Journal of Child & Adolescent Mental Health
ISSN: 1728-0583 (Print) 1728-0591 (Online) Journal homepage: http://www.tandfonline.com/loi/rcmh20
Psychotherapy in distressed communities Sue Hawkridge To cite this article: Sue Hawkridge (2007) Psychotherapy in distressed communities, Journal of Child & Adolescent Mental Health, 19:1, v-vi, DOI: 10.2989/17280580709486630 To link to this article: http://dx.doi.org/10.2989/17280580709486630
Published online: 12 Nov 2009.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rcmh20 Download by: [University of Nebraska, Lincoln]
Date: 06 November 2015, At: 00:38
EDITORIAL
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Psychotherapy in distressed communities As child and adolescent mental health professionals, we are spending ever-increasing amounts of time either attempting to alleviate the effects of traumatic experiences on our young clients or dealing with perpetrators who are themselves still children. Such interventions absorb a large proportion of the limited resources available to children’s mental health services. Whatever the broader causes of crime and violence in South Africa, researchers both here and abroad have implicated various factors, such as disturbed parent-infant relationships, parents with damaged personalities, chaotic homes, parental substance abuse, poor parenting skills, undetected and untreated learning disabilities, the lack of positive role models, and many other environmental factors that combine to distort children’s development and eventually to produce citizens who endanger the well-being of themselves and others. We need also to examine the effect of chronic exposure to belief systems that create either a false self-image of superiority or a false self-image of unworthiness, usually related to gender and/or race, based on nothing other than one’s position in a warped social hierarchy, planted in us from the cradle, and consciously or unconsciously transmitted from generation to generation. There is a growing body of evidence that well-managed parent empowerment programmes addressing early behavioural problems in children do have positive outcomes which can be seen in reduced rates of juvenile crime, less substance abuse, better educational outcomes, lower rates of teenage pregnancy and sexually-transmitted diseases, and lower rates of mental illness in adulthood. Programmes to monitor and assist new parents show evidence of efficacy in reducing the incidence of later attachment disturbances. Diversion programmes seem successful in rescuing many young adolescents from criminal futures. Clearly, the potential saving to the nation is significant, and the need to institute such programmes as an accepted and supported part of health/social services is urgent. But what of children whose caregivers are unable or unwilling to participate in any such programme? How can we attempt to reverse the damage done and prevent further harm? A possible solution is the provision of psychotherapy to heal the wounds already inflicted and to increase the child’s resilience to further harm. Traditionally, children in unstable circumstances have not been regarded as suitable candidates for psychotherapy, owing to the need for stable structural containment during the therapeutic process. Another argument is that a child who is forced to live in distressed and distressing circumstances will be repeatedly damaged, undoing any progress made in therapy. Winnicott himself said that ‘the clear management of the deprived child is not psychotherapy. Psychotherapy is something which eventually, one hopes, may be added in some instances to whatever else is done. The essential procedure is the provision of an alternative to the family’ (Winnicott 1984). However, ‘provision of an alternative to the family’ is not something which is immediately possible in our context of fractured communities and hopelessly overburdened social services, and we need to act now if we are going to salvage our future. Practical arguments against psychotherapy for children in deprived circumstances include the difficulties of access and high default rates, owing to lack of parental supervision or motivation. Perhaps we do need to consider the possibility that children can indeed make use of appropriate psychotherapy, even in unstable circumstances. Obviously, the child who is in physical danger needs immediate removal to a safe environment, and every attempt must be made to engage the caregivers of distressed children in processes that will lessen their own psychic pain and assist them in meeting their children’s emotional needs. But there is a large group of children whose v
Downloaded by [University of Nebraska, Lincoln] at 00:38 06 November 2015
Hawkridge
caregivers are not amenable to such interventions, and who seek or are referred for help on their own. Perhaps we can find a way to give such children a consistent and reliable emotional space in which a process of reconstitution of their psychic structures can begin. This might be in the form of therapeutically-informed supervised group activities or of individual psychotherapy. Children for Tomorrow (SA), a non-profit organisation in the Western Cape, has for the last seven years been providing free community-based psychotherapy services for traumatised children in some of Cape Town’s most deprived and unstable areas, along with family, group and schoolbased interventions. Careful screening procedures, child and adolescent mental health service back-up, and ongoing liaison with provincial health structures have been established over the years. A preliminary outcome study over a period of two years (2003–2005) has shown that of 115 children (64 boys and 51 girls, with an average age of 10.3 years) who were referred by community agencies, 81 were assessed and 69 were referred for individual psychotherapy with a psychologist or a child psychiatrist — in — training. Supervision was provided by experienced child mental health professionals. At follow-up, of the 69 children who had been offered psychotherapy, only 18 had terminated prematurely, and of those, 13 were then receiving counselling from other agencies. Six of the children who were referred but did not attend for assessment had subsequently entered psychotherapy with other agencies. Twelve children had completed their therapy and were doing well. The remaining 39 were still attending therapy (Stellermann 2005). While this study was clearly not a rigorous scientific investigation (a costly and much-needed exercise), these preliminary data suggest that the majority of children who are offered psychotherapy do in fact find value in it, enough to attend more or less regularly for relatively extended periods, and may in the long run find that their lives are changed by the experience. Stellermann describes in her paper some problems encountered in offering psychotherapy to children in unstable circumstances, including intermittent compliance difficulties, ongoing stressors and recurrent trauma, and the extraordinary efforts that have occasionally to be made to enable a child to continue in therapy or to maintain the ‘analytic frame’. But despite the difficulties involved, the opportunity to think the unthinkable, feel the unbearable and say the unspeakable in the presence of a reliable empathic adult who can hold their pain without being destroyed by it and suffer their anger without retaliating, may offer these children their best chance to deal with their life circumstances in a new way. The challenges are enormous, and the capacity of health services is currently insufficient, but if new ways can be found of both introducing a ‘psychological-mindedness’ to people and institutions that deal with children, and providing psychotherapy to children whose caregivers are not available for such interventions, we may begin to reverse the destructive tide of personality distortion which is contributing to the untenable situation in which our country now finds itself. Partnerships between health services and non-profit organisations, as well as capacitation and support of communitybased mental health workers, are two areas that appear to hold promise, and therefore deserve our consideration. References Stellermann K, Bawa U, Adam H et al. (2005) Community-based services for traumatised children in an urban setting in South Africa. Poster presentation at the Biennial Congress of the South African Association for Child and Adolescent Psychiatry and Allied Professions, Port Elizabeth, September 2005 Winnicott DW (1984) The deprived child and how he can be compensated for loss of family life. In: Winnicott C, Shepherd R and Davis M (eds.), Deprivation and Delinquency. Tavistock Publications, London. pp 72–188
Sue Hawkridge Principal Specialist, Western Cape Child and Adolescent Mental Health Services Senior Lecturer, Department of Psychiatry and Mental Health, University of Cape Town and Department of Psychiatry, Stellenbosch University e-mail: [email protected] vi
ISSN: 1728-0583 (Print) 1728-0591 (Online) Journal homepage: http://www.tandfonline.com/loi/rcmh20
Psychotherapy in distressed communities Sue Hawkridge To cite this article: Sue Hawkridge (2007) Psychotherapy in distressed communities, Journal of Child & Adolescent Mental Health, 19:1, v-vi, DOI: 10.2989/17280580709486630 To link to this article: http://dx.doi.org/10.2989/17280580709486630
Published online: 12 Nov 2009.
Submit your article to this journal
Article views: 27
View related articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rcmh20 Download by: [University of Nebraska, Lincoln]
Date: 06 November 2015, At: 00:38
EDITORIAL
Downloaded by [University of Nebraska, Lincoln] at 00:38 06 November 2015
Psychotherapy in distressed communities As child and adolescent mental health professionals, we are spending ever-increasing amounts of time either attempting to alleviate the effects of traumatic experiences on our young clients or dealing with perpetrators who are themselves still children. Such interventions absorb a large proportion of the limited resources available to children’s mental health services. Whatever the broader causes of crime and violence in South Africa, researchers both here and abroad have implicated various factors, such as disturbed parent-infant relationships, parents with damaged personalities, chaotic homes, parental substance abuse, poor parenting skills, undetected and untreated learning disabilities, the lack of positive role models, and many other environmental factors that combine to distort children’s development and eventually to produce citizens who endanger the well-being of themselves and others. We need also to examine the effect of chronic exposure to belief systems that create either a false self-image of superiority or a false self-image of unworthiness, usually related to gender and/or race, based on nothing other than one’s position in a warped social hierarchy, planted in us from the cradle, and consciously or unconsciously transmitted from generation to generation. There is a growing body of evidence that well-managed parent empowerment programmes addressing early behavioural problems in children do have positive outcomes which can be seen in reduced rates of juvenile crime, less substance abuse, better educational outcomes, lower rates of teenage pregnancy and sexually-transmitted diseases, and lower rates of mental illness in adulthood. Programmes to monitor and assist new parents show evidence of efficacy in reducing the incidence of later attachment disturbances. Diversion programmes seem successful in rescuing many young adolescents from criminal futures. Clearly, the potential saving to the nation is significant, and the need to institute such programmes as an accepted and supported part of health/social services is urgent. But what of children whose caregivers are unable or unwilling to participate in any such programme? How can we attempt to reverse the damage done and prevent further harm? A possible solution is the provision of psychotherapy to heal the wounds already inflicted and to increase the child’s resilience to further harm. Traditionally, children in unstable circumstances have not been regarded as suitable candidates for psychotherapy, owing to the need for stable structural containment during the therapeutic process. Another argument is that a child who is forced to live in distressed and distressing circumstances will be repeatedly damaged, undoing any progress made in therapy. Winnicott himself said that ‘the clear management of the deprived child is not psychotherapy. Psychotherapy is something which eventually, one hopes, may be added in some instances to whatever else is done. The essential procedure is the provision of an alternative to the family’ (Winnicott 1984). However, ‘provision of an alternative to the family’ is not something which is immediately possible in our context of fractured communities and hopelessly overburdened social services, and we need to act now if we are going to salvage our future. Practical arguments against psychotherapy for children in deprived circumstances include the difficulties of access and high default rates, owing to lack of parental supervision or motivation. Perhaps we do need to consider the possibility that children can indeed make use of appropriate psychotherapy, even in unstable circumstances. Obviously, the child who is in physical danger needs immediate removal to a safe environment, and every attempt must be made to engage the caregivers of distressed children in processes that will lessen their own psychic pain and assist them in meeting their children’s emotional needs. But there is a large group of children whose v
Downloaded by [University of Nebraska, Lincoln] at 00:38 06 November 2015
Hawkridge
caregivers are not amenable to such interventions, and who seek or are referred for help on their own. Perhaps we can find a way to give such children a consistent and reliable emotional space in which a process of reconstitution of their psychic structures can begin. This might be in the form of therapeutically-informed supervised group activities or of individual psychotherapy. Children for Tomorrow (SA), a non-profit organisation in the Western Cape, has for the last seven years been providing free community-based psychotherapy services for traumatised children in some of Cape Town’s most deprived and unstable areas, along with family, group and schoolbased interventions. Careful screening procedures, child and adolescent mental health service back-up, and ongoing liaison with provincial health structures have been established over the years. A preliminary outcome study over a period of two years (2003–2005) has shown that of 115 children (64 boys and 51 girls, with an average age of 10.3 years) who were referred by community agencies, 81 were assessed and 69 were referred for individual psychotherapy with a psychologist or a child psychiatrist — in — training. Supervision was provided by experienced child mental health professionals. At follow-up, of the 69 children who had been offered psychotherapy, only 18 had terminated prematurely, and of those, 13 were then receiving counselling from other agencies. Six of the children who were referred but did not attend for assessment had subsequently entered psychotherapy with other agencies. Twelve children had completed their therapy and were doing well. The remaining 39 were still attending therapy (Stellermann 2005). While this study was clearly not a rigorous scientific investigation (a costly and much-needed exercise), these preliminary data suggest that the majority of children who are offered psychotherapy do in fact find value in it, enough to attend more or less regularly for relatively extended periods, and may in the long run find that their lives are changed by the experience. Stellermann describes in her paper some problems encountered in offering psychotherapy to children in unstable circumstances, including intermittent compliance difficulties, ongoing stressors and recurrent trauma, and the extraordinary efforts that have occasionally to be made to enable a child to continue in therapy or to maintain the ‘analytic frame’. But despite the difficulties involved, the opportunity to think the unthinkable, feel the unbearable and say the unspeakable in the presence of a reliable empathic adult who can hold their pain without being destroyed by it and suffer their anger without retaliating, may offer these children their best chance to deal with their life circumstances in a new way. The challenges are enormous, and the capacity of health services is currently insufficient, but if new ways can be found of both introducing a ‘psychological-mindedness’ to people and institutions that deal with children, and providing psychotherapy to children whose caregivers are not available for such interventions, we may begin to reverse the destructive tide of personality distortion which is contributing to the untenable situation in which our country now finds itself. Partnerships between health services and non-profit organisations, as well as capacitation and support of communitybased mental health workers, are two areas that appear to hold promise, and therefore deserve our consideration. References Stellermann K, Bawa U, Adam H et al. (2005) Community-based services for traumatised children in an urban setting in South Africa. Poster presentation at the Biennial Congress of the South African Association for Child and Adolescent Psychiatry and Allied Professions, Port Elizabeth, September 2005 Winnicott DW (1984) The deprived child and how he can be compensated for loss of family life. In: Winnicott C, Shepherd R and Davis M (eds.), Deprivation and Delinquency. Tavistock Publications, London. pp 72–188
Sue Hawkridge Principal Specialist, Western Cape Child and Adolescent Mental Health Services Senior Lecturer, Department of Psychiatry and Mental Health, University of Cape Town and Department of Psychiatry, Stellenbosch University e-mail: [email protected] vi
