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.
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.