Children's turn-arounds in psychotherapy: the doctor's gesture

Over the past year, a number of us have been examining the organizing principles behind dramatic turning points in the psychotherapies of children. We wondered whether any particular techniques or occurrences in therapy promoted childhood change.

One of us (L. T) asked the health care professionals on the UCSF child psychiatry grand rounds email list and 50 colleagues across the United States and Canada to select key "moments," or turning points, in their treatments of young people. No organizing principles were suggested in the request letters. Over 3 months, 21 vignettes telling of major changes in children and adolescents arrived in San Francisco. Some of them came from psychotherapies-others, from consultations or very brief therapies. Eleven are included in this paper.

Gestures from the psychotherapist were shown to effect dramatic turn-arounds in some young people. These shifts in the doctor's emphasis or behavior included: (1) making an entirely unexpected statement; (2) advocating strongly for the youngster; (3) confessing personal flaws and/or frustrations to the patient; (4) feeding or rewarding the young patient; and (5) inquiring deeply into something personal with the child. A gesture never given--in this instance, an undelivered inquiry into incest--is shown to have left an adolescent patient unchanged. The young people described in this report suffered from anxiety, trauma, neglect, cancer; anorexia, bulimia, and personality disorders. Two were institutionalized at the time of their dramatic changes. One had been previously hospitalized 4 times. Another small child had suffered a double amputation. These children came with a far broader spectrum of problems than the relatively mild disorders for which child-psychodynamic psychotherapy was originally tailored. Although we were not primarily concerned with the "ground" on which the doctor's gesture fell, in 5 of our cases there had been little to no therapeutic relationship prior to the gesture; in 4, the relationship had been primarily positive; and, in 2, it had been negative.

Doctors' gestures are usually given on impulse and unexpectedly during psychotherapy. To the child, these gestures appear counter-intuitive and surprising. From the therapist's perspective, they first generate a brief sense of confusion in the patient, and then a strong sense of connection between the young person and the adult. In the cases we report, the physicians'gestures created a new alliance. The tone of the therapy switched, leading to a noticeable psychic shift in the child.

A doctor's gesture may elicit a dramatic turn-around in a young patient. This therapeutic climax is implicitly understood between the two parties and then may be converted to consciousness and worked with explicitly. Therapeutic "moments" occur in a broad range of disorders, that in many cases are also being treated simultaneously with medications, and with family or institutional counseling.