Is counselling effective?

Bindu Prasad

The demands of modern life are such that stress is on the increase all the time. As a clinician I have been receiving referrals from both parents and teachers, about problems their children face.

Until recently, in dealing with children with special needs and behavioural problems, the focus was on the child. Then it shifted to the mother-child interaction. The emergence of Family Systems Therapy led to the realisation that the family is a dynamic unit, and therefore, the focus should be shifted from the child to the relationships of various sub-systems, where the child is seen in the context of the family and the family seen in the context of the community. There is an interactive impact of all these three units, the child, the family and the community.

Family Systems Therapy is a treatment approach and a way of understanding and thinking about human behaviour. The main emphasis here is that behaviour must be understood in its total context because there is an interactive effect among various units.

One important component of systemic thinking is that behaviour can only be understood in the context in which it occurs. e.g. take the behaviour of a mother with her child. In individual therapy perspective, it will be understood in terms of unconscious fantasies and/or learned responses. In family systems therapy, it is seen as being affected by many factors such as effect of culture, child's responses to the mother, the relationship of the child with the mother, with the father and other family members.

The second component is the recognition that people living in close proximity develop a stable pattern of interactions. If a family develops a problem it is assumed that it is a manifestation of the organisation of the family. Family therapists are concerned with the family organisation and how it is related to the problem, rather than with any one individual.

The appearance of a symptom is viewed as disturbance in the balance of interpersonal relationships within the family system. Symptoms develop to maintain an equilibrium, i.e. to adjust to the tension/s existing in the family. Hence, in family systems therapy, the focus is not on the symptom per se but on the functions served by the symptom.

The consideration of the context in which problems occur has led to the practice which looks to maximise resources within families and communities in the management and resolution of such problems. The following cases show how the systemic perspective helps in such situations.

Manjit (6) is mentally retarded. He is aggressive and throws tantrums in his class. He has three elder brothers (20, 18 and 16). His mother is a housewife, his father, an autorickshaw driver.

His parents were requested to come to the clinic because Manjit's behaviour deteriorated. Only the mother came. She was almost in tears. She reported that her husband abused her verbally and kept making allegations that she was having extra marital relationships. If she tried to earn some money by sewing, he did not like it.

According to the mother her husband was close to his mother, who did not accept her daughter-in-law, because she came from a poor family. Manjits' father worked only when he needed money, otherwise he remained at home. He is suspicious and demanding regarding food and sex. He complained that the sons did not respect him or talk to him.

The school made a second effort to involve the father. The authorities wanted to meet him to discuss Manjit's progress in school. But he did not show up.

The goal in therapy, therefore, had to be to empower the mother so that she could deal with the stress and her feelings and fulfill her responsibility. The second goal was to increase the connectedness among the family members. It was believed that this would automatically help Manjit.

In the second session the mother came on her own. She expressed her helplessness and lack of hope. I asked her what gives her the strength. She said if she listened to Gurbani it does help. She was encouraged to do so. We also explored how the relationship between husband and wife could be improved. The question was raised: if she took some extra care about food and came physically close to her husband, would it help? Although she was angry towards him, she said she would try. She was also encouraged to take steps to have control over her own life, irrespective of her husband's help. She was not hopeful about getting her husband's support, but stated that her sons were helpful. She had never asked for help from them as they were studying and because "it was her duty to provide."

Then in the later sessions the sons were invited. The aim was to relate them with each other and create a support system for the mother. I asked them what their worries were. Did they talk about their problems to anyone? How could they be supportive to each other, especially in taking care of the younger brother and helping in running the household? This helped. They realised that they were feeling isolated. These sessions helped to acknowledge their mother's condition and also helped in creating physical and emotional support for the mother from her sons.

The father's behaviour indicated that he might have been feeling lonely due to the strenuous relationship with his wife and his sons keeping away from him on account of his bad temper. The eldest son, who was more confident of himself was encouraged to seek help from his father in his new business so that some relationship could be created between the two. When he approached his father, he responded positively. As the father started feeling a little more connected, there was less tension in the family and the frequency of fights between the mother and the father was reduced.

Manjit's teacher worked out a behaviour modification programme for him. The mother was put in touch with the local parents' association for disabled children. Avenues for self-employment were explored, to make her economically independent.

The systemic intervention kept in view the various sub-systems and their inter-relationships. The emotional and physical support provided by the sons made the mother feel stronger and less lonely. The father also felt more connected and happier. The mother later reported that she felt less tense and her fights with her husband were less frequent. As the family tensions diminished, Manjit's tantrums in school also reduced. It is possible that if there is again a stressful situation the problem may reappear. This point was discussed with the mother to find out ways of coping with the situation if it recurred.

Bhawana (6 - Pre-K.G.) was naughty and restless. She was accompanied by her parents, maternal aunt and uncle. They were worried about her. None of her cousins played with her, but she would try to include herself in their games by running to their rooms and creating problems for the mother.

Dilip Sinha

Bhawana cut her own hair. When she went to her aunt's house in Delhi from their home town, she rang the door-bells of the neighbors.

Is Bhawana hyperactive? Is there anything mentally wrong with her? The extended family believes that Bhawana is "abnormal". The clinical assessment revealed that Bhawana has normal IQ and has fairly good concentration span.

Soon after her birth her parents went through much tension. During pregnancy and at the time of birth, Bhawana's mother was going through the process of adjustment in her in-laws' home. In trying to fulfill the household duties she felt tense. She dealt with her tension by taking it out on Bhawana. She would shut her up in a room or seat her on a high table to be able to complete her house work. Occasionally Bhawana also got beaten up. Even now when the mother gets upset, she beats the child.

In their home-town people do not have door bells. In Delhi when Bhawana saw them she became curious and behaved in a "strange manner" ringing door bells. When she saw her younger brother having a haircut, Bhawana expressed her wish to have short hair. As her mother did not allow this, she cut her hair herself.

Bhawana does not like physical restraints, She tried to run to others' room because she was locked up in a room for hours. This should be taken as her effort to break physical constraints. Her touching prohibited objects seems to stem from her feeling of deprivation, social isolation and curiosity, This was discussed at length. The parents were told that children who are forcibly isolated have a deep sense of rejection and feel insecure. Such feelings can lead to hyperactive behaviour. It was not naughtiness but curiosity which made her ring others' door bells.

The thrust of counselling in this case was to reduce parents' anxiety by helping them to understand that what they considered strange behaviour was not abnormal at all. Bhawana's experiences during her early years and developmental stage accounted for some of her "strange behaviour." After a couple of sessions, Bhawana's parents could see that there was nothing wrong with her, and that they would have to change their attitude towards her. The sessions helped the parents see Bhawana in a different light.

As the family does not live in Delhi it was not possible to do any long-term work with it. Bhawana's parents and the other members of the extended family see her as a naughty and a strange girl. Whether the parents will be able to continue viewing her as normal will depend on a number of factors, such as: (a) Bhawana should be able to continue doing well in studies. (b) her father's status in the extended family remains important enough, i.e. his financial success, and (c) the couple develops some support system.

Sameer. (13 - grade VII) is not doing well in studies and demands his mother's attention. His parents are divorced. He lives with his mother, who came seeking help for Sameer.

Sameer is a demanding child. His mother finds it difficult to take a firm stand with him. Being a single parent she has to work long hours for meeting their economic needs. Moreover, Sameer has no sibling company.

Through counselling the mother's relationships with her parents, her ex-husband, her hurts, worries and fears were explored. It helped in understanding what factors underlay her feeling of guilt, which was preventing her from taking a stand with her son. It also enabled her to see her own behaviour, worries and attitudes in the context of the larger system.

In a joint session, the child and his mother, were able to examine the occasions when they had conflicts and the underlying reasons for such fights? What makes it hard for her to take a firm stand? What change would the child like and how? What can and should they do to reach this goal?

Marital relationships, parents' and the child's personalities, their attitudes, social circumstances influences a child's behaviour. Through the process of counselling we were able to make the mother and the child aware of these connections, which helped in changing their behavioural pattern. The mother later reported that she was able to take a firm stand on some major issues and did not give in to her son's demands. She encouraged him to look at what they had rather than on what they did not. She was able to acknowledge the need for companionship and work out how she could fulfill her responsibility towards her own parents, who were getting old.

The arrival of a disabled child is a stressful event for the entire family. It generates a number of conflicting emotions and requires the family to make adjustments and changes in its orgnisation.

Hearing impaired or spastic children feel frustrated when they are not able to communicate or if others do not understand what they are trying to say. This results in frequent tantrums. In such situations parents try to overprotect or reject the child. Counselling helps the parents to work out how they should deal with their child's tantrums and to communicate with the child.

Twelve-year-old Suhail is immature and soils his pants. He has a younger brother. His father is a business man and the mother a housewife.

Suhail is a slow learner and attends an integrated school system. Working with the parents revealed that they were ashamed of their son, primarily because of his social immaturity. They compared him with their friends' children and felt hurt when they saw him being laughed at. They stopped going to parties. They used to get angry with the child and punished him.

Through counselling we were able to work with the child to explore what made him feel scared? What were the parents' expectations? Were such expectations realistic? What were their anxieties regarding the child's future? Did they have any other tensions in their relationship?

Dilip Sinha

The parents were ashamed that the boy was a slow learner. They were worried about his future. They were encouraged to see that Suhail continued to have a normal social life. Fortunately they had a sensitive friend, who encouraged them to attend parties and also supported them.

Work with the child's teachers was done to examine why he was soiling only in the school and that too during certain periods. It became clear that he was afraid of a particular teacher. He soiled his pants only in her class. It was found that she was strict and Suhail was not able to cope with it.

Further work with the couple revealed that the father was going through a difficult period in his business. The mother was feeling overburdened regarding her responsibilities and also feeling unhappy regarding the lack of physical support from her husband. The couple admitted that they did not have enough patience in dealing with Suhail because of their pressures. The mother said she did end up spanking Suhail.

Suhail's mother and his teacher were advised to deal with him gently and with a positive attitude. The parents realised that they were anxious about Suhail's progress and as a result they were pushing him about his school achievement. Secondly, their own pressures were also making them less tolerant. At the end of the second session the father said that it was they who needed help and not their son.

Eighteen-year-old Neha, who is partially spastic, felt depressed as her sister was going out with her friends and going to get married. She asked. "Why cannot I run? Why cannot I have boy friends? This is not fair."

We tried to deal with her feelings. But we were only partially successful.

Realisation of differences is a stage of crisis in the life of a disabled child. In such cases effectiveness of counselling depends upon whether the person has a supportive relationship with the family or not. Are opportunities for friendships and vocational rehabilitation available?

Neha had a supportive family, which helped her in coping with her social isolation.

The examples given above are just a few to illustrate children's behavioural problems, and how counsellors and therapists deal with them. Each of these cases varied in terms of the number of sessions but it was not less than five sessions. The effort in therapy was to help the family, perceive the problem differently and thus change the meaning of the problem. The function of the counsellor and the therapist is to help people to think for themselves and discover their conflicts, feelings and potential so that they can learn and try to solve their own problems.

The names used in this article are not real.

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