Monthly Archives: December 2011

Chinese Culture and Caregiving Practices

Contribution from Kate Yan, Researcher and Participant in Shanghai Program

I feel very fortunate to be able to post these fascinating and thoughtful comments about the relevance of the Touchpoints approach for Chinese caregivers. Kate, a researcher and participant in the Shanghai lecture series, also the mother of a young daughter, sent them to us. Kate also alerted me to the first children’s hospice care organization in China,

Why Chinese Parents need Touchpoints

1. Most (if not all) of the books about infant and child that could be seen in Chinese bookstores are “nurture-related”, unlike in Touchpoints, which is “development-related”. Most of the books that Chinese parents may read about will emphasize on nurturing (ie, how to judge whether an infant feels cold/hot, how to take a bath for a newborn, when and how should solids be added, etc.). Culturally speaking, China has experienced significant changes in the past decades, while the living standard arises fast, people still subconsciously put a lot of attention on physical wellness over mental development. Most parents do not have the opportunity to understand their new child from the perspective of psychology. Touchpoints can open a new world for them to understand their baby.

2. As a new mom, when I read other books on market, I often think: “Oh, now I see this is how people do it, let me try and see if it woks…” Sometimes I would also feel a bit stressful and guilty while some of the authors seem to be such brilliant parents themselves. But when reading Touchpoints, I often feel: “Yes! This is exactly what I was thinking/experiencing. I feel much better to know that this is common situation, and my baby is really growing in her pace!” Most other books may be a perfect guidance in raising a baby, while Touchpoints is not only like that, it is also a perfect support for new parents.

Some special situation in China

3. Intergenerational issues: Given the culture of respecting Hierarchy, the biggest pressure that most new parents may face in China comes from their respective original families: grandparents is a big point that cannot be missed when talking about a newborn and his/her parents. There indeed are quite a few understanding and “liberal” grandparents, but in most cases, grandparents could place way too much control over new parents and their baby. This complicated family issue could create anxiety for babies and their parents in the days to come. On the other hand, the participation of grandparents can also bring benefits to a new family: it creates flexibility for new parents to continue their own workings and lives.

4. Misunderstanding of breastfeeding. In China, many pediatricians (60% at least) would recommend milk powder to a new family and urge mother to give up breastfeeding under many circumstances. One realistic reason is because milk powder manufacturers sponsor hospital programs, and in return some pediatricians will promote their products. Breastfeeding mothers in China face a lot of pressure from the moment the baby was born. The support a breastfeeding mother can get from family and community is quite limited. As a result, most mother wean within 6 months.

5. “The Calcium Fever”. Similar to “milk powder fever”, many Chinese parents are misled by pediatricians that their babies need to take in extra calcium pills to sustain growth. When Chinese parents have a baby who wakes up very often during the nights, they may come up with the first question of “does he/she lack calcium?”

6. Solids. While adding solids step by step is a general practice in United States, it is normal to see a 3-months-old baby being fed egg or orange juice in China. Besides limited knowledge on how to add solids, some caregivers (especially grandparents) would worry that the baby will be left behind others in physical growth if they don’t add sufficient nutrition besides breast milk. “The anxiety of being left behind” will be with caregivers throughout years, they compete with other kids in nutrition, in who starts to crawl first, in which kindergarten to go, in what supplementary early education classes to attend… Historically Chinese has been suffering from shortage of food and resources during 1950s to 1990s, so subconsciously many people would compete to win the “resource” for the child. This subconscious pass through generations.

7. Stranger anxiety and finger sucking. Most Chinese parents or caregivers see stranger anxiety and finger sucking as bad habits of baby and will do whatever they can to stop or change the situation. Pacifier is also deemed as something harmful to a baby’s teeth and mental development.

8. Nannies. In big cities as Shanghai, if both parents are working, the caregiver of a baby will either be grandparents or a Nanny. Nannies are mostly from rural areas of China to earn a living in big cities. The relationship between nanny, the parents and the baby could sometimes create tension. As nannies change frequently, some baby will also experience multiple separations during early childhood.

9. “Well behave=obedient”. In traditional Chinese culture, a good child=an obedient child=a quiet child. An energetic and exploring child may be seem as troublesome for some caregivers and will not receive encouragements for their active behaviors.

Supporting the Professional Caregivers

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In each case when we referred to the parent consultation model that initiated every case, we talked about restoring power and authority to the parents in a helpful way. Two of the biggest challenges of the training were: (1) understanding parents’ roles in the development of children’s psychological problems; and, similarly, (2) understanding parents’ roles in the repair of the problems.

Joshua and I talked from the beginning about our concern for the caregivers and our motivation to support them in their difficult work. I recalled the image of Leonardo da Vinci’s beautiful cartoon of the Virgin and Child with Saint Anne in which Mary is holding the baby Jesus while she is resting in the arms of her own mother, Saint Anne. I have long thought of that image as representing the natural intergenerational support of the caregiver in her caregiving function, whether the caregiver is the mother or another caregiving person, such as a helping professional.

Josh and I discussed the enormous pressures on a caregiver when the child has a problem, and when the child is suffering. When a child is suffering, it stirs in each of us the wish to rescue the child and there is always a temptation to hold someone responsible for the child’s suffering. This simple framework easily slips into a “good guy”, “bad guy” scenario in which the parents are the bad guys and the professional or another observer is the good guy. There is tendency to blame the parents, or the “first line” caregivers, in all professionals involved in the care of suffering children. Therefore, Josh and I were concerned to emphasize the complexity of these situations. We repeated in many different contexts the idea that here are many reasons for children to have psychological problems, and no one is to blame.

After the four days of lectures, we were eager – and a little anxious – to hear the feedback from the caregivers in the training.

Professional Caregivers’ Feedback after the Training:

1. I used to blame parents for the problems of the child, but now I understand that it isn’t the parents’ fault, that it more complicated. Now I can be more empathic to the parents.

2. I am going to use the PCM in my work with children and parents. I think it is a good tool, and it is empathic to the parents.

3. I liked it the way you treated the parent in the interview with the child. Even though she had angry feelings about him you were able to find something positive to say about the child and about the parents.

4. I liked the way you treated the parents in the interview. Even in the last case when the child’s problems were so serious, you were able to find some positive things to say to the mother; you were able to give her hope.

5. The Parent Consultation Model requires the consultant to listen more carefully to the parents and to be patient. The continuing personal growth of the therapist, consultant, or supervisor is necessary and beneficial to the professional role.

6. We do look at the strengths of the child and the parents as the basis of what we do.

7. We desire openness and acceptance of all observations and thoughts about the cases. Our work is not to pretend that negative thoughts and feelings are not there, for example, the rescue fantasies the therapist may have towards a child whose parent has died, or even a child whose parents are angry or critical towards him or her. We want to have a full discussion including our negative reactions so that we can come to a more complex sense of the family that moves beyond blame.

8. Problem of PCM in China and many other societies – parents avoid consultation because of their fear of the consequences of having big problems –the negative judgments about mental disorders.

9. They had discussion about the question re pet. It is not common for Chinese families to have a pet. If the purpose of the question about the pet was to get a sense of the family’s capacity to nurture and protect, what could we ask instead to discover something important about the role of the parent in this family? our Chinese students suggested an alternative: “What is your favorite fairy story or folk tale in the family?”

10. How we feed back our observations about the play sessions to the parents? It is important to strike a balance between protecting the confidentiality of the child against the need to help the parents grow in their empathy and their capacity to imagine the mind of their child.

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.

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?

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.