Monthly Archives: June 2012

More About “Ben”

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In Sydney, my husband and I make our way to the International Transfer Terminal, not without a few mishaps and irritable moments. Jetlagged, with my ticket in hand, I board the plane to Melbourne. I am looking for row 15. I pass 10 in Business Class and suddenly find myself at 19, in Economy. Braving the oncoming flood of stressed fellow passengers, I turn around and try to find a flight attendant. “Row 15,” she says, “is upstairs.” I gasp. 

Upstairs in my mind is every bit as wonderful as Ben had pictured it in our play. And I didn’t even have to pay for this upgrade. Of course, the upgraded part of the flight lasted 1 hour and 11 minutes, 3 of which were used up by the safety film, but we enjoyed every bit of it. 

But getting back to Ben. It is not that Ben has no imagination. Actually, he is a visionary. The problem is that his imagination cannot bend and blur into something that isn’t quite real (Winnicott, Playing and Reality, London:Tavistock Publications Ltd., 1971), that can give him pleasure in that dreamy kind of way that enhances you just by picturing it. For Ben, as soon as he begins on that path of dreaming about what he desires, the intensity of his desire is not mitigated by fantasy. It short circuits into “needing” something real. In Fonagy et al’s term, he stops mentalizing (Fonagy P, Gyorgy G, Jurist EL, & Target M, Affect Regulation,Mentalization, and the Development of the Self. New York:Other Press, 2002). 

Imagine the plight of his parents. When Ben gets a bee in his bonnet, he wants the real thing, the biggest boom box, the most powerful electric fan, anything. The internet is an opium den for kids like Ben, where they can identify and locate the biggest, the best thing that they desire. When his parents tell him that he cannot have it, he becomes disconsolate, he cannot stop asking, demanding, pleading. He promises that this is the last time he will ever ask for something like this. If they set a limit, he is miserable and makes their lives miserable. If they give in and get it for him, his excitement is unbounded, and he cannot talk about anything else, making their lives miserable in a different way.

How do I help his parents make decisions about what to do in this kind of situation? It is not easy. In our therapy, I try to engage Ben in building new capacities. “Ben,” I tell him, “You have a remarkable brain.” He looks content. “You are one of the smartest people I know.” He still looks happy. But there are parts of your brain that need work.”  He looks mad and exclaims vehemently, “Not true.” “Well,” I say, “It is hard for you to stay in your imagination long enough for you to build your dreams bigger and better. Suddenly, something cracks and you fall down into reality again and want the real thing right now. That is a problem because life doesn’t work that way.” He gets belligerent for a while, but he sees that I am unflustered. He restates his position that when he desires something, he has to have it, and that is that. I call up in my mind another boy years ago who struggled with similar issues and decide to use his solution. “You can have your opinion, and I can have mine.” Ben cannot argue with that logic.

But I have gotten distracted from my message to his parents. I am on the right track now, though, because I am fully in empathic contact with them. As I leave the plane, I think, “Shall I tell Ben that I went upstairs?” But even more pressing is my concern that if I did tell him, he would ask me if there were a private pool, and somehow I feel a huge resistance to taking that fantasy away from him. That must be how his parents feel, too.

 

Read this blog in Spanish.

“Ben” and the Magic 747

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An Exploration of the Mind of a Gifted ASD Boy and Implications for the Life of His Parents

I am on my way to Australia to give a paper and to explore a little. I brought with me a pile of articles I had been collecting to read or to re-read. Not surprisingly, most are about autism. It is a chance for me to put together various perspectives on this fascinating subject.

But before I give you some impressions of my readings, I want to tell you a set of thoughts and images that occurred to me. I am sitting in a big plane, you see, and I don’t know exactly what kind – to me it is just a “big plane”. But as I sit here, an image of a 9-year old boy with brown hair and freckles and laser sharp eyes comes into my mind. “What kind of plane is it?!” I hastily dig into the seat pocket in front of me to find the safety card. “B747”. “Whew.” “B747,” I will say. But then I sigh because I know I will be unprepared prepared for the onslaught of technical questions that will follow. I will save my ticket, of course. “Ben” and I have a stash of airline tickets that we use when we play our airplane game. In this game, Ben sits imperiously on my couch with the toy cash register in front of him and a pile of airline tickets at his side. I play the prospective passenger. 

“Hello, Sir,” Ben greets me. “Where would you like to go today?” “Where would I like to go?” I whisper. Ben frowns. “You decide.” “Well, maybe to California?” I venture. “How about Australia?” he asks. “Great,” I say. I know Ben has a thing about Qantas Airlines. I should have thought of that. “That will be 5 million dollars,” Ben declares. Now here I am stumped. Am I supposed to be the ordinary unenviable would-be passenger who gasps and mumbles that he couldn’t possibly pay such a fare, or am I instead supposed to be a zillionaire for whom 5 mill is a drop in the bucket? I whisper, “Am I rich or poor?” He frowns. “You decide.” I groan. “OK.” I start to exclaim, “5 million dollars!”, but he cuts me off. “That’s nothing to you,” he pronounces. “Oh,” I correct myself. “Sure, only 5 million. What about an upgrade?” Ben warms to this developing representation of a Fortune 500 businessman. “That’s a good idea,” he says. “You could ride on the top. I hear there’s a whole suite up there with your own private pool.” 

His facial expression grows increasingly animated. Suddenly he stops, abruptly. “Let’s make the tickets for the upgrade and the private pool!” I say OK, but inside I am wary. I anticipate that the bigger than life gold embossed tickets with accurate replicas of 747’s that I imagine is in Ben’s mind will be completely out of our reach in terms of execution. In fact, Ben’s fine motor coordination is considerably behind his chronological age.

It is an exhausting business – my mind is about to explode as it tries to hold the image of the grand and glorious tickets next to the sloppy, ragged, red watercolor soaked strips of paper that I remember having made with him. And what is more, Ben will see those red messy strips as just that – red messy strips – because he lacks the capacity to imaginatively elaborate a fantasy beyond a certain point. Soon he begins to feel the need for the real thing. 

In the next posting I will continue the saga.

 

 

Read this blog in Spanish.

 

Comments on Last Blog Posting – A Cast of Thousands

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New Comments from my Infant Parent Mental Health colleagues:

Hi Alex,

I appreciate and agree with your blog post.  I work with many families who face this dilemma and many who experience reduced quality of life as they attempt to schedule a huge cast of helpers, many of whom will present conflicting advice in imperative terms, adding to the caregiver’s sense of being overwhelmed and frustrated.

I wanted to share this link, showing information collected by the Interactive Autism Network out of Kennedy Krieger, which shows results of data collected online from families across the US about the number of treatments modalities families are using.

The greatest number of respondents reported using 4 treatment modalities, but many families are using 5 and 6, with the highest number of treatments going up to 56(!).  

I was curious about your view of treatment modalities that place the caregivers in the role of interventionist.   What kinds of roles do parents in your practice take in the therapeutic process?  

Tamara, 6/17/2012

Another Comment: 

Hi Alex and all,

If I might add a third point to the two you listed concerning multiple individual specialists treating a child for a disorder in this case ASD or PDD (and for this point it doesnt matter if it is developmental or physicial) — they dont communicate with each other and/or with the primary care physician and so in the process care can be compromised with the left arm not knowing what the right arm is doing no less the medical home where all the reports are suppossed to go.

Richard

 

 

A Cast of Thousands

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A Case of Thousands

I recently received a neuropsychological testing report on a little patient of mine who has developmental problems in the general category of autistic spectrum disorder. The report was exceptional in its careful attention to detail – in the description of the tests, in the account of the child’s performance on the tests, and in the way it set out the implications that these subtest results had on the child’s learning and more general development. I was very pleased. Then I looked at the recommendation section, and I was disappointed. That is not to say that the recommendations were incorrect. They were detailed and comprehensive. However, they included recommendations for multiple specialists. 

Some of these specialists could provide services at school through the school system; the family is fortunate in that the city where they live makes many special needs services available to children in the school system. However, too many of the recommendations for specialists – such as a CBT therapist and an autism specialist in addition to my psychotherapy with the child – will not be provided by the school. This presents a dilemma for the family. Either the family finds the time and money to pay for these specialists and to take the child to these additional appointments, or the family lives with the worry that they are not giving the child all of what he needs – with long-term negative consequences.

I believe strongly in the team approach to the treatment of children with autistic spectrum disorders (ASD) or pervasive developmental disorders (PDD). However, I also believe in paying attention to the “family economy”, meaning the resources in time, money, and emotional reserve that the family has at its disposal. I have led a number of parent groups for parents of “quirky” children, and I have witnessed the anguish of parents who were trying to make decisions about allocating limited resources to the care of their ASD or PDD child. 

Also, perhaps because my husband is an economist, I am sensitive to the pull of the marketplace and the influence that has on recommendations for treatment. I am not suggesting that all these specialists do not believe that what they are offering is the very best and in fact necessary for the health of the children they treat. I am suggesting, though, that each specialty has a financial incentive to compete for patients. In addition, it is sometimes true that the more defined and therefore narrower perspective of a specialist may have a negative effect for two reasons. The first is that they may be less well prepared to integrate the various aspects of the child’s treatment than a therapist with a more general approach, and the second and related reason is that they may duplicate various aspects of the treatment, sometimes causing confusion and certainly costing more.

I do not hide my bias for a psychodynamic therapist to be at the center of the treatment of these children. That is my training and my conceptual model. However, I have other reasons for suggesting this plan. The first is that children with ASD and PDD essentially have problems with development, and developmental science now teaches that development occurs in the context of a relationship. Of all the therapeutic disciplines, psychodynamic therapy is the one that primarily emphasizes the therapeutic relationship. The second reason is that psychodynamic therapists aim to make meaning of the particular child’s experience, and to do that they must search for the unique personhood of that child and try to join it. This begins, as it does in normal development, with a shared focus of attention and proceeds to the sharing of complex experiences of affectively charged symbols. It is only through the energetic building of  a position of mutual understanding and collaboration that the therapist can help the child build new developmental capacities. 

The dynamic therapist, though, must not limit herself to the verbal narrative and symbolic play of these children. Instead, she must learn – especially from her O.T. colleagues, but also from child trauma researchers – how to help the child regulate himself, and then work with the parents to help them continue the work at home. She must focus relentlessly on the child’s agenda and support it by recognizing and joining it, then nudging it slightly forward by making contributions of her own, in a repetitive but flexible manner. This approach shares a lot with the DIR floor time method; I have learned a great deal from floor time practitioners. 

The therapist must also comment on the relationship between herself and her patient, and acknowledge patterns that may repeat themselves with parents, teachers, and peers. She must network with the parents and other caregivers and clinicians as frequently and consistently as possible. Through these therapeutic interventions, the therapist and child make links between the child’s inner world – emotions and fantasies – and his body (physiological arousal state and experience of body in action), and between his inner world and the outside world of objects and other people.  In essence, the psychodynamic therapist can fulfill many of the roles of other specialists, while keeping the meanings of the child’s inner world always in mind.  This is what I hope to do in the Cornerstone project beginning in September and what I also try to do in my own clinical practice. While I am learning more and more about ASD and PDD from current research in these fields, I don’t call myself an autism specialist, because what I am learning about these children applies and enriches my work with all my patients.

 

Read this blog in Spanish.

 

Cambridge Cornerstone

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 On Saturday and Sunday, June 2 and 3, The Cambridge Ellis School hosted a training on treating autistic spectrum and other children with serious dysregulation syndromes in the preschool classrooms. The training was led by Dr. Gil Kliman, the recipient of many awards, including an International Prize for “World’s best book concerning the well-being and nurture of children”. Dr. Kliman has worked intensively with preschool children for over forty years and has developed a method for treating seriously troubled children in their own world – their preschool classroom. It is called, “The Cornerstone Method”, or “Reflective Network Therapy”.  I was honored to assist him in this important training. 

Those attending the conference included the Director of the preschool, Jenifer Dempko, many teachers from the school, several fellows from the U Mass Boston Parent-Infant Mental Health Certificate Program, a psychoanalyst and a preschool teacher from New Jersey, a psychoanalyst from Michigan, and a group of day care providers and some supervisors from Catholic Charities from the Boston area.

Reflective Network Therapy (RNT), carried out in the classroom by a collaboration of individual therapist, preschool teacher, peers, and parents, is I think the treatment of choice for psychologically troubled preschoolers. The therapy occurs in multiple short (15-20 minute) sessions, four or five times a week, and these sessions are optimally designed to help the children make sense of their otherwise chaotic and frightening worlds “on the spot”, making it an essentially practical therapeutic modality. 

In addition, Kliman has done something very unusual in the field of child mental health: he has conducted scientific studies to test the efficacy of the method. In addition to the anecdotal evidence that child mental health practitioners usually put forth to support their methodologies, Kliman has data to demonstrate its effectiveness, including improvement in IQ scores, an unintended but very welcome result of the study. The method is shown to be a remarkable “cost-effective” treatment for young children with severe mental conditions – autistic spectrum disorders, pervasive developmental disorders, trauma, behavior disorder, and other serious emotional disorders. I would add disorganized attachment to the list, in keeping with Kliman’s in-classman work with a series of thirty foster children and his studies of guided activity workbooks for children in disaster areas. 

In the RNT work that I have done, I have aimed to help the child understand his world through a particular use of play and language. The play is based on psychoanalytic play therapy and attempts to improve both the developmental competency of pretend play, and also the capacity to make meaning through elaborating potential symbolic themes (such as “good guys” and “bad guys” representing what the child perceives as the “good” and the “bad” parts of himself and of his parents). The language makes links between the child’s inner world of intentions, thoughts, and feelings and his own behavior, plus the outside world of other people. The RNT method uses repetition to keep the elements of meaning in awareness long enough to allow the child to attend to them and to begin to reflect on them. For this aspect of the method, the presence of others in the child’s environment is crucial. The collaboration of peers, teachers, and parents, is a critical piece of the work. 

In my work with children in the classroom, I as the therapist make use of the group of peers and the teachers to elaborate a simple narrative linking behaviors to inner affective experience. This vital communication begins with the “briefing” of the parents to the teacher at the beginning of the school day to fill her in on what has happened to the child since she last saw him. Then there is the briefing of the therapist by the teacher when the therapist comes for her session with the child. Finally, there is the de-briefing of the teacher by the therapist at the end of the therapy session and a de-briefing of the parent by the teacher at the end of the day. This chance for multiple iterations of the communication, displaced slightly to other listeners away from the target child, allows the child to consider the message (multiple times) while minimizing the stress of social engagement and without having to shut down his emerging reflective capacity. Often the peers contribute variations of meaning in their own words as part of a growing meaning about something that happened.

One time a little girl on the autistic spectrum I was treating took a bucket that a group of boys were playing with on the playground, seemingly oblivious to anything but her own compelling desire for the bucket. When the boys loudly objected, she was stunned. I had begun to tell the story to the teacher, when one little boy said, “Maybe she didn’t know it had a treasure in it.” A second boy said, “Yeah, maybe she thought it was just a bucket.” A third boy chimed in, “Maybe she didn’t know we were using it.” As I watched the little girl take in these various communications from her classmates – simple, short verbalizations from her peers – I began to see in her face a dawning of awareness about what she had done and what had been going on. In the acceptance and tolerance generated by the children and scaffolded by the adult caregivers, the little girl found the safety to consider what she had done, and why she had done it, and even what she might have done towards a better result, all without fear and shame.

In the first day of the training, Dr. Kliman showed us many videos. In one of them a little boy, Lonny, had withdrawn in anger after another boy had “wrecked” his tea party. After the essential briefing by the teacher, Dr. Kliman approached the boy. Getting down to his level where was hiding under the table, Dr. Kliman began to sing a song about a ruined tea party, with many verses about what had happened and how the party had been spoiled by the uninvited intrusion of the other boy. Lonny, an autistic spectrum disorder (ASD) child who was prone to aggressive outbursts, began to calm. By the end of the play, the offending child was welcomed into the tea party.

The day was filled with fascinating videos of children in treatment in the classroom. Another child was very agitated because of having witnessed domestic violence at home, including having seen his father throw a cup of scalding coffee in his mother’s face that morning. Despite his dysreguation, he was engaged by the therapist, with his teacher’s help, and finally began to build towers that seemed to represent houses that were “unsafe”, kept falling down. After a while of continuing to build structures with the therapist and a peer, the structures became increasingly solid, representing the safety the child could experience when he felt acknowledged and understood. 

The training was designed as the first step in creating a school within a school at Cambridge Ellis (CES), a therapeutic learning experience for children who need special help, within the already enriched preschool environment. Next year we will begin a pilot program in which I will treat several children who have been identified as needing special help, using the Cornerstone Method. I am excited to be able to treat children who are struggling in what I consider the optimal setting – their own natural world, in the company of their wonderful peers and their talented teachers, with many chances to bring their parents into the process.

I would like to emphasize as well that a program such as this benefits the entire school. All the children will learn more about emotions and how they influence behavior. They will all refine their capacity for reciprocity, for compassion, and for self-reflection. These critical developmental competencies will be practiced more often in a RNT classroom. 

In addition, I am counting on the fact that the contributions of a child psychoanalyst who has spent her career learning about the inner life of children and helping them make sense of themselves and their worlds using that knowledge, can be supportive and vitalizing to teachers who have learned so much about children from another perspective and who are so good at communication with them.  It seems to me to be a natural match. And if we bring parents more closely and respectfully into the mix and provide for them ways of better understanding their own children, we will be providing the best possible environment for young learning.

 

Gilbert Kliman, Contributing Editor Elissa Burian, Reflective Network Therapy int he Preschool Classroom, University Lanham, MD, Press of America, 2011.

 

Read this blog in Spanish.

 

 

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