Tag Archives: China

Using the Parent Consultation Model in Shanghai

 

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We used the parent consultation model in videotaped cases and with two real families from Shanghai. 

Josh and I adapted the PCM in a new way to explore more carefully the cultural factors involved in caregivers’ concerns – what matters to them – about their children’s problems.  Josh had suggested that we consider including questions designed to bring forth the particular and sometimes hidden meanings that parents give to their child’s troubles. These questions, drawn from the work of the Harvard Medical Anthropologist, Arthur Kleinman, were:

What do you call the problem?

What do you think has caused the problem?

Why do you think the sickness started when it did?

What do you think the sickness does and how does it work?

How severe is the sickness?  Will it have a short or long course?

What kind of treatment do you think the patient should receive? 

What are the most important results you hope she receives from the treatment?

What are the chief problems the illness has caused?

What do you fear most of the illness?

We did not ask the parents all these questions, but we asked them questions during the course of the interview that reflected the issues identified as important by Kleinman’s list. For example, in one moving case from the clinic, the mother revealed that her daughter’s diagnosis of autism meant to her that she should not have another child (because of her belief that autism was inherited), and that her daughter was destined to have a tragic future. Understanding the caregivers’ concerns at a deeper level reveals hidden fears and cultural differences that are important in planning the next step. In another case, the mother described telling morality tales to her son with a disruptive behavior problem so that he would grow up to be a decent and moral man. This was particularly important for us to take into consideration in our discussions with her, since we believed that the boy’s developmental disorder played a significant role in his behavior problems, and so helping his parents see him as a good boy who had trouble controlling himself, instead of a disobedient boy who chose to do other than he was told, was an important part of the intervention. 

In our teaching to the mental health professionals, we used a developmental framework to explain the psychological problems of children.  We had examples of children with autistic spectrum disorder, anxiety disorder, disruptive behavior, trauma and loss, and depression. In each case, we discussed some of the ways they had gotten knocked off course in their development to result in this problem.  Then we talked about how with the help of the caregivers – parents and therapist – they could be nudged back on track.

 

Developmental Framework

In our developmental framework, we listed the developmental competencies children of these ages typically possess – (1) self and mutual regulation (the capacity to calm yourself and to generate calm with another person), (2) shared subjectivity (the ability to imagine what is in another’s mind – their desires, intentions, beliefs – so that you can engage in collaborative activities with them, such as play or work, and (3) the capacity to use symbols in increasingly complex ways in thinking, language, and play. (4) Finally, we included self-regard, the capacity that is predicated on shared subjectivity and symbolic thinking because it includes being able to continually rediscover who you are as a unique human being, in the context of change, and to recover the positive in who you are after a disappointment or a loss. 

Using this didactic framework, we presented videotape material from child therapy sessions. Included in the clinical examples were children with autism spectrum disorder, disruptive behavioral disorder, anxiety disorder, trauma and loss, and depression. In each case we emphasized the parents’ concerns and questions as the focus of the consultation. Then, we illustrated the symptoms of the disorder by demonstrating the child’s difficulty accomplishing the developmental competencies appropriate to their age.  Finally, we showed how the child therapist worked to support the child’s attainment of these developmental achievements. 

For example, the child with autistic spectrum disorder (ASD) demonstrated the symptoms of gaze aversion, diminished range of affective expression, difficulty imagining what made the characters in her play do what they do (intentionality – shared subjectivity) and repetitive, stereotyped behavior (organizing the toys in colors in rows). He could engage in modest pretend play when I was actively scaffolding her, but he often retreated into a more impoverished story line of “two teams fighting each other”, without any elaboration about what they were fighting about and why. On my part, I would say,  “I am wondering – if they both, as you say, want to be rich, what makes the difference between the good guys and the bad guys?” Or, “I wonder why the bad guys would just steal the good guys’ gold instead of going to find it for themselves the way the good guys did.” In the course of the session, he and I were able to elaborate a more complex narrative that included a representation of intentionality, desire, and anger. Using the treatment in this way, and with the critically important support of his devoted parents, we expect he will be able to grow in his developmental competencies of shared subjectivity and symbolic thinking.  

In the case of the child with anxiety disorder who panicked when her mother left the waiting room to do an errand, we demonstrated how through active mutual regulation between us she became calm enough to tell a story in the play about a girl who tricked the kids by going away.  In this way, she was able to reclaim the most recently acquired developmental functions of symbolic thinking to put her fears into perspective, imagine where her mother had gone, and believe that she would come back. 

 

Shanghai Part II. Disruptive Behavior from a Cultural Point of View

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We used the parent consultation model in videotaped cases and with two real families from Shanghai. 

Josh and I adapted the PCM in a new way to explore more carefully the cultural factors involved in caregivers’ concerns – what matters to them – about their children’s problems.  Josh had suggested that we consider including questions designed to bring forth the particular and sometimes hidden meanings that parents give to their child’s troubles. These questions, drawn from the work of the Harvard Medical Anthropologist, Arthur Kleinman – http://www.fas.harvard.edu/~anthro/social_faculty_pages/social_pages_kleinman… – were:

What do you call the problem?

What do you think has caused the problem?

Why do you think the sickness started when it did?

What do you think the sickness does and how does it work?

How severe is the sickness?  Will it have a short or long course?

What kind of treatment do you think the patient should receive? 

What are the most important results you hope she receives from the treatment?

What are the chief problems the illness has caused?

What do you fear most of the illness?

We did not ask the parents all these questions, but we asked them questions during the course of the interview that reflected the issues identified as important by Kleinman’s list. For example, in one moving case from the clinic, the mother revealed that her daughter’s diagnosis of autism meant to her that she should not have another child (because of her belief that autism was inherited), and that her daughter was destined to have a tragic future. Understanding the caregivers’ concerns at a deeper level reveals hidden fears and cultural differences that are important in planning the next step.

In another case, the mother described telling morality tales to her son with a disruptive behavior problem so that he would grow up to be a decent and moral man. This was particularly important for us to take into consideration in our discussions with her, since we believed that the boy’s developmental disorder played a significant role in his behavior problems, and so helping his parents see him as a good boy who had trouble controlling himself, instead of a disobedient boy who chose to do other than he was told, was an important part of the intervention. 

 

 

Teaching Caregivers in Shanghai

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I have just returned from a trip to Shanghai, where I taught in a four-day training program for mental health professionals caring for children. I was invited to participate by Dr. Joshua Sparrow, a colleague from Children’s Hospital Medical Center in Boston, and Director of Strategy, Planning, and Program Development of the Brazelton Center. The program was held at the Shanghai Mental Health Center and was conceived and organized by Dr. Wenhong Chen. It was a powerful experience for many reasons. 

First of all, there was the excitement of being in Shanghai – a beautiful, vital, city of extreme contrasts. We walked through a warren of small wooden building where multigenerational families once lived in single rooms; now, the current residents live, side by side chic international shops. Over these old wooden communities, rise modern skyscrapers in glass and steel.

The lectures were fun to put together.   Josh and I developed a curriculum to teach common childhood psychological disorders in the age group of 6-12-years years old organized around a developmental framework and using the Parent Consultation Model  (PCM).  For an explanation of the PCM, see below.  

The Caregivers 

Second was the group of participants – psychiatrists, psychologists, guidance counselors, teachers, and others.  Their commitment to learning was demonstrated by their decision to attend the intensive course – about ten hours per day, by their almost universal attendance, and by their thoughtful and generous questions and feedback after the lecture.  After the training, one of the participants offered to begin the translation of this blog into Chinese, stating that Chinese caregivers could benefit from the information in the blog.  I will provide a link to this translation sometime in the future.  


 

The Parent Consultation Model (PCM)

Harrison AM., Herd the animals into the barn: a parent consultation model of child evaluation. The Psychoanalytic Study of Child, 2005; 60:128-157.

In our lectures we presented a number of cases of child psychotherapy.  Each case was introduced with a description of the evaluation of the child and family using the Parent Consultation Model. Included in the clinical examples were children with autism spectrum disorder, disruptive behavioral disorder, anxiety disorder, trauma and loss, and depression. In each case we emphasized the parents’ concerns and questions as the focus of the consultation. Then, we illustrated the symptoms of the disorder by demonstrating the child’s difficulty accomplishing the developmental competencies appropriate to their ages.  Finally, we showed how the child therapist worked with the parents, (caregivers) and the child ,to support the child’s attainment of these developmental achievements.

Brief Description of the Parent Consultation Model

The Parent Consultation Model emerged from my work in early development with infant research colleagues, as well as from my earlier work as a consultant to surgeons.  I offer parents what I call a “parent consultation” in three sessions.  The first session is with the parents alone to hear their concerns about their child and to get a history of the child and the family, but primarily to generate consultation questions for me as the parents’ consultant.  The second meeting is with the whole family for a play (or talk with older children) session, designed to gather data to answer the parents’ questions.  These are almost always pleasant meetings, which I direct and do not let anyone feel put on the spot.    I videotape these family sessions since my infant work has taught me to value observational data, especially with videotape.  The videotape is of course completely confidential.  In between this meeting and the final meeting, I analyze the tape and come up with impressions that address the parents’ questions.  Then in the final meeting, with the parents alone again, I get out the paper on which I have written their questions and address them one by one, giving them my impressions and illustrating what I think with short clips of videotape from the family meeting.  Finally, I help the parents brainstorm what they want to do. 

Adding Talk to the Family Session: 

In those cases involving older children or adolescents, it is more appropriate to talk instead of play with toys. (Sometimes playing with puppets can be acceptable to older children in a family setting and can be very productive.) IChildren who are still young enough to express themselves in play (early school years), yet also highly verbal and can participate in a family play session that includes some talking.

The talking section of a family play session resembles a semi-structured interview.  I ask each family member to tell me three things he or she likes about his or her family.  Then I ask every family member to tell e three things they do not like, their complaints. Then I ask each parent to tell me a story from their own lives when they were the ages of each child in the family. Finally, I ask if the family has a pet.  If the family does have a pet, I ask the story about the pet – how the family decided to bring a pet into the family, how the pet was chosen, and how the pet was named.  

Results:

I do many of these consultations, so that I have known parents to choose a variety of options.  One is to go home and try out some of the ideas we have come up with together.  Another is to request an extended parent consultation with more observation of the video and more brainstorming about how to change family patterns.  Another is to begin a psychotherapy with me or with someone else who takes their insurance or who lives closer to them, etc.  The method gives the parents a lot of freedom to make choices.  

What I have found over the many years I have been using this model is that it is rarely necessary to see the identified problem child alone in order to answer the parents’ questions, and in those cases in which it is important, that visit can follow naturally from new questions that arise in the third parent meeting.  One advantage of this approach is that I don’t immediately begin to make an individual connection with a child who may not become my patient.  Another is that I am free to make all sorts of important observations of the child in the context in which he or she lives – the way the child (and the family) express affect, communicate with language and in non-verbal ways, the way the family manages transitions and sets boundaries and maintains them, etc.  These observations are in addition to the usual ones a child therapist makes about the content of the child’s speech or symbolic play. 

In my teaching at a local hospital clinic in Cambridge, I have adapted the model to see a family in one morning. We do some of the important information gathering over the phone ahead of time – talking to the parents, pediatrician, and teacher, plus any other professionals involved with the family who have important information about the child. Then we see the family in a family play or talk session.  This is videotaped.  Finally, we speak to the parents alone to answer their questions and show them videotape illustrations of why we came to the conclusions we did in response to their questions.  Finally, we help them brainstorm what they want to do.  This tool has proven as effective in the clinic as in the private office.