J. Child Psychol. Psychiat., Vol. 20. on. 81 lo 86 Pe^g.mo« Pr«s Ltd 1979. Printc^i in GrJ.^ Britain. © Assoeialion for Child Psychology and Psychiatry,
„„ „ 0012-9630/79/0101^081502.000
ANNOTATION PSYCHOTHERAPY AND THE SCHOOL A. R. NicoL* much common ground between education and psychotherapy so the two processes need first to be delineated. The ways in which they may be related and the special properties and advantages that psychotherapy may have in the school situation will then be explored. Finally, some published studies will be examined to see whether they have taken account ofthe special characteristics of schoolbased psychotherapy. Education can be defined in many ways. In the broadest view (Dewey 1916) It can be seen as providing the link which transmits the accumulated products of a culture between one generation and the next. In complex societies, the materiaJ that has to be communicated through education becomes too distanced from immediate experience to be managed entirely in any informal way by parents and other adults. Teachers and schools then become necessary and education becomes a deliberate and planned process. This broad conception includes all aspects of behaviour and attitudes, not merely those usually considered as formal learning Many may find this concept of education too general to be of much practical use but It does emphasize the point that education should include guidance ofthe child in how to conduct his life and is, in this way, a more general process than for example, mere training or instruction (Peters, 1966). In common with other complex organisations, the school develops aims which are subsidiary to the primary one of education. These include ordering the motivation and b'^haviour of the children and providing a working environment for the teachers (Etzioni, 1964). Many aspects ofthe school as a "social organism" have been found to affect the attitudes and behaviour ofthe children, for example, its size (Barker THERE IS
tS^, ^""P: ' ^ ^ ^ ' 7 ^ ^ " ""^"^^"^ "^"^'"^^ of different ability (Hargreaves, H L ^°P.^,^/"^ •^°°^' ^^^^^ ""^ '^' ^"^l^^y of interaction between the teache; and the children in the classroom (Kounin, 1970; Smith and Geoff^rey 1968) School rules, the way they are enforced and the aspects of behaviour and achievement that are valued in the school may all help to mould the behaviour and value orientation ofthe children (Vaughan, 1975). Guidance of schoolchildren has been categorized by Milner (1974) into five related areas. First, there is orientation to the school and transition between schoolssecond, there IS guidance in using the educational facilities of the school most efiectively; third, there is course choice and vocational choice; fourth, there are aspects of home-school liaison and liaison with other outside agencies, and finally there is personal, educational or vocational counselling on an individual or small lf
RoirM "'' 'Ti ^•^^^'l^P^y^'^^^gy - ^ Psychiatry Unit, Fleming Memorial Hospital, Road, Newcastle-upon-Tyne NE2 3AX, England. 81
82
A. R. NICOL
group basis. In larger, more complex schools these functions may be taken over by specialist staff (Jones, 1977). This is a fairly recent trend, however, and these functions are traditionally seen as part of the teachers' "pastoral role". It_ is an aspect of their work which some teachers value highly, while others consider it secondary in importance to their work in formal teaching. The pastoral staff of a large school in the U.K. will include senior staff members such as heads of houses or year tutors and may also include a school counsellor with or without a qualification in this subject. School counselling is a recent innovation in Britain but has a longer history in the United States (Gadza, 1978). It is generally considered to be orientated to helping children with relatively minor transient problems and to use educational and problem-solving techniques rather than psychotherapy. In the school it is seen as that part of general guidance which necessitates a personal encounter of some kind. The difference between counselhng and psychotherapy needs to be clarified if either word is to have a usefully distinct meaning. In its original conception, psychotherapy was quite alien to the school setting, being a purely clinical technique. Psychoanalysis as conceived by Freud (1922) was for the relief of neurosis. In contrast to other medical treatments, the therapist worked from a purely psychological basis and the patient was asked to co-operate actively in the analysis of his own thoughts and impulses as revealed by free associations, dreams and mistakes and interpreted according to psychoanalytic theory. Since that time the variety of techniques and disorders treated by psychotherapy has broadened considerably. However, Ford and Urban (1971) point out some unifying characteristics; for example, all psychotherapists are tied to some conceptual framework or theory of action. Further, psychotherapy is always a dehberate process undertaken to modify some problem, particularly to alleviate a psychiatric disorder. Meltzoff and Kornreich (1970) add that the therapist and chent must have a formalized understanding about the nature of their relationship and respective roles; they must both agree that psychotherapy is taking place and have some common understanding of its nature and purpose. Psychotherapists call this the treatment alliance (Sandier et al., 1970). Among children and young adolescents there are difficulties about the concept of treatment alliance as the paUent isJisuaUy brought to treatment by someone else. However, those responsible for the child will have an understanding and usually, except in the case ofthe very young, the child itself will have some understanding that treatment is taking place. A final characteristic of psychotherapy is that the relationship is a confidential one. • This definition of psychotherapy is a more restrictive one than some authors favour Marks (1971), for example, sees psychotherapy simply as the art of reheving psychiatric problems by psychological means. To adopt this definition in the present context would widen the concept to include many teaching activities and obscure some ofthe special problems of more formal psychotherapy in the school context. A more restricted definition excludes from psychotherapy interventions with essentially normal children and those where there is no treatment alhance or no underlying psychological theory. It may be that many of these activities could appropriately be called counselfing, but it is quite possible for a teacher to influence profoundly a child in the normal process of class teaching. This could not be classed
ANNOTATION
as either counselhng or, indeed, psychotherapy (Meltzoff and Kornreich, 1970) fortunately, teachers have not been inhibited by these niceties and have used a wide variety of ways of coping with and helping disturbed children. Two early pioneers, Redl and Wineman (1952), contrast their treatment in the ongoing social environment of-the child with the "pressurized cabin" of formal psychotherapy. Catterell (1970) provides a four-fold classification of types of prescribed intervention that may be applied in the school to help children with emotional problems These are (1) those that indirectly attempt to help the child by making adequate provision tor him in the total environmental setting by some degree of individuahzation (2) where additional skills or equipment are brought into a child's environment to help cope with a problem, (3) when there is an individually directed approach to produce behaviour change (e.g. role playing activity or specific physical exercise) and (4) hnally there are those where the therapist works with the child in a direct personal way. AU psychotherapy as defined in this paper would be included in this last category. We can see from this that formal psychotherapy has at most a modest part to play in the school, alongside a variety of allied techniques. This IS hardly surprising when we consider that, as Lewis (1953) points out psychiatric disorders of childhood are commonly quantitative deviations from normal behaviour or emotional life and come to notice because of their troublesome social consequences. They are identifiable as disorders because of their repetitive quahty and adverse effects on the child's development but are often situation specific (Rutter et ai 1970). Disorders which are manifest in the school situation are often understandable in terms ofthe situational stresses that school life imposes on the vulnerable child. The fact that the prevalence rates of disorder vary between schools in a way that cannot be accounted for entirely by factors outside the school (Rutter 1974) suggests that some at least of tliese stresses are alterable without recourse to'special techniques. Psychotherapy, then, may be appropriate when there is a specific problem in an individual child. To take another view, what advantages does school based psychotherapy have when compared with conventional clinic based work? First, psychotherapy techniques have been used to alleviate not only behavioural and emotional problems but also educational problems (e.g. Barcai et al., 1973; Axline, 1947; Coles, 1977; Lawrence, 1973; McCollum and Anderson, 1974) as well as poor motivation, self-concept and underachievement (Mezzano 1968Mann .^ al 1969; Dickenson and Truax, 1966). This brings psychotherapy ver^ much mto the educational sphere where it can be used in co-operation with other educational techniques. Second, the main thrust of advance in psychotherapy is towards more active and briefer treatment (Malan, 1976) and away from the idea that one type of psychotherapy is the best for all problems (Goldstein and Stein, 1976). Brief active treatments are well suited to the school situation and close contact with teaching staff allows the rest ofthe school curriculum to be modified to fit the needs of a child who IS in difficulties. Psychotherapy can thus be offered in the context of some limited treatment plan. A third possible advantage of school based psychotherapy is that it allows the therapist to gauge the general social climate that is impinging on the child. Dis-
84
A. R. NICOL
turbed children commonly have difficulties in social relationships with both their peers and school staff. It is very helpful if the therapist is able to detect these problems and find ways of putting them right. A fourth advantage is that the school base is a familiar environment for the child and the established guidance system ofthe school may make it easier to prepare the child and familiarize him with what is involved in therapy. Recent work has shown the importance of this. It particularly influences whether clients remain in treatment (Holmes and Urie, 1975). In this connection, the fifth advantage of school based psychotherapy is that with pooriy motivated famihes there is a greater chance of ensuring attendance as the child is at school anyway. Sixth, and finally, it may be very important to have an individual in the school who has some acquaintance with concepts and techniques of psychotherapy. Many commentators have written of the isolation of teaching staff when faced with classroom difficulties (Newman et ai, 1971; Knoblock and Goldstein, 1971). A school counsellor or social worker, potentially at least, may be able to act as a consultant and resource person for teacher colleagues. It is also important to look at the disadvantages of school based psychotherapy. First, it should be said that the above advantages are dependent on having a good psychotherapy service with properly trained staff who are aware of the difficulties their work may present in this environment. Equally, a good cUnic based service with community links can provide many of the special features enumerated above. One disadvantage of school based psychotherapy is a relative lack of confidentiality. Traditional clinic work has a medical component and with this an obligation backed by law to maintain confidentiality. This allows a degree and quality of parental and family involvement which is not possible in a school context and which in turn enables the workers to make a much fuller assessment of factors leading to the child's difficulty. It is not that confidences are not made and kept in the school situation but rather the way that society views the role of a school as opposed to a clinic. A second and related possible disadvantage is that ofthe "labelling" of a child who is selected from among his or her peers for some kind of special help in school. Unfortunately, labelling theories, apart from some preliminary attempts in the criminology field (Farrington, 1977) and in school achievement (Brophy and Good, 1974) have not been fully put to empirical test so that we do not know at present how much they should infiuence our management. A third difficulty with school based psychotherapy, also one with no empirical support but intuitive appeal, is that the therapist in the school, like the teachers and children, is part of a social system which demands conformity to norms and has implicit rules such as loyalty to colleagues and a hierarchy of authority. The school based psychotherapist will inevitably be a part of this system and, in the absence of outside support, may unwittingly serve institutional needs, for example for behaviour control, rather than those of the child. There is also, of course, the danger of thr lliorapist brcominir ovrr-invnlved and siding with the child in his conRicts with the
ANNOTATION
school. An adequate support system and supervision outside the school is needed to offset these difficulties. We are hampered in our exploration of school based psychotherapy by the lack of empirical evidence bearing on the issues that have been raised. Research on child psychotherapy in general is at an early stage and there are many methodological problems to overcome [see Abramowitz (1976) and Levitt (1971) for reviewsl Evidence becomes even sparser when we turn to specialized topics such as a school based approach. Important issues such as the attitude of school authorities and teachers are commonly Ignored in published studies. This is a pity as in many cases it would be relatively easy to measure as an independent variable. Hinds and Roehlke (1970) for example, carried out a behavioural programme in a group counselling setting They record significant behavioural changes which tended to generalize to the classroom and It would be interesting to know if the generalization was equal to all the four classes involved m the study. Barcai and Robinson (1969) carried out a study of conventional group therapy in two schools in Baltimore. They speculate that the poorer outcome of one ofthe groups may be related to the somewhat cooler reception of their technique in the school concerned. In a later study of three approaches to underachieving children Barcai et al. (1973) analysed the outcome of teacher ratings separately for the two teachers whose classes provided children for the groups As expected, the outcome was quite different for the two classes. Unfortunately, it is not clear whether the therapists for the children in the different classes were not also systemaucally different—a matter of some importance (Nicol et al 1977) It seems safe to conclude that school based psychotherapy has a role somewhat different from chmc based work. There is a need to study some ofthe issues involved ''".^"'^P^"^^/.^°°t^^g «
„„ „ 0012-9630/79/0101^081502.000
ANNOTATION PSYCHOTHERAPY AND THE SCHOOL A. R. NicoL* much common ground between education and psychotherapy so the two processes need first to be delineated. The ways in which they may be related and the special properties and advantages that psychotherapy may have in the school situation will then be explored. Finally, some published studies will be examined to see whether they have taken account ofthe special characteristics of schoolbased psychotherapy. Education can be defined in many ways. In the broadest view (Dewey 1916) It can be seen as providing the link which transmits the accumulated products of a culture between one generation and the next. In complex societies, the materiaJ that has to be communicated through education becomes too distanced from immediate experience to be managed entirely in any informal way by parents and other adults. Teachers and schools then become necessary and education becomes a deliberate and planned process. This broad conception includes all aspects of behaviour and attitudes, not merely those usually considered as formal learning Many may find this concept of education too general to be of much practical use but It does emphasize the point that education should include guidance ofthe child in how to conduct his life and is, in this way, a more general process than for example, mere training or instruction (Peters, 1966). In common with other complex organisations, the school develops aims which are subsidiary to the primary one of education. These include ordering the motivation and b'^haviour of the children and providing a working environment for the teachers (Etzioni, 1964). Many aspects ofthe school as a "social organism" have been found to affect the attitudes and behaviour ofthe children, for example, its size (Barker THERE IS
tS^, ^""P: ' ^ ^ ^ ' 7 ^ ^ " ""^"^^"^ "^"^'"^^ of different ability (Hargreaves, H L ^°P.^,^/"^ •^°°^' ^^^^^ ""^ '^' ^"^l^^y of interaction between the teache; and the children in the classroom (Kounin, 1970; Smith and Geoff^rey 1968) School rules, the way they are enforced and the aspects of behaviour and achievement that are valued in the school may all help to mould the behaviour and value orientation ofthe children (Vaughan, 1975). Guidance of schoolchildren has been categorized by Milner (1974) into five related areas. First, there is orientation to the school and transition between schoolssecond, there IS guidance in using the educational facilities of the school most efiectively; third, there is course choice and vocational choice; fourth, there are aspects of home-school liaison and liaison with other outside agencies, and finally there is personal, educational or vocational counselling on an individual or small lf
RoirM "'' 'Ti ^•^^^'l^P^y^'^^^gy - ^ Psychiatry Unit, Fleming Memorial Hospital, Road, Newcastle-upon-Tyne NE2 3AX, England. 81
82
A. R. NICOL
group basis. In larger, more complex schools these functions may be taken over by specialist staff (Jones, 1977). This is a fairly recent trend, however, and these functions are traditionally seen as part of the teachers' "pastoral role". It_ is an aspect of their work which some teachers value highly, while others consider it secondary in importance to their work in formal teaching. The pastoral staff of a large school in the U.K. will include senior staff members such as heads of houses or year tutors and may also include a school counsellor with or without a qualification in this subject. School counselling is a recent innovation in Britain but has a longer history in the United States (Gadza, 1978). It is generally considered to be orientated to helping children with relatively minor transient problems and to use educational and problem-solving techniques rather than psychotherapy. In the school it is seen as that part of general guidance which necessitates a personal encounter of some kind. The difference between counselhng and psychotherapy needs to be clarified if either word is to have a usefully distinct meaning. In its original conception, psychotherapy was quite alien to the school setting, being a purely clinical technique. Psychoanalysis as conceived by Freud (1922) was for the relief of neurosis. In contrast to other medical treatments, the therapist worked from a purely psychological basis and the patient was asked to co-operate actively in the analysis of his own thoughts and impulses as revealed by free associations, dreams and mistakes and interpreted according to psychoanalytic theory. Since that time the variety of techniques and disorders treated by psychotherapy has broadened considerably. However, Ford and Urban (1971) point out some unifying characteristics; for example, all psychotherapists are tied to some conceptual framework or theory of action. Further, psychotherapy is always a dehberate process undertaken to modify some problem, particularly to alleviate a psychiatric disorder. Meltzoff and Kornreich (1970) add that the therapist and chent must have a formalized understanding about the nature of their relationship and respective roles; they must both agree that psychotherapy is taking place and have some common understanding of its nature and purpose. Psychotherapists call this the treatment alliance (Sandier et al., 1970). Among children and young adolescents there are difficulties about the concept of treatment alliance as the paUent isJisuaUy brought to treatment by someone else. However, those responsible for the child will have an understanding and usually, except in the case ofthe very young, the child itself will have some understanding that treatment is taking place. A final characteristic of psychotherapy is that the relationship is a confidential one. • This definition of psychotherapy is a more restrictive one than some authors favour Marks (1971), for example, sees psychotherapy simply as the art of reheving psychiatric problems by psychological means. To adopt this definition in the present context would widen the concept to include many teaching activities and obscure some ofthe special problems of more formal psychotherapy in the school context. A more restricted definition excludes from psychotherapy interventions with essentially normal children and those where there is no treatment alhance or no underlying psychological theory. It may be that many of these activities could appropriately be called counselfing, but it is quite possible for a teacher to influence profoundly a child in the normal process of class teaching. This could not be classed
ANNOTATION
as either counselhng or, indeed, psychotherapy (Meltzoff and Kornreich, 1970) fortunately, teachers have not been inhibited by these niceties and have used a wide variety of ways of coping with and helping disturbed children. Two early pioneers, Redl and Wineman (1952), contrast their treatment in the ongoing social environment of-the child with the "pressurized cabin" of formal psychotherapy. Catterell (1970) provides a four-fold classification of types of prescribed intervention that may be applied in the school to help children with emotional problems These are (1) those that indirectly attempt to help the child by making adequate provision tor him in the total environmental setting by some degree of individuahzation (2) where additional skills or equipment are brought into a child's environment to help cope with a problem, (3) when there is an individually directed approach to produce behaviour change (e.g. role playing activity or specific physical exercise) and (4) hnally there are those where the therapist works with the child in a direct personal way. AU psychotherapy as defined in this paper would be included in this last category. We can see from this that formal psychotherapy has at most a modest part to play in the school, alongside a variety of allied techniques. This IS hardly surprising when we consider that, as Lewis (1953) points out psychiatric disorders of childhood are commonly quantitative deviations from normal behaviour or emotional life and come to notice because of their troublesome social consequences. They are identifiable as disorders because of their repetitive quahty and adverse effects on the child's development but are often situation specific (Rutter et ai 1970). Disorders which are manifest in the school situation are often understandable in terms ofthe situational stresses that school life imposes on the vulnerable child. The fact that the prevalence rates of disorder vary between schools in a way that cannot be accounted for entirely by factors outside the school (Rutter 1974) suggests that some at least of tliese stresses are alterable without recourse to'special techniques. Psychotherapy, then, may be appropriate when there is a specific problem in an individual child. To take another view, what advantages does school based psychotherapy have when compared with conventional clinic based work? First, psychotherapy techniques have been used to alleviate not only behavioural and emotional problems but also educational problems (e.g. Barcai et al., 1973; Axline, 1947; Coles, 1977; Lawrence, 1973; McCollum and Anderson, 1974) as well as poor motivation, self-concept and underachievement (Mezzano 1968Mann .^ al 1969; Dickenson and Truax, 1966). This brings psychotherapy ver^ much mto the educational sphere where it can be used in co-operation with other educational techniques. Second, the main thrust of advance in psychotherapy is towards more active and briefer treatment (Malan, 1976) and away from the idea that one type of psychotherapy is the best for all problems (Goldstein and Stein, 1976). Brief active treatments are well suited to the school situation and close contact with teaching staff allows the rest ofthe school curriculum to be modified to fit the needs of a child who IS in difficulties. Psychotherapy can thus be offered in the context of some limited treatment plan. A third possible advantage of school based psychotherapy is that it allows the therapist to gauge the general social climate that is impinging on the child. Dis-
84
A. R. NICOL
turbed children commonly have difficulties in social relationships with both their peers and school staff. It is very helpful if the therapist is able to detect these problems and find ways of putting them right. A fourth advantage is that the school base is a familiar environment for the child and the established guidance system ofthe school may make it easier to prepare the child and familiarize him with what is involved in therapy. Recent work has shown the importance of this. It particularly influences whether clients remain in treatment (Holmes and Urie, 1975). In this connection, the fifth advantage of school based psychotherapy is that with pooriy motivated famihes there is a greater chance of ensuring attendance as the child is at school anyway. Sixth, and finally, it may be very important to have an individual in the school who has some acquaintance with concepts and techniques of psychotherapy. Many commentators have written of the isolation of teaching staff when faced with classroom difficulties (Newman et ai, 1971; Knoblock and Goldstein, 1971). A school counsellor or social worker, potentially at least, may be able to act as a consultant and resource person for teacher colleagues. It is also important to look at the disadvantages of school based psychotherapy. First, it should be said that the above advantages are dependent on having a good psychotherapy service with properly trained staff who are aware of the difficulties their work may present in this environment. Equally, a good cUnic based service with community links can provide many of the special features enumerated above. One disadvantage of school based psychotherapy is a relative lack of confidentiality. Traditional clinic work has a medical component and with this an obligation backed by law to maintain confidentiality. This allows a degree and quality of parental and family involvement which is not possible in a school context and which in turn enables the workers to make a much fuller assessment of factors leading to the child's difficulty. It is not that confidences are not made and kept in the school situation but rather the way that society views the role of a school as opposed to a clinic. A second and related possible disadvantage is that ofthe "labelling" of a child who is selected from among his or her peers for some kind of special help in school. Unfortunately, labelling theories, apart from some preliminary attempts in the criminology field (Farrington, 1977) and in school achievement (Brophy and Good, 1974) have not been fully put to empirical test so that we do not know at present how much they should infiuence our management. A third difficulty with school based psychotherapy, also one with no empirical support but intuitive appeal, is that the therapist in the school, like the teachers and children, is part of a social system which demands conformity to norms and has implicit rules such as loyalty to colleagues and a hierarchy of authority. The school based psychotherapist will inevitably be a part of this system and, in the absence of outside support, may unwittingly serve institutional needs, for example for behaviour control, rather than those of the child. There is also, of course, the danger of thr lliorapist brcominir ovrr-invnlved and siding with the child in his conRicts with the
ANNOTATION
school. An adequate support system and supervision outside the school is needed to offset these difficulties. We are hampered in our exploration of school based psychotherapy by the lack of empirical evidence bearing on the issues that have been raised. Research on child psychotherapy in general is at an early stage and there are many methodological problems to overcome [see Abramowitz (1976) and Levitt (1971) for reviewsl Evidence becomes even sparser when we turn to specialized topics such as a school based approach. Important issues such as the attitude of school authorities and teachers are commonly Ignored in published studies. This is a pity as in many cases it would be relatively easy to measure as an independent variable. Hinds and Roehlke (1970) for example, carried out a behavioural programme in a group counselling setting They record significant behavioural changes which tended to generalize to the classroom and It would be interesting to know if the generalization was equal to all the four classes involved m the study. Barcai and Robinson (1969) carried out a study of conventional group therapy in two schools in Baltimore. They speculate that the poorer outcome of one ofthe groups may be related to the somewhat cooler reception of their technique in the school concerned. In a later study of three approaches to underachieving children Barcai et al. (1973) analysed the outcome of teacher ratings separately for the two teachers whose classes provided children for the groups As expected, the outcome was quite different for the two classes. Unfortunately, it is not clear whether the therapists for the children in the different classes were not also systemaucally different—a matter of some importance (Nicol et al 1977) It seems safe to conclude that school based psychotherapy has a role somewhat different from chmc based work. There is a need to study some ofthe issues involved ''".^"'^P^"^^/.^°°t^^g «
