As is well known, each specialist approaches his patients concentrating on his particular field of work. If his investigations result negative, he can only try to reassure the patient or, if considered appropriate, refer him/her to another specialist – where the same clinical principles will be followed. General practitioners, paediatricians and various other specialists will often find themselves struggling with children or adolescents who present physical complaints that do not respond to words of reassurance or to multiple treatment attempts, even though all laboratory investigations fail to identify any underlying physical abnormality. My new book, The Language of Distress, describes a particular approach to such cases, where the consultation led to the finding that the response given by the parents to their child’s symptoms was, in fact, perpetuating their presence.
I am a psychoanalyst and had a NHS career as a Consultant Child and Adolescent Psychiatrist. Indeed, many of the cases to be described were seen in a Child Guidance Clinic and in a Child Psychiatry department in a General Hospital. But how is my approach to be classified? My child psychiatry colleagues had very different techniques when seeing their patients and my psychodynamic colleagues also followed completely different methods in their practice. I did not prescribe medicines and only in particularly complex cases did I recommend long-term individual psychotherapy.
At one point I was told that, even if I was a competent psychoanalyst, the way I practised and taught did not match the typical image of one.
Indeed, it will be seen that, though I speak of the “unconscious” very often, there is no attempt to describe the “mechanisms” followed in my patients’ communications. The word ”instinct” is not used, much as “transference” or ”counter-transference”. Essentially, I concentrate on trying to understand the message expressed by the child in his words, drawings, and play. I believe I learnt this from Winnicott’s work with the squiggle game, as described in his book Therapeutic Consultations in Child Psychiatry. His objective was to understand the unconscious content of the child’s communications. The language of the squiggles, one might say. As it happens, I am fascinated by language and how each individual aims, tries, or manages to convey and express what he thinks and feels. I believe very strongly that very soon after coming into my consulting room, a child (or any patient, really) knows whether he has any chance of being helped by me – and this impression will influence how he proceeds to address me.
Meeting the child and the parents, one proceeds as in a standard diagnostic consultation. General questions to the child about his/her feelings are followed by the presentation of toys and drawing materials. In most cases, one simply tells the child to draw anything they like, though occasionally the subject of the picture is chosen in line with the presenting symptoms or other related features emerging in the conversation. As the child draws, one addresses the parents, requesting some account of their life experiences (“so as to understand the environment in which the child grew up” is my usual formula) and then, more specifically, of their views of the child’s complaints.
When the child indicates being “ready”, one examines and discusses with him/her the content of the drawings and explanations offered by the child. This will, ideally, help us to identify the unconscious conflicts that were underlying the physical complaints – and quite often the child’s feeling of relief is visible and immediate. The parents can then recognize that they had misinterpreted the child’s behaviour. This will usually lead them to see that they had come to interpret the child’s complaints on the basis of their own private lives. In practice, this led to their ineffectual approach to the child and the persistence of the symptoms. As soon as the parents change their response to the child, the symptoms disappeared.
This book puts forward the view that the presenting complaint is a manner, a language through which the child conveys to the parents his/her emotional suffering: hence the expression “language of distress”. And it follows that I define my role as that of a translator, finding the words that express the child’s anxieties in a manner that both child and parents can understand each other.
A. H. Brafman trained as a psychoanalyst of adults and children. In his NHS career he worked as a Consultant in Child and Adolescent Psychiatry, and for many years ran a group for parents and under-fives. He ran Infant Observation courses at the Institute of Psychoanalysis and also seminars on psychodynamic work with children, adolescents and adults for the British Society of Psychoanalysis and several other training organizations. He was also Honorary Lecturer at University Hospital Medical School, where he taught students and psychotherapy trainees. He has published a number of books, including Untying the Knot, Fostering Independence: Helping and Caring in Psychodynamic Therapies, and The Language of Drawings: A New Finding in Psychodynamic Work. His latest work, The Language of Distress: Understanding a Child’s Behaviour, has recently been published by Karnac.
Reviews and Endorsements
‘Dr A.H. Brafman occupies a unique place in the field of child and family mental health. For more than half a century he has worked indefatigably, with unique compassion and clinical intelligence, to demonstrate the many ways in which young people and their parents can be understood, helped, and, in more severe cases, healed. I recommend all of Dr Brafman’s books, but his newest title should become required reading for every health care professional and every parent.’
– Professor Brett Kahr, Senior Fellow, Tavistock Centre for Couple Relationships, Tavistock Institute of Medical Psychology, London, and author of Tea with Winnicott
‘Through the case vignettes in this book, Dr Brafman vividly demonstrates the way children may communicate their distress in the language of their bodies when their feelings are not understood. He convincingly shows that in a consultation, if the professional meets the child’s wish to be understood then the emotional meaning of their physical symptoms can be illuminated and thus may abate. In the present culture of pharmacological and behavioural intervention, it is a pleasure to read these accounts of effectively simple understanding of children’s distress. This book is a timely contribution and will be of interest to all who seek to work with children and their families.’
– Angela Joyce, child and adult psychoanalyst, training and supervising analyst at the British Psychoanalytical Society