ACQ_Vol_11_no_3_2009

Mental health

My journey into relationship-based practice Kristy Collins

S andra 1 and her son, Jonah (2), arrive late to their first speech pathology appointment at the Child and Adolescent Mental Health Service (CAMHS). Jonah is unsettled and Sandra looks exhausted and somewhat agitated. I usher them into a clinic room, where a range of toys are laid out on the floor. Sandra launches into a vivid description of her son’s explosive tantrums, her concerns that he only says a couple of words and her fears that he will turn out like his abusive father. As she speaks, Jonah moves aimlessly around the room. I ask Sandra what she is hoping to gain from attending CAMHS. She says she wants Jonah to say more words and that she would like the psychologist, who is also seeing the family, to address his anger management problems. Where should I begin with this family? As a young graduate, I felt compelled to rush into gathering data about a child’s developmental milestones, risk factors for communication difficulties and current functioning. I found this information useful but soon realised that I was asking about areas that trigger strong emotions. A child with difficulties tugs at the very core of parents and many of the families I was seeing were experiencing grief, loss, anger, frustration, and even gut-wrenching guilt. This was scary stuff! Clearly, I needed to acknowledge and validate these emotions but I felt totally out of my depth in providing what I then viewed to be counselling. Too often, I found myself trying to put a “bandaid” on a parent’s negative affect by being the “bright and bubbly” clinician and by prematurely offering problem-solving strategies. Now, after a decade of experience and reflection, I understand that all clinical encounters occur in the context of relationships. This means that when a parent presents as overwhelmed or anxious my first goal should be to create a safe environment in which their feelings can be acknowledged and supported (Geller & Foley, 2009; Weatherston, 2000). Information gathering is complemented with the building of therapeutic relationships, which constitutes a shift from simply establishing rapport for the sake of encouraging participation in therapy. The time it takes to establish a therapeutic relationship can be lengthy with some families, particularly when the barriers parents face in forming relationships with their children also act as barriers to forming therapeutic relationships with the clinician (Geller & Foley, 2009). With this in mind, I spend the first part of the session with Sandra and Jonah sitting with the strong emotions

in the room. I empathise with Sandra’s difficulties, explore the history of her relationship with Jonah and highlight her good intentions for his development. At the same time, I watch how Jonah interacts with his mother, his environment and with me. I am interested in where he positions himself in the room, his use of other people, verbalisations, eye contact and emotional regulation. Observing the relationship between a child and caregiver is crucial because the quality of the infant–caregiver relationship may impact on emotional and developmental difficulties in children (Mares, Newman, Warren, & Cornish, 2005). I notice that Jonah moves quickly from one toy to the next, with only the occasional glance at his mother. Although I am concerned about this behaviour, I resist the temptation to initiate interactions with him or to scaffold his play. While I have always invested much energy into building connections with children, I have learnt that it is critical to first attune to the emotional needs of the parent, particularly when there are difficulties in the parent–child relationship. Fully concentrating on connecting with Jonah at this stage may only result in Sandra feeling inadequate, undermined and unheard (Chambers Amos, Allison, & Roeger, 2006). When Sandra has expressed her feelings and concerns fully, I encourage her to engage with Jonah in play. This allows me to observe Jonah’s communication and play skills as well as providing insight into how well Sandra can follow his lead and read his emotional cues. This is important as it reflects how sensitive and attuned she is to him, both of which are pivotal in the formation of a secure attachment relationship (Cohen et al., 1999; Mares et al., 2005). I move away from traditional ideas of (1) assessment, (2) recommendations, and (3) therapy and instead use a more dynamic therapeutic approach where all three may be occurring simultaneously. At this moment, Jonah is pulling pieces out of a puzzle. Sandra sits down next to him on the floor and asks him to name the animals in the puzzle. Jonah responds by looking at her, offering her the piece he was holding and making the noise of a dog. Sandra does not take the piece or extend on his utterance. Instead, she tells him to put the piece in the puzzle. Jonah tries but quickly gives up without asking for help. He throws the pieces across the room. Sandra flinches. I wonder aloud about what might have triggered the outburst. She tells me that Jonah is “feeling naughty” and if they were at home, he would “trash the whole house”. I work to contain the situation by speaking on behalf of Jonah, and by mirroring the emotional tone and internal states of both mother and

Kristy Collins

1. Names and details have been changed.

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ACQ Volume 11, Number 3 2009

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