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Inside The Consulting Room. Episde 5. Childhood Fear And The Need For Rituals · Inside The Consulting Room - Understanding the Child Behind the Behaviour

• 0:00
  SPEAKER_00: Hello and welcome back.
• 0:01
  SPEAKER_00: This is Kim Lee from the Children's Consultancy.
• 0:04
  SPEAKER_00: And this is episode five of Inside the Consulting Room.
• 0:10
  SPEAKER_00: In this episode, I want to look at something that is a bit more complex and which can't reason reasonably be completely covered in a podcast.
• 0:22
  SPEAKER_00: And so I'm going to just give you an overview and the highlights as such.
• 0:32
  SPEAKER_00: But the story itself is far more complicated.
• 0:35
  SPEAKER_00: And it concerns a boy called Liam.
• 0:41
  SPEAKER_00: He enters the room cautiously and before sitting down he glances towards the door.
• 0:49
  SPEAKER_00: I notice that he touches his left knee twice with one hand and his right knee twice with the other.
• 1:01
  SPEAKER_00: He looks through the open doorway into the hall.
• 1:07
  SPEAKER_00: And only after scanning the room very carefully does he sit down.
• 1:11
  SPEAKER_00: He doesn't say a word.
• 1:14
  SPEAKER_00: But when he does sit down, I notice that his shoulders remain tense and slightly hunched, almost as if he's waiting for something unexpected to happen.
• 1:26
  SPEAKER_00: Liam was eleven years old, and his parents described him as a boy who experienced constant anxiety.
• 1:35
  SPEAKER_00: He had pervasive difficulties where sleep was concerned.
• 1:40
  SPEAKER_00: He constantly checked doors and windows, and he'd begun to develop rituals, and at night before he went to sleep, his mother had to say goodnight to him ten times in the correct way before she could leave the room.
• 1:54
  SPEAKER_00: Sometimes he could be heard counting from one to ten.
• 1:59
  SPEAKER_00: This was before he switched his bedroom light on and off, which he had to do ten times.
• 2:07
  SPEAKER_00: If he touched an object with his left hand, he had to touch the same object with his right.
• 2:13
  SPEAKER_00: When he ate with the rest of his family, his food had to be presented to him in a particular manner.
• 2:20
  SPEAKER_00: The plate had to be exactly in the centre of the table mat.
• 2:25
  SPEAKER_00: Once that happened, it could be eaten.
• 2:30
  SPEAKER_00: Now kindly relatives and friends described his behaviors as controlling and that his parents shouldn't allow it.
• 2:41
  SPEAKER_00: Were it that simple, I thought when I heard this.
• 2:45
  SPEAKER_00: But the price that they paid for not engaging in the rituals was what they described as experiencing meltdowns of epic proportions.
• 2:56
  SPEAKER_00: His distress could last for hours, and sometimes it would explode into destructive behaviors, often culminating with threats of killing himself.
• 3:08
  SPEAKER_00: At school, teachers noticed that he was easily startled.
• 3:13
  SPEAKER_00: His attention often seemed fixed on the environment around him, and that he was watching and listening in a way that suggested hypervigilance.
• 3:24
  SPEAKER_00: He was constantly seeking reassurance about the environment and often needing to leave the classroom to go to the toilet.
• 3:33
  SPEAKER_00: Now Liam's symptoms reflected hypervigilance associated with developmental trauma.
• 3:41
  SPEAKER_00: And from a clinical point of view, it was clear that there were additional what we call comorbid powerful symptoms that had developed.
• 3:50
  SPEAKER_00: So in some senses, the clinical picture wasn't entirely clear because there were specific symptoms of generalized anxiety combined with OCD, extreme emotional dysregulation in certain situations, and pervasive symptoms of sleep disorder.
• 4:10
  SPEAKER_00: And I was also concerned about his relationship with food and later learned that there were emerging episodes of selective eating and avoidance.
• 4:21
  SPEAKER_00: So my working clinical opinion was divided into two parts.
• 4:26
  SPEAKER_00: Had this boy experienced cumulative or singular trauma, which could very well explain the presentation and symptom formation, or was there an emerging disorder which might have a genetic component?
• 4:42
  SPEAKER_00: But in any event, my task was to help this incredibly distressed child.
• 4:47
  SPEAKER_00: And I did wonder about whether or not medication might be indicated.
• 4:52
  SPEAKER_00: And this is because there are times in psychotherapy when patients are so overwhelmed by their symptoms that their ability to utilize the therapeutic work is just compromised.
• 5:03
  SPEAKER_00: So we're sort of firefighting.
• 5:07
  SPEAKER_00: So for that reason, I might consider medication for symptom control alongside the therapeutic work.
• 5:14
  SPEAKER_00: And controlling symptoms makes the therapeutic work more likely to be effective.
• 5:19
  SPEAKER_00: And it's a stepping stone, it's not a solution.
• 5:23
  SPEAKER_00: But I was also alert to the fact that the children exposed to chronic emotional conflict and heightened stress environments develop kind of nervous system response that is organized around anticipating danger.
• 5:44
  SPEAKER_00: So the brain's threat detection system becomes persistently activated, far too overactive, and then disproportionately expressed at small events.
• 5:58
  SPEAKER_00: And even when the environment seems to appear calm, the body remains and the brain remains prepared for potential threat.
• 6:11
  SPEAKER_00: Inside the consulting room, when I've worked with such cases before, I've invariably chosen to name the difficulties that I understand the child to be experiencing.
• 6:23
  SPEAKER_00: And this is important because when an adult can benevolently say something like, I understand that at times you feel that you need to do certain things to make yourself okay, like touching things with your left hand and then your right, and having mum say goodnight to you ten times before you can go to sleep, and needing people to reassure you that everything is okay.
• 6:47
  SPEAKER_00: This naming of the child's experience in a sensitive and reassuring way brings the difficulty into the room.
• 6:55
  SPEAKER_00: And if this is followed by look, these I can see these things must be really very, very hard for you, and they must be exhausting.
• 7:04
  SPEAKER_00: I'm inviting the child to tell me about themselves from their point of view, but it also allows for me to respond to what they tell me in a way which confirms to them that they are experiencing something that is known about.
• 7:21
  SPEAKER_00: Now, the simple act of doing this can reassure the child that what they're experiencing is real, it's not their fault, it is known about and can be made better when they are in a room with a grown-up who knows about these things and who is not distressed by them.
• 7:40
  SPEAKER_00: In the early sessions, Liam rarely relaxed.
• 7:44
  SPEAKER_00: It was as if he remained vigilant and seemingly self-conscious, even while sitting.
• 7:50
  SPEAKER_00: His eyes moved around the room.
• 7:53
  SPEAKER_00: He was noticing sounds, whether or not there was movement.
• 7:58
  SPEAKER_00: And I sometimes said to him, You know, you seem very aware of everything happening around you.
• 8:04
  SPEAKER_00: And he just nodded.
• 8:06
  SPEAKER_00: And I said, Why do you think that might be?
• 8:09
  SPEAKER_00: And he said, I'd just like to know what's going on.
• 8:11
  SPEAKER_00: And I said something like, Yeah, I can see that.
• 8:16
  SPEAKER_00: And then in an impromptu kind of way, he said to him, you know, you're not always going to feel like you need to do that.
• 8:25
  SPEAKER_00: Sometimes in my work, I offer a kind of soft forecast which conveys the message that even though things seem impossible right now, I know that they will change.
• 8:39
  SPEAKER_00: One session, in one session, I asked him how things were at home, and I wasn't sure what to expect, so it was a bit of a blind shot.
• 8:52
  SPEAKER_00: And he said, Sometimes I stay awake listening, and I said, Yeah, that's right, because you have real trouble sleeping, don't you?
• 9:01
  SPEAKER_00: Is that because you're listening?
• 9:04
  SPEAKER_00: And he nodded, and I said, Do you know what you're listening for?
• 9:10
  SPEAKER_00: And then he said something which I found quite unnerving.
• 9:14
  SPEAKER_00: He just said the voice.
• 9:18
  SPEAKER_00: And I said, The voice?
• 9:23
  SPEAKER_00: You hear this voice when you are just on your own at night, or do you hear it other times too?
• 9:31
  SPEAKER_00: And he just burst into tears and said, I hear it all the time.
• 9:37
  SPEAKER_00: And I asked him whether or not the voice told him what to do, and did he have to do it?
• 9:46
  SPEAKER_00: He continued to cry but nodded his head.
• 9:51
  SPEAKER_00: There are times in my work when the distress that I witness triggers the most incredible desire for me to comfort the child, just like a parent would.
• 10:01
  SPEAKER_00: But actually, that's not what is required.
• 10:06
  SPEAKER_00: What's required is for me to be alongside the child in their in their distress.
• 10:11
  SPEAKER_00: It's not for me to make it better, it's for me to make it tolerable, survivable, so that they can learn that such things are possible.
• 10:23
  SPEAKER_00: It's also the case that I am trying to enable the child to say the words, say the distress rather than have them find expression in distressing ways.
• 10:39
  SPEAKER_00: It was painful, but we established that there was an invisible controlling voice which was largely responsible for his distress and symptoms.
• 10:50
  SPEAKER_00: The internal conflict in this boy was immense.
• 10:53
  SPEAKER_00: Eleven years old and trying to deal with an internal attacking voice.
• 10:58
  SPEAKER_00: I've witnessed these things before, I've seen them in adults and young people, particularly those who self-harm and those with eating disorders, this mysterious self-attacking voice.
• 11:11
  SPEAKER_00: Clearly, we had a lot of work to do.
• 11:13
  SPEAKER_00: Ultimately, we had to understand why the attacking voice had developed, what its function was.
• 11:20
  SPEAKER_00: And I suspect I expect the most important thing was about trying to find a way of enabling him to develop a different way of protecting himself from the disproportionate anxiety that was underneath.
• 11:41
  SPEAKER_00: In situations like this, therapists never challenge the voice.
• 11:52
  SPEAKER_00: We don't correct it.
• 11:54
  SPEAKER_00: And there's a reason for that.
• 11:55
  SPEAKER_00: And as strange as it may seem, children develop an attachment to the attacking voice because it keeps them safe.
• 12:03
  SPEAKER_00: If they obey the voice, they don't get it wrong, therefore they are safe.
• 12:07
  SPEAKER_00: But clearly it doesn't work because if it did, they wouldn't have to keep needing and listening to the voice.
• 12:16
  SPEAKER_00: So what we have to be careful of is not removing the voice from them, so to speak.
• 12:24
  SPEAKER_00: Our task is for the child to understand that the voice is part of themselves, uh, and it's that part that is frightened and has developed this protective mechanism, but it's working against them.
• 12:39
  SPEAKER_00: And that it's it is possible to do things differently, but it is delicate work.
• 12:46
  SPEAKER_00: And given this new development, I took the view that seeing Liam once weekly wasn't enough.
• 12:53
  SPEAKER_00: And that it was imperative for me to explain to and include his parents that explain the difficulties that he was experiencing in this what I considered new clinical context.
• 13:09
  SPEAKER_00: We weren't dealing with simple anxiety if there is such a thing, or OCD, which is can and can be incredibly complex, and the two things are linked.
• 13:20
  SPEAKER_00: We were dealing with a child in turmoil.
• 13:25
  SPEAKER_00: Back inside the room, I asked him him if he could tell me what the voice tells him to do.
• 13:33
  SPEAKER_00: And he said it it tells me to do the touching thing and the patterns.
• 13:38
  SPEAKER_00: And I said, And you have to do them, right?
• 13:41
  SPEAKER_00: And he nodded.
• 13:43
  SPEAKER_00: And I said, Sometimes thoughts sound like voices, and sometimes they can be very loud.
• 13:50
  SPEAKER_00: And he looked at me and said, Yeah, that's exactly what it's like, is like shouting in my head, and I can't stop it.
• 13:56
  SPEAKER_00: And I said, Yes, I know.
• 13:58
  SPEAKER_00: And those thoughts can be and seem very real and very loud and quite frightening.
• 14:07
  SPEAKER_00: Now, this was an important intervention because we'd managed to make a distinction between voice and thought, and by moving the emphasis away from an internal voice that did not belong to him, we identified the existence of self-attacking thoughts.
• 14:27
  SPEAKER_00: And this was to serve as a really important therapeutic step because we were no longer dealing with a mysterious entity, but we were dealing with thoughts which ultimately served the purpose of protecting him and simultaneously damaging him.
• 14:46
  SPEAKER_00: Over the following months, the consulting room became a different kind of environment for Liam.
• 14:52
  SPEAKER_00: It was possible for him to voice his thoughts out loud, and then for us to be able to ask questions about them and be curious about whether or not these thoughts were helpful or harmful, or a strange mixture of both.
• 15:08
  SPEAKER_00: Now, little by little he was able to incorporate the idea that the thoughts were inaccurate and didn't work, and that other more self-forgiving thoughts might take their place.
• 15:22
  SPEAKER_00: And he did this in an environment that was predictable, calm, nothing bad happened, and that even if things went wrong or that if he took the risk of disobeying his thoughts, he was okay, and more than that, he was going to be.
• 15:40
  SPEAKER_00: I said to him earlier, you won't always feel this way, and reminded him of that.
• 15:47
  SPEAKER_00: One afternoon something really subtle changed.
• 15:50
  SPEAKER_00: He for the first time leaned back in his chair and his shoulders dropped.
• 15:57
  SPEAKER_00: And I saw this and said, You look quite different today.
• 16:01
  SPEAKER_00: You almost look like you're more comfortable.
• 16:03
  SPEAKER_00: And he smiled.
• 16:06
  SPEAKER_00: He said, I think this room is kind of quiet.
• 16:10
  SPEAKER_00: And I asked him if things had been quieter in his head.
• 16:14
  SPEAKER_00: And he just said, Sometimes I don't listen anymore.
• 16:18
  SPEAKER_00: And I said, Do you mean to the voice?
• 16:21
  SPEAKER_00: And he said, Yeah, at night I just go to sleep now.
• 16:25
  SPEAKER_00: And for a child whose nervous system had been organized around vigilance, this was an almighty shift.
• 16:34
  SPEAKER_00: Work with Liam and his parents continued for quite some while.
• 16:38
  SPEAKER_00: Eventually, we were able to reduce his sessions to once weekly, not without the occasional regression, but I expect that.
• 16:46
  SPEAKER_00: But overall, his symptoms significantly reduced.
• 16:51
  SPEAKER_00: His parents were wonderful, and they followed the guidance, and things began to change significantly at home.
• 17:00
  SPEAKER_00: There's a lot more to say about Liam and his family and the very complex circumstances which caused his incredible distress.
• 17:08
  SPEAKER_00: But like so many other cases I'm talking about, they deserve more than a podcast, and here's the shameless plug, hence my book, Small People, Big Lives.
• 17:22
  SPEAKER_00: Fear in children is really just irrational.
• 17:28
  SPEAKER_00: It's often the nervous system responding intelligently to environments that have felt unpredictable.
• 17:36
  SPEAKER_00: Inside therapy, Liam experienced something new, a place where nothing exploded, nobody cried, nobody shouted, nothing escalated, and nothing required him to remain on guard.
• 17:53
  SPEAKER_00: Inside the consulting room, children who've lived in fear very often discover something that they have not felt for a very long time safety.
• 18:06
  SPEAKER_00: Thank you for listening.