REFLECTIVE NETWORK THERAPY: AN APPLICATION OF PSYCHOTHERAPY IN PRESCHOOL TREATMENT GROUPS

Reflective Network Therapy involves the treatment of stressed children, such as those entering foster care, or emotionally disturbed children entirely within their preschool and day care groups. We and our associates have treated dozens of foster children this way, among more than 800 preschool disturbed children treated. As previ­ously reported, bouncing is sharply reduced among foster children receiving this treatment: down to zero in the first 12 months in our pilot studies (Kliman et al., 1982). Equally engaging to us is the presence of regular and substantial IQ gains among children treated with the Cornerstone method (Lopez and Kliman, 1979, Zelman et al., 1985; Zelman and Samuels, 1996).

We have tested the feasibility of using this intensive method of psychotherapy as a pilot study in a public school special education setting. One purpose was to determine broader feasibility and acceptability as well as out­comes. Nineteen therapists in the nation have carried out this method with more than 900 children for over 30 years. But, until recently, the bulk of Reflective Network Therapy work has been conducted in mental health centers, within therapeutic nursery classes filled with patients referred by other clinicians for treatment.

Parents in a public school special education setting were offered the option to enrich their disturbed preschoolers’ special education with this mental health service. Six of 30 consecutive children selected were foster children. As part of the public sphere testing, the author was in the public school classroom, as a therapist, using the method in San Mateo, California. Providing treatment for entire classes of disturbed preschoolers within the San Mateo public preschool special education classes, Kliman supervised other therapists using the method in the San Mateo public special education preschool. It has also been feasible to apply the method by supervising psychology interns with preschoolers at a transitional living shelter for homeless families.

As a result of several hundred hours of videotaping, we now have three instructional DVD’s available (Kliman et al., 1998), which include documenta­tion of the method’s techniques and its applicability in a public school setting. The DVD’s show substantial improvement of a four-year-old with Asperger’s syn­drome with prominent autistic and psychotic features, a former foster child with post-traumatic stress disorder, and a child with overanxious disorder. The child with Asperger syndrome, who was untreatable in other settings: wild, masturbat­ing, throwing furniture, and striking others. Nevertheless, the child improves and actually develops empathic sociability. A tape concerning the treatment of homeless preschool children is in preparation (Kliman and Vigilante, in prepara­tion) and this has special relevance because of the close connections between a history of foster placement and homelessness.

Unique Features of the Method

The therapeutic process has, as its primary focus, behavior and communication: the modality is here and now based. Though it is derived psychoanalytically, it differs markedly from a classical psychoanalytic approach because it occurs in the child’s real life space, taking place in a classroom the child would be attending whether or not the mental health services were provided. It is oriented to the young child’s immediate troubles, worries, conflicts, deficits, ambitions, loves, hates, adventures, and achievements as reflected in a classroom.

Reflective Network Therapy relies primarily on interactive, dynamic, or cognitive techniques rather than chemical or primarily behavioral interventions. Therapy thus relates mainly to what behavior occurs in the child’s life within the classroom, in response to classroom events, or in reaction to family-related or other events that may have just preceded entry in to the classroom. In psychoanalytic hands, this behavior may be used interpretively, and can then be used to bring the child in touch with past experiences that control present behavior.

The site for the child’s treatment is exclusively the classroom itself. Regardless of orientation, the psychotherapist works with the child only within the special education classroom or day care group in. She or he works with each child individually and consecutively in a set sequence. Seven to

12 children are treated this way in the midst of each classroom’s regular educational activities, with the help of two or three teachers. The therapist works for 15–20 minutes at a time with each child in the classroom each day the class meets, all of the school year.

The psychotherapy is based on the particular psychotherapist’s highest level of training, which is preferably psychodynamic. Successful psychotherapy can also be carried out this way by psychiatrists, social workers, and, in good circumstances, by inexperienced therapists such as psychology interns, when well supervised. This model of supervised therapy conducted by an intern has been carried out now at the Union Baptist Day Care Center in Greenburgh, NY and the Salvation Army shelter for homeless families with preschoolers, San Francisco Gateway facility and the Ann Martin Center in Piedmont, CA.

Use of a team with distinct roles for the members: The roles of teachers and psychotherapists are completely different in the classroom, but the interplay of the two disciplines is critical to the success of the work. Teachers trained in Reflective Network Therapy deliberately refrain from making interpretations. They do no psychodynamic work. They facilitate the child’s management of impulses which may be released by the therapy, and encourage the child to be curious and creative. The therapist stays in the role of forming a personal therapeutic relationship with the child, whereby the child is encouraged to mentalize rather than simply act, understand, and express feelings, to gain mastery around traumatic experiences, and to free energy for learning tasks.

Structured communications in the classroom help to create a network of cognitive and emotional support: Briefings and debriefings occur systemati­cally. Immediately before the therapist starts a session, teachers give the therapist and child a one or two minute summary “out loud” of the child’s recent behavior and play, so the child and therapist have the advantage of their current observations. A concerned, neutral, and mentalizing example is thus conveyed. Sometimes this is the first time in a child’s life a constructive team has worked with him. Role modeling of acceptance and encouragement for progress occurs without humiliating the child. After each treatment session, a debriefing is made by the therapist and child to the teacher, or by the therapist while the child listens. This debriefing enables the child and teachers to continue the themes of treatment work after the child’s individual 15-minute psychotherapy session ends.

Parent guidance is intensive and given mainly by educators: the therapist meets once a month with each parent. The teachers meet once a week with at least one of the child’s parents or foster parents. The teachers’ interactions with the parents are supervised by the same therapist who treats the class­room full of patients.

Results

Recently, 14 of 20 eligible families with preschoolers in special education public school classes and seven of 10 families in a homeless shelter accepted the oppor­tunity for their preschoolers to receive Reflective Network Therapy. Previous studies show clinical gains are substantial across a wide range of clinical conditions. Results are highly significant clinically (in terms of GAF improvement) and cognitively (in terms of IQ gain) among mildly to moderately traumatized children, three- and four-year-olds (rather than five-year-olds), and especially among those who attend many treatment sessions and have many parent guidance meetings. IQ testing and retesting of 50 preschool  patients treated with Reflective Network Therapy in a commu­nity mental health center and followed for at least one year show the average child had a rise of 12 points, whereas 10 long-term preschool patients at the same center treated intensively by other methods did not have an IQ rise (Zelman and Samuels, 1996).

Case Example

Henry, aged three and a quarter began Reflective Network Therapy (then called the Cornerstone Therapeutic Preschool Method) in our White Plains, New York Cornerstone facility. He was an African American boy referred by the Department of Social Services. He had been in foster care for six months and already was in his third home. Henry’s mother was in a drug rehabilitation center and saw him for an hour a week, and his father was serving penitentiary time for sale of heroin. In his two prior foster homes, Henry’s cries of lonely protest and his sobs of despair, his bed-wetting and property damage had pre­cipitated the foster parents’ unplanned termination of the arrangement: they literally requested that he be removed. In a day care and then a Headstart program, Henry’s biting and kicking of other children, and his assaults on teach­ers with blocks and toys, ended his stays. Cornerstone seemed a last resort to Henry’s caseworker, and she arranged for him to be transported daily to our in-classroom therapy program, where he spent 15 hours a week. His foster mother came regularly for guidance, which was mainly a weekly mutual sharing of events with Henry’s teachers.

Reflective Network Therapy literally started with a bang for Henry, as he threw a wooden block at a window. Fortunately, it was a plexiglass window, made for the purpose of invulnerability to such assaults. His play focus soon gravitated to other children, with whom he wanted to cook. He usually wanted to be “daddy” and over the next weeks showed many nurturant and hygienic interests in baby dolls. Henry created a wide variety of soups for them to drink and bathed them rigorously but tenderly. His angry spells grew fewer, and, as analyst in the classroom, Kliman interpreted some of them as his way of showing he missed being cared for. His great tenderness to dolls was later interpreted as showing what was on his mind – how nice it is when a Daddy loves and takes care of a child. Henry had brief outbursts when this line of interpretation evolved, but grew closer to Kliman, developing a clearly paternal transference. Kliman responded with muted but heartfelt tenderness of his own toward Henry. Toward the teachers Henry had similar apparently maternal transferences, and they responded in kind, often helping him with toileting. He rapidly achieved full day and night training for bowels and bladder. His clarity of articulation, vocabulary, and length of speech production grew far more than the passage of time would lead us to expect. Property damage ceased in the foster home. The foster parents reported a growing tenderness of their own toward Henry, and sympathy for the parents. In class there was much working through of his historical disappoint­ments in his parents, his anxieties about the health of his foster mother, and his memories of his parents injecting themselves with heroin. Many features of a psychoanalytic psychotherapy were observable, including the following:

Henry’s IQ rose 14 points in his year and a half of Cornerstone treatment. His foster placement never changed. Follow-up five years later showed Henry living with his mother and a stepfather, functioning well socially and academically. He displayed no antisocial behavior.

DATA CONCERNING GLOBAL CLINICAL ASSESSMENTS AND COGNITIVE CHANGES IN RESPONSE TO CORNERSTONE THERAPY AND OTHER THERAPIES

We have been able to study the cognitive effects of Reflective Network Therapy with 53 treated preschoolers who were tested twice. Forty-two of those subjects were located through archival studies. To avoid a self-selecting effect among twice-tested children, we mounted a study of 10 consecutively referred children in a public school RNT project. These preschoolers were seriously emotion­ally disturbed, consecutively referred, and consecutively treated within a public school early childhood special education center where we placed a therapist using Reflective Network Therapy. We had a control series of six similar preschoolers in a nearby early childhood special education class. Three other preschoolers were given a com­parison treatment in a homeless shelter, a supportive–expressive therapy with no interpretations. The results of the 53 RNT-treated and twice-tested children, six control subjects, and 109 comparison-treated young children were highly significant for an advantage to Reflective Network Therapy outcomes in the Children’s Global Assessment and Wechsler Preschool and Primary Scale of Intelligence – Revised (WPPSI-R) IQ. A meta-analysis of the projects appears below.

IQ Change by Treatment Modality Data and Graph

Tables 1 and 2 show Cornerstone therapy compared to control and comparison treatment modalities toward a meta-analysis of IQ change in Cornerstone therapy versus other interventions. The total number of subjects was 115.

Distinctions and Commonalities in the Cornerstone Method and PLHB Method

Both the PLHB method and the Cornerstone method are effective in reducing transfers between foster homes. So far, the PLHB has not been studied for IQ outcomes, although other comparison studies have contained that feature. The Cornerstone method has so far been demonstrated as raising the IQ of child patients significantly. The 12-point rise shown in Cornerstone therapy is three times greater than the rise among foster children within intellectually stimulat­ing foster homes (Fanshel and Shinn, 1978; Freeman et al., 1928; Kliman et al., 1982). However, the Cornerstone method involves 6–15 hours a week of a class­room or group program for months at a time, and the PLHB method can be accomplished within 30 sessions, compressed into a couple of months.

Reflective Network Therapy has so far been demonstrated as raising the IQ of child patients significantly. The 12-point rise shown in Reflective Network Therapy is three times greater than the rise among foster children within intellectually stimulat­ing foster homes (Fanshel and Shinn, 1978; Freeman et al., 1928; Kliman et al., 1982). However, the RNT method involves 6–15 hours a week of a class­room or group program for months at a time, and the PLHB method can be accomplished within 30 sessions, compressed into a couple of months.

Both methods have a feature especially relevant to traumatized children living in foster care. (We believe that “traumatized” is an adjective that applies to most such children before they ever arrive in a foster home.) The feature is that of providing a benevolent compensatory non-traumatic perspective. The method moves away from demanding therapeutic focus primarily or nearly exclusively on trauma. There is an antidote given to emphasizing repeated recall of the traumatic memories which plague the children. An entire social system is called into service, which includes a family network and often teachers and peers. Thus, instead of reinforcing and perhaps ingraining the neuropsychologi­cal and brain pathways, there is an opening up of new representations and a wide repertoire of adaptive tasks. This allows the child a respite from the poten­tiating effects of traumatic intrusions. In fact, like a good psychoanalysis, these analytic methods emphasize the development of as broad a repertoire of healthy coping as possible, moving from templates to creativity. The techniques provide additional focus on appropriate benign perspectives, develop corrective object relationships, and employ nurturant network creation components. They help children to mentalize, semanticize, think about, use, appreciate, articulate, and seek out what is good in life, rather than behaviorally enact traumas. Treatment goes beyond therapeutically dwelling primarily upon the malignant past. This feature may help to make both methods clinically effective for etiologic reasons related to compensation for some of trauma’s neurophysiologic and psychologic effects. Those effects include production of chronic, harmful, reverberating, intrusive, constricting, and involuntary preoccupation with nega­tive memories (Kliman, 1992, 1994, 1996, 1997). Both therapies are broadening, freeing, consoling, and vividly enliven a benevolent and mentalized here-and­-now. Both methods encourage a coherent narrative exploration and expression of the child’s broad personal self and history. Neither elaborates only on the traumatic historical basis for a traumatized or disordered child’s self-concept.

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