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An Exploratory Study of
Premature Termination in Child
Analysis
Nick Midgley & Evanthia Navridi
Available online: 07 Jul 2008
To cite this
article: Nick Midgley & Evanthia Navridi (2007): An
Exploratory Study of Premature Termination in Child Analysis, Journal of
Infant, Child, and Adolescent Psychotherapy, 5:4, 437-458
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Journal of Infant, Child, and Adolescent Psychotherapy, 5(4): 437–458, 2006
An Exploratory Study of Premature
Termination in Child Analysis
Nick Midgley and Evanthia Navridi
Dropping out of psychotherapy among children and
adolescent is a signifi-cant problem affecting 40–60 percent of the cases
receiving outpatient care. Many factors have been investigated as possibly
contributing to premature termination, but most of the findings were found to
be inconsistent and con-tradictory throughout the literature. The present study
is about premature termination in child analysis and includes an audit of the
closed files from the period 1999–2003 at the Anna Freud Centre, London, and a
qualitative study of five cases that were terminated prematurely. The audit
confirmed that the rate of dropout from therapy, when understood to be an
ending which is not agreed by all parties, at whatever stage this may be in the
treat-ment-is around 60%. The audit also suggested that there are differences
be-tween cases that terminate prematurely or by mutual agreement in relation to
gender and average length of therapy, but not in several other respects. The
second part of this study, based on a thematic analysis of initial family
interviews, discovered a set of themes characteristic of the assessment phase
of work with families who were later to withdraw from treatment prema-turely.
These themes related to the parents’ motivations for entering into therapy,
their expectations about treatment, both in terms of its process and outcome,
as well as their ability to think about feelings.
“We know more, about the right moment to begin a
child’s analysis than about the optimum moment for its termination”
(Freud, A., 1957, p.21).
FROM THE
VERY BEGINNING OF
PSYCHOANALYSIS, ENDINGS — especially
endings involving young people—have been a problem. Freud, in his first full
case study of an adolescent girl, Dora, describes how she came into her session
one day and announced that she was leaving.
Despite Freud’s attempts to interpret the meaning of
this decision, Dora went ahead, to Freud’s obvious dismay. He wrote:
437 © 2006 The Analytic
Press, Inc.
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438 Nick Midgley and Evanthia Navridi
“Her breaking
off so unexpectedly, just when my hopes of a successful termination of the
treatment were at their highest, and her thus bringing those hopes to
nothing-this was an unmistakable act of vengeance on her part.’ (Freud, S.,
1905, p.150).
Freud’s experience of this premature termination had
enormous theoret-ical implications for the development of psychoanalysis, as it
led him to a first definition of the “transference,” and an appreciation of its
power both to disrupt and contribute to treatment. Freud also continued to
consider the nature of endings and in particular the ending of therapy, most
fa-mously in his late essay, “Analysis Terminable and Interminable” (1937).
Following Freud, psychoanalysts have paid a great deal of attention to the question
of what criteria are the basis for the successful termination of treatment and
the importance of the “termination phase” itself. (For a re-view, see Bergmann
1997).1
Consideration has also been given to the question of
the criteria for ter-mination in psychoanalytic work with children, and the
degree to which such criteria may be the same or different as those used in the
treatment of adults. Some authors suggest that the criteria for terminating a
therapy both for adults and children should be viewed as a continuum, since
they share many common elements. Thus, with adults but with children as well,
perhaps the major aim has been to strengthen the ego, and once this is
ac-complished then it can be used as a criterion to terminate the therapy
(Brenner, 1976; Firestein, 1978; Rangell, 1982).
On the other hand, there are others who believe that
most of the criteria for terminating adults’ analysis do not apply to children,
since the develop-mental processes of childhood make such criteria irrelevant.
In relation to child analysis, Anna Freud (1966–1970) therefore offered a more
develop-mental perspective, and suggested that the appropriate time to end a
treat-ment is “as soon as developmental forces have been set free again”
(p.14).
Given such an approach,
the timing of the termination in a child analysis is seen as especially
complicated because of the relation to the child’s on-going development (Green
and Fabricius, 1995). Some authors recom-mend the continuation of analysis into
the next developmental phase, meaning that “the child should at least progress
to the next developmental
1Apart from the different criteria for termination supported
by different psychoanalysts there are also objections regarding the
appropriateness of the terminology. In agreement with Pedder (1988), Wittenberg
(1999) points out that the terms “termination” and “termi-nation phase” are
inappropriate since they imply finality and often irrevocability, which have
nothing to do with analytic work.
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stage before
leaving therapy, in order for the new psychic organization to be explored and
to ensure that it works towards health” (Kohraman, 1969, p.192). Others offer a
more modest approach. For example, Bornstein and Kris stated that the treatment
should not go on forever, but should rather stop as long as the symptoms are
removed, internal consolidation is achieved and development is progressing
(cited in Kohraman, 1969).
But unfortunately, despite Freud’s own experience of
the problem in the case of Dora, the criteria for terminating therapy are not
necessarily applied since many cases drop out of treatment prematurely. This
has led to what Fabricius and Green describe as a “disjunction between the
theoretical con-ceptualizations of termination in child analysis and the
process as it actually occurs” (1995, p.205). In the wider psychotherapy
literature, this disjunction is normally addressed under the terms “attrition,”
“premature termination” or “dropout”.
Dropout from therapy is an important obstacle to
psychoanalytic
treat-ment,yetnotonethathasbeenwrittenaboutasfrequentlyasthetopicofter-mination
itself (Frayn, 1995; Roback and Smith, 1987). Child analysis raises specific
issues in relation to drop-out, because of the greater length and in-tensity of
many treatments and the complexities for parents of a therapy in
whichthechildisencouragedtodevelopadeeprelationshiptoanotheradult figure. As
early as 1921, the very first child analyst, Hermine Hug-Hellmuth, suggested
that for many parents, the child’s treatment creates anxious and stressful
feelings which may well lead to premature termination.
Although there are enormous difficulties in defining
what “premature termination” actually is, a number of studies looking at the
broader child psychotherapy literature (not specifically psychoanalytic) have
attempted to measure the size of the problem and to investigate possible
predictive factors. The literature is not consistent regarding the point at
which the dropping out takes place, yet for all of the cases (e.g. dropping out
after the initial appointment, or three years into an intensive treatment but
without agreement between therapist and family) the same terminology is used,
leading to huge difficulties in comparing the results of different studies
(Kazdin, 1996).
Despite these
methodological short-comings, most reviews have con-cluded that, among
therapies for children and adolescents, 40–60 percent leave treatment
prematurely, i.e. without all parties to the treatment agree-ing on an ending
or a set period of treatment being completed. Moreover when it comes to
adolescents many authors have suggested that premature termination is the most
usual experience of termination (Freud, A., 1970; Reich, 1950; Spiegel,1951);
Novick also pointed out that premature termi-
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440 Nick Midgley and Evanthia Navridi
nation “is often the condition under which the
adolescent enters and thus avoids the analysis” (1982, p. 334).
The high rate of
premature termination is something encountered gen-erally, in a variety of
settings, regardless of the therapeutic approach. For example, Patterson (1974)
found that two out of five families failed to com-plete a behavioral program.
Flieschman (1981) reports a 50% dropout rate from a similar therapeutic regime.
For Cottrell, Hill, Walk, Dearnaley, and Ierotheou (1988) the dropout rate was
46,6% regardless of the phase in which the treatment was terminated. Capes
(1973), and Rutter & Giller (1983) also reported high dropout rates in
children treated with other ther-apeutic approaches. Moreover, the research of
Lazaratou, Vlassopoulos & Dellatolas (2000) has shown that 58% of patients
terminated their treat-ment prematurely. Parents who initiate treatment have been
shown to drop out prematurely from child and family treatment at a rate as high
as 60% (Armbruster and Fallon, 1994; Gould, Shaffer, and Kaplan, 1985; Pekarik
& Stephenson, 1988; Weisz, Weiss, and Langmeyer, 1987).
There are few figures available that specifically
refer to child analytic treatment, but those that exist suggest a similar
picture. According to Anna Freud, during the years of 1954–1957 in the
Hampstead Child Therapy Clinic (now the Anna Freud Centre), from the 49
therapies that were termi-nated, only 17 were ended by mutual agreement and the
rest of them were terminated prematurely (Freud, A., 1966–1970). Likewise, a
long-term fol-low up of child analytic patients at the Anna Freud Centre,
although it did not specify exact numbers, also indicated that premature
termination was a common experience, often with quite negative long-term
consequences from the perspective of the former patients themselves (Midgley,
2003).
Although drop-out from child therapy is a major
problem for child men-tal health services in general, few studies have focused
on the factors re-lated to it (Novick, Benson, and Rembar, 1981), in comparison
to the greater focus on predictive factors for drop out among adult patients
(Baekeland and Lundwall, 1975; Luborsky, Chandler, Auerbach, Cohen, and
Bachrach, 1971). The fact that until today research has dealt mainly with
adults is an issue of great significance, since the factors that are related to
dropout from such therapy may not apply in the case of children. For in-stance,
a poor match between therapist and client is very important as a predictor of
drop-out in the case of adult therapy, but the same has not been shown to be
true for children. (Armbruster and Fallon, 1994; Armbruster and Kazdin, 1994;
Weisz et al., 1987).
When looking at children’s therapy more specifically,
the most impor-tant factor in premature termination, studies have suggested, is
the parents.
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It is they who usually decide that the child should
enter therapy and it is they who-most of the time-decide to stop the child’s
therapy (Pekarik and Stephenson, 1988). The significant role of the parents in
a child’s treat-ment is very obvious in clinical practice, since most
frequently the parents are also involved in the therapy (Fauber and Long, 1991;
Henggeler, 1994; Kazdin, Siegel, and Bass, 1990; Rodrique, 1994). As Kazdin
(1996) has pointed out, the bond between the therapist and the parents is in some
ways more important than that of therapist and child for treatment to con-tinue
to a “mature” termination, since the child’s continuation of treat-ment most
likely depends on that.
When the findings of
studies are broken down in greater detail, many factors have been identified as
possible predictors of dropping out of treat-ment. The factors that have
attracted most attention include: socio-eco-nomic status, source of referral,
delay in waiting for services, geographic dis-tance from services, history of
previous treatment, parental stress, parental expectations and the nature of
the child’s psychopathology. The findings regarding the impact of these factors
are contradictory (Armbruster and Kazdin, 1994), and Kazdin (1996) has
suggested, that “no single factor may be necessary or sufficient” (p.150)
regarding the dropout of treatment; in-stead there are multiple factors
involved in this process.
Nevertheless, it has been suggested that therapists
may successfully pre-dict from the intake which cases will end treatment
abruptly. Kazdin, Hol-land and Crowley (1997) compared the perceptions of
parents and thera-pist in relation to barriers to treatment, and found that the
therapist’s version was a better predictor of dropping out of treatment when
parents and therapist’s versions were contradictory. However, to what degree
these findings from the research literature on child therapy generally would be
true for child psychoanalysis is not clear.
Overall, when returning to the specific case of child
psychoanalysis, these studies therefore suggest that premature termination, or
drop-out, is probably a significant reality, although its extent is not fully
known; and that it may be possible to predict which cases will terminate
prematurely during the earliest assessment stages, although exactly which
factors are predictive is hard to determine with any certainty.
The Current
Study
Given the above
findings, the present study therefore has two parts. The first part is an audit
of the cases that were closed within the a set period at
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442 Nick Midgley and Evanthia Navridi
one
particular child analytic centre, the Anna Freud Centre, London, with the aim
of exploring any different trends between the cases that were termi-nated
maturely (i.e. with the agreement of child, family and therapist that it was
time for treatment to end) and those that came to an end prematurely. The
second part is an exploratory qualitative study of the assessment re-ports from
a smaller number of cases of prematurely terminated treatments, in order to
explore whether there are any patterns at this early stage of en-gagement that
might indicate such an ending.
Sample
All the case records of children whose analytic
treatment at the Anna Freud Centre was terminated within the five-year period
from 1999–2003 were included in the first part of this study. The total number
of such cases was thirty-eight. Of these thirty-eight children, twenty-one were
girls and seventeen were boys. Their age ranged from three to seventeen years
(See Table 1).
For the purpose of the second part of the study five
cases were selected for a more in-depth analysis on the following basis. Of the
23 cases from the first study that were terminated prematurely, only five sets
of case notes had full details about the diagnostic assessment (i.e. the
parents’ interviews, the child’s diagnostic assessment and the historical
background) and reports on the work with parents. Although the number is small
and not necessarily representative, it was decided that-for an exploratory
study such as this-these five cases would give some indication of possible
patterns in cases of premature termination, as a form of hypothesis-generation
rather than hypothesis-testing.
Table 1
Demographics of Sample
|
|
No
|
Frequency %
|
|
|
|
|
|
Gender
|
|
|
|
Male
|
17
|
45%
|
|
Female
|
21
|
55%
|
|
Age*
|
|
|
|
Pre-school age
|
8
|
21%
|
|
School age
|
19
|
50%
|
|
Adolescent
|
11
|
29%
|
|
|
|
|
*Pre-schoolers means children up to 5,11 years old,
school age means from 6 to 11,9 years old and adolescent from 12 years old and
above
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Data Collection and Analysis
For
the first part of the study, a checklist was made and used as a guide for
collecting all potentially relevant information from the 38 case files of
closed cases. The checklist was composed of the following sections:
•
Demographics, including gender, age, family condition.
•
Information in relation to therapy, such as the source
of referral, the length of therapy, attendance, presence or absence of parental
guid-ance, reasons for termination.
Then all coded data were explored using the Excel
software package. The initial sample was divided into two groups, according to
termination (premature / mature termination), in order to investigate the
similarities and differences between them. “Premature termination” was defined
as any ending of the therapy which was not based on the mutual agreement of
an-alyst, parents and child-regardless of how far the treatment had progressed
in other respects. Although the sample was relatively small, some attempt was
made to see whether there were any statistically significant differences
between the two groups, or whether any trends emerged.
For the second part
of the study, all of the diagnostic and assessment ma-terial for the five cases
that had complete case notes and had terminated prematurely were analyzed
qualitatively. The assessment file includes a so-cial history, the parents’
interviews and the diagnostic assessment of the child. The historical
background comprises information about the referral, the family condition, the
personal history of the child, the mother’s and fa-ther’s background and the
parents’ relationship. Furthermore, each assess-ment file comprises a number of
interviews with the parents, depending on the family condition. Additionally, there
are also two diagnostic interviews with the child in each file. These data are
not direct transcripts of the meet-ings but rather process notes made by the
therapists after the meetings. Therefore, what was analyzed was the
therapist/social worker’s accounts of the meetings and their comments on the
children and their families, not the verbatim words of the children and
families themselves. The analysis was focused primarily on the parents’
interviews and historical background, since in all five cases it was the
parents who decided to end the therapy.
The data came through
files that were in the form of case notes and doc-uments, so their analysis was
done in a qualitative way, using thematic anal-ysis (Leininger, 1985), through
which patterns of attitudes and perceptions discovered from the analysis of the
data are associated and given meaning.
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444 Nick Midgley and Evanthia Navridi
As
Leininger explains, “themes are identified by bringing together compo-nents or
fragments of ideas or experiences, which often are meaningless when viewed
alone” (Leininger, 1985).
For this project the researchers tried to find any
themes that emerged from a study of the assessment data and to classify in
categories the infor-mation that was found. After having a group of
themes/categories for each case, the researchers returned to the original
documents to check for data to confirm or question the themes and to ensure
that they remained as close as possible to the original data.
Mays and Pope (2000) propose assessing qualitative
research according to its own criteria of validity and relevance, including
clear exposition of methods of data collection and analysis and the use of
researcher reflexivi-ty. Therefore, the steps followed throughout the research
process and the various interpretations made concerning the data were made available
for scrutiny and peer review at each stage of the research process. To enhance
the credibility of the findings, the researchers asked another colleague to
read through one file and to comment on the issues that emerged and to note
possible new ones. The themes suggested by her were very similar to those that
the researchers had developed. Nevertheless, any differences that occurred were
seriously taken into consideration and the analysis was modified accordingly.
In order to
ensure confidentiality, the identities and properties of the in-dividuals will
remain confidential.
Results of Study
One: Audit of the Cases That Ended at the Anna Freud Centre Between 1999–2003
Among the thirty-eight cases that had finished their
therapy within the pe-riod of 1999–2003, in nine cases termination was mature
(24%), in twenty-three cases termination occurred prematurely (61%) and for the
other six cases (15%) there was insufficient data on file to make an
appro-priate judgment. Moreover, when termination was premature, apart from two
cases where the therapist decided to terminate the therapy (for mater-nity
reasons or because she was moving back to her country), all the others were
terminated abruptly either because the child decided not to continue his/her
therapy, or because the parents wanted their child to stop therapy. Further
details about the differences between those who terminated ma-turely or
prematurely are given in Table 2.
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Termination
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Table
2
|
|
|
|
|
|
|
Comparison of Children Whose Treatment had “Mature”
Versus
|
|
|
|||||
|
|
“Premature”
Termination
|
|
|
|
|
||
|
|
|
|
|
|
|
||
|
|
|
Mature
Termination
|
|
Premature
Termination
|
|||
|
|
|
|
|
|
|
|
|
|
|
|
No.
|
%
|
|
No.
|
%
|
|
|
|
|
|
|
|
|
|
|
|
Gender
|
|
|
|
|
|
|
|
|
Male
|
2
|
22
|
10
|
43
|
|
||
|
Female
|
7
|
78
|
13
|
57
|
|
||
|
Age
|
|
|
|
|
|
|
|
|
Pre-school age
|
2
|
22
|
4
|
17
|
|
||
|
School age
|
5
|
56
|
11
|
48
|
|
||
|
Adolescent
|
2
|
22
|
8
|
35
|
|
||
|
Family condition
|
|
|
|
|
|
|
|
|
Single-parent home
|
6
|
67
|
17
|
74
|
|
||
|
Two-parents home
|
3
|
33
|
6
|
26
|
|
||
|
Referral
|
|
|
|
|
|
|
|
|
Parents
|
7
|
77
|
17
|
74
|
|
||
|
School
|
1
|
11
|
1
|
4
|
|
||
|
Mental health centre
|
1
|
11
|
5
|
22
|
|
||
|
Nature of therapy
|
|
|
|
|
|
|
|
|
Intensive
|
6
|
67
|
15
|
65
|
|
||
|
Non-intensive
|
3
|
33
|
7
|
31
|
|
||
|
No information
|
|
|
|
1
|
4
|
|
|
|
Parental guidance
|
|
|
|
|
|
|
|
|
Child’ therapist
|
2
|
56
|
5
|
22
|
|
||
|
Parents’ own therapist
|
5
|
22
|
16
|
70
|
|
||
|
No information
|
2
|
22
|
2
|
8
|
|
||
|
Attendance
|
|
|
|
|
|
|
|
|
Regularly
|
71
|
78
|
13
|
57
|
|
||
|
Irregularly
|
1
|
11
|
7
|
30
|
|
||
|
No information
|
|
|
11
|
3
|
13
|
|
|
|
Length of therapy
|
|
|
|
|
|
|
|
|
Less than 2 years
|
2
|
22
|
16
|
70
|
|
||
|
More than 2 years
|
7
|
78
|
7
|
30
|
|
||
|
Breaks in therapy
|
|
|
|
|
|
|
|
|
No breaks
|
4
|
45
|
12
|
53
|
|
||
|
One or more breaks
|
32
|
33
|
7
|
30
|
|
||
|
No information
|
|
|
22
|
4
|
17
|
|
|
|
|
|
|
|
|
|
|
|
According to these data, most of the children whose
therapy ended by mutual agreement between all parties had received treatment
for more than two years. On the other hand, regarding the cases that were
termi-nated prematurely, more than half had been in treatment for over a year,
but the overall length of the treatments was shorter on average (see Figure 1).
Calculations of a logit regression model indicated that only the length of
therapy variable had a statistically significant effect on the probability of
be-
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Figure 1. Comparison of Length of Treatment for Children with a
Premature Ver-sus an Agreed Termination.
longing or not to the group of prematurely ended
therapies.2 In particular, the results indicate that if the
length of therapy increases by one year, then the probability of a premature
end to the therapy decreases by 0.9.
In terms of other
variables, there were no significant differences between the premature and
mature termination groups in terms of age, referral source, family situation or
intensity of treatment. On the other hand re-garding gender it appears that it
might play a role regarding the termination of therapy since although in both
groups (mature vs. premature termina-tion) there are more females (57% and 78%)
the percentage is higher in the cases where termination was mature, suggesting
girls were more likely to continue to an agreed termination point. However,
with such a small sam-ple, such a trend did not reach statistical significance.
The premature
termination group also showed a higher rate of irregular attendance at therapy
(30% vs 11%), indicating that attendance was a greater issue for this group
even prior to the premature ending. Finally, re-garding parental guidance, in
most cases where the termination was mature parents were seen for regular
meetings by the same therapist as their child (56%); whereas when the
termination was premature most of the parents (70%) were seen by a different
therapist. Thus it seems that the parent’s
2This result is reached using a simple t-test.
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therapist and whether he/she is also the child’s
therapist, might influence the termination of therapy, although again trends
did not reach statistical significance.
Discussion
of Results of Study One
Some
of these findings are consistent with previous studies whereas others are in
contrast to the literature. Starting with the high rate of premature
termination that was found on the current research (61%), it is confirmed from
previous studies (Armbruster and Fallon, 1994; Gould, Shaffer, and Kaplan,
1985; Pekarik and Stephenson, 1988; Weisz, Weiss, and Langmeyer, 1987), which
all refer to a rate of premature termination of therapy as high as 60%.
Furthermore in the same setting according to Anna Freud (1966–1970), within the
period of 1954–1957, forty-nine cases were terminated in the Hampstead
Child-Therapy Clinic. Of these, seventeen (35%) ended by mutual agreement,
whereas the other thirty-two (65%) were terminated prematurely. The similarity
of the results obtained by the present study and that conducted by Anna Freud
confirms that despite the time difference the general picture remains the same.
That is, the majority of therapies are terminated prematurely, meaning without
the mutual agreement of all three parts.
Additionally, in
comparison with Anna Freud’s research, there are fur-ther elements that are
consistent, such as the length of the therapy. Ac-cording to Anna Freud the
cases that were terminated by mutual agree-ment were in analysis for two and
three years, while the others averaged one and a half years to two years
(1966–1970, p.9). Such figures are fairly closely matched by the current
research, although they do also indicate the differences between studying
“premature termination” in child analysis compared to most other child
psychotherapy treatments, where a prema-ture termination would rarely include
treatments that had continued for one or two years.
Unlike other studies
of premature termination in child therapy, a num-ber of variables, such as
family composition, were not able to differentiate the premature termination
cases from the mature termination cases, al-though again the small numbers involved
must be kept in mind. Perhaps surprisingly, regarding age, no clear differences
were found between the cases that were terminated maturely and those that were
terminated pre-maturely. This is very interesting if one takes into account
what the litera-
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448 Nick Midgley and Evanthia Navridi
ture suggests about adolescence and the particular
problems for drop-out that this age-group raises.
Finally, regarding
the parental guidance, according to these findings, when the termination was
premature in most of the cases (70%) parents had their own therapist, whereas
in those treatments that terminated “ma-turely” the parents were more likely
(56%) to have been seen on a regular basis by their child’s analyst. This is a
very interesting fact, since tradition-ally within the child analytic literature
there has been a view that is better for the child’s therapist not to work with
the parents as well, as this would be felt to intrude upon the child’s belief
in a confidential space and informa-tion from the parents could also prevent
the child’s analyst from working “without memory or desire” in the room with
the child. This is a view, how-ever, that has remained controversial. Child
analysts at the Anna Freud Centre have often worked with the parents too in
cases of children under five. According to Rustin (1999) when a child’s
therapist is working with the parents as well, “it gives the therapist more of
a sense of child’s develop-ment in the family … and to the parents an
opportunity to enquire about the therapy and test out their confidence in the
therapist’s capacity to help their child” (p.87). This is a view that appears
to be confirmed by the cur-rent study, which suggests the potential value of
the child’s analyst working supportively with the parents to avoid the danger
of premature termina-tion.
Results of the
Second Study: A Qualitative
Analysis of
the Assessment Data of Cases
That
Terminated Prematurely
The initial audit study showed a high level of
premature termination and indicated some possible trends that distinguish the
cases that terminate prematurely from those cases that terminate maturely.
Nevertheless no clear differences were found regarding therapy that could
explain what dis-tinguished these cases from those that terminated by mutual
agreement of all parties.
In the second part of
our study, our thematic analysis of the diagnostic assessment data of five
cases that had terminated prematurely led to the identification of three main
themes: Parents’ motivation for wanting ther-apy; parents’ expectations from
the therapy; parents’ ability to think about feelings. Within each of the
themes related to the parents a number of sub-ordinate themes were also
identified (see Table 3). While the initial audit
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Table 3
Subordinate
Themes Within the Parent Categories
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Parents’ Motivation
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Parents’
Expectations
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Parents’ Ability to
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for Wanting Therapy
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From the Therapy
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Think About Feelings
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Parents’ evaluation
of other
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Parents’ view of child’s
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Parents’ difficulties in
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support services
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problem
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thinking about the
child’s
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feelings
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Parents’ impatience
for the
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Parents’ view of child’s
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Parents’ difficulties in
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child to get therapy
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problem
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thinking about the
child’s
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feelings
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Parents’ feelings of
shame/
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Anxiety about the child’s
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Therapy threatens
the family
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guilt
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attachment to the
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system
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therapist
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Parents’ hesitation
towards
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|
entering therapy
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study found few
obvious differences between the mature and premature termination cases, the
second part of our study made it clear that during the assessment phase some
elements are revealed which might identify those cases that have a tendency to
drop out from therapy (see Appendix A).
Theme
One: Parents’ Motivation for Wanting Therapy
In our analysis of these files, one of the most
important sources of informa-tion regarding the parents’ motivation for
bringing their child to therapy was found to be their evaluation of other
support services, meaning their previous experiences with psychological support
services and the child’s school. In four out of five cases the parents’
evaluation had a negative tinge. For example parents dismissed previous
psychological report as “unproduc-tive” or “not a good or useful experience.”
Furthermore, the parents’ impa-tience for the child to get therapy constituted
another major element re-garding parents’ motivation. Again, in four out of
five cases, it was found that the parents expressed great impatience for the
child to enter therapy “as soon as possible.” That kind of attitude may reflect
their despair, or great need, or their stress towards the child’s problems, but
it may also show a wish for a “quick fix,” in terms of not thinking in depth
about the treatment and its requirements over a long period of time. Thus, the
parents’ decision is more likely to be thoughtless leading to weak motivation,
that wouldn’t be enough to hold them in the therapy until its completion.
Another theme in the assessment material of this group
of parents was their feelings of shame or guilt, with the therapists reporting
on a number of
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450 Nick Midgley and Evanthia Navridi
occasions
ways in which parents blamed themselves for their child’s prob-lems yet did not
want others to know about the child’s difficulties.
The last but not least aspect of parents’ motivation
was their hesitation towards entering therapy, which may be expressed in the
form of practical difficulties, like the difficulty of bringing the child to
therapy, a factor also recognized by other studies as undermining therapy
(Kazdin, Holland, and Crowley, 1997; Liakopoulou, Protagora, Hatzielefteriou,
Soumaki, Kolaitis, and Tsiantis, 1994). Furthermore, the parents’ own
ambivalence was in some cases transformed into the parents’ (imaginary?)
hesitation on the part of the child, or was even shown by their attitude during
the assessment itself, for example by their inconsistency with appointments.
Theme
Two: Parents’ Expectations From the Therapy
The second very
important element that was found in the assessment mate-rial of those cases
that prematurely terminated their therapy, was the par-ents’ expectations about
treatment, in terms of its process and outcome. One aspect of the parents’
expectations was their desire or not to partici-pate in treatment themselves.
From this study it was shown that some par-ents did not want to participate,
either because they thought that the child’s problem had nothing to do with
them or because they didn’t feel able to help the child. Furthermore, the
parents’ wish to be excluded from the treatment also became evident by their
physical distance during the assess-ment itself, for example staying in the car
while the child was being seen.
Another element in the parents’ expectations of the
therapy was related to their view of their child’s difficulties. What was found
here is that some parents appeared to have a misleading view of the child’s
problem, or saw the child’s difficulties only as “bad” without any sense of
there being reasons for such behavior. One mother, for example, believed that
the symptoms of her child existed because he was suffering from a rare disease,
and not be-cause of emotional difficulties, despite medical investigations
which had shown this not to be true. In another case, according to the
therapist’s notes, one parent’s description of her child’s difficulties felt “like
a long list of complaints,” with little ability to link these
difficulties to a number of trau-matic events in that child’s early life.
Parents in these prematurely termi-nating cases also tended to worry about what
kind of information about the family the child would reveal in his or her
individual sessions; and whether the child would form a close attachment to the
therapist in a way that might challenge their own relationship to their child.
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Theme
Three: Parents’ Ability to Think About Feelings
Another theme that emerged from our analysis of the
assessment material of families that were later to drop out of therapy
concerned feelings, and in particular the parents’ inability to think about
feelings; their own and/or the child’s feelings. This is not a factor that has
appeared in the literature about drop out and premature termination before now.
In the present study, this became evident in the parents’ own difficulties in
recalling mem-ories from their own or their child’s past, or by the
inappropriate affect that accompanied their words during their interviews or by
their defensive atti-tude towards stressful events in their lives. In one case,
the parent said that “he had blocked out much of the past and that he
wouldn’t be able to remember”. In another case the therapist commented that
the parent “was detached when describing the child’s problems.”
Furthermore, these
same parents had difficulty in recognizing their child’s affect (e.g. being
angry or sad) in particular moments, or else they found it hard to consider how
incidents from everyday life may have influ-enced their child’s emotional world
and struggled to appreciate the way in which their child’s behavior could be
seen as an emotional reaction to par-ticular experiences. In one case, the
mother believed that a very strong event in her child’s life, “didn’t deeply
affect her, since it wasn’t mentioned again.” In another case the
mother was taking away and sometimes destroy-ing her child’s favorite toys
whenever the child began to be attached to them, without seeming to be aware of
how this might feel for the child. In addition, for these parents, their
child’s therapy was often seen as a poten-tial threat to the established family
system.
Among the five cases
that were investigated in this study, there was one (case five in the
Appendix), which was in contrast to the others in almost all the thematic
categories that we identified. In this case the parent recog-nized and
positively evaluated the support that other services had offered her; the
mother was feeling guilty instead of ashamed about her child’s problems and she
wanted to participate in the child’s treatment. Addi-tionally, this mother
seemed to be very much in touch with her feelings and she also seemed to
respect and take into account her child’s feelings. This apparent contradiction
to our general findings led us to return to this case and study it in more
detail. Interestingly, this child was in treatment for a longer period than any
of the other prematurely terminated treatments (over three years); and the
clinical reports suggested that both she and her mother made extremely good use
of the treatment. The premature termi-nation followed a significant change in
the family’s living situation, which
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452 Nick Midgley and Evanthia Navridi
led mother to rather abruptly decide that the
treatment should come to an end. While the case therefore met our criteria for
“premature termination” (in so far as the decision to end was not made jointly
by parent, child and therapist), in other respects one could consider this a
“successful” treat-ment. The case therefore illustrated the difficulties of any
clear categoriza-tion of “premature termination,” but also-by its
contrast-appeared to con-firm the validity of the themes found in our other
four cases of premature termination.
Discussion of
the Results of Study Two
The
assessment data of the cases that terminated prematurely, made it clear that
during the assessment phase some elements are revealed which might identify
those cases that have a tendency to drop out from therapy. Most of the themes
that were identified are in agreement with previous studies but some contradict
the literature. The importance of parents’ pre-treatment motivations and
attributions has been mentioned by a num-ber of researchers (Johnson, 1996;
Morrisey-Kane, and Prinz, 1999; Nock and Kazdin, 2001). From the very earliest
days of child analysis, Hug-Hellmuth (1921) suggested that from the beginning
parents often have a time limit in their minds and that they are not able to recognize
the negative impact of a premature break of treatment. She also pointed out
that practical difficulties, such as bringing the child to therapy, are
some-times used by parents as a reason for terminating the treatment, a finding
that has been confirmed by other researchers, (Kazdin, Holland, and Crowley,
1997; Liakopoulou, et al., 1994).
Furthermore, the
nature of parents’ previous experience with other sup-port services and the way
they have perceived it (helpful or not, easy or dif-ficult) has also been
mentioned by other researchers as a factor in prema-ture termination
(Armbruster and Kazdin, 1994). Likewise, some psychoanalytic commentators have
suggested that, in relation to making a commitment to treatment, the situation
is more precarious when the par-ents are overwhelmed by feelings of shame,
rather than the more construc-tive (and potentially reparative) feelings of
guilt (Tsiantis, 2000, p.24).
Parents’ expectations
from the therapy, and whether they wish or not to participate in treatment
themselves, is an element that was also identified by other research. Thus,
according to the literature, one of the most impor-tant factors influencing the
outcome of child therapy appears to be the par-ents’ motivation for
participation in this process (Ewalt, Cohen, and
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Harmatz, 1972; Pekarik and Stephenson, 1988). As
stated by Miller and Prinz (2003), when parents wish for the treatment to focus
on the child and not on parenting or other family issues, then the premature
ending rates were higher. Similarly, parents’ attitude during therapy is
particularly im-portant for its outcome, since when they “were uncooperative,
negative or had no desire to make change in themselves [they] were more likely
to have their children drop out of treatment” (Morrisey-Kane and Prinz, 1999,
p. 531. Furthermore, children with parents who were involved in the treat-ment
were more likely to remain until a mutually agreed termination (Cole and
Magnussen, 1967; Ross and Lacey, 1961). 184).
Conclusions
The
first study, the audit of the cases that were closed at the Anna Freud centre
between 1999–2003, has confirmed the picture that exists in the lit-erature,
that the rate of dropout of therapies is around 60% and that in most of these
cases the decision was the parents’ and/or the child’s. Fur-thermore, it has
shown that other differences exist between the cases that terminate maturely
and those that terminate prematurely. First, the length of the therapy is longer
in the cases where the termination is agreed, and during therapy attendance
appears to be more consistent. Regarding gen-der, as well, it has been shown
that there are more females among the cases with a mature termination. Finally,
based on this study, when parallel to child’s therapy the parents were seen by
the same therapist as their child and not by a different one, this might help
the therapy reach an ending agreed upon by all parties involved.
Likewise, in relation
to the findings of the second qualitative study, we could venture to illustrate
the profile of the cases that tend to terminate their therapy prematurely. In
these cases the parents are inclined to nega-tively evaluate the previous support
that they got, feel shame towards the child’s difficulties, about which they
also have a misleading view. Addi-tionally, they express hesitations towards
the child’s entering therapy, wish to exclude themselves from the treatment and
feel insecurity regarding in-formation that would be revealed and the possible
intimacy that would de-velop between the child and the therapist. Furthermore,
these parents seem to have difficulties in thinking about their own and the
child’s feelings as well, and they give the impression that the therapy might
threaten the fam-ily system.
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454 Nick Midgley and Evanthia Navridi
On the other hand, and despite all of these
“resistances” to treatment, such families took the crucial step of asking for
help. Since of all cases who need help only a few ask for it, it is important
for the clinicians to be able to identify these cases and to intervene right
from the very beginning in order to keep them in therapy until its completion.
Additionally, these parents show impatience for the child to get therapy,
although there is a danger that this may lead to a rushed decision to begin
treatment. Maybe what is hidden here is a part of the answer we are looking
for; maybe these parents need some preparation before entering therapy, for
their thoughtlessness to become thoughtfulness.
Important limitations of the present study deserve
comment. First, the absence of an analysis of matched cases that were
terminated maturely is of great significance, regarding the second study.
Without such a comparison, we cannot say for sure whether the themes that
emerged were specific to families that went on to terminate prematurely, or
whether such themes may be found in the assessment literature of all child
analytic cases. Thus more studies are needed, in order to see if there are any
differences between these cases in relation to these findings. Secondly, the
possibility of general-izing the findings to a wider population in both studies
must be restricted, since in the first study the sample was still a relatively
small one-and only from one particular clinic-and in the second study the
sample was very small (five cases) and the analysis was qualitative. Clearly,
further research is needed to evaluate the value and the generality of the
findings.
Nevertheless, the findings of this study are broadly
consistent with the general literature, where it has been recognized that the
parents play a most significant role in the child’s treatment (Fauber and Long,
1991; Kazdin, Siegel, and Bass, 1990; Pekarik and Stephenson, 1988; Rodrique,
1994; Henggeler, 1994) and, furthermore, that the bond between the therapist and
the parents is in some ways more important than that of the therapist and the
child in so far as treatment not ending prematurely is concerned (Kazdin,
1996).
The most important
and powerful findings of this study is the fact that the parents’ evaluation
for other support services, their impatience for the child to get therapy and
the fact that in some cases the therapy might threaten the family system, were
found to play a very significant role in dropping out from therapy in the
present study. These are themes that do not appear to have been given the
requisite attention from previous re-searchers. Even though the history of
previous treatment has been identi-fied as a possible contributor in dropping
out of treatment (Armbruster and Kazdin, 1994) it hasn’t been investigated in
depth in order to explain how
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this contributes to premature termination.
Furthermore, the characteristic of some parents of being impatient for the
child to get therapy was not men-tioned at all, although it may give hints of
the parents’ way of confronting their difficulties. Finally, the fact that the
child’s difficulties may serve a role in the family system and thus the therapy
may threaten these dynamics has been perceived as a superficial explanation
“not covering the facts” of drop-ping out of therapy (Freud, A., 1957[1970]:11),
whereas in this study, it was suggested that it contributes more significantly
to the attrition of treat-ment. These are important leads that it may be
important for further re-search studies to pursue, in order to help increase
our understanding of why treatments may sometimes break down. Without this
understanding, there is little chance that the worryingly high rates of
attrition in child psycho-therapy treatments can be altered.
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Nick Midgley Anna Freud Centre
21 Maresfield Gardens London NW3 5SD
nickmidgley@btconnect.com
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Appendix A
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Presence/Absence of Themes in Each Case Included in
Study Two
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Case 1
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Case 2
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Case 3
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Case 4
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Case 5
|
|
|
|
|
|
|
|
|
Parents’ evaluation of other
support services
|
–
|
–
|
–
|
–
|
+
|
|
Parents’ impatience for the child
to get therapy
|
+
|
+
|
+
|
+
|
|
|
Parents’ feelings of shame/guilt
|
|
|
–
|
–
|
+
|
|
Parents’ hesitation towards
entering therapy
|
|
|
+
|
+
|
|
|
Parents including themselves in treatment
|
|
–
|
|
–
|
+
|
|
Parents’ misled view of child’s problem
|
+
|
+
|
+
|
|
|
|
Insecurity regarding
information revealed
|
|
|
+
|
+
|
|
|
during therapy/intimacy between the child
|
|
|
|
|
|
|
and the therapist
|
|
|
|
|
|
|
Parent’s ability to think about their feelings
|
–
|
–
|
–
|
|
+
|
|
Parents’ ability to think about
child’s feelings
|
–
|
–
|
–
|
|
+
|
|
Therapy threatens the family system
|
+
|
+
|
+
|
+
|
|
|
Child’s openness and ability to
make contact
|
–
|
+
|
–
|
–
|
+
|
|
|
|
|
|
|
|
+ shows positive direction
– shows negative direction
Blank
shows that the variable was not evident
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