Listen to thisThe debate over what constitutes effective psychotherapy is at least as old as Freud, and while he is generally accepted as the first psychotherapist (Hubble, Duncan and Miller, 1999), it did not take Freud's disciples long to establish their own brands of Psychotherapies (Corey, 1996).
The debate heated up in the 1950’s over claims by those adhering to a behavioral perspective, that talk therapies were not effective, and that to achieve public credibility, the effectiveness of psychotherapy had to be empirically established (Bachelor and Horvath, 1999).
By the 1960's, when Child and Youth Care was gaining public credibility with the publication of Cottage Six (Polsky, 1962), and The Other 23 Hours (Trieschman, Whittaker and Brendtro, 1969), this debate, essentially was a fight between adherents to a psychoanalytic model and a learning theory model, had taken on the characteristics of a “holy war” (p.9). No small wonder then, when John Bowlby a psychiatrist himself, formulated attachment theory (Bowlby, 1969/1982) which he saw as an attempt to better understand human development and that recognized concepts from both models, that he was immediately ostracized by the psychoanalytic community.
Child and Youth Care then, as a profession, has emerged within the context of this historical conflict and has contributed the idea of the therapeutic milieu to the discussion over what constitutes therapy.
Recent trends in the field of psychotherapy towards a managed care model of service delivery which emphasizes empirically validated treatments, the use of therapy treatment manuals, and protocol-driven interventions (Ogles, Anderson and Lunnen, 1999) requires Child and Youth Care professionals to continue to speak eloquently to the therapeutic value of their work. While Child and Youth Care continues to be welcome in some fields of children's mental health, and new opportunities may arise within the youth justice system, other Child and Youth Care practitioners have been laid off within traditional areas of Child and Youth Care employment such as schools, and within the Ministry for Children and Family Development (MCFD). Recently on the Sunshine Coast, here in the province of British Columbia, child care programs funded by MCFD have been drastically cut. The reasons given were that best practices research had shown that child care workers were not effective, the programs were too expensive, that child care workers did not contribute to healthy attachments for children, and that child care workers offered “recreation only”.
While I am not suggesting that improvements cannot be made to such programs, or that child care staff, like other professionals, require supervision and support to increasingly develop a vision of their work that includes a therapeutic focus, I am suggesting that any notion that suggests that quality Child and Youth Practice is not therapeutic needs to be vigorously rejected, and is not in keeping with recent outcome research which suggests the reverse.
The rest of this article makes the case that quality Child and Youth Care practice constitutes the cornerstone of what may be considered an effective therapy.
Defining therapy
As previously noted, defining therapy has preoccupied therapists since
the days of Freud. Unfortunately, despite the best efforts of many
therapists to prove the validity of their specific theoretical
orientations, there remains no empirical evidence suggesting the
superiority of one approach over another, although there is empirical
evidence that psychotherapy works; that is to say treated patients fare
much better than untreated (Asay and Lambert, 1999). Today, more than
400 distinct brands of psychotherapy compete for clients (Mahoney,
1991), and each brand lays claim to being superior to the rest (Tallman
and Bohart, 1999).
However, the fact that it has been empirically established that psychotherapy works, despite the fact there appears to be no superiority of any particular perspective, has led recent research into investigations of what does work in psychotherapy. This empirical outcome research has focused on identifying factors common to all approaches, which appear to be responsible for the efficacy of psychotherapeutic healing (Hubble, Duncan and Miller, 1999). These findings have implications for Child and Youth Care interventions, and for how we understand therapy.
Common factors in relation to Child and
Youth Care therapeutic practice
Assay and Lambert (1999) in establishing the empirical case for common
factors in therapy, refer to meta-analytic outcome reviews. These
reviews document the empirical evidence supporting psychotherapeutic
outcomes across six decades, including: controlled studies, thousands of
clients, many presenting problems, and “highly diverse therapeutic
approaches” (p.23). The results are not encouraging for those therapists
attached to a specific theoretical orientation, for no extraordinary
therapeutic benefits accrue to any one theoretical perspective. Instead,
the most powerful factor associated with therapeutic change (accounting
for 40% of positive change) were events occurring in the lives of
clients outside of therapy. The quality of the therapeutic relationship
accounts for a further 30% of change, followed by placebo effects, and
perhaps surprisingly for some, therapeutic technique each at 15% (p.31).
Even here it is important to note that therapeutic technique is not
specific to any particular theoretical orientation, but includes diverse
techniques associated with a variety of orientations which were useful
for some clients. These common factor findings should be encouraging for
Child and Youth Care practitioners, especially given that the practice
of Child and Youth Care has always emphasized developing a rapport with
children and youth.
The Child and Youth Care context: personal
observations
It has been my experience in working with children and young people in a
number of treatment contexts, that most young persons are not prepared
to engage in formal “talk therapy” sessions. I have found that one
exception to this has been in addictions counselling, where extremely
negative impacts of drugs can sometimes cause young people to enter
counselling. However, most young people struggling with problems in
their lives, may be what Prochaska and DiClemente (1982) term as
pre-contemplative (not willing to consider that they may be experiencing
a problem), with a minority being in the contemplative (beginning to
think they may have a problem) stage of change. At this point in the
evolution of Child and Youth Care practice, a formal survey of this
situation with young people who are in treatment settings of one sort or
another would be a valuable research contribution, for Prochaska (1999)
claims that therapeutic interventions need to fit with the stage of
change of the client.
Defining therapy in a Child and Youth Care
context
It may be useful in developing a definition of therapy in a Child and
Youth Care context, to consider the origins of the word “therapy”. The
Greek word “therapeia” means: to carry; to support; to hold (Hillman, 1991). In this sense, the work of therapy is being done by the client,
who is being supported by the therapist while this work is being done.
The fact that many children and youth may not be ready for formal talk
therapy does not mean that therapeutic benefits do not take place, and
it certainly does not imply that the two most powerful common factors
associated with change (outside of talk therapy events in the lives of
clients, and relationship factors), also do not occur with
pre-contemplative children and young people. Taken together, these
factors account for 70% of positive change events in the lives of
clients. Child and Youth Care operates in the milieu of these two common
factors; that is to say Child and Youth Care is primarily concerned with
providing children and youth with rich, healthy life experiences within
the context of a therapeutic milieu promoting prosocial skills,
wellness, and safety. Child and Youth Care practitioners depend on
relationships they establish with young people for cooperation, and it
is these relationships which will support young people while they do
their own unique therapeutic work.
Therefore, current outcome research reconfirms the potential therapeutic benefit of quality Child and Youth Care practice. It also provides new challenges; what kinds of experiences are most likely to be therapeutic; how, or even should, new experiences be targeted for specific problems; what relationship factors are therapeutically beneficial; would different kinds of relationships be therapeutic under specific circumstances?
Experience as therapy
It may be useful for purposes of this discussion to distinguish between “therapy” and “talk therapy”. Tallman and Bohart (1999) in developing a
model of client generativity and self-healing, maintain that most
therapy happens as a result of life experiences, as people experience
problems, think about solutions, and try out different behaviors. Talk
therapy is simply a distillation of these processes. Tallman and Bohart
(1999) comment:
“The real therapy is living. What we call therapy is a special example of processes that occur outside of therapy. [Talk] therapy concentrates or distills the experiential and intellectual contexts of everyday life. [Talk] therapy then can be thought of as a prosthetic provision of contexts, experiences, and events which prompt, support, or facilitate clients” self healing.” (p.111)
Tallman and Bohart (1999) emphasize the importance of felt experience at a “bodily level” (p.113). They claim that real change appears to happen at this level, beneath an intellectual understanding of the problem and possible solutions, and claim that intellectual insight by itself is not therapeutic.
Seen through this lens, Child and Youth Care practitioners have every right to think of themselves as therapists. The professional Child and Youth Care practitioner is constantly thinking about how to maximize the possible therapeutic benefit of experiences, whether these experiences occur within the context of a residential milieu, or within the broader context of the social milieu that exists within the community. These experiences provide children and young people with opportunities for felt experience. This work may involve structuring the residential milieu for specific client needs, or it may involve considerations of social experiences which may be had within the context of the broader community. Uppermost on practitioners' agenda are considerations of client needs.
Targeted experience: the client as expert
Should Child and Youth Care practitioners attempt to target specific
experiences to the special needs of their clients? This is a complex
question to which there is not an easy answer. On the one hand, the age
of clients often puts practitioners in a guardianship role where
decisions regarding experiences have to be made by the practitioner on
behalf of children and young people, especially where safety is
concerned. On the other hand lies the notion and evidence for the fact
that all change is self change, and that given the chance, people will
select the experiences they need for psychological healing. Tallman and
Bohart (1999) refer to evidence suggesting many individuals “mature out
of” Borderline Personality Disorder, Antisocial Disorders, alcoholism,
and smoking (p.99). Underpinning this belief of self change is the idea
that life provides, or that people choose subconsciously or otherwise,
the experiences they need for psychological healing, and that “human
psychosocial development is highly buffered and self righting” (p.109).
Perhaps the answer to this question in a Child and Youth Care context, lies in the direction of collaboration. Tallman and Bohart (1999) refer to this as more than client participation and compliance. It involves clients taking a leading role in the therapeutic journey and creatively generating their own solutions to problems. Surely this idea is equally applicable to children and young people, and the selection of experiences.
Relationship factors and therapy
While current outcome research indicates that therapeutic relationship
factors account for 30% of client change in talk therapies, the
implication is that these relationship factors are operative in
relationships outside of talk therapy sessions. Simply being listened to
is therapeutic, and Tallman and Bohart (1999) suggest that in instances
where people have friendships in which active listening occurs, therapy
also may be occurring. The problem is that this is rare. Tallman and
Bohart (1999) comment:
For example, outside of (talk) therapy people rarely have a friend who will listen to them for more than twenty minutes. Friends do not usually provide the time and space for individuals to think about and explore their problems ... Instead friends and relatives may jump in with premature advice, and inadvertently, discount their fears ... Nonetheless, as noted above, people often solve their problems by talking to friends, relatives, co-workers, religious leaders, or some other confidant in their lives. (p.111)
In a Child and Youth Care context these outcome findings are important to remember. Simply listening to children without judgment or comment, can be a therapeutic act.
Bachelor & Horvath (1999) indicate that attachment styles of both client and therapist may affect therapeutic outcomes through their impact on the quality of the therapeutic relationship. For example, not paying attention to client avoidance behaviors may result in less engagement on the part of the client. They suggest that with avoidant clients, therapists should be wary of expressions of warmth, and interpretive or challenging responses. Conversely, anxious or ambivalent clients may benefit more from a therapist who can tolerate opposition, and who can work to establish collaboration in therapy.
Therapists' attachment styles and previous personal relationship histories have also been shown to affect therapeutic outcomes in that secure therapists are able to challenge both avoidant and anxious/ ambivalent clients in a sensitive and timely way. This involved responding to the dependency needs of clients who dismissed these needs, and appropriately not responding to clients who were preoccupied with these needs. Conversely, therapists preoccupied with their own attachment needs, or therapists who tended to be dismissive of their own attachment needs, intervened more or less with their clients in accordance with their own attachment style. Generally, therapists with secure attachment styles were found to be more proficient at establishing early therapeutic alliances (McKee, 1992, as cited in Bachelor & Horvath, 1999). This research suggests that in a Child and Youth Care context, practitioners should be aware not only of children's attachment styles, but also of their own, as they plan and implement interventions and engage with their clients in the therapeutic milieu.
Conclusions
During the current economic climate of funding cuts to social services
that has seen these services shrink in the province of British Columbia,
the profession of Child and Youth Care will increasingly need to
demonstrate its effectiveness. Outcome research provides us with the
opportunity to argue eloquently for the worth of quality Child and Youth
Care practice, in that the factors which are the cornerstone of our work
(the relationships we establish with our young clients and the
experiences we facilitate) are the very factors demonstrated to be
therapeutically efficacious in bringing about change.
The next time MCFD case workers want to know how that bike trip, horseback riding excursion, summer camp experience or trip to the local coffee shop after school, is going to benefit little “Johnny” or “Susy”, tell them!
References
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Bachelor, A. and Horvath, A. (1999). The therapeutic relationship. In Hubble, M.A., Duncan, B.L. and Miller, S.D. (Eds.). The heart and soul of change: What works in therapy (pp.92-133). Washington, D.C. American Psychological Association.
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This feature: Rayment, J. (2005). Child And Youth Care Practice as Psychotherapy. Relational Child and Youth Care Practice, 18,2. pp.29-33
