_00: In the next episode, I will look some more at this.