In my presentation, I was hoping to illustrate how we have developed an NVR clinic that sits within the CAPA model, which is the service management system used in our service. I also wanted to be thinking about how brief interventions can still generate relational change, and what might contribute to this.
What is CAPA?
CAPA: Is a clinical flow management system that brings together:
● collaborative practice
● goal setting with regular reviews involving the young person/families
● demand and capacity flow management
● an approach to clinical skills and job planning
CAPA presents a real challenge for clinicians, in that we are expected to complete work within a limited time framework. I will often go on training, and at the back of my mind I am thinking about ‘how I can use this understanding in a way that is going to create meaningful change for our families / young people in 8 sessions!’ I really wanted following our NVR training, to make sure that we could deliver NVR within the CAPA model, and I needed to think about the tools and resources that we would need to be effective and efficient.
For the work to be truly systemic we needed to consider the triangulation of need between the needs of the family, the service and the practitioner.
We were fortunate enough to be able to consult a Lead Psychologist, who was working in a neighbouring NHS trust and we were able to participate in the development of the outcome tool with her, building on the key pillars and components of NVR. She worked and co-constructed the tool with us, her Trust and with families, to think about the model, and the language that we were using.
In the first appointment, I will use the outcome tool to provide an assessment framework that helps to generate a good understanding of what the parent’s concerns are. Using the outcome tool allows me to facilitate a robust understanding of what is going on for the family. Where does the work need to be? This is where we start care planning. Where do we dedicate our time? So for the family that I used as a case study, the outcome tool looked like this:
It was clear from both parents that they were feeling helpless, and hopeless. That they were not looking after themselves, and had little resilience. Both scoring self-care 1 and 2.
Using the outcome tool, our discussions suggested a rupture in the relationship between the child and her parents, but in particular between mum and the child. I started to learn about the family, and about their experience of trauma. Their eldest child had died in the care of health professionals, prior to the birth of their younger child. The death was entirely preventable and was a consequence of poor practice and that the parents had not been listened to. Working our way around the outcome tool, we started to open up conversations about their family that they had not had before. These reflections allowed me to start to think about how we could shape our work together and to understand this family’s story. It was clear that they could not understand their younger child’s distress, they had lost sight of how to connect with her or how to improve their relationship with her. This was enormously triggering for them, given their history.
The outcome tool helped me to build an understanding of parental presence. It also helped to develop my relationship with the family, building an alliance together. Allowing me to give the family space to be heard, for me to show that I cared and felt compassion for them. Many of these families have had long journeys with other agencies before meeting CAMHS, in which they have felt that they are not good enough parents and have not been listened to. This family had been battling for years, feeling that they had not been listened to, and shown little compassion. Their second child had started to present as challenging, and disruptive. They felt judged, they were told they might be overlooking something, and there might be something wrong with their child? They were fearful of letting their child down, confused by conflicting advice and information.
An NVR treatment plan starts to take shape:
This is not set in stone, but we start to consider where we need to focus our attention, and then things start to evolve from there. However, we always have to consider our time constraints and how to use our sessions wisely.
Before the end of the initial assessment, I will ask our families to start to think about what they are most concerned about, I will set them an exercise to complete, called the 3 baskets exercise, to bring to our next session. This allows us to have a clear understanding of what the parents want to work on, and what they are prepared to let go of. This helped me to start to hold in mind what meaningful change would look like for this family, and to start to explore expectations and what might be behind these behaviours.
This is what this looked like for this family:
The object of the work is to raise parental presence and rebuild the relationship between the parents and their child. This will mean that there will be some areas that require more attention than others, and for our family, this work led to needing to know more about what was behind their child’s distress, and what was the unmet need.
People who are born after the death of a sibling are sometimes conceived to fill the void left by their deceased sibling, although this dynamic varies in intensity. It might be counterintuitive to think that a death that occurred before someone’s birth might have an impact. But if we consider the ways that a family changes and reacts to the loss of a child, we can begin to picture the possible significance of being born into a bereaved family. A child’s death might result in lifelong mourning. Studies have shown that being born as subsequent children can have a significant impact on someone’s identity, attachments and life story.
Bereaved parents can sometimes struggle to attach to their subsequent baby as they fear another loss. They might have hoped that having another child would make the family feel whole again, but later realise that this does not erase their grief. In some cases, subsequent children inherit elements of their parent’s grief and trauma, in a process known as transgenerational transmission, where children can absorb some of the psychological burdens of their parents.
If we imagine the experience of an infant who is parented by a grieving or traumatised parent, we can understand that even before verbal communication occurs, the baby might absorb the parent’s sadness, stress or absence (Shoshan, 1989). When families struggle to mourn, a pattern of complicated grief may be passed down from one generation to the next (Liberman, 1979). Their family’s narratives of grief may become a significant part of their identity and lived experience.
Sarah Vollmann has done a lot of work on grief and the ‘replacement child’. She identifies the possible repercussions for children are difficulties in the bonding process. Low self-esteem and difficult relationships may develop. The replacement dynamics that can surround these children can mean that they frequently experience existential uncertainty, guilt and lingering grief. Many children will be prompted by these difficulties to look deeper and to examine their own existence, which our family’s surviving daughter experienced in the form of health anxiety, constantly fearing death, suffering and a feeling of not being safe.
Bowlby believed that a style of attachment is passed from one generation to another. He asserted that the child born to a mother who is highly anxiously attached will grow up to be anxious, guilty and perhaps phobic. It seems likely that a child who was born to a mother who was anxious or overinvolved due to the loss of her previous child, could develop an anxious attachment to their parents and other people.
This experience of attachment insecurity is increasingly being understood as a form of traumatic stress. In order for our family’s child to feel safe, she required both the anchoring function of attachment and a prolonged, trust-building effort from her parents. Mum had been clear that at the time of their engagement with CAMHS, she did not like her child, she avoided her because of her dysregulated and controlling behaviour.
This family had been in a sustained and protracted legal dispute over the preventable death of their first child for all of the early years of their surviving daughter’s life. They were on first-name terms with reporters, who were often outside or in their home, along with lawyers, other grieving families etc Their grief was complex and the impact on them was profound.
In order to support this family, the need to develop their parental presence and their strength was the first focus. Omer has contributed to Bowlby’s attachment theory by developing the concept of the anchoring function of attachment. In order to develop this anchoring function, we dedicated 2 sessions to explore the impact of their loss, and their child’s distress on them.
Peter Jakob also highlights the importance of parents being more likely to be able to focus on their child’s unmet needs when they experience some measure of strength. These parents introduced self-care, which had quite an immediate positive impact on them. For Mum in particular, the importance that was placed on this allowed her for the first time to have guilt-free time away from her family. This allowed her to develop her resilience. For Dad this enabled him to stop, anchor himself and think about what was the root cause of his child’s distress, what was being triggered in him, and allowed him to support her rather than escalate with her.
It was important for both parents to acquire what Jakob refers to as ‘presence-mind states’ and to no longer be controlled by their child. This would allow their child to start to face developmental challenges and grow in response to this, supported by a parent who is becoming more anchored in their responses. So having time out, which had previously been prohibited by their child was an extremely positive step for the whole family.
Wilson (Jakob et al,2014) highlights the importance of possible meanings in the child’s distress, and describes this as ‘The voice of need’. In order to develop a caring dialogue between our parents and their child, we started to focus on the voice of need in their child. Understanding why their child was so distressed and controlling was an important part of reconciling their relationship.
We dedicated a whole session, creating space for both parents to imagine what the need was behind their child’s distress. We reflected on the impact of the loss of her sibling, the impact of grief on others and their attachment. This was the stand-out moment for me- the lightbulb moment for us.
This in turn allowed us to start to consider what they needed to plan and implement in terms of reconciliation gestures. We talked about the language that they used, and the messages given. We also considered creating a space for their child to be heard (worry time), and for them to be fully present and to show their care. And on a more practical level a space for them to get alongside her to learn problem-solving strategies commensurate with what we would expect for a child of her age. The family were already doing lots of things that we would recommend in NVR- such as notes in lunchboxes, making favourite meals and lots of messages of love and care and hugs!
We then looked at reducing accommodation- both parents wanted to help their child understand that she could cope when she was not with them, and wanted more time together, which was in their small basket- so we considered how this might look to begin with, thinking about it in terms of graded exposure. Understanding how this might feel for their child, so setting it up in a way that allowed her to be exposed to her anxiety with the right support, for a short amount of time, and for this to be gradually increased. We talked about the distinction between accommodation and healthy protection, and that although their child would feel anxious, it would also be an opportunity for her to realise that she can cope when her parents go out together. It was an opportunity for her parents to start to give her different messages about their belief in her ability to cope. We talked about how they might share this change with their child, by introducing this in a considered way, with enough time and preparation, we then used our next session to elaborate some more on this.
We continued to think about how they would share their concern with their child- first of all letting them know how important she was to them, then what they were concerned about. What they were going to do differently, and how that was going to look. And how they were looking forward to her feeling confident and safe without them being there at times. We completed a role play of delivering the announcement and also of completing a sit-in.
An action plan was generated. I also directed parents to Eli Lebrowitz’s work (SPACE) for further information and guidance.
However following our review- it was felt by the family that further work was needed here, so we used another session to develop these ideas further.
Supporters
This was a moment that I wanted to be a significant moment that was not. The family was very isolated, we were able to identify friends and an ex-brother-in-law, who was a social worker who could provide both practical and emotional support, but there was some resistance from the family in accessing this support. There was an ongoing conflict with Dad’s family, particularly around their lack of support regarding this family’s historic legal battle. Mum’s father had cancer and was unwell, her mother was his main carer. Her sister had no children, and although I believe she was sympathetic to their situation, was unable to offer any practical support.
I tried to work with the family to build on the support that they had available to them. Dad set up a meeting with the school and shared the NVR literature and PowerPoint that we used. This had a positive impact and was also part of developing a supportive transition for their child to secondary school.
However the review highlighted little movement in this area, so I tried to set up a supporters meeting, which was sadly cancelled by the family due to another rupture in their relationship with Dad’s family.
The limitations of CAPA are such that this work had to be left outstanding. On reflection I would have liked to explore more with them their ongoing difficulties placing trust in others outside of their immediate family unit, which given their history was understandable, but worth further consideration.
Whilst I am aware that this family felt that they had received a timely intervention, there are families where this can be more problematic. This is why the criteria for the NVR pathway have to be given due consideration. There are families that require more input than the pathway allows, so we need to think about alternative systemic interventions that can be offered in a specialist setting as an alternative.
However delivering NVR within the parameters of our service provision has been very successful, with many positive testimonials from the families who have been offered this service pathway. By using the assessment tool to effectively identify areas of strengths, areas of concern and as part of the care planning review, I have been able to provide a bespoke intervention that targets the areas where families feel they initially need to focus their care and attention.
Written by
Jenny James-Moore, Specialist CAMHS Clinician
Accreditation Module Participant, 2023
References
Herefordshire Child and Adolescent Mental Health Services Operational Handbook
Jakob, P. 2011 Reconnecting parents and young people with serious behaviour problems- child focused practice and reconciliation work in Non-Violent Resistance Therapy. Tel Aviv. New Authority Network International.
Jakob, P. 2018 Working with Trauma. PartnershipProjects UK Ltd
Lebowitz, E.R. 2021 Breaking free of child anxiety and OCD- A Scientifically Proven Program for parents. Oxford University Press.
Lieberman, S 1979. A transgenerational theory. Journal of Family Therapy, (1), 347-360.
Omer,H. 2004. Non-Violent Resistance. A new approach to violent and self-destructive children. Cambridge. Cambridge University Press.
Omer, H. 2013. The Anchoring Function Parental authority and the parent-child bond. Family Process 52 193-206
Shoshan,T 1989. Mourning and longing from generation to generation. American Journal of Psychotherapy, 43: 193-207.
Wilson, J. 1998. Child-focused practice. A collaborative systemic approach. London. Karnac
Vollman, S. Psychology Today Blog. Grief and the Replacement child.