Difficulties of Childhood

Family therapy or systemic therapy considers the relational patterns at every level of system that create and maintain symptoms in children. Effectively addressing these issues and the patterns which connect all involved, requires a comprehensive understanding of inequality and disadvantage which is a fundamental constraint to change. The philosopher John Rawls (A Theory of Justice, 1971) after Rousseau, locates inequality at the heart of justice. The Bower Place Model guides the thinking, enquiry, and intervention activities of the practitioner and Bower(Note) provides a set of protocols for effectively conducting practice and addressing inequality. (see the detailed explanation of the Bower Place Model and BowerNote in the education and training section of our website) The following explicates these ideas with specific reference to work with children.  

How to think 

Inequality – Political, Problem, Psychological 

Inequality is at the heart of all difficulties and effective therapy relies on addressing this both in relation to the presenting issue and in therapy. While inequality cannot and should not be removed in clinical practice a failure to manage it will disadvantage the most vulnerable person. In families this is often a child. ‘If the client can’t remember information, or process information that information won’t make a difference’ (Robinson,M.2018) and therapy will be of no value. Managing these three forms of inequality is critical to success when working with children. 

Political inequality refers to the fact that the practitioner represents the social institution of helping and social assistance in relationship with the client, the citizen. This is an inherently unequal relationship with the practitioner carrying the weight of society’s requirement to abide by ethical and legal obligations of their position. Children are particularly vulnerable in this respect. They are rarely voluntary clients and while a parent may chose to attend therapy, the child has little or no option. They are also subject to the rules and especially those in relation to child protection where the state may deem, they are unsafe and remove them from home and family irrespective of their wishes. The state, in concert with the practitioner, has the power to dictate who, how and where a child resides, where they go to school and who they can spend time with and under what conditions. While this may be the safest decision, it is not necessarily the child’s desire and they have little or no power or influence. Protecting themselves and family members from this outcome can effectively undermine the process and render therapy useless. Clearly addressing this form of inequality with children and families, it’s limits and extent does not remove it but does make it overt and in doing so can reduce anxiety. 

Problem inequality refers to the fact that the client shares their most private thoughts, actions, hopes and dreams while the practitioner, quite appropriately, does not. This form of inequality can be particularly oppressive for children who have not chosen to share their lives with a stranger. They may have had multiple experiences of trusting those in authority; parents, teachers, counsellors and doctors only to be blamed or punished. 

Psychological inequality is the differential between the psychometric profile of the practitioner compared to the client. Children do not have the cognitive, language, memory or information processing capacity of an adult, let alone a practitioner whose strengths are in this domain. In addition they are in an unfamiliar environment with a stranger who asks intimate, personal and potentially secret and frightening questions about their lives. This will increase anxiety and further undermine cognitive proficiency. Given these constraints how does the Bower Place Model and BowerNote address them? 

The Bower Place Model 

The Bower Place Model is fully explicated in other articles on the site but a brief review with reference to work with children may be useful. The Bower Place Model comprises four metaframes through which the practitioner can explore and understand the presenting difficulties and develop effective intervention. Each lens guides both the thinking and questioning of the practitioner and is a visual guide to ensure their attention remains systemic and comprehensive rather than becoming captured by a single lens. It is informed by philosophy, psychology, systems theory, neuropsychology and, sociology. No lens is exclusive, and information can properly fit in more than one meta-frame. 

Politics 

This meta frame is primary, for unless issues of power, justice and inequality are effectively addressed no effective change is possible. This specifically refers to the question of who has authority in any matter and who is willing to exercise responsibility to effect change. Unless questions of ownership are resolved the therapeutic process is paralysed by power struggles between family members, practitioners, teachers, and agencies. Often the dispute is about who is unwilling to exercise proper authority rather than attempts to take power. These dynamics are common with child presenting problems and are often driven by socio-relational fractures which may have nothing to do with the overt struggle over a child and their problems. This is clearly seen in acrimonious separations where the parents may present as overtly respectful of each other but are in dispute over child management. Alternately we may see a child who should be exercising authority over their conduct whose parents and teachers have continued to take responsibility for change they cannot effect. It also occurs in disputes between parents and school where both sides want to locate the blame for the child’s difficulties in the other and neither are willing to make changes to resolve the issues. Perhaps the most challenging are where agencies engage in the same process. For the child’s difficulties to be addressed it is crucial that those who have the power to effect change, child, parent or professional take responsibility to ensure that it happens. 

Space 

Understanding the recursive patterns which develop between inside neurobiological space and the outside socio-relational world is important to appreciate the elements which maintain the problem. Inside space includes understanding of the front and back brain which may be affected by childhood trauma and the memory and understanding that is easily recalled and described and that which is hidden from the person. It is not uncommon to see clients who experienced a difficult childhood who are unable to access information about their early years. Many difficulties of childhood represent an incapacity to manage back brain, emotional responses through front brain constraints. As this is also a developmental issue, both understanding, and intervention should be tempered by this awareness. 

Understanding childhood symptoms also requires an analysis of the outside socio-relational world in which they present. This is done in the first session with the construction of the ecogram, a three generational family tree inclusive of all significant family and non-family members. Mapping the pattern of interaction around the presenting problem will often explain factors on the outside that perpetuate difficulties. For example, a child who has uncontrolled tantrums may be supported by a parent who gives special attention and comfort to them when distressed but is relatively absent when they are calm. Mapping patterns of alliances, coalitions and boundaries between family members and others who are influential in the system can be instructive. 

Time  

The time meta frame focusses on the unfolding story of the child and family’s life and the appearance of the symptom. It is mapped through the visual representation of the time-line which records both positive and negative events in the family’s life and their imagined future. In talking to children about time it is important to remember that this is a concept which develops as the child grows and that  sensitivity to time improves with age to become similar to adults by eight years. This is explained as due to more limited cognitive resources available to young children. It should also be appreciated that the passing of time alters with age such that a long time for a five-year-old may be a short time for an adult. Which may be significant in understanding that child’s experience. It also means that an hour-long session which may pass rapidly for a parent is a very long time for a child. 

Development 

This meta frame acknowledges the importance of the physical being and includes genetics and temperament, bodily functioning and health and the impact of sleep deprivation, alcohol and other drugs. It also incorporates the unfolding of both the individual and family life cycle and the centrality of attachment and differentiation to successful adulthood. Development culminates in the formation of identity which is comprised of attachment identity, those who we call ‘family’, peer identity, our friends, sexual identity and productive or work identity. These develop through childhood and adolescence into adulthood. With children it is important to be cognizant of all four facets and be appraised of what developmental psychologists deem to be expected for children of different ages. For example, peer identity develops predictably with young children engaging in parallel play followed by the development of friendships which may favor same sex friends at on stage and mixed groups at others.  Understanding normal development is particularly important with sexual identity where a child’s precocious understanding or enactment of sexuality can be a signal of abuse. 

What to Do 

BowerNote 

The protocols that comprise BowerNote are explicitly developed to manage the inequality between client and practitioner. These comprise working to an agenda, which includes eliciting a request from each person, construction of the ecogram and time-line, feedback from the client and the note taking process.  

These protocols are helpful when working with children as they provide a structure and form that is reassuring to both client and practitioner which aids engagement. Children are given clear and explicit instructions as the session unfolds that allows them to more actively and successfully participate than is often the case when adults meet to discuss children. The process of the session is explained using both words and with reference to the agenda which is written in bold colors and attached to the table in the therapy room. The practitioner addresses each item in turn and ensures the child understands as well as possible.  It is important that each child, no matter how young, is explicitly asked for their request in language they can comprehend, and their answer treated with the same interest and respect as others. Notes are taken on A3 paper using colored texta pens and where possible the child is invited to co-create these with the practitioner. They may be asked to make a drawing to represent an experience or write their name. Wherever possible they become contributors to the process. This is a central goal in construction of the ecogram where children and practitioner work collaboratively to draw the shapes, write name and put colored lines between them to denote the quality of the relationship. At the conclusion of the session each person is asked for feedback about their experience of the session and this is recorded with equal interest and concern for each one.  

Working with children requires a set of skills tailored to their needs. This particularly applies in  exploration of the difficulty and questioning and also giving Advice in a way they can understand. These skills are more fully explained in the sections Questioning and Enquiry with Children and Giving Advice to Children and Families