I began my work as a child psychotherapist in a different era. I was trained, circa 1980, in a supportive-expressive psychodynamic approach to child therapy. Our goal was to create a therapeutic relationship, through play and talk, that encouraged children to express feelings that were a source of conflict and distress, to provide understanding and insight, and to facilitate a child's ego development, with the therapist serving as an auxiliary ego and an object of healthy identification. At the time, this basic model of child psychotherapy was largely unchallenged, and I was able to help most of the children and families who consulted me. To a great extent, this is still how I work.
But there were limitations and unanswered questions. In the course of therapy with most children, parents would ask for help with daily problems: What do I do when my child refuses to do his homework, or go to sleep on time, or stop playing video games; when he teases his sister or has a tantrum whenever I say no; when he eats very few foods, or cries when I leave the house, or is late for school every morning?
Often, I was able to provide helpful advice. I offered parents ways of thinking about their children's behaviors that focused on the child's frustrations and disappointments, anxieties and hurt feelings, and feelings of unfairness. With this new perspective, parents were able to listen more openly and communicate more constructively with their children, with less criticism and anger, and with more emotional support. This, too, remains the foundation of how I work.
To help many parents and children, however, I needed to do more. Parents needed more practical advice about how to solve the problems they faced on a daily basis. And, in the background, there was the question of “therapeutic action”: What is essentially therapeutic about the work we do? This question, asked and answered in different ways by different schools of thought (and by many skeptical parents), is especially nagging and uncertain in play therapy with children.
In looking for answers to these problems, I found important insights in diverse sources—in Stanley Greenspan and Serena Wieder's therapeutic program for children with autism spectrum disorders (The Child With Special Needs, 1998); in the evaluation of children with learning disabilities and their emotional sequelae; in the emerging “functionalist” theory of human emotions; in Jaak Panksepp's description of basic emotion systems, especially SEEKING, PLAY, and PANIC/GRIEF (Affective Neuroscience, 1998); in John Gottman's research on family meta-emotion structure and the importance of repair in successful marriages (What Predicts Divorce?, 1994; Gottman, et al., Meta-emotion: How Families Communicate, 1997); in Ross W. Greene and J. Stuart Ablon's program of Collaborative Problem Solving (Treating Explosive Kids, 2006); and in Carol Dweck's research on children's motivation and the importance of a “growth mindset” (Mindset, 2006). Among the behavioral methods, Alan Kazdin's focus on incremental positive reinforcement (finding a “positive opposite”) was both more effective and more theoretically compatible than earlier behavioral techniques (Parent Management Training, 2005). And from psychoanalysis, Heinz Kohut's profound understanding of children's needs for mirroring and idealization offered guiding principles (“Forms and Transformation of Narcissism,” JAPA, 1966). In raising my own children, I found daily evidence of Kohut's developmental theory.
This theory and research offered help with many common clinical problems—how we can engage more children in treatment, support improved emotion regulation, combat a child's discouragement, and arrest vicious cycles of pathogenic family interactions.
In several publications, drawing from these and other sources, I have presented an integrative theory of healthy and pathological development in childhood and a corresponding model of therapeutic change in child and adolescent psychotherapy (“What is Therapeutic in Child Therapy?,” Psychoanalytic Psychology, 2004; Emotions in Child Psychotherapy, 2009; How to Be a Better Child Therapist, 2018). I tried to show how we can retain the essential contributions of humanistic and psychoanalytic theory—enduring ideas that are helpful to all children and families—and also use active strategies for solving children's emotional and behavioral problems.
The central focus of this developmental model is children's emotions and the vicissitudes of these emotions in both health and pathology. To psychoanalysts, of course, the importance of emotions in psychopathology and psychotherapy is not a new idea. Emotions have held a central place in psychoanalytic theory from (literally) the beginning, in Breuer and Freud's “Preliminary Communication” and the theory of “strangulated affect.” In child therapy, helping children express painful emotions—feelings they may consciously hold back or unconsciously disguise or disavow—has always been the “therapeutic core purpose” of our work (Theodore Shapiro and Aaron H. Esman, “Psychotherapy with Children and Adolescents: Still Relevant in the 1980s?“ Psychiatric Clinics of North America, 1985).
In health, children learn that bad feelings are part of life, temporary and therefore bearable, and through their own efforts or with the help of supportive adults, they can make things better—that this bad feeling, however painful, will not always be there, at least not in the same way it is now.
At times, however, in subtle ways, both in theory and perhaps in practice, we move away from children's emotions toward more abstract concepts and clinical formulations, which, although perhaps true, may miss the essence of children's experience. Especially, as Robert Emde noted 30 years ago, we neglect children's positive emotions. Emde reminded us that there is very little freude—the German word for “joy”—in Freud's metapsychology (“Positive Emotions for Psychoanalytic Theory: Surprises from Infancy Research and New Directions,” JAPA, 1991). For successful child and adolescent therapy, this is an unfortunate omission.
Perhaps even more than adults, whose time and energy are often taken up with more purely economic concerns and practical tasks of survival, children are always in search of good feelings. Motivated by curiosity and the drive to show others what they can do, they are continually “SEEKING”—exploring their world for the possibility of good feelings and the opportunity to share these feelings with others.
Several years ago, I was talking with Paul, a bright but mischievous and impulsive 10-year-old boy, about his frequent conflicts with his mother. Paul told me, “I don't like the rules … so I'll say something … and she thinks I'm being fresh … and she'll punish me … and it makes me angry … and it stays with me … and she thinks I'm always angry … it's a big cycle.” With this statement, Paul succinctly explained the theory of pathological development I will describe below.
A few weeks later, I was again talking with Paul about his conflicts with his mother. I reminded him of our previous discussion. This time, Paul said, “You forgot the part when the kid apologizes and the mom is still angry.” With this statement, Paul identified another core aspect of pathological development—a parent's failure to respond positively to a child's effort at repair.
With this brief anecdote in mind, I offer a summary statement about pathological development in childhood: Persistent emotional and behavioral problems in childhood and adolescence are caused by painful emotions that remain active in the mind of the child. Or, stated more simply, by a bad feeling that does not go away. As Paul said, “It stays with me.”
Over time, painful feelings that remain active become “absorbing states” (Gottman, 1994) or “deep attractors” (Mark D. Lewis and Lori Douglas, “A Dynamic Systems Approach to Cognition—Emotion Interactions in Development,” 1998) in a child or adolescent's emotional life—states of mind that are easy to get into but difficult to get out of, often experienced in adolescence as an underlying, more-or-less conscious feeling of loneliness or failure.
The symptoms of child psychopathology typically develop in the context of ongoing pathogenic family relationships—vicious cycles of frequent criticism, punishment, or lack of understanding on the part of parents and increasing defiance, resentment, and withdrawal on the part of children. Especially in family relationships, bad feelings lead to bad attitudes and bad behavior, and then more bad feelings. Causation is cyclical.
Troubled children have become discouraged. In the present moment, they do not expect to be heard or understood; often, as they imagine their futures, they do not expect to succeed in important areas of their lives. The more deeply they feel this way, the more extensive their pathological development has become and the more difficult our therapeutic work will be.
Of course, children and adolescents may not always tell us they feel discouraged. Their discouragement may be disguised or denied, and children may not be aware of the extent to which demoralization has taken hold of their lives, limiting their interests, motivation, and effort. If they become rebellious, underneath—or along-side—their rebellion, their discouragement remains, now more deeply hidden. Often, they look urgently for a way to feel better, and they are therefore at high risk for dangerous and self-destructive behaviors.
This psychological process can be compared to an infection or a malignancy. Like biological malignancies, we may sometimes see the pathology in its early stages, and in these instances children and adolescents are likely to respond positively to most forms of psychotherapy. More often, however, parents consult clinicians at advanced stages—when sadness, resentment, or anger has become a child's dominant mood; when she has lost initiative; when oppositional attitudes and retaliatory feelings are deeply ingrained; and when vicious cycles of criticism and defiance have led to stubborn attitudes and states of mind. Cynical and mistrustful attitudes may seep in, making our work especially difficult.
Healthy emotional development has a different trajectory. In health, children learn that bad feelings are part of life, temporary, and therefore bearable, and through their own efforts or with the help of supportive adults, they can make things better—that this bad feeling, however painful, will not always be there, at least not in the same way it is now. Disappointments are disappointments. Problems can be solved. Bad feelings are not forever. In this way, a child's capacity for emotion regulation is strengthened from the bottom up, not as the result of conscious emotion-regulation “strategies” but as a memory and an expectation of emotional support.
In this context, important maturing processes take place. Children will be stuck less often in angry, defiant attitudes, less avoidant of challenges, more attentive in school, better able to resolve conflicts with their peers, and less reliant on self-protective mechanisms that limit their initiative, effort, and concern for others.
From the Child & Adolescent Psychoanalysis Editor
Kenneth Barish gives us a real treat in his “Reflections on Child Development and Child Therapy: A Personal Journey Toward an Integrative Model of Therapeutic Change.” In this contribution, Barish describes the evolution of his approach to children and their families over the span of several decades. He highlights some of the sources who have influenced his work: Stanley Greenspan, Jaak Panksepp, and Heinz Kohut, among many others.
With his integrative approach, Barish identifies ten principles for therapeutic change: (1) Interest (2) Empathy (3) Repair (4) Problem Solving (5) Emotion Regulation (6) Encouragement (7) Play (8) Sleep (9) Helping Others and (10) Limits and Discipline.
This contribution from a master clinician is a must read. Dr. Barish has permission to report on the case example in his contribution. He is the author of How to Be a Better Child Therapist: An Integrative Model for Therapeutic Change as well as a book for parents, Pride and Joy: A Guide to Understanding Your Child’s Emotions and Solving Family Problems.
Based on this understanding, I offer the hypothesis that all successful therapies for children and adolescents—whether through empathy and understanding or through active efforts to change patterns of thought and behavior—arrest malignant emotional processes, especially vicious cycles of painful emotions and negative family and peer interactions. Our most successful interventions then set in motion positive cycles of healthy emotional and interpersonal experiences—increased confidence and engagement
in life and more affirming interactions between parents and children. As therapists, our clinical choice with each new child and family that consults us, and at each moment in the course of therapy, is to determine at what point(s) in a complex cycle of biological vulnerability, ongoing pathogenic influences, and inner psychological processes we can most effectively intervene.
I believe this integrative perspective on therapeutic change has several advantages to alternative models, both practical and theoretical. The most important practical advantage is that an integrative approach offers therapists more ways to intervene to help troubled children and families, and these interventions often synergistically support each other. Especially, this perspective offers us more ways to help parents improve the quality of their relationships with their children, which, for many young people, may be the most lasting benefit of therapy.
In How to Be a Better Child Therapist, I discuss ten specific principles of therapeutic change that organize our efforts to arrest vicious cycles of pathogenic emotional development and set in motion positive cycles of increasing self-confidence and supportive family relationships. These principles are (1) Interest (2) Empathy (3) Repair (4) Problem Solving (5) Emotion Regulation (6) Encouragement (7) Play (8) Sleep (9) Helping Others and (10) Limits and Discipline.
With regard to theory, this model offers a unifying account of how cognitive, behavioral, and psychodynamic therapies work. My proposal is that the essential mechanism of therapeutic change in child and adolescent therapy is not increased acceptance and expression of feelings, as in psychodynamic theory, and it is not changing interpersonal relationship patterns, as in relational child therapy. It is also not the development of new cognitive skills or the reinforcement of positive behaviors, as in cognitive and behavioral models.
All of these therapeutic processes may be helpful and important, but they are means to an end. Over time, successful therapy fosters in children and adolescents a more encouraging, less critical inner dialogue and, perhaps most profoundly, more positive expectations for their futures—a new sense of what is possible in their lives.
Kenneth Barish, Ph.D., is Clinical Professor of Psychology at Weill Cornell Medical College and Faculty, Westchester Center for the Study of Psychoanalysis and Psychotherapy, and the William Alanson White Institute Child and Adolescent Psychotherapy Training Program.