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ACQ Volume 11, Number 3 2009 167
Mental health
in the room. I empathise with Sandra’s difficulties, explore
the history of her relationship with Jonah and highlight her
good intentions for his development. At the same time, I
watch how Jonah interacts with his mother, his environment
and with me. I am interested in where he positions himself
in the room, his use of other people, verbalisations, eye
contact and emotional regulation. Observing the relationship
between a child and caregiver is crucial because the quality
of the infant–caregiver relationship may impact on emotional
and developmental difficulties in children (Mares, Newman,
Warren, & Cornish, 2005). I notice that Jonah moves quickly
from one toy to the next, with only the occasional glance at
his mother. Although I am concerned about this behaviour,
I resist the temptation to initiate interactions with him or to
scaffold his play. While I have always invested much energy
into building connections with children, I have learnt that it
is critical to first attune to the emotional needs of the parent,
particularly when there are difficulties in the parent–child
relationship. Fully concentrating on connecting with Jonah
at this stage may only result in Sandra feeling inadequate,
undermined and unheard (Chambers Amos, Allison, &
Roeger, 2006).
When Sandra has expressed her feelings and concerns
fully, I encourage her to engage with Jonah in play. This
allows me to observe Jonah’s communication and play
skills as well as providing insight into how well Sandra
can follow his lead and read his emotional cues. This is
important as it reflects how sensitive and attuned she is to
him, both of which are pivotal in the formation of a secure
attachment relationship (Cohen et al., 1999; Mares et al.,
2005). I move away from traditional ideas of (1) assessment,
(2) recommendations, and (3) therapy and instead use a
more dynamic therapeutic approach where all three may be
occurring simultaneously. At this moment, Jonah is pulling
pieces out of a puzzle. Sandra sits down next to him on
the floor and asks him to name the animals in the puzzle.
Jonah responds by looking at her, offering her the piece he
was holding and making the noise of a dog. Sandra does
not take the piece or extend on his utterance. Instead,
she tells him to put the piece in the puzzle. Jonah tries but
quickly gives up without asking for help. He throws the
pieces across the room. Sandra flinches. I wonder aloud
about what might have triggered the outburst. She tells me
that Jonah is “feeling naughty” and if they were at home,
he would “trash the whole house”. I work to contain the
situation by speaking on behalf of Jonah, and by mirroring
the emotional tone and internal states of both mother and
Sandra1 and her son, Jonah (2), arrive late to their
first speech pathology appointment at the Child and
Adolescent Mental Health Service (CAMHS). Jonah
is unsettled and Sandra looks exhausted and somewhat
agitated. I usher them into a clinic room, where a range of
toys are laid out on the floor. Sandra launches into a vivid
description of her son’s explosive tantrums, her concerns
that he only says a couple of words and her fears that he
will turn out like his abusive father. As she speaks, Jonah
moves aimlessly around the room. I ask Sandra what she
is hoping to gain from attending CAMHS. She says she
wants Jonah to say more words and that she would like the
psychologist, who is also seeing the family, to address his
anger management problems.
Where should I begin with this family? As a young
graduate, I felt compelled to rush into gathering data
about a child’s developmental milestones, risk factors for
communication difficulties and current functioning. I found
this information useful but soon realised that I was asking
about areas that trigger strong emotions. A child with
difficulties tugs at the very core of parents and many of the
families I was seeing were experiencing grief, loss, anger,
frustration, and even gut-wrenching guilt. This was scary
stuff! Clearly, I needed to acknowledge and validate these
emotions but I felt totally out of my depth in providing what
I then viewed to be counselling. Too often, I found myself
trying to put a “bandaid” on a parent’s negative affect by
being the “bright and bubbly” clinician and by prematurely
offering problem-solving strategies.
Now, after a decade of experience and reflection, I
understand that all clinical encounters occur in the context
of relationships. This means that when a parent presents
as overwhelmed or anxious my first goal should be to
create a safe environment in which their feelings can
be acknowledged and supported (Geller & Foley, 2009;
Weatherston, 2000). Information gathering is complemented
with the building of therapeutic relationships, which
constitutes a shift from simply establishing rapport for the
sake of encouraging participation in therapy. The time it
takes to establish a therapeutic relationship can be lengthy
with some families, particularly when the barriers parents
face in forming relationships with their children also act as
barriers to forming therapeutic relationships with the clinician
(Geller & Foley, 2009).
With this in mind, I spend the first part of the session
with Sandra and Jonah sitting with the strong emotions
My journey into
relationship-based practice
Kristy Collins
1. Names and details have been changed.
Kristy Collins