Primary Menthal Health

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Paul van Heeswyk

A CHILD PSYCHOTHERAPIST IN PRIMARY

MENTAL HEALTH

This paper outlines the authors application of psychodynamic thinking and approaches tobrief therapeutic work with children, adolescents and their families in community mentalhealth settings. It is the authors belief that systemic and narrative therapy insights andtechniques combine well with psychoanalysis in the assessment and treatment of manyconcerns felt and expressed by parents and young people. The therapists tasks are to listenempathically to clients who are in distress and to explore the clients beliefs about theorigins of their problems, as well as their previously attempted solutions. In proceeding atthe familys pace, opportunities arise for facilitating more effective ways of resolvingconflict. Clients are often more free than they realise to change their interpretation of theirexperience, and this has important consequences for the maintenance and solution of

problems. Brief therapy seeks to remind clients of their strengths and resources and to shareways to encourage clients to resume effective ways of learning about themselves.

Keywords child psychotherapy; primary care; psychodynamic; narrative;systemic; brief interventions

Introduction: timely services

The real voyage of discovery consists, not in seeking new landscapes, but inhaving new eyes.

(Marcel Proust)

The National Service Framework for Children, Young People and Maternity Servicesestablishes 11 standards for promoting the health and well-being of young people, theninth of which covers mental health needs. This standard requires that all children andyoung people should have access to timely, integrated, high quality, multi-disciplinary mental health services. A marker of good practice is when child andadolescent mental health (CAMH) professionals provide a balance of direct andindirect services and are flexible where children, young people and families are seen.An important component of indirect services will be consultation, training andsupport to all first line services who have contact with young people and theirfamilies, in health, education, social work and other community settings.

Clinicians recognise that the provision of timely services requires the quickestpossible response to people in need. This is not just a matter of dutiful compliance


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with what can feel like an excess of targets and recording demands, in a world whereservices are continually being reviewed, authorised or deleted. We all know howpainful the worries and concerns about their children are for parents who often feelisolated in the absence of support from extended family and local neighbourhood or

community. As CAMH professionals, we feel better about ourselves and our workwhen we do not have to make families wait for our help. We also know that a rapidresponse, delivered close to the moment at which families recognise the need forhelp, can prove especially effective. However, in the finite world of human resourceswithin CAMH Services (CAMHS), a corollary of improved accessibility and rapidresponse is the requirement for services to be brief or time-limited. Where suchinterventions are appropriate and well-matched, so much, of course, the better. Butthere remains the concern that the impact of financial and other pressures can lead tothe provision of services that are possible and available, rather than those that areneeded. This can seriously undermine the professional morale of clinicians who may

feel themselves to be confronted by an apparent obsession with quantity and statisticsat the expense of quality of work.

I qualified as a child psychotherapist in 1981 and have worked for the last fiveyears as a Primary Mental Health Worker in a Health Centre, alongside generalpractitioners (family doctors), health visitors, school nurses, district nurses and othercolleagues in NHS professions. The policy within our particular CAMH Directorate,in the spirit of the National Service Framework, is for experienced professionals fromsocial work, nursing, family therapy, clinical psychology and child psychotherapy topractise as Primary Mental Health Workers at Tier 2, providing a specialist individualprofessional service to families, as well as consultation and training to colleagues inprimary care. In addition, Primary Mental Health Workers are members of thespecialised multi-disciplinary Tier 3 service which is offered for more severe,complex or persistent disorders. In this paper, I will outline my specific contributionas a child psychotherapist, in terms of thinking and approach, to the field of primarymental health.

Principles for making therapy shorter

Child psychotherapists have always worked in community settings and haverecognised the need for brief interventions in their work with young people andtheir families. This sometimes comes as a surprise to other mental health professionalswho refer to the long training of child psychotherapists, the minimum of five years ofpersonal analysis, and the core commitment to intensive and long-term individualtreatment of clients that is required for qualification. Clearly, much of the therapycarried out by child psychotherapists at Tier 3 will be open-ended and of longerduration, a task for which our training uniquely qualifies us, but an important aspectof the lone practitioner role in primary mental health is the assessment of suitabletreatment for children and young people who present with emotional and

psychological difficulties. In particular, one question that continually arises incommunity child mental health settings is whether a brief therapy approach isappropriate to the needs of a presenting family I myself share the view of the Italian

2 5 2 J O U R N A L O F S O C I A L W O R K P R A C T I C E


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family therapist and trainer Mario Andolphi, who was once apparently heard to say ata workshop: to make shorter the therapy, first make longer the training (quoted inEcker & Hully, 1996).

Moshe Talmon (1990) reminds us that Sigmund Freud, the founder of

psychoanalysis, (probably the longest form of therapy), once treated a patient knownas Katharina in one session whilst on vacation and that Freud later claimed to havecured the composer Gustav Mahler of impotence during a single long walk in thewoods! My own interest in psychodynamic approaches to brief therapy began with thework in the 1920s of two close colleagues of Freud Ferenczi and Rank who wereconcerned that psychoanalysis had become too didactic and cerebral. These two analystssought to shorten the treatment (which could often appear interminable) through anemphasis on a more experiential encounter of doctor and patient. I am often remindedin my clinical work of some observations of Otto Rank, which, with a few changes ofterminology and emphasis, could have contemporary relevance and warnings:

While the parents are inclined to overlook the part played by their own conflictsin the childs problems, or to completely deny it, the child on the other hand ismore inclined to feel itself responsible for the parents difficulties. And actuallythis feeling of the child is to a certain extent justified. The child brings a newelement into the relation of the parents one to another, and this element is notalways, or is not completely, a harmonious one. The fact that the child seems tofeel this more than the parents is obviously connected with its whole attitude tothe world of reality. The child inclines too much to identification, which he onlygradually gives up at the adult stage of the so-called adjustment to reality if he

ever gives it up at all. In contrast to this, the adult is very much inclined toprojection, which is to say is the price at which he purchases his adjustment.

the child inclines altogether to introversion guilt feelings can more easilybe unburdened if he is permitted to project his conflicts onto the parents thechild has to learn to allow himself to make the parents responsible for certaindifficulties, instead of looking for the fault exclusively within himself whichleads to the feelings of guilt and inferiority such an attitude on the childs parttempts pedagogues and parents to look with the child for the cause ofall evil in the childs own emotional life

(Otto Rank, 1927)

As absolutely dependent infants, we are born with the imprinted urgent need toform close attachments to our carers. The inherited memory of the species is thatchildren who bond with their parents will be looked after and will live, whereas thosethat do not will be abandoned and will die. Our sensitivity to the actions and responsesof our parents towards us is therefore a felt matter of life and death that leaves us witha propensity for fundamental anxieties in terms of whether we are loved or not. Suchanxieties can leave a residue in terms of templates for future relationships: If mymother does not love me, I am unlovable, in and of myself, and for all time.

Abusers, we know, typically project guilt and may exploit a tendency invulnerable children to believe that their bad treatment is in fact deserved punishment.B t R k i t t th b i ti h I t f th

A C H I L D P S Y C H O T H E R A P I S T I N P R I M A R Y M E N T A L H E A L T H 2 5 3


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family life cycle, the birth of a child to the couple can constitute a normative crisis,unleashing all sorts of conflict in the parents. Partners become parents and thetwosome must adjust to accommodating a third member, with the possible re-emergence of early feelings of rivalry and exclusion. Similarly, in Ranks anticipation

of Winnicotts work on the anti-social tendency, environmental failure mustsometimes be acknowledged and repaired before a childs atrophied development canresume its course. However, Gregory Bateson states an important principle forindividual therapists to take into account.

In the field of psychiatry, the family is a cybernetic system and when systemicpathology occurs, the members blame each other, or sometimes themselves. Butthe truth of the matter is that both these alternatives are fundamentally arrogant.Either alternative assumes that the individual human being has total power overthe system of which he or she is a part no part of such an internally interactive

system can have unilateral control over the remainder or over any other part. Themental characteristics are inherent or immanent in the ensemble as a whole.(Bateson, 1972).

This systemic principle has helpful and liberating implications for working withthe mental health needs of young people in challenging the scapegoating orpathologising of individuals. As such, it forms part of an approach that underpins thework of family therapists. For myself as a child psychotherapist, the work ofWinnicott is similarly fundamental.

Interventions based on theories of emotional development

Winnicott was a paediatrician who later trained as a psychoanalyst. For these reasons,probably, he believed that one must have in ones bones a theory of the emotionaldevelopment of the child and the relationship of the child to the environmentalfactors (Winnicott, 1971). The parents are the first environment and their task is toadapt actively to the needs of the infant, but it is clear, of course, that children need adifferent and evolving quality of relationship to their carers at each stage of theirdevelopment to sustain growth. A Winnicottian-based approach seeks out and

highlights the strengths and resources of both children and parents and combines thiswith a developmental theory that facilitates the identification of the particular goal foreach stage of development and the kinds of interaction that will facilitate its successfulattainment.

Case example: John

John is eight and has begun stealing from his family. He also has episodes ofencopresis. I sense from the anxious looks in my direction from his worried but

clearly devoted parents that they are concerned that he may have been abused. Theyseem to want me to get to the bottom of this, so to speak, seemingly, if our

th d f tt ti t i t ith h th id b f



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of mind-reading or other divination. Fortunately, as it turns out, my easily assumedair of incompetence and incomprehension forces mother to ask her son directlythe question she has hitherto felt too frightened to ask. I am now witness to amoving dialogue which convinces and reassures both parents and myself that no one

has ever physically harmed this boy. Parental relief opens up further sharing.Mother tells her son how, when John was a few months old, she lost her own motherin a fatal road accident, a family story that clearly John already knew. However,mother now feels that in retrospect, she was certainly traumatised by this suddenbereavement and she wants to let John know that he must have felt that he suddenlylost his mother too. Father regrets that he did not help out more at home,preoccupied as he was with work commitments. One year later, the first of Johnsthree siblings was born.

The parents have linked their sons stealing with his loss of something he wasentitled to assume was his by right, a certain and continuing quality of care and

attention from his mother and father. The family ask to return in two weeks when Ilearn that there has been little change in Johns behaviour. We look together at howthe parents have been responding to Johns stealing (there has been another incident)and it becomes clear that their attempts to encourage John to earn his pocket moneythrough good behaviour are not working. The main problem in the family, theparents agree, is Johns stealing. In the spirit of their understanding of the origins ofthis, they agree to give John an appropriate sum of pocket money every week,irrespective of his behaviour and, more importantly perhaps, to ensure they spendsome special time with him on a regular basis, sharing with him an activity he reallylikes to do that is chosen by him.

I feel the parents have symbolically returned to and addressed an infants missingrelational experience and my wish now is for us to engage with the undoubtedstrengths and capacities of the eight year old before us. All four of us work outtogether a version of the honesty test ritual (Durrant & Coles, 1991; Epston, 1989)in which Johns parents will inform him of a place in the house where they will leave asum of money unattended, after they have heard from him some methods he hassuccessfully used to stop himself stealing in the past and have talked through with himsome strategies they have themselves found helpful in dealing with temptation. Johnwill then let them know next day, on a scale of 1 to 10, how difficult it was to resist

the temptation and which particular strategy he found most useful. Parents and childleave with a spring in their step, and I ask John if he might think about sharing the planwith his grandfather, who, he had told me previously, was the person outside of theimmediate family who was most worried about him.

In listening to some of the concerns parents bring to child mental health settings, Isometimes think to myself that I have often had similar or more severe concerns aboutmyself as a parent or partner, and likewise equally unsettling worries about mychildren, and yet I did not seem to feel the need to seek professional support. As Ireflect on this, it does not seem to me that this is my professional pride or personaldenial in operation, since I have no difficulty in talking about these matters to anyone I

can get to give me attention. Again, Winnicott can be helpful here in putting mattersin perspective. We are poor indeed if we are only sane he once famously remarkedand true neurosis is not necessarily an illness we should think of it as a tribute to



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the fact that life is difficult. Again, even when our patients do not get cured they aregrateful to us for seeing them as they are.

Solution or reawakening?

Through psycho-education and normalisation, therapists in primary mental health cansometimes alleviate parental concerns about what they may be identifying as worryingbehaviours in their children. It is a measure of how isolated families can be incontemporary urban areas that they do not realise that many children struggle in verysimilar ways with particular developmental challenges that lead to no serious longterm consequences for their emotional health.

But more than this, childrens problems, struggles and conflicts can even be seenas necessary and inevitable for growth. At each developmental stage, children have to

negotiate optimal personal and environmental mismatches, the complex interactionsbetween their psychological functioning and the values of their families, peers, schoolsand communities. This can lead to disequilibrium and new problems . Thetherapist needs to be sensitive to the effects of the childs own adaptation to hisdevelopmental struggles on other family members and how family members, in turn,respond to the child (Selekman, 1997).

There is another important issue here as well, an issue that those cliniciansworking within a brief or solution focused approach continually highlight. A majordifficulty with outcome studies in the area of mental health is that the successfulcase at discharge may not be a cure in the sense of the elimination of a problem

or symptom, but may instead be the reawakening in the family of the belief thatthey have now (and probably always have had in other areas of their life at least),the tools and resources to deal with problems as they arise, even if life may behard sometimes and solutions slower to take effect than they would like. In this ageof rapid change, demands for instant solutions become increasingly more insistent(as five minutes spent watching television commercials will confirm). However,we humans are a problem-solving species and if, inadvertently, in the course of ourwork, we take the recognition of this capacity away from our clients then they leavewith less than they came. The task of the therapist in primary mental health is not tofind out what is wrong with the clients and then tell them, but to share with theclients ways to enable them to resume effective ways of learning about themselves.The work sets in motion or re-starts a process, in the hope that this will be self-maintaining.

For example, all therapists presumably share a belief that humans create much ofthe meaning they attribute to the events and relationships they perceive in the worldaround them. Narrative therapists maintain that the ways we perceive ourselves andthe world are organised through the stories we tell ourselves, and that this is theinevitable accompaniment of our interactions with others. Moreover, because storiesimply certain futures, they inevitably exert powerful influences on our present

thinking and behaviour.In constructivist approaches, the emphasis is on recognising that people are active

in the creation of their experiential reality even though they usually feel that this



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inner world of meaning is operated by some remote control device in the hands ofsomebody (close relatives) or something (the culture) else. This is the often reportedsense of feeling like a helpless passer-by in ones own life. As a child psychotherapist, Iam inclined to feel that the reason people are unaware of their role in assembling their

model of reality and of the extent to which they choose to give meaning to events intheir lives, is that much of this process is carried out unconsciously. Nevertheless,even though there may always be some difference in terms of the extent to whichpeople can or should reinvent their subjective picture of the capacities, responsibilitiesand relationships of themselves and others, I share with brief therapists the convictionthat people are freer than they realise to make changes in how they view and interprettheir reality, and that this has important consequences for the ways problems arecreated and solved. This is not to say, of course, that all personal suffering can orshould be eliminated by reframing, or by authoring another story. The grief andsadness of loss, or the rage at frustrating obstacles or unfair and abusive treatment, are

appropriate responses, however unpleasant for the sufferers concerned or thosearound them. These responses might only be considered symptomatic if expressed inself-endangering behaviour, displaced onto undeserving targets, or if appearing to bestuck and unchanging over a protracted period of time.

A common criticism of some solution-focused approaches to brief therapy,however, is that families can feel that their worries are not taken seriously andthat they have not been listened to, if they are not given sufficient opportunity totalk about their problem. Worried parents and young people should not be rushedand the therapist, of course, also needs time to gain an understanding of the stepsthe family have taken to secure an appointment with the primary mental healthservice. Did the parents and children feel they were unclear why they were referredby a concerned professional from another agency, or were there specific triggers thatled the family themselves to a decision to seek help? It is important to take time tolisten to how each family member views the problem and to explore their thoughtsabout its causes and origins, as well as attempting to ascertain what the consequencesof the problem have been for each individual. We know that a problem shared is aproblem halved, and a problem well-defined is half solved. Thus, if my maths is right,we could at this stage already be down, problem wise, to quarter size. But moreimportantly, the statement of the problem will greatly inform the assessment.

Furthermore, the therapists hurry to move into solution-talk may mean that anopportunity is missed to help those families who have not found effective ways toresolve conflict and who are over-reliant on repressive or scapegoating methods ofmanaging difference.

Although the key transformational insight in narrative and constructivist therapiesis the recognition that the person is not the problem, it is often the case that familieswill arrive for a first meeting with the firm belief that one of their number is indeedthe problem. Generally, the parents, and sometimes the referred young person aswell, will see the problem as undesirable and will feel powerless to stop or controlit. Family members may also take the existence of the problem to prove something

very shameful about themselves. The parents may feel they are inadequate or failures,the child may just feel bad and guilt-ridden. Through careful listening it becomespossible at some points to check out whether the familys account of their difficulty



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comprises what narrative therapists call thin or totalising descriptions. In otherwords, is there a pattern in which only a limited number of events in the childs lifeare selected and given weight, when others which contradict the dominant story areignored and discounted? Often, a childs whole identity may succumb to a totalising

description: He is aggressive, a bad child; He is a bully, etc. For the child or youngperson, the multi-faceted experience of self may become narrowed and circumscribedas he or she fuses or becomes one (identifies) with a single set of experiences that isfelt to offer a complete and final definition of self.

Thus, an important part of the assessment in primary mental health consists ofthe attempt to see what the family does when encouraged to look for andaccess alternative stories about their child that contradict the problem-saturatedone. To some extent, this may take the form of a suggestion that the parents move outof their habitual and emotionally-charged immediate reactions to their childsbehaviour and become, for a period of time, interested observers and diarists. For

many parents, this offers the possibility not only of seeing with new eyes a fullerpicture of their child and themselves, but also of regaining a sense of perspective andcompassion. The therapist attempts to see whether whatever is said or believed by thefamily could be looked at from other points of view, and could, thereby, lose itsabsolute quality.

One advantage of keeping a diary is that you become aware with reassuring clarityof the changes which you constantly suffer and which in a general way arenaturally believed, surmised, and admitted by you, but which youllunconsciously deny when it comes to the point of gaining hope or peace from

such an admission. In the diary you find proof that in situations which todaywould seem unbearable, you lived, looked around and wrote down observations,that this right hand moved then as it does today, when we may be wiser becausewe are able to look back upon our former condition, and for that very reasonhave got to admit the courage of our earlier striving in which we persisted even insheer ignorance.

(Franz Kafka, 1948)

An important presupposition of this kind of intervention that seeks to broaden

observational powers and parental perspective is that even if one member of thefamily is exhibiting worrying behaviour, it may be that the problem in fact is locatedin the way the family operates as a group. If new information, in the form of changedparental beliefs as a consequence of new perspectives, is introduced, there is thepotential for change in the patterns of interaction and communication within thefamily.

In other words, if obsolete parental beliefs and interactions with the child can bechanged, this may lead to changes in the child. But for this to become possible, theparents observation of their child, and the childs self-observations, must be inrelation to a problem that can be solved. Oppositional Defiant Disorder, for example,

is a diagnostic category but not a solvable problem for a family in therapy. However, ayoung person who behaves in a challenging way, swears and refuses to comply withparental requests and rules presents us with an operational problem that is in



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principle capable of being solved. Questions to the child and family need to be framedin language that suggests a way of looking at problems in terms of events orbehaviours that can be measured and observed and that will allow clear feedback interms of whether change is occurring. Does your child always speak in an abusive

manner to you, or does she sometimes speak in an acceptable way? Even when yourdaughter is behaving in ways you do not like, are there times when this is lesstroublesome or severe?

To the child: Do you know when you are going to respond in a rude way to yourparents? Are there times when you do what is asked of you without complaint? Whatis different about those times?

Where such interventions and approaches do not seem to lead to change,important information has been gathered in terms of the assessment. Perhaps theproblem is not simply the consequence of outmoded beliefs or dominant oppressivestories. Perhaps it is not the case that the repetition and intensification of the same

parental attempts at solutions is maintaining the symptom or difficulty.Child psychotherapists are used to thinking of the possibility that a childs so-

called symptom, however distressing to the child himself, may constitute a solution toa problem that to the child seems worse. In other words, although consciously thechild may express the desire for the symptom to stop, he may at times feel theproblem to be necessary and must therefore continue to produce it. Some aspects ofthis kind of issue will be familiar to all CAMHS practitioners, especially whereproblematic behaviour clearly seems to serve a function in the family. For example, itis common for children to attract attention to themselves by employing worryingbehaviours or symptoms if they feel that their warring parents will only stop fightingwhen they can unite in their shared concern for their child. Such a strategy may beimplemented by the child with varying degrees of consciousness but if the maritalproblem is missed in the assessment then no attempt to persuade the child to give upthe problem will be likely to succeed. From a psychodynamic perspective, I am alwayslistening to clients in therapeutic conversations with certain key questions in mymind. Who is talking (with whose voice) to whom? And about what, orwhom, are they talking?

I may listen, for example, to a mother talking about her child as a disguisedcomplaint about her husband and the marriage. If a child is threatening to run away all

the time, is this a kind of sympathetic magic, the enactment of the wish that themother leave the impossible bullying father? Where the father talks endlessly of hissons refusal to communicate with him, is he saying he feels his wife to be cold andrejecting?

Some of these questions can be explored in meetings with the parents alone,when they may feel freer to open up about their own difficulties as part of anexploration of their theories about the origins of their childs problems.

But it is in an attitude towards the area of puzzling child behaviour orsymptomatology that the child psychotherapist may have a specific contribution tomake within primary mental health work. I am thinking here of those cases where the

childs presenting difficulty seems to be a genuine and personal construction of thechild alone, and is not an understandable reaction to parental difficulties, and whereth bl d t t l f ti i th f il



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Case example: Susan

Susan is 17 and is failing at school, despite major academic success in the past. She nolonger completes homework on time and her grades have tumbled. She feels

depressed. Her parents and school are bewildered, as is Susan, who sees the onceclearly identified dream of her identified chosen future career as now hopeless andunrealisable. I speak to the parents to eliminate the possibility that they are applyingpressures to their daughter but I am convinced by their loving and supportive concernthat this is not the case. They are happy for their daughter to take a break from schooland return to study at a later date if she would like to. But Susan is paralysed, unableto leave or stay.

I meet Susan on her own at her request and ask her, through her tears, toassume, for a moment, that this is not the incipient madness she fears, but is thelogical self-protective action of a person who feels, somewhere, hurt and

frightened, or is perhaps troubled by her own excitement. In what kind ofsituation, I ask her, might this apparently self-defeating behaviour be logical andappropriate? When might it make sense? She does not, of course, answer but I believethat the question has conveyed my certain conviction that this seeminglyincomprehensible difficulty is in principle understandable, even if it is not yet, orperhaps never, fully understood. She is visibly less anxious and we joke as she leavesthat perhaps she could write a short story in which the heroine struggles with exactlythis problem. She might also, I suggest, pay close attention to whatever she findsherself dreaming.

At a further session, Susan tells me she has started to work at schoolagain, although she is not sure what has led to the change. During theintervening weeks, she has found herself thinking about her fears of success,with the possibility this might mean she will be alone and unhappy. She has thoughta lot about loyalty and betrayal, without ever being able to link these thoughts toany beliefs about her parents or siblings, although she has found herself wondering,at moments, if she is frightened about standing apart from her friends. While sheis talking, I try to remember who it was that said: whenever we approachthe unconscious it is always closing time, when Susan suddenly tells me that shehas had a problem with her composition of the short story we joked about last

time. Apparently, the explanation for the heroines predicament, which onlycomes to light in the last sentence of the last page, changes every time she goes towrite it.

Kafka again:

Usually the one you are looking for lives next door. This isnt easy to explain, youmust simply accept it as a fact. It is so deeply founded that there is nothing youcan do about it, even if you should make an effort to. The reason is that you knownothing of this neighbour you are looking for. That is, you know neither that youare looking for him nor that he lives next door, in which case he very certainly

lives next door. You may of course know this as a general fact of your experience;only such knowledge doesnt matter in the least, even if you expressly keep itforever in mind



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References

Bateson, G. (1972) The cybernetics of self: a theory of alcoholism, in Steps to an Ecologyof Mind, ed. G. Bateson, Ballantine, New York.

Durrant, M. & Coles, D. (1991) The Michael White approach, in Family TherapyApproaches with Adolescent Substance Abusers, eds T. C. Todd & M. D. Selekman, Allyn& Bacon, Needham Heights, MA.

Ecker, B. & Hully, L. (1996) Depth Oriented Brief Therapy, Jossey-Bass, San Francisco.Epston, D. (1989) The Collected Papers of David Epston, Dulwich Centre Publications,

Adelaide, South Australia.Kafka, Franz (1948) The Diaries of Franz Kafka 19101923, ed. Max Brod, Minerva,

London.Rank, Otto (1927) Parental attitudes and the childs reactions, in A Psychology of

Difference The American Lectures of Otto Rank, ed. Robert Kramer (1996),Princeton University Press, Princeton, NJ.

Selekman, Matthew D. (1997) Solution-focused Therapy with Children, The Guilford Press,New York.

Talmon, Moshe (1990) Single Session Therapy, Jossey-Bass Publishers, San Francisco.Winnicott, D. W. (1971) Therapeutic Consultations in Child Psychiatry, The Hogarth Press

and the Institute of Psychoanalysis, London.

Paul van Heeswyk is Head of Child and Adolescent Psychotherapy in Bexley,

Bromley and Greenwich CAMHS. Address: Highpoint House, Memorial Hospital,

Shooters Hill, London SE18 3RZ, UK. [email: [email protected]]



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