Book Review: Therapy with Children – An Existential Perspective

I want to like this book but I find that there is a contradiction deep in the heart of it. Scalzo writes about his own work with children as an existential psychotherapist and he has attempted to reconcile his work with existential philosophy. There are chapters on authenticity and anxiety; language; knowing and not knowing, and existential phenomenology as well as comparisons of existential psychotherapy to both psychoanalysis and systemic family therapy. Scalzo illustrates his theoretical description with vignettes from the case histories of his clients that are sensitively written and indicate that within a session he interacts with kindness and respect towards his child clients. It does seem that his intentions are good but unfortunately he cannot overcome the schism between his theory and his practice.

The principal question for me when reading the book is whether existential child psychotherapy is a contradiction in terms. Scalzo is writing about his work not as a family therapist working with children in their family context, his work is that of a child psychotherapist. Parents or carers are met prior to the therapy and at review meetings but therapy sessions are primarily with the child. In my view, child psychotherapy conflicts with an existential approach for two reasons: first, a child cannot give his or her own informed consent for psychotherapy; second, offering psychotherapy to a child colludes with the opinion that there is something wrong with the child.

Scalzo is very clear that he is not just talking and playing with his child clients:

…a relationship that is to include dialogue is not uniquely about the therapist following the child and allowing them to be, but a process of interaction and disturbance. The benefit of a child engaging with therapy, therefore, is not in escaping or taking refuge from the world, but in confronting it.

(pp12-13)

So, according to Scalzo, child psychotherapy is not simply allowing a child to be. He does not remind us that this 'process of interaction and disturbance' takes place without the child's consent.

Scalzo explains the importance of consent for anyone entering psychotherapy: "To begin a therapeutic journey, a decision has to be made by the client to put themselves in a position to happen for something new to happen' (p5). Consent is essential for the therapeutic relationship, but entering psychotherapy is a major commitment and it is a difficult decision for an adult to make. An adult has a choice: 'Even when the client is compelled to sit in front of a therapist by a person in authority, there is ultimately a choice as to how that person chooses to engage' (p5). This may be so as regards an adult, but a child simply does not have the knowledge of the world necessary to make choices of this kind. In our society, we have laws whereby a child cannot consent to sexual relations nor can a child make a contract. Similarly for any child psychotherapy, the consent of the parents or carers is required. There is a reason for these laws: a child cannot make an informed choice on these complex matters.

There are many circumstances where an adult may work in loco parentis with a child: for example, as a teacher. The question of psychotherapy is somewhat more complex. In general, needing a teacher carries no stigma. Referral to a psychotherapist without consent carries a very different message, and it is difficult if not impossible to avoid conveying the message to a child that there is something wrong with him or her. This inevitably has an impact on the child. Also, the aim of teaching is relatively well understood by the general population, whereas the aim of psychotherapy is not. In a number of places in the book (pp2, 24, 48, 89 & 90), Scalzo gives the aim of child psychotherapy as helping the child to transcend his or her family context: 'An existentially based psychotherapy must... be directed...towards the possibility of the child being able to transcend their family circumstances' (p24). It is not clear from the book whether the parents of the children with whom Scalzo works explicitly agree to this direction. Therefore there are two questions: Do the parents of the children understand to what it is they are consenting on behalf of their children? And can the children themselves understand why they are in therapy?

One thing is clear: it is not the child who gives consent. Scalzo asks: 'How, then, can working with children ever be truly therapeutic?' His answer is to provide a case vignette about a seven-year-old child who 'was always keen and enthusiastic about attending' (p8). When his father began to attend sessions with him, the dynamic was changed. 'It seemed that he was very pleased to have the opportunity to come to our sessions himself, but that his father's attendance... set a different context for his decision making' (p8). This vignette seems to demonstrate the power of sessions with combinations of family members but does not adequately answer the question raised. Scalzo writes: 'This brief example illustrates how the choice to attend therapeutic sessions is present for even very young children (p7). His argument seems to be based upon his observation that the child enjoyed coming to see him. I find this argument very disturbing having come across it many times as a justification used by paedophiles to excuse themselves and torture their victims. That a child enjoys an activity is no evidence that it is in any way beneficial to him or her, and it may in actual fact be harmful. Family members or carers may choose to make this decision on behalf of a child and this begs the question: why would an adult want a child to enter psychotherapy?

Scalzo's reply goes to the heart of the moral dilemma faced by child psychotherapists:

In many circumstances, children are referred to a psychotherapist by a parent or professional concerned about their behaviour or the 'wrong' choices they seem to be making. By accepting the referral, the therapist is often in danger of implicitly agreeing with certain judgements as true ...The moral therapist working with children must be conscious of the implications that will be construed through accepting a referral for a child...The therapist can find themselves in a position of agreeing: it is the pupil who is struggling to manage their emotions appropriately, not the teacher; it is the child who is uncontrollable not the parent; it is the 'unruly' and outspoken child who needs greater boundaries, not more freedom or affection.

(p134)

Scalzo elucidates some of the dangers of collusion, but surely a 'child' psychotherapist by definition is agreeing that there is a problem with the child. This in itself is a judgement.

Despite his warning of the risks of collusion with judgements, Scalzo is not entirely clear about the difference between judgements and facts. Most importantly, he seems somewhat muddled about the negative aspects of medicalisation. He begins his discussion very well by stating clearly:

It should not be the aim of the psychotherapist to diagnose a child, although families, schools, medical professionals, and officers of the court frequently request this. Any form of existent psychotherapy should be inherently against the fixed and deterministic categorization that diagnosis brings. Intrinsic within providing diagnoses is the belief, or world-view, that our behaviours or difficulties can be pathologized.

(p11, emphasis in original)

Unfortunately after this promising start, Scalzo dilutes his argument by muddying the waters with a discussion of different sorts of categories:

When working with children in any context, however, there exists the temptation to categorize them. This can be done according to their age, understanding, or cognitive abilities, a 'medical' model of diagnosis (e.g., ADHD), emotional literacy, styles of 'attachment', and so on. Even the definition of a person as a 'child' involves a level of categorization that is easily overlooked or given little attention by some professionals.

(p11)

By broadening this discussion to that of all categorisation, he has almost entirely submerged the point. Age is a fact. A 'medical' diagnosis is an opinion based upon behaviour and is in effect a judgement. A child may be influenced by this judgement for the rest of his or her life. The incompatibility that I see between existential therapy and child psychotherapy need not exist for a family therapist who does not regard the child as the 'problem' but works with the parents or carers to try to understand what is happening within the family relationships. Scalzo agrees that 'work with more than one family member alongside a child should not be ruled out', but in his work he focuses on the exicstential concerns of the child.

The family is not the client, and while relationships are indeed paramount in the context of understanding a child's worldview, the intention is not to correct a distorted way of relating. The family is not seen as an organism in itself.

(p24)

But why would a family therapist view a family as an organism any more than a couples therapist would view a couple in this way? Surely it is possible to work with the adults in a family in order to help them to find a new way of being with their children? It is not clear to me from reading the book why Scalzo favours child psychotherapy over family therapy.

Scalzo does question his own work:

As therapists, however, when we are in relationship with a child, is it possible to facilitate the child to become more aware of his or her self? I wonder, also, what the therapeutic significance of such self-knowledge may be, for it could well be a tricky line along which I tread, furthering their knowledge of themselves and their choices, but ensuring that they remain a part of society. At the end of each session with me, a child must, of course, return to their everyday life: with their family; back to their carers; and so on….As well as the practical responsibilities that arrive with any process that may facilitate 'self' knowledge or awareness, there is the ethical and philosophical dimension. It is simply insufficient to assume that a greater awareness of a child's situation and struggles in life is inherently therapeutic.

(pp119-120).

These are profound questions but unfortunately Scalzo's reply is impenetrable: 'One response to such dilemmas is to remember that as individuals, however inward or individualized, we must always think of ourselves as being in "relation to"' (p120). This answer seems to bear no relation to the questions raised.

Scalzo raises many questions that are relevant to professionals working with children as well as for psychotherapists in general, but some of his answers are inadequate. Indeed, it does not seem possible to overcome the inherent contradiction between existential thought as he describes it and child psychotherapy.

Angela Buxton

Response by Chris Scalzo to Angela Buxton

I would initially wish to take the opportunity to thank the reviewer for raising some interesting areas of debate around consent and choice. I would also wish to thank the editors of the journal Existential Analysis for this opportunity to respond and share some of the conclusions I have come to in my own writings and practice. I hope readers of my book will come to their own. But also let me start by clarifying that my book is not written about the general ethics of whether it is appropriate to practice psychotherapy with children. Despite the strong opinions of the reviewer, mental health and therapeutic services for children already exist and continue to grow. The real question then is whether there is something particular to the parameters of 'existential psychotherapy' which make it inappropriate to work in this way with children.

It is important to clarify some fundamental truths, which exist regardless of where this debate leads: Therapy with children, however sensitive, is not a substitute for good parenting; counselling, psychotherapy, psychology and psychiatry with children is conducted around the world; the practice of therapy with children should not preclude a role for family therapy, parenting programmes or parent-focused therapy; psychotherapy is an endeavour which constantly raises moral and ethical questions, requiring us to reflect on our own assumptions and judgements; unfortunately the world in which we live inflicts great suffering upon many children. There are indeed very challenging ethical decisions to be made along the way in all child psychotherapy. These questions are woven throughout the core of almost every chapter of my book and the questioning of many assumptions to practice is in fact its central essence. However, the conclusions, I believe, should be left to each practitioner and each reader to make for themselves.

There are of course limits to the choices a child may make. These are invariably limitations of understanding, social control and power. However, it would be a misunderstanding of existential philosophy to believe that any of us exist in a world without limitations. As Betty Cannon so eloquently writes, 'I fall into bad faith if I take one or both of the two dishonest positions about reality: if I pretend either to be free in a world without facts or to be a fact in a world without freedom.' (Cannon, 1991: p46) The opportunity in existential psychotherapy is to become aware of the freedoms we do have, meaning we are not rigid 'facts' of existence, whilst understanding the 'givens' of being-in-the-world we must all face.

Secondly, as existential therapists we must also consider the importance of not sharing our thoughts and ideas in this arena. All too often when children are considered unable to take responsibility for themselves the outcomes unfortunately leave them far from protected and nurtured by wider society. Increasingly children are excluded from schools, diagnosed with conduct disorders, or ADHD, and medicated accordingly. The prescribing of amphetamine-based medication designed to alter children's behaviour is growing at an alarming rate. I strongly believe if we adopt a path which agrees that children are unable to think for themselves, then we as a society must also face the consequences of generations of young people who will inevitably feel out of control. Existential thought may provide some answers. Continental philosophy as a whole, starts from a premise that we are always inter-connected, part of the world. We cannot for example pretend that psychotherapy with children is not practised or indeed that many of us do not choose to find solace in 'turning a blind eye' to the distress and abuse children endure in our society. This is something which is often thought to be far away from our world or our experiences. Existential philosophy places us not only firmly in a world in which suffering is part of the human condition, but also as part of the society which creates and allows abuse to take place. The pain of children is not beyond us and to be ignored. As a community of existential psychotherapists I believe we should not be excluding ourselves from this responsibility or be satisfied to allow ourselves to become a marginalised sect, adopting an aloof or theoretical position not grounded in reality. Supporting and working therapeutically with children, who may at a very young age feel there is something 'wrong' or 'bad' with them, should not just be left to modalities of practice which may collude with notions of pathology or diagnosis. The aim of my book is not to set out a new model for practice, (enough of these probably exist already), but to draw attention to the important role existential thought and psychotherapy could play in influencing this work.

The 'uncovering', or opening up, of the child's perception of their family should not be seen as a method for analysis, however. In order to develop greater awareness of the choices and possibilities a child faces, it is essential for the therapist to look at the relationships of which the child is a part through awareness of the phenomena. If this type of circumspective interpretation is reduced to a set of techniques and methods, then the interpretation of the relationship can only be understood in one way. In effect, all else is lost.

(p49)

As far back as 1887 when Professor Carl Emminghaus, head of the Psychiatric Clinic at Freiburg wrote a book called, Emotional Disturbances of Childhood, or the early writings of Richard von Krafft-Ebing or Herman Oppenheim at the turn of the last century, physicians and psychological practitioners have expressed an interest in childhood distress. What has often been missing however, is the voice of the child. Rarely are the key ethical questions considered in any great depth, let alone from a philosophical perspective. Central to the core of my book is the importance of the therapist questioning at every stage what their role and ethical position is on each decision taken. The therapist should consider what is in the best interest of the child, at every point, not only at the start of the relationship around consent, but in each session, review or intervention (see chapters on 'The Process of Child Therapy' and 'Family and Method'). Each point discloses aspects of a child's Being and context, and in turn raises questions to which the therapist must remain acutely aware.

Each step along the way should be addressed as poetry... Existentially speaking, each relationship and encounter is unique. Each experience is new, and the therapist must be open to this. It is necessary to look beyond simple explanations of cause and effect...When reading poetry we must expect surprise. Each word may be used in a new context, with new emphasis or new meaning.

(p19)

The above critique of child psychotherapy is based, I believe, on a misunderstanding of existential choice. Although choice exists for us all, it is never limitless. By our very existence, by our being-in-the-world we have limitations: the choice we face is how to respond to these 'givens' of Being. The choice of a child who has been terribly abused or removed from the care of a neglectful parent may be limited in an overwhelmingly clear and explicit way, but the opportunity to challenge their experiences of life and essentially their own assumptions about themselves, or simply to be able to relate to an adult in a different and new way through therapy, ultimately goes to the heart of true existential choice.

A frequently coiled rope may retain within its structure a desire to return to its established pattern, even when pulled out of shape, or forced into an alternative pattern. It appears to retain a true shape or be taken to adopt a false shape. This shape, however, is not an inherent part of its makeup. The natural tendency of the rope to repeat its experience and adopt the familiar is similar to the tendencies that exist in all of us, and children are by no means exempt from this. It is important to note, however, that the desire and comfort found in returning to familiar patterns does not demonstrate the existence of a core or true self, more real than any other. As with a child's play, each character they adopt is representative of them in that moment. In so far as a child's play provides a key to their life, it is because in their play is projected their manner of being towards the world, that is, towards time and others.

(pp36-37)

Perhaps unlike the reviewer, I believe it is possible, indeed imperative to good practice, to create a therapeutic process for parent and family which makes clear that offering therapy to a child is not about pathologising them. I believe it is equally dangerous to make the assumption that children cannot be provided with a therapeutic space and relationship in which they are able to become autonomous, free-thinking individuals.

The point at which a child does become autonomous and able to consent, understand and choose freely in a way existential psychotherapists may acknowledge is still largely unexplored. Stern has laid some of the foundations and Merleau-Ponty (see pp37 & 85) has considered some initial aspects of child development from an existential perspective, but many of the key existential philosophers have little to say on this topic. I would also thoroughly recommend the chapter by Wenkart, (1965) in the book, Existential Child Therapy. Whilst we must await the emergence of a more complete existential theory of the journey from childhood to adulthood, I feel, perhaps unlike the reviewer, that when it arrives it will not be tied to the same chronological stage-posts as a traditional psychoanalytic or psychological model.

From an existential perspective, the development a child must go through to reach adulthood is not a linear progression of becoming a mature finished individual. In effect, the child already has a primordial experience of being with others, and it is a greater understanding of this that will grow and develop as the child moves towards being an adult…The significance of this emerging understanding of a relational existence is great. It is our context and our relational world that provides us with a place in space and time.'

(p85)

The reviewer unfortunately appears to misinterpret my discussion of age and judgement by not recognising the importance of how children are perceived as influencing their lives every bit as much as clinical diagnosis. Age is a fact, but clearly the assumptions often attributed to a child because of their age will greatly impact on a parent's perception of their child, or even the child's interpretation of themselves. Any mother whose child may not have been the first in the nursery to walk, talk or hold a cup of milk will be acutely aware of the emerging pressure when reflecting upon the social implications of making judgements about a child due to their age. Typically a parent does not hope for their child to enter psychotherapy or to be 'judged,' but instead simply wishes for their child not to suffer.

Finally, I would wish to correct a fundamental error in the review, which states that 'Scalzo is not just talking and playing.' This is exactly what I aim to do in my sessions. The reviewer justifies this comment by a contrast of play with my description of dialogue as, 'a process of interaction and disturbance.' Play is a serious business and often disturbing to child and therapist. That is not to say, of course, that it cannot be enjoyed, but if we are to truly enter into play it is necessary to give up our current position and take a leap into something new and unknown. The dialogue created in true play presents a huge opportunity for growth and change, central to existential psychotherapy. As Gadamer wrote, it has '…a seriousness of purpose…[In play] above all, what no longer exists is the world, in which we live as our own.' (p38) Through role-play, a child is able to try out future projections of themselves and the person they wish to become. It provides an opportunity for a child to adopt the roles and characters of the people in their lives, and to try to make sense of where they find themselves: to explore their past and their present. From an existential perspective it allows a child the chance to try to redefine their understanding of time:

During childhood, for many of us, an understanding of time and our own identity is as far from our thoughts as it will ever be, but for others, the mortality and vividness of life, which time can thrust upon us, are all too real.

(pxiii)

Understanding Counselling and Psychotherapy

Meg Barker, Andreas Vossler and Darren Langdridge (eds). (2010). London: Sage, Open University.

Introduction

In their introduction to this book the editors make quite a bold claim that this book is really for anyone interested in understanding, and working with, 'sadness' and 'fear'. More specifically the book seeks to contextualise psychotherapy historically and to illustrate how different approaches engage with common problems such as depression and anxiety, or, as they are described here, as 'sadness' and 'fear'.

The book is broken down into four main parts: Parts 1 and 3 look to contextualise psychotherapy historically – in Part 1 in terms of the field of the mental health professions, and in Part 3 socially, in terms of families and other social groupings. Part 2 looks at four 'key' therapeutic approaches – humanistic, existential, cognitive-behavioural, and mindfulness; and part 4 looks at research and practice, and ways of attempting to evaluate outcome and process.

On reading the blurb on the back of the book, I was surprised that psychoanalysis had not been itemised as a key therapeutic approach given the pervasiveness of psychoanalytic thinking within contemporary psychotherapy, not to mention more generally within the epistemological dialectic of the last century, although it was included in part 1 as part of the historical background to the development of psychotherapy generally. My initial feel for the book was that it would not necessarily be the best of reads for more experienced practitioners so, rather than being for anyone interested in understanding, and working with, 'sadness' and 'fear', it would serve better as a basic introduction to the field of psychotherapy.

Background

Part 1 of the book, 'Counselling, Psychotherapy and "Mental Health"', is divided into three chapters which look at diagnosis, drug treatments and psychoanalysis. In this part of the book 'formulation' is proposed as an alternative term to diagnosis (p22) whilst also acknowledging that diagnostic labels may, too, have their place.

A chapter called 'Understanding Drug Treatments: A Biopsychosocial Approach' may seem more in place in a psychiatric handbook than one on counselling and psychotherapy, but did also seem relevant since psychotherapists will often encounter clients either taking, or being offered, prescription drugs and, if we include other physical stimulants, the effects of stimulating our neurons and neurotransmitters as the biological bases of our emotions (p62) can have even wider implications in the consulting room.

Ian Parker, on his chapter about psychoanalysis, challenges what he says are some common myths about psychoanalysis and also points out the significance of Freud's notion of a 'talking cure' as a root of many of today's psychotherapies. Parker also talks about structure and power within the psychoanalytic relationship, a phenomenon observed elsewhere (Davies, 2010) within its own training institutes (and arguably others, too).

Approaches to therapy

Part 2, 'Individual Therapeutic Approaches', introduces and outlines four ways of working with 'sadness and fear'. Chapter 5 discusses humanistic approaches as the 'third form' in psychology and as a holistic reaction to the 'mechanics' of psychoanalysis and behaviourism, and focuses on the work of Carl Rogers.

Chapter 6 looks at existential psychotherapy and it is usefully defined here as adopting a phenomenological attitude whilst using aspects of existential philosophy to frame responses (p125). This seemed like a succinct and helpful way to summarise the existential approach, especially given the frequent reluctance of existential practitioners to be drawn into defining what they do. Darren Langdridge also makes an interesting point here about the selection of appropriate candidates for training due to the demands of understanding existential philosophy (p142). Regrettably, possibly due to a lack of space in the book, Langdridge does not expound this view here.

My defences seemed to kick in quite strongly as I read the next chapter on CBT, since it appears to threaten other approaches as the model of choice for those pulling the purse strings in public services. However, I did also feel challenged to question some of my own prejudices and assumptions here. For example, 'emotional disorders' as the result of a person becoming stuck in patterns of meaning and responses to those meanings (p150) didn't seem a million miles away from ideas of sedimentation used in an existential approach.

There has been much focus and promotion of mindfulness in the past couple of years, and whilst I think this is interesting I'm not sure I would see it as a 'key therapeutic approach'. This point, in fact, is actually addressed quite soon in the chapter covering mindfulness, authored by Meg Barker. Barker looks at the Buddhist background of mindfulness and says how we can understand this in terms of it being a way of approaching suffering in everyday life rather than it being seen as a type of therapy per se (p169).

Context

Part 3 of the book, 'Beyond The Individual', starts by looking at systemic approaches, highlighting the importance of understanding the wider context of issues of human suffering or difficulties in living, describing systemic therapy as a co-constructed, creative and contextual approach (p209). In keeping with this part of the book the following chapter, 'Sociocultural Issues', focuses on race, gender and sexuality.

At this point the book feels somewhat like it is trying to squeeze in as many relevant themes as possible, a bit like those record attempts to fit large numbers of students into Mini Coopers. Arguably a Mini will function a lot better if it has a maximum of four people in it, and the book also begins to feel somewhat weighed down by its ambition.

Practising and evaluating counselling and psychotherapy

This is the final part of the book, and the first chapter here looks at context and setting, starting with a bold statement that '…contextual factors have largely been neglected by counselling theory and research…' (p237). As well as looking at boundaries here (e.g. confidentiality) the author, Andreas Vossler, also looks at the impact of technology and rightly points out that forms of therapy will now reflect the 'zeitgeist' of technology-dominated Western culture, and questions whether an 'authentic' counselling can be provided through such means. My own recent experience working through Skype suggest to me it can, although the limitations and frustrations of using such technology need to be acknowledged along the way.

Chapter 12 looks at the therapeutic relationship and, more specifically, at 'the therapeutic alliance' (p261), 'goal consensus' (p262), empathy, and self-disclosure as components of this relationship, to be explored with due care.

Chapters 13 and 14 look at two main approaches to research and allow for engagement with what seems to be a contentious area. The area of research seems especially relevant in an age of accountability and the audit culture, and these chapters certainly provoked a critical dialogue with the text for me as a reader.

Statements made on the 'validity' and 'reliability' of measurements such as CORE seemed provocative to me, but could stimulate interesting discussions in training. The dangers of employing such nomothetic measures and the development of 'norms' (p288) as opposed to idiographic ones are clear to me, as an existentially informed practitioner coming up against issues that reflect the constant oscillations between authenticity and inauthenticity.

John McLeod's following chapter 'Process Research' is on using non-numerical data and a qualitative approach. Interestingly he concludes his chapter paralleling the skills needed for qualitative research with those needed to be a therapist, and that, therefore, many therapists are drawn to this type of research (p324), and makes an impassioned plea for this 'vital role to play in the development of theory, practice and policy making' (p325).

Conclusion

I think again that it would be possible to come away from this book with a view that therapists only deal with 'fear' and 'sadness' and not many other emotions and difficulties. This is somewhat reductive and the choice to use these particular terms rather than the more commonly used psychological terms of 'anxiety' and 'depression' might have been an interesting decision to explain. On the whole, however, I found the book to be comprehensive and clear in its approach to introducing the major schools of thought within psychotherapy and counselling to those starting out in the field. It offers an accessible introduction for trainees and those early in their careers, and provides sufficient depth to prompt interesting discussion in training environments. The book tackles important areas such as research and evaluation, sociocultural issues and ethics, and presents them in a balanced and thought-provoking way. It would indeed also be useful for people approaching psychotherapy and counselling from outside the profession as an introductory guide. However, for the more experienced reader, the material presented may feel somewhat familiar and potentially lacking in the greater depth sometimes required for advanced discussion of the key issues presented.

Malcolm Freeman