In this paper, after a summary of explanations of why child psychotherapy is important in 0 to 3 years of age group, some different psychotherapy approaches will be introduced. The paper will be focus on psychoanalytic / psychodynamic models; however, other approaches will be described. Every approach will be examined in theoretical and practical aspects.
The very beginning years of human life attracts the attention of researchers in recent years. Especially in the period of 0-3 years of age, brain development is very fast and also the basis of the characteristic features is discarded.
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Through the psychotherapy practices with adult patients, the importance of early childhood times on mental health began to understand more. Today we know that early childhood experiences have power to affect rest of one’s life in physical, emotional, cognitive or social areas (Movder, Rubinson & Yasik, 2009). Therefore, in the early years of childhood, therapeutic interventions are quite valuable to minimize the risk factors of future problems.
The main goal of this paper is to make a summary about different approaches in early childhood psychotherapies. Although there are hundreds of different therapy techniques in the literature, this paper will only focus on some of the technique which use in 0- to 3-year-old-children.
Psychotherapy in 0- to 3-year-old-children: from past to present
The therapeutic work with children had begun with the case of Little Hans who had been analyzed by Freud (1909). Hans was five years old when Freud started to treat him. On the other hand, a two and three-quarters-year-old patient Rita, was treated by Klein (1960). This was the first case study in 0 to 3 years of age group.
At the beginning of the therapeutic work with children, it was known the effect of the psychoanalytic ideas. Later, child psychologists, who work with different schools, developed different approaches and different techniques. Some of them were non-directive and took the child to the center. Others were directive and focused on parent-child relationship. In this paper, I will focus to psychoanalytic / psychodynamic theory based approaches. And then, I will shortly mention some other approaches.
Psychoanalytic Play Therapy
This therapy approach is based on Freud’s classic psychoanalytic thoughts. Anna Freud (1946 as cited in Astramovich, 1999) and Melanie Klein (1960) established the framework of this therapy technique. They stayed loyal to the some of the basic concepts of psychoanalysis such as unconscious materials and defense mechanisms. But still there were some differences between them.
According to Klein (1960), children play purely symbolic games. In this regard, child’s play is similar to “free association” in adults and must be analyzed and interpreted by the therapist. Klein stated that even little children have insight capacity; therefore she found it important to interpreting the child. In her view, interpreting the unconscious symbols and metaphors will help the child to understand his or her real feelings. So that the anxiety level of the child will decrease. She also mentioned about the transference process in children. When she began to treat her two and three-quarters-year-old patient Rita, she was going her home and playing with her toys in her room. But then, she thought that this process may not let the transference occur, and consequently she proposed to analyze child in consulting room, not in the child’s house. (Klein, 1960)
Anna Freud (1946) thought different from Klein in some matters. She brings two main objections to Klein’s methodology. Firstly she mentioned about the issue of “free association”. According to Freud, child’s play cannot think as a version of free association in adults. She believed that a child’s play is not always symbolic; it could be a replaying of real events. She also thought different in transference process. In terms of her point of view, the child’s interest to the therapist can be seen as an affectionate attachment rather than transference (Freud, 1946).
According to Astramovich (1999) toys and child’s play are tools to get unconscious material. The therapist tries to make the unconscious processes conscious, and to gains insight into the child. Therefore, the therapist should be empathic and encourage the child to develop a transference relationship. The main goal of this technique is to foster the awareness of wishes and conflicts; and help to children to improve tolerance to their own feelings.
Child-Centered Play Therapy (CCPT)
CCPT was developed by Virginia Axline (1947) who was student of Carl Rogers. This approach based on Rogerian view. Axline gave place to some of the basic concepts of humanistic theory such as unconditional positive regard, genuineness and empathic understanding. Although Axline herself did not work with the 0 to 3 years of age group, CCPT is used for this period. In a study (Frick-Helms, 1997) 2.8 year old child was treated with this approach.
According to Axline (1947) this is a child-led, nondirective approach. It has two main purposes: to help for change and to increase the self-determination of the child. There are no diagnostic interviews before the treatment. Past is past and the child will tell his or her story when the time comes. Therefore, CCPT therapist does not focus to interpreting the child. In play room, the child is free to do what he or she want. The therapist follows the child; accommodates child’s steps and not try to lead to the child or not hurry up to solve the problems. The therapist must be vigilant and tender to the child’s requirements. Acceptance and understanding of the child is crucial. When the child realizes that he or she accepted by the therapist, it increases the self confidence of the child. (Axline, 1947)
CCPT also focuses the recognition of the child’s real self. Moustakas (1959 as cited in Astramovich, 1999) mentioned that the lack of recognition of the real self shows negative effect on children and thus, children can not reveal their potentials. The therapist’s task is to help the child for realization his or her own real self. This process will bring emotional insight to the child.
Jungian Analytic Play Therapy
This approach is based on Carl Gustav Jung’s theoretical view about human psychology. Jung (1954 as cited in Robson, 2010) believed that we all have two types of unconscious: personal and collective. And both of them have archetypes which contain ideas, images, voices and etc. In his point of view, the therapist should provide a reliable environment to the child for playing and revealing the unconscious material. Then the therapist interprets the play and that gives a chance to therapist to promote the child through a healing process (Robson, 2010).
There is not enough information about the practice of this approach with 0 to 3 years of age group. However, I can mention about a kind of Jungian sandtray therapy technique called as “sandplay therapy” which is suitable for every age period. I will touch on this subject later in “sandtray therapy” chapter.
Psychoanalytic Parent Infant Psychotherapy
The foundations of this approach come from psychoanalytic theory. It is a version of psychoanalytic play therapy for 0 to 2 years of age period. Therefore, some changes are made.
According to Baradon (2005) one of the changes is the position of parents in the therapy process. Unlike classical psychoanalytic view, parents have crucial position in this approach. The therapist tries to support parents to enable better relation with the infant, to enable emotional regulation of both themselves and their infants. Also this approach more focused on the infants to support their development. Positive attachment behaviors, baby’s coherent sense of self, potential developmental risks, separation and individuation process are worked with parents and infants together. (Baradon, 2005)
Baradon also mentioned that, in this approach, the relationship between parents and their infants is seen as patient. The therapist tries to establish a laborsaving environment for the therapy and leans on the relationship. Transference and counter-transference processes; defense mechanisms and resistance are taken into consideration by the therapist. The therapist also procures guidance to parents about the care of the baby. Other important features of this method are assessment and observation of the infant. Psychoanalytic Parent Infant Psychotherapy may use in group settings. It also should be noted that each session is videotaping in this approach. (Baradon, 2005)
Filial Therapy (FT)
This approach was developed by Drs. Bernard and Louise Guerney in the late 1950’s. According to Drewes (2009) FT is a kind of multi theoretical psychoeducational approach which exploits other approaches such as family therapy, play therapy and cognitive-behavioral therapy. In this technique, the therapist teaches and guides parents as they learn how to play their children. FT is suitable for children 2-12 years of age. It is also useful in group settings. Individual parent sessions generally continue between 15 to 20 one-hour sessions. And group sessions meet for two hours between 10 to 20 weeks.
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Drewes also mentioned that FT practice begins with an intake session. Then the therapist observes the family while they are playing together. This observation process takes about 20 minutes. Right after the observation, the therapist talks with parents about the play and tell them the FT method. Then the therapist plays with the child in a non-directive way in order to teach to parents how to play. Meanwhile, parents watch the therapist. Towards the end of the session the therapist and parents discuss about the child’s play. The therapist listens to parents empathically and answers their questions (Drewes, 2009).
When the training period starts, the therapist trains to parents about playing skills. Parents learn four basic skills: structuring the play, empathic listening, child-centered imaginary play and limit-setting skill. Later, the therapist acts like a child and parents play with the therapist. Parents are encouraged to show what they learn about the play. The therapist gives them feedbacks. After that, parents play with their own children with the supervision of the therapist. Finally, towards the end of the treatment, parents practice the play in the home settings. (Drewes, 2009).
Theraplay (Attachment-Enhancing Play Therapy)
Theraplay is a short-term therapy approach which is based on attachment theory (Booth & Jernberg, 2010). It is appropriate to children from eighteen months to twelve years. The core aim of this approach is to improve a safe, compatible, playful relationship between a child and his or her parents.
According to Booth & Jernberg (2010) the treatment plan of theraplay practice is generally for eighteen to twenty-four sessions. Every treatment plan includes; assessment, treatment and checkup phases. In assessment phase, the child’s behaviors and the parents’ attitudes are assessed by the therapist. In the first treatment phase there can be one or two therapists. If there are two therapists, while one of the therapists is playing with the child; the other one, the interpreting therapist, works with parents. In the beginning of the treatment parents do not join to play sessions. They watch their child from two-way viewing mirror with the interpreting therapist or they watch from videotape after the session (if there are not two therapists). The interpreting therapist talks about the rationale of the theraplay, the problem areas of the child, wishes, concerns and expectations with parents. In the second treatment phase, after observing process, parents play with the child in theraplay room. In this phase, four basic skills are taught to parents: structuring, challenging, intruding and/or nurturing. After a termination session, the checkups phase comes. Checkup sessions are made quarterly in first year and annual thereafter. (Booth & Jernberg, 2010)
Watch, Wait and Wonder (WWW) / Infant-Parent Psychotherapy (IPP)
I will introduce these two approaches as together because both of them were developed by same team at the Hincks-Dellcrest Children’s Mental Health Centre (Toronto, Canada). WWW and IPP are effective on infants and based on psychodynamic principles such as “unconscious”, “transference”, “countertransference” and “potential space” ( Tuters, Doulis & Yabsley, 2011). Also these concepts are considered in conjunction with the attachment theory.
One of these two approaches is WWW. First W tells to parents “watch” the play of the infant! What is the infant doing? Second W tells to parents “wait” the infant’s play. Don’t hurry! Let the infant take to lead in the play! And third W tells to parents “wonder” about the infant’s play. What is the infant trying to tell you? The infant’s play is seen as “potential space” between the infant and the parent ( Tuters et al., 2011). There are two basic principles of WWW. To accept the leadership of the infant in the play and to accept that the play has a symbolic meaning. Every WWW session has two parts. In first part, the infant plays and the parents are asked to play with the infant on the floor. In play, leadership must be in the infant and the parents should follow the child. In second part the play and the thoughts and feelings of parents are discussed with the therapist.
Infant-Parent Psychotherapy (IPP) approach is similar to WWW. Their basic principles are same, but there are some little differences between them. In IPP, in order to show the effect of parent’s unresolved past issues, the therapist is more active in play. And also countertransference process is more considered in IPP (Tuters et al., 2011).
The Developmental, Individual-Differences, Relationship-Based (DIR) Approach
This approach was developed by Stanley Greenspan and it provides a multi-dimensional system in order to assess and support of infants and children with different developmental characteristics (Greenspan & Wider, 2006). It is especially effective for children who have autism spectrum disorder, down syndrome, learning disorders and developmental disorders. However, DIR approach is suitable to define the child’s and family’s features.
According to Greenspan (2006) the “D” expresses developmental levels. It gives an idea about that question: “Where is the child in developmental continuum?” The “I” expresses individual differences. It emphasizes biologically based capacities such as auditory processing, motor planning and etc. And the “I” expresses relationship. It calls attention to the relationship between the child and the parents. DIR approach benefits from floortime, which is a kind of play technique, so as to practice the model. Floortime is performed with little children on the floor. Taking into account the children’s individual differences, floortime supports their developmental levels relationship skills. (Greenspan & Wider, 2006)
This approach was developed by Dr. Susan McDonough so as to understand mother-infant relationship through the interactive play experience. It aims to consolidate the relationship between infant and the mother and to increase the mother’s enjoyment from interactions with the infant (Balbernie, 1998). Core concepts of this approach are “therapeutic alliance” and “strengths of the family”. According to Balbernie (1998) the model focuses on strength features of the family system and tries to consolidate them. The mother’s past is not analyzed. Transference dynamics are considered but there is no fully interpretation. Treatment phase contains 5-12 sessions. Videotape is used in this approach.
Ecosystemic Play Therapy (EPT)
This approach was developed by O’Connor who emphasizes the importance of the children’s whole ecosystem. According to O’Connor (1997) EPT is a multi theoretical approach. It is not based on only one perspective. The main aim of the EPT is to promote the child’s abilities in order to cope with their needs. The basic role of an EPT therapist is to replace the core beliefs of the child with a functioning way. And also, the therapist tries to make the system to be more responsive to the requirements of the child. (O’Connor, 1997)
Caregiver-Toddler Play Therapy
This approach deals with disturbed relationship between the caregiver and the toddler. According to Schaefer & Kelly-Zion (2008), the main goal is to improve this disturbed relationship with the play. There are three constituent in this approach. First, the therapist establishes a “simultaneous relationship” with the toddler and the caregiver. Second, the therapist is able to “speak for the child” and that supports the communication between the toddler and the caregiver. And third, the therapist guides to caregiver for teaching relational skills. In the beginning treatment, the therapist is very active, but then the caregiver is expected to be more active. (Schaefer & Kelly-Zion, 2008)
It is a Jungian version of “Sandtray Therapy” which is developed Dr. Margaret Lowenfield. A Jungian therapist, Dora Kaff, adapted Sandtray Therapy to a Jungian perspective and she called this new version as “Sandplay Therapy”. According to Zhou (2009) this is an expressive therapy which is appropriate for all ages. This approach helps to emerge nonverbalized emotions. In this technique, children play with sand, water and little miniatures. The symbols in the play reflect personal and collective unconscious and with the help of the therapist the ego of the child is restructured (Zhou, 2009).
If we consider human life such as a building; 0 to 3 years period correspond to foundation of it. And if this foundation is not strong enough; this building encounters with the risk of falling down. Today, although preventive approaches has already started to gain importance, in some cases, more serious interventions are needed. Child psychotherapies in 0 to 3 years of age group meet this need.
The main goal of this paper was to mention different psychotherapeutic approaches which use in 0 to 3 years of age group. It is impossible to mention all approaches therefore I have tried to describe most known and most effective approaches. However, psychotherapy world is not static, in time, different new approaches will emerge.
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