Healing the Heart
(Preface to the authors' 1990 book)
This monograph grew out of a collaboration that began in 1977. One of us
(Dr. Alvin A. Rosenfeld) became Stanford University's Director of Child
Psychiatry training. As part of his teaching responsibilities, he consulted
to the Child and Adolescent Psychiatric Inpatient Unit (CAPI) of San Jose
Hospital, teaching residents who rotated through the unit and discussing
their progress with its new director, Dr. Saul Wasserman. In our
discussions, we found that both of us had a deep interest in a group of
children that child psychiatrists had tended to ignore up until then,
relatively speaking. We were interested in finding better ways to heal these
children's wounds.
We began to discuss our experiences and to talk about children we had known or were seeing in our daily clinical practice. Out of these discussions, and other activities related to child abuse, we began to understand these children better and developed a clearer picture of what needed to be done to treat them more successfully.
Over the years, both of us were profoundly influenced by a beloved teacher and friend, Dr. Bruno Bettelheim, who had retired in Palo Alto and who became both an active teacher in the child psychiatry training program and subsequently a clinical consultant at CAP!. Dr. Bettelheim taught us much that he had learned about severely disturbed children in his 30 years as the director of the Sonia Shankman Orthogenic School of the University of Chicago. We found that many of the approaches he had originally developed for work with autistic and psychotic children were particularly useful in restoring severely maltreated children to emotional health.
We consider this work crucial to the children as individuals and to society as a whole. The children's wounds need to be healed so that they can live good productive lives, and also so that our society can be spared the damage these children are prone to inflict on themselves and the revenge they take on others if they are not well treated and healed.
Both of us have applied our understandings and treatment principles to residential treatment centers, group homes, and foster homes.
Our views and approaches have not been universally accepted with joy. We are both familiar with the arguments clinicians and administrators, as well as some who shape governmental policy, make about an approach that emphasizes using a deeper understanding of what drives these children's behavior as a foundation for treating them.
Resistance to this approach is understandable. The work we describe is not easy; anyone undertaking it needs to be deeply committed to repairing the damage that cruel, indifferent, self-centered, or inadequate parents have inflicted. The work involves dealing with children who are extraordinarily emotionally and intellectually demanding. Furthermore, our approach will not work with every child and cannot be applied easily to every program, particularly at a time when the well-being of children ranks so low as a social and economic priority, and when we mortgage our future by investing proportionally so little in the next generation.
Our experience has convinced us that the approach we describe has a greater likelihood of producing long-term attitudinal, personality, and behavioral change than simpler and more mechanistic behaviorist strategies. Furthermore, in our experience the approach ultimately leads to work that is more gratifying to the clinicians involved in treatment. This may diminish the huge staff turnover at many residential treatment centers, which would itself benefit the children. In the long run, we believe that the savings to society will far outweigh the additional expenditures that have to be made to adequately staff and fund excellent therapeutic facilities.
Our medical training has emphasized that we treat a disorder best if we understand its origin and provide as specific a remedy for the defect as is possible. In a way, these children suffer from a deficiency disease. Their lives have not given them nurturance and enough experience with positive and stable human relationships for them to join society willingly and to live well in it. The dilemma that treating them presents is that any sensitive clinician who tries to learn about the unique and terrible experiences these children have had tends to be overwhelmed just by hearing about their lives and imagining what it was like to endure so much suffering.
A wise man once said that God is in the details. Understanding the details of these children's lives is essential to treating them successfully. Before coming into care these children have failed miserably in human relationships; their efforts to evoke from their parents the love and care they need to thrive psychologically and to flourish emotionally have been greeted with hostility (child abuse) or gross indifference (neglect). This is the generic insult that causes their illness. Although we consider the parents at fault for this failure, social policy often reflects our society's concurrence with the view that the children, or their disturbing behavior, and not their upbringing or terrible experiences, are to blame.
A treatment facility that treats these children must regard each as precious and unique so that their hearts can be healed and they can come to live a good life. Only through careful observation of each child can the particular insults and deficiencies the child suffered be understood. Only with this insight can the treatment team devise the unique interventions that persuade the child that he or she has worth and the hope for a better future. The challenge is to find a creative way to give each child a new chance for stable, restorative relationships in a setting that must serve many children at once. We emphasize that the process takes time and is demanding. Our experience, however, has been that the creative energy invested in understanding and helping these children is richly rewarded over time. As an old Jewish saying tells us, anyone who saves a single life has as good as saved the whole world.
The treatment approach for these children needs to be cut from a single cloth; each of its component parts are important to the whole process. We have used the term "therapist" to describe a person, typically a social worker, psychologist, or child psychiatrist, trained in providing psychotherapy. In the treatment programs we are describing, each child receives individual therapy several times a week. Family sessions may occur frequently, intermittently, or not at all. In coordination with the child care staff, the therapist also may provide the case management and develop the child's treatment plan. The child care staff comprises those individuals who provide the parenting for the children. They have been specially trained in psychological principles, with a focus on understanding and responding to the children in ways that will further the children's growth. Since they live with the children, they are crucial in giving them the direct experiential learning that creates growth. The goal is to create a specific environment and relationships in which learning can occur throughout the day as the children try to negotiate the tasks of daily living. (1) We consider this living situation "therapeutic." At times we have used the term "clinicians" as a general term for all those adults who adhere to these goals when they interact with the child. either in therapy or in the therapeutic environment.
We hope that the explanations, approaches, and examples we use in this monograph will help all those who work with maltreated children to deal with them more sympathetically and effectively. We encourage you to look honestly at your feelings. No one feels benevolent all the time, especially to these provocative children. Your own anger can become an important tool that can help you form a relationship with a disturbing child. Your skill in understanding can help solve problems. The children will learn more from what you actually do with them, particularly when the going gets rough. than they ever learn from what you tell them to do.
These children are numerous. Many intelligent,
wellÂintentioned people need to work hard if we are ever to heal the wounds
their young hearts have sustained at a very tender age. We hope that others
will supplement these ideas so that with time we all can become wiser in our
understanding. more precise in our interventions. and more potent in our
therapeutic efforts.
ALVIN ROSENFELD and SAUL WASSERMAN
Rosenfeld, A. and Wasserman, S. (1990) Preface, to Healing the
Heart. A therapeutic approach
to disturbed children in group care. Washington, DC: Child
Welfare League of America.
NOTE
1. See Redl and Wineman, Controls From Within
(New York:: Free Press. 1965) for an extensive discussion of this approach.
