Children's turn-arounds in psychotherapy: the doctor's gesture.

UNLABELLED: Over the past year, a number of us have been examining the organizing principles behind dramatic turning points in the psychotherapies of children. We wondered whether any particular techniques or occurrences in therapy promoted childhood change. METHOD: One of us (L. T) asked the health care professionals on the UCSF child psychiatry grand rounds email list and 50 colleagues across the United States and Canada to select key "moments," or turning points, in their treatments of young people. No organizing principles were suggested in the request letters. Over 3 months, 21 vignettes telling of major changes in children and adolescents arrived in San Francisco. Some of them came from psychotherapies-others, from consultations or very brief therapies. Eleven are included in this paper. RESULTS: Gestures from the psychotherapist were shown to effect dramatic turn-arounds in some young people. These shifts in the doctor's emphasis or behavior included: (1) making an entirely unexpected statement; (2) advocating strongly for the youngster; (3) confessing personal flaws and/or frustrations to the patient; (4) feeding or rewarding the young patient; and (5) inquiring deeply into something personal with the child. A gesture never given--in this instance, an undelivered inquiry into incest--is shown to have left an adolescent patient unchanged. The young people described in this report suffered from anxiety, trauma, neglect, cancer; anorexia, bulimia, and personality disorders. Two were institutionalized at the time of their dramatic changes. One had been previously hospitalized 4 times. Another small child had suffered a double amputation. These children came with a far broader spectrum of problems than the relatively mild disorders for which child-psychodynamic psychotherapy was originally tailored. Although we were not primarily concerned with the "ground" on which the doctor's gesture fell, in 5 of our cases there had been little to no therapeutic relationship prior to the gesture; in 4, the relationship had been primarily positive; and, in 2, it had been negative. CONCLUSIONS: Doctors' gestures are usually given on impulse and unexpectedly during psychotherapy. To the child, these gestures appear counter-intuitive and surprising. From the therapist's perspective, they first generate a brief sense of confusion in the patient, and then a strong sense of connection between the young person and the adult. In the cases we report, the physicians'gestures created a new alliance. The tone of the therapy switched, leading to a noticeable psychic shift in the child. SUMMARY: A doctor's gesture may elicit a dramatic turn-around in a young patient. This therapeutic climax is implicitly understood between the two parties and then may be converted to consciousness and worked with explicitly. Therapeutic "moments" occur in a broad range of disorders, that in many cases are also being treated simultaneously with medications, and with family or institutional counseling.

Follow-up study of Cambodian youth who experienced war trauma as children

Twenty-seven Cambodian young people, who were severely traumatized at age of 8 to 12, were followed up three years after an original study. Using a structured interview (SADS) and self-rating scales, post traumatic stress disorders were still highly prevalent (48 percent). Depression existed in 41 percent. Those with PTSD differed significantly from those without PTSD on the Global Adjustment Scale, the Social Adjustment Scale, the Beck Depression Inventory, and the Impact of Event Scale. Eight subjects had PTSD at both interviews, while 11 had PTSD neihter time. Eight showed a variable course. Avoidance behavior was highly prevalent even among those without PTSD diagnosis. Even though funtioning relatively well, these youth continued to show symptoms related to their trauma of eight to 12 years before (AU)

The single-parent family and abusive child punishment.

This retrospective survey of 802 noninstitutionalized adults reveals that abusive punishment in single-parent households is twice that of two-parent families. However, the sex of the single parent was not related to abusive punishment. Parent-child compatibility findings delineate these relationships further.

The children of imprisoned parents: a psychosocial exploration.

This study of children's reactions to the imprisonment of a parent identifies temporary behavioral symptoms that commonly follow the incarceration of a parent, as well as antisocial behavior on the part of a few pubertal children. The stigmatizing and traumatizing effects of imprisonment on the spouse and child left behind are discussed, and suggestions for clinical intervention are offered.