Clinical Process

Requests for parenting help often begin with “We have tried everything and nothing we do makes our child comply “. The parent may then go on to explain how they have bought every parenting book and implemented every strategy to no effect. In fact they often report that things have“ got worse”. Herein lies the problem and it is manifest on 2 levels. The first is in the very linear understanding of the child’s behavioural difficulties and the notion that if they can only find the right key to the problematic lock they can undo the problem without addressing the recursive patterns of interaction that includes themselves and others who are central to maintaining it. It also fails to appreciate that each of us including the child is a system in our own right and that each person will respond differently to the same information dependent on how their own unique system. This is the insight of Gregory Bateson who used the analogy of the difference between kicking an object and kicking a dog. If you kick an object it is possible to accurately predict where it will land. However, if you kick a dog the response is utterly dependent on that creature. A dog may run away, cower or bite dependent on its nature and experience.  

The second difficulty lies in the fact that parent and child are often caught in a symmetrical or complementary escalation or a mix of the two. This involves a struggle for control over the child or adolescent or by them over the parent. A symmetrical escalation involves they exchange off the same behaviours. For example, a child may be rude and defiant to the parent’s requests and in response the parent becomes verbally and perhaps physically abusive. Alternately the parent may engage in behaviour that is complimentary whereby they attempt to cajole, persuade and encourage their child to cooperate which is met by the opposite or complementary behaviour by the child in defiance, disrespect and no co-operation. Often these patterns will alternate with parents attempting positive and rewarding approaches, becoming frustrated at the child’s lack of cooperation and move to authoritarian control which is equally ineffective. Such escalations may become dangerous for both parent and child and culminate in violence to one or both and involvement of child protection authorities when notification is made. This analysis is central to the work of Haim Omar who noted that ‘Parental exhorting, entreating, and apologizing, increase the risk of complementary escalation; parental arguing, threatening, blaming, and screaming, increase the risk of reciprocal escalation’. He also identified the powerful impact of both parent and child’s need to ‘win’ with the recognition that the greater the dominance orientation of those involved the greater the risk of escalation. His work utilized principles of nonviolent resistance to inform his approach to working with extreme child behaviour problems to develop strategies to interrupt such patterns. 

Such escalations become particularly problematic at development stages where the child or young person are establishing their identity. This explains the escalation of these difficulties at two or three years old and in adolescence both times when the need to understand and define oneself as separate from the parent becomes primary.  

One of the greatest risks working with parents is that the practitioner replicates the escalation and finds themselves struggling with parents who ‘refuse to follow advice’. Just as the parent attempts to impose their authority over the child so the practitioner my find themselves insisting that the parent must do as they are told resulting in resistance and the ultimate collapse of the therapeutic system. 

The Bower Place Approach 

Request 

Bower(note) the processes and protocols for managing clinical matters at power place includes the Agenda for each session, the first item of which is the request. This forms the contractual basis for all service delivery, and in parenting matters negotiating the request is the first step in moving the definition of the problem from one that is inside the child that can be corrected through education of the parent to one that is inherent in the system in which they all operate. Asking each person in the session to articulate their request often results in a more systemic perspective rather than a linear one. For example, if parents ask for help to learn to manage their ‘difficult child’ and the child’s request is for help to stop fighting in the family we already have two definitions of the problem for the practitioner to explore. The redefinition of the problem continues throughout the interview as the practitioner asks questions that clarify the relational nature of the struggle between parent and child.  

Word and Image 

Drawing the ecogram and time-line allows different perspectives of the problem to emerge. In therapeutic practice verbal description is usually privileged over image and the drawing of the timeline and ecogram reverse this dominance. In parenting matters adults discuss the child in language and with concepts they may not understand but reinforce the perspective that they are ‘the problem’ This is a good opportunity to engage a child who has attended fearing that they will be the centre of negative attention and locus of change. Requesting the child assist the practitioner to draw can interrupt a pattern of complementary escalation where the practitioner insists on cooperation from the child who resists all their entreaties which may become controlling and potentially abusive or pleading and cajoling that mirrors the family’s pattern and the reason, they have sought help. The practitioner explores patterns of behaviour, feelings, the meaning ascribed to actions and beliefs, over the generations and within the timeline that may provide alternative explanations for the child’s difficulties. Exploration of fracture, alliance and coalitions both historically and in the present may begin to explain the severity or longevity of the difficulty experienced with a child. In Salvador Minuchin’s terms they may reveal “whose shoulders the child is standing on”. The rationale behind this statement is that if a child can defy adults who should be able to exercise authority then there is someone in the system who is overtly or covertly supporting this resistance. This activity also reveals others in the family’s world who may be available to support change. 

The Practitioner’s Stance 

The demeanour of the practitioner is crucial.  The position of neutrality or curiosity as defined by the Milan team, a nonjudgmental stance where each person’s view is accepted as equally valid while questioned at the same time, is the most helpful. It is not disengaged, cold or disinterested but rather curious. However, this does not apply to issues of violence or abuse where the practitioner always takes a clear and unequivocal stance which may result in statutory notification. Equally there is no acceptance of abuse towards adults by children or between children either in the session or outside. 

Advice 

Advice as an item on the agenda of Bower(note) is delivered near the end of the session and represents the amalgamation of each person’s request, the practitioners understanding of situations like the one they are addressing and the family’s unique story. In most parenting matters advice addresses a difficulty in relation to ownership, that is a mismatch between authority, the capacity to act or effect change and responsibility, the willingness to ensure it occurs. Parents often find themselves attempting to compel a child to act in ways they cannot enforce with the child resisting their efforts. For example, a child who lies cannot be made to tell the truth, yet parents may engage in increasingly desperate attempts to persuade them to become honest. These may range through threats, punishments and deprivation to increasingly elaborate reward systems. As each of these fail the parent may become more desperate with the risk of abusive or violent exchanges becoming part of the ‘solution’. Little wonder parents report that they have ‘tried everything and nothing has worked’. These solutions are termed 1st order change in that they attempt to alter problems without addressing the underlying relationship patterns which are maintaining the problem and a characteristic of most traditional parenting advice. Systemic advice attempts to address the recursive patterns between parent, child and others in the wider system, perhaps grandparents or teachers or other helpers that includes the problem. This is termed 2nd order change and is the goal. 

Advice may come in two forms. Parents are often asked to do more, to add something to an already overcrowded emotional and relational space. At Bower Place we conceptualize advice in terms of cessation, that is giving up something, a behaviour, a feeling, the meaning attached to an event or a belief. Cessation directly addresses the constraints that have prevented the system functioning in a more effective fashion. Removal of constraint may then allow more ordinary 1st order advice to become effective. Removal of the constraint means information will make a difference. The challenge is to identify that which must be ceased and it is not always the most obvious feature. Often that which must be ceased is in a parent rather than a child and may be hidden.  For example, a parent may need to give up excessive accommodation to a child, give up excessive sympathy for a child who has had major health problems or being disadvantaged in some other way or give up explaining the reasonableness of their position. Sometimes we discover that the problem with which the child presents is the mirror image of conduct demonstrated by the parent. This might be overt for example a parent who requests that their child does not swear, and scream may direct this behaviour to the child. In matters such as this the most helpful position is that we will never ask a child to do something a parent would not do and for us to support their request the parent will need to cease their behaviour first. It is only fair. Sometimes the issue is less obvious and only becomes apparent with inquiry. A parent my request that their child learn to tell the truth yet in exploring the family system we discover a fact that is central to the child’s world is kept secret from them. For example, the parents may have separated yet wish to keep this secret from the children, believing this is protective of them or have begun a new relationship and fear that this becoming known will distress the child or separated partner. Thorough exploration of the family system will with patience, reveal the constraint that must be removed for change to occur. 

In Conclusion 

Work with parents and children may seem deceptively simple and require only the following of a manual and the willingness of parents to take direction. However, those who work from a systemic perspective understand that parenting difficulties are no different from any other presentation and the task of the practitioner is the same. We need to understand the system in its entirety from the child to the parents, extended family and every other person with whom they engage. We then need to identify the questions of authority and responsibility that are central to the matter and the constraints that prevent the system operating in a way that does not include the problem. We then need to be clear about what must cease and find creative and supportive ways for this to happen.