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Formulation during the Child Assessment Process

Tikkanen, S., 2014. Formulation during the Child Assessment Process. Reformulation, Summer, pp.38-44.

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Introduction

This article is based on a plenary presentation given at the 5th International CAT Conference in Malaga 2013 and on a case study from Tikkanen et al. (2011, 2013) and Tikkanen and Leiman (2014) research project.

In psychotherapy research, case formulation is used as a base line for following individual change trajectories (Leiman & Stiles, 2001; Kaunisto et al, 2013; Stiles, 2002; Stiles et al.,1990; Stiles et al., 2006; Stiles et al. 1992; Zonzi et al., in press). Ryle has similarly used formulation as a means of investigating therapeutic change (Ryle, 1975, 1979). Cognitive analytic therapy uses shared reformulations as tools for the self-refiection of the client and to open prospects for development of the action patterns described in them (Ryle, 1979, 1991, 1994; Ryle & Bennett, 1997). In CAT reformulation (Ryle, 1979, 1994, Ryle & Kerr, 2002), the problems and symptoms (e.g. burn out, stress) are connected with the underlying reciprocal role pattern (e.g. demanding-not good enough). Building an observer position (Leiman, 2012) with respect to these patterns enables the finding of exits (e.g. accepting limits, listening to oneself). Verbal formulations in therapeutic discourse may serve different functions and have different consequences for the ongoing therapeutic process (Antaki, 2008).

CAT conceptual tools can be used in different contexts. The context of the case described in this article is that of a child neurological assessment process. The neuropsychologist with CAT orientation is working with the parents. Child neurological assessment procedures primarily focus on the developmental deficits of a child. It is not intended to be psychotherapy for the child nor the parent. In clinical work with children it is a relevant to aim to promote parental insight and awareness which may have beneficial effects on the child (Seligman & Darling, 1997).

The research project by Tikkanen et al. (2011, 2013) focuses on the mother’s developing empathic stance toward herself and her problematic ways of interacting with her four-year old daughter during the neurological assessment process analysed by a dialogical sequence analysis (DSA, Leiman, 2004, 2012) and assimilation model (Stiles et al, 1990; Stiles, 2002). The results have shown (Tikkanen et al 2011, 2013) that the development of the mother’s empathic stance during the child assessment, from the initial session to 3 months follow-up, was mediated by an observer position that allowed her to adopt a more empathic attitude, first to herself, and then towards her daughter. Observer position is described as a place, which enables movement between one person’s view and the other’s view/ counter position empathically.

The intention of the empathic stance is to perceive the internal frame of reference of the other (the object) with accuracy (Rogers, 1957). Strong identification with one position in a reciprocal pattern (‘my view’) may be shown as enactments of the reciprocal pattern or lead to confiicts of perspectives when the object (the other, part of self or whatever is in counter position) is viewed only from this position.

The aim of this article is to describe the therapeutic potential of the network meeting regarding the parent’s developing empathic stance during the assessment process. It describes the resolution of impasse by using a shared formulation at the network meeting arranged during the child assessment (Tikkanen & Leiman, 2014).

Method

The case of Satu1, a pseudonym, was selected from a database of 7 videotaped child neurological team assessments, collected in the Developmental worries and parent positions in child neurological assessment process project at a University Hospital in Finland. This project was approved by the hospital’s ethics committee, and informed consent procedures were followed. Due to the child’s age (4 years) the parents’ consent for taking part in a research project was considered sufficient. In their consent the parents gave permission to the use of anonymized case excerpts in the publications from the project. The entire multi-professional child neurological assessment procedure spanned over 70 days and comprised 9 consecutive encounters.

Dialogical sequence analysis, (DSA) (Leiman, 2004; 2012) combines Bakhtin’s theory of utterance (Bakhtin, 1984) and CAT derived reciprocal roles and procedures representing the formulation of recurring patterns as dialogical pattern and sequences rooted in Vygotsky’s theory of sign mediated activity (Stetsenko & Arievich, 2004) and British psychoanalytic object relations theory (Leiman, 1992; Ryle, 1991). These concepts are used to analyze the sequential fiow of the discourse, as well as the emotional stance of the speakers both to the content, or the topic of discourse, and to each other. Initially, DSA has been used as a conceptual tool to assist early case formulation in psychotherapy. Subsequently, it has also been used as a micro-analytic method to study discourse in psychotherapy and counselling (Leiman & Stiles, 2001; Stiles et al., 2006; Tikkanen et al., 2011, 2013; Kaunisto et al., 2013).

Analytic procedure. The parent-professional encounters during clinical assessment processes were videotaped and transcribed by the author. The DSA analysis of the sessional case material was conducted by experienced clinicians 1.5 years after the clinical procedure. DSA analysis starts with exploring the author’s stance to referential objects and the addressee (Bakhtin, 1981,1984) and continues by describing the sequences of the reciprocal patterns. Consensus of the baseline formulation of the problematic pattern was reached.

Results

First, the results will show the initial problematic pattern, the shared formulation and the mother’s developing observer position with respect to the problem procedure, in addition to the consequent exit. Then, six episodes from the network meeting will be presented to illustrate how the use of this shared formulation helped solve the imminent impasse created by the re-enactment of the problematic procedure during the network meeting.

In the following excerpts the mother is denoted by M, the father by F and the neuropsychologist by N. Special emphasis, or tone, in the utterance is marked with underlining. Overlapping speech is denoted by square brackets.

The initial problematic pattern

Episode 1 (turns184 -199)

N: Yes – Ok. – Well. What has her character or personality been like from the baby times onwards? [How would you describe it?

M: Well], ok. - Hm. - Now that she has grown up a little bit she has got her own will, “bullheadedness, what can be found in the mother too”(laughing)

N: Hm.

M: She is indeed quite a self-willed person, it has a strong will. (in a strict tone of voice)

N: Hm.

M: And now that the terrible twos are coming. It does know how to make public that things didn’t turn out the way she had wanted.” (with a strict voice)

N: Hm-m yes. - How does she show her own mind?

M: Well now, especially during these terrible twos, ”cries and jerks, cries and [jerks!”. (in a laughing and strict voice)

N: Hm.]

M: So it is indeed a kind of, huh-uh, “a somewhat powerful reaction.”(laughing)

N: Yes. What helps then?

M: Well we have this yelling corner at home, and she can cry out her bad mood there.

N: Right.

M: And it has clearly helped that we don’t take her to her own room. She has this one place. She knows that there you can cry if you have done something naughty or if you are feeling bad or something else, [off you go!

F: Hm]

‘Controlling and forcing’ parents to the ‘rebellious, defiant and oppositional’ Satu was the repetitive pattern that was enacted particularly between the mother and Satu. Initially, the parents were not aware of their controlling position nor had they any empathy for the child’s perspective (from this position) and the problem was viewed to reside in the child. The parents attempted to control the child without the benefit of refiection. Strong shifts to the ‘controlling’ position are evidenced by the parents’ language.

The shared formulation

The parents (described in the initial interview) several instances of Satu’s oppositional behaviour and how they managed the confiict. This pattern of coercion and opposition was shared with the parents during the assessment. The following excerpt from the third session illustrates this.

Episode 2 (turns 461-463)

N: Yes, well well, is it in a way such a situation that, on one hand, Satu has this kind of a strict way to say :No way!” and shows that “This is what I want” and then the adult - or you as a parent have this same kind of strict way [“Do like this!”]

M:Yes of course] and I am in many matters.

N: So there you have some kind of battle between commanding and resisting

Mother observes her own contribution to the pattern and finds ‘an exit’

The problematic pattern was explored between the mother and the neuropsychologist especially during the third session of the assessment. In Episode 3 the mother is able to begin to formulate the problematic pattern. Mother is empathic towards herself and is supported by the neuropsychologist in being able to begin to perceive herself as part of the problematic pattern.

Episode 3 (turns 506-508)

M: I think it is quite telling that Satu comes for comfort and closeness, showing that we are not that bad. (laughing)

N: Right. The situation can be going on well and your warm relationship can go on even though you at times have these angry outbursts [[and battles of will.

M: Yes. Yes]. So it is, so it is]]. Two strong-willed women at home, it is a hard thing, you know.

A little later the mother is able to formulate an exit to her problematic contribution to the pattern: the need to control her temper.

Episode 4 (turns 512-514)

M: But yet; I have to try to control this temper of mine. I am quite a hot-tempered and bull-headed person, to that. Sometimes it just is a good thing that even you take a step back, that you learn to give in.

N: Yes

M: Not in every- but in some situations. (quietly)

N: Yes.(quietly)

The network meeting

The network meeting was arranged a month after the start of the assessment phase; (the assessment with the parents, the assessing team, and personnel from the day-care, special education and rehabilitation). The agenda was to discuss Satu’s special needs in the preschool group and in speech therapy. The plan to move Satu from her current day-care group into a new preschool group after the summer caused an acute confiict between the parents and the preschool personnel at the meeting. The participants at the network meeting were Satu’s mother (M) and father (F), the neuropsychologist (N), the speech pathologist of the assessing team (SP1), two personal assistants (the current assistant A1 and the succeeding assistant A2), the special education coordinator (C) and the local health centre speech pathologist (SP2).

The confiict, which can be seen as a re-enactment of the initial problematic pattern, and its resolution will be shown in six phases and subsequent excerpts from the episodes 5 to 10.

Phase 1. Enacting the pattern from an institutional/ coercive stance

The conflict emerges. In episode 6 the neuropsychologist introduces the topic of the new day-care group arrangements.

Episode 5 (turns 2039-2046)

N (addressing the coordinator): Yes, yes. How about next autumn then; you just said that the group will then have more children who are of the same age?

C: We cannot place her in a smaller group. All our groups are full and [ ]

N (addressing the parents): Have you been there [erm what do you [think of it?

M: No.] No.]] We have not, but even the thought of how many kids there are just gives me the creeps, that’s for me

N: Yes. /I see.

M: And I also wish that A1 could continue to be her personal assistant because Satu has grown so fond of her.

N: Hm.

C: We have the problem that we are only allowed to have the permanent ones, [] this is our situation now.

The special education coordinator gives an account of the new arrangements, which do not allow a smaller group. Her tone of voice is optimistic, but from the institutional perspective there is no choice, although the mother makes a strong case against the suggested change.

Phase 2. Formulating the pattern: Shocked to coercive

Episode 6(turns 2056-2059)

N (addressing the parents): Yeah, yeah. Somehow I hear this evidently came as a surprise for you as parents [the way the day-care is organised

M: Yes] it surely did.

N (addressing C): the way you told us. Well, is it really the only way, the only way, [or are there alternatives that you have been thinking of?

C (addressing both the parents and the neuropsychologist): That is the problem]; well, we have just the alternative that all the groups with older children are so terribly big…

The parents’ stunned reaction is voiced by the neuropsychologist who focuses upon the apparent rigidity of the decision. She asks for alternatives, but the special education coordinator responds infiexibly.

Phase 3. Re-enacting and formulating from the shocked position to coercive

The neuropsychologist is re-enacting the perspective of ‘shocked to coercive’ and is attempting to demonstrate ‘fiexibility’ as an exit to the pattern.

Episode 7 (turn 2071)

N: Yes. Yes. Is there anything that; well; this sounds like this arrangement has been planned beforehand in your day-care service, then is there anything that we could do to get some more resources for Satu… [ ]Is there? Or is this the, in a way, now the best alternative; that there is nothing else then available, or how is it?

Phase 4. The confiict escalates: mother’s oppositional enactment

The next topic, which concerns plans for the speech therapy, leads to further confiict. The day-care coordinator (C) remains unmoved and soon the mother assumes the stance of direct opposition.

Episode 8 (turns 2129-2132)

C: (addressing the parents) There is one that comes to our service: a speech pathologist,

SP2: (addressing the parents) Hm. I reckon this feels quite ok [or what do you think?

SP1: Yes]

M: Yes. I am…the speech pathologist does not change and that’s sure. Satu likes you so much and has been asking about you and when we will be coming to you. If the group and even the assistant is going to change then this is just too much for her, no! We do want to visit you still.

SP2: Well. Let’s try to sort out this situation. Yes.

C: (addressing to parents) Of course these changes are miserable. But they just are what they are. I have the feeling that Satu would be better off in the group that has been planned for her than to stay in the old one.

Mother shows empathy to Satu’s perspective in the confiict and the speech pathologist (S2) models space and time as an alternative, but the special education coordinator (C) continues to rigidly assert her argument for the appropriateness of the new group. There is scarce empathy for the counter position of the confiict although empathy for Satu is used as an argument.

Phase 5. Formulating the here-and-now from the child perspective

The confiict continues. The neuropsychologist refers to the original coercive pattern between Satu and the parents, now re-enacted between the special education coordinator and the parents.

Episode 9 (turn 2159)

N: Well yes. Maybe we are here facing a comparable situation as dealing with Satu, as we just have discussed. That when we are confronted with a lot of new things, how could we digest them in peace, little by little. So as then not suddenly blast: “This is how it is.” And then in a way, perhaps, there emerges a kind, like, a bit knotty, knotty thinking, whether this is now, suddenly, indeed the ultimate best thing.

The neuropsychologist is formulating the on-going interaction from Satu’s perspective, but also suggests a more tolerable, and piecemeal, alternative that might be found. This formulation has an immediate impact on the interaction.

Phase 6. The consequences of the formulation: Rapprochement between C and mother

Episode 10 (turns 2176-2179)

C: (addressing the parents) And this is the group to which Satu will go, it is a good group, it is, the children are gorgeous and it is a well-functioning group.

N: Yes, yes.

C: (addressing the parents) that just, like, although the size is frightening.

M: It is just the size that frightens, and that all adults will change, not the children or the age level, that is not, but just that everything, the familiar adult, really all the familiar adults will change. That is what makes one think. It is the mother’s instinct, the mother’s instinct that is knocking there (chuckles).

The neuropsychologist’s formulation enables the special education coordinator to begin to empathise with the mother about her concern regarding the changes. The mother takes a refiective stance with respect to her identifi cation with Satu’s situation. From this observer position she is able to move between Satu’s, and her own, perspectives. At the end of the meeting it was agreed to monitor Satu’s situation in the group in another meeting before other decisions were made.

A follow-up session of the entire assessment process took place two months after the network meeting. The parents acknowledged many positive changes and developments demonstrating a predominantly empathic stance to Satu (see also Tikkanen et al. 2011). Satu was communicating more and the parents had developed greater resources to interact with her. Satu had adapted well to the new day-care group. The mother had shortened her working days and described an improved control of her own anger outbursts. The “yelling corner” was not needed anymore. Satu was observed as a individual person, in her own right, with her own choices preferences.

Conclusions and implications

In this case study what was initially perceived as the problem of the child (oppositional behaviour) was formulated as a problematic reciprocal pattern between the parent and child. The case describes how the mother started to see her own contribution to the pattern and found an exit. At a later stage of the assessment, at a network meeting, the mother identifi ed strongly with Satu and was defending her with the power of a “lion mother”. This provoked the parallel enactment, in which she adopted the ‘rebellious’ position in the pattern of coercion and resistance.

It seems reasonable to assume that this enactment and its immediate ‘naming’ by the neuropsychologist offered the mother a possibility to disengage from the position of rebelliousness and to, instead, adopt an observer position and thus develop an over-view of the coercive-rebellious pattern, which comprised both the parent and child perspectives (Leiman, 2012; Tikkanen et al., 2011, 2013). The mother, as a participant, was instead invited to assume the role of an observer (Leiman, 2012; Sullivan, 1954) of the problematic pattern. By doing so, the mother was able to use the help offered by the neuropsychologist and, recognising her identifi cation with Satu, she could adopt a more detached attitude to the suggested changes.

Observing the enactments and re-enactments of the ‘helpless/shocked position’ may also have helped the parents to gain an enriched understanding of the child perspective i.e. Satu’s intolerable feelings which fuelled her opposition. In formulating the here-and-now situation from the child’s perspective, the neuropsychologist offered an alternative to the coercive position, involving a more fl exible and gradual understanding, and approach, with respect to all the changes in Satu’s life. This can be seen as in-session impacts (Stiles & Snow, 1984) in the parents’ process of accepting the child’s ‘otherness’ and using more fl exible and child-centered means that were evident at the 3 month follow-up (Tikkanen et al., 2011).

Case formulation methodology gives an outsider perspective on whatever patterns each case brings to the fore and enables a detailed exploration of the therapeutic effects of child assessment procedures. In this case DSA (Leiman, 2004, 2012) also allows triangulation and validation of the neuropsychologist’s clinical formulation that was shared with the parents during the assessment (Bennett & Parry, 1998), as a consequence of the baseline DSA formulation being constructed 18 months after the clinical procedure.

Future process research using DSA, within the context of CAT reformulation, would be of interest in exploring the process of children, and their families, learning to develop an ‘observer position’ as part of the process of enabling all parties to identify problematic reciprocal role patterns, as well as potential setbacks and relapses, from a more empathic and refl ective stance. The challenge for clinically relevant practice research is to capture such phenomena without abstracting the context or the content.

Soile Tikkanen is a CAT psychotherapist, supervisor and trainer in Helsinki, Finland. She has been working as a developmental psychologist and child neuropsychologist and doing research on parent development during child neurological assessment using psychotherapy process research methodology, DSA and the assimilation model, at the University of Eastern Finland, School of Educational Sciences and Psychology. She is currently the chair of board of members of Finnish Association for Cognitive Analytic Therapy, FINACAT. Her email is soile.tikkanen@mailsuomi. com

Acknowledgements

I want to thank professor (emer.) Mikael Leiman and professor (emer.) W.B. Stiles for their contribution in this project. I also thank the data session group.

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