Published in Policy briefings on October 30th 2019
Children's mental health and inter-parental conflict
Research conclusively demonstrates that exposure to frequent, intense and poorly resolved inter-parental conflict puts children’s mental health at risk (Harold et al, 2016).
“Family relationships” is the second most common reason why children contact ChildLine (NSPCC, 2018).
It is also the most commonly cited presenting problem inyoung people’s IAPT services: in a sample of over 42,000 children being seen across 75 young people’s IAPT services, family relationships was cited by professionals in 52% of cases (Wolpert, 2017).
Furthermore, interviews with nine clinicians working in an inner London CAMH service, covering 313 cases, revealed that inter-parental conflict had contributed significantly to the mental health difficulties of the child or young person for nearly half of all cases (Mees, 2017).
Why does couple therapy not form part of the standard CAMHS offer?
The list of practitioners which comprise atypical CAMH service includes: psychiatrists, psychologists, social workers, nurses, and psychological therapists – this may include child psychotherapists, family psychotherapists, playtherapists and creative art therapists.
The reasons for the omission of couple therapists from this list largely relate to the fact that couple therapy, as a profession, has historically sat outside of the NHS. This is largely because, after the second world war, “the Government of the day was not convinced that the state had any business directly intervening in the private lives of familiesand so gave funding to set up National Marriage Guidance services to offer advice and assistance”(Hewison, 2017).
While the evidence base for couple therapy – in terms of its effectiveness in improving relationshipquality and reducing relationship distress – is strong (e.g. Shadish and Baldwin, 2013; Hewison,2016), the fact that there has been very little research conducted on the impact of couple therapy in improving the mental health of children whose parents receive it, has also had the effect of maintaining the position of couple therapy outside of CAMHS.
This is a regrettable position. But while the impact of inter-parental conflict and relationship breakdownhas long been recognised (for example as long ago as 1947 The Report of the Matrimonial Causes Procedure Committee could acknowledge “the effect of broken marriages upon children”), there is now much more interest in exploring ways of working to alleviate the impact on children. Indeed, in 2017, the Manifesto for Strengthening Families (backed by more than 50 MPs) argued that “couple counselling should be available for parents within Children and Young People’s Mental Health teams as a matter of course” (Bruce, 2017).
The Early Intervention Foundation’s review (Haroldet al., 2016), which showed not only the impact of inter-parental conflict on children’s mental health, also highlighted the degree to which the mental health needs of children affected by interparental conflict are currently unmet. Moreover, it made a particular point of stressing that parenting interventions – which do not include a focus on addressing inter-parental conflict – are not sufficient: “just targeting the parental–child relationship in the context of ongoing interparental conflict does not lead to sustained positive outcomes for children”.
This is a crucial point, since CAMH services often provide parenting support only. In fact, responses to a freedom of information request submitted by Lord Farmer’s office in 2017 revealed that only a tiny fraction of services work directly to address conflict and relationship distress between children referred to CAMH services.
While it is probably fair to say that the practice of couple work in CAMH services is not widespread,there are nevertheless pockets of interesting and innovative practice. Two such are presented below.
Case study 1:
The Tavistock and Portman NHS Foundation Trust’s CAMH service estimates that 40% of parents of the children referred to the service have extremely poor relationships, whether they are living together or separated. The acknowledgement that, where there is inter-parental conflict, whatever work is done with the child will be undone if the couple relationship isn’t improved, led to discussions in 2017 between the Trust and the charity Tavistock Relationships about the creation of an honorary couple therapist role in the service.
The service already runs yearly Parents as Partners Therapy Groups. This intervention is unusual, especially in the UK, in that addresses family-wide issues by targeting the couple relationship, and is unique in its integration of issues in the couple relationship, parenting and the psychological wellbeing of parents and children.
Parents’ responses to the follow-up questionnaires administered about one month after the groups ended showed positive changes in their psychological wellbeing (global psychological distress and parenting stress), multiple measures of couple relationship quality (satisfaction, overall conflict, conflict about children, violent problem solving), father involvement (for those initially less involved), and their children’s problematic behaviours.
Over the following two years, a couple therapist (trained and employed by Tavistock Relationships) treated more than 10 couples, delivering around 300 sessions of couple therapy to parents of children referred to CAMHS. For some of these cases, the dysfunctional parental relationship was the primary cause of the child/ren’s presenting symptoms. For others, the child had difficulties of their own, e.g. ADHD, depression, anxiety but the parental difficulties were either getting in the way of their treatment or exacerbating the symptoms. In some cases the child’s chronic illness had caused the parental conflict, which was then keeping the child stuck in a negative cycle and impeding recovery.
Both the psychiatrist leading the multidisciplinary team and also the social worker in the service found that having a couple therapist with a psychoanalytic training and perspective was invaluable in helping parents reflect on the nature and quality of their relationships, as well as enabling the service as a whole to think about couple dynamics from a psychoanalytic perspectiveenabling the service as a whole to think about couple dynamics from a psychoanalytic perspectivemore often and in a more thorough way. Such was the demand for her time from the outset that the couple therapist was quickly seeing six or seven couples per week, with a waiting list. In some cases, particularly where the dysfunction between the couple was marked, only the parents were seen. In others, work with the parents would run alongside treatment of the child.
The couple therapist was an active contributor to the multidisciplinary CAMHS team, working with social workers psychologists and child psychotherapists who acknowledged thatimproving the family environment was key to improving children’s mental health outcomes.The couple therapist was clear that what she was able to bring to the team was a new way of lookingat the couple as a patient; for while many of the members of the multi-disciplinary team had beentrained to work with parents, their focus was on family dynamics and the relationships between parents and children, rather than the couple relationship and couple conflict specifically. Had the couple therapist not been in post, some parents experiencing significant levels of inter-parental conflict affecting their children would not have been given any help that specifically targeted this issue.
While family therapists, psychologists and child psychotherapists in the team do work with parents separatelyto their children, they rarely have a mandate to address intra-couple dynamics directly. Using a stepped care model, Jenny saw all the referred couples for a 3-4 session assessment intervention, in which their difficulties / conflicts were identified and worked with. Several couples were able in this period to understand the impact their conflict was having on their children’s mental health, and the causal link to their poor behaviour, in a way that hadn’t been possible before. For most this was followed by a period of 4-6 months treatment weekly. For others it felt more appropriate to refer them for couple therapy elsewhere – in the Couples Unit at the Tavistock Clinic, or at Tavistock Relationships. A smaller number were seen for a year or more in treatment, when their difficulties were severe, and more input was needed to stabilise their relationship.For some couples the outcome of the work was that they were helped to separate in a way that reduced the negative impact on the children, and strengthened the ability of the couple to co-parent successfully.
Promisingly, outcomes for children (as well as parents) were very good, with reductions in children’s mental health problems and behavioural issues, and many of the cases closed as a result of thisintervention.
Case study 2:
Hackney Council employs a couple therapist within the clinical service embedded in its Children’s Services. This service is part of the CAMHS alliance, and therefore is linked to Hackney’s NHS CAMH service.
The couple therapist, who had applied for the role of Specialist Clinical Practitioner, was employed on account of the particular skills that she could bring to the multidisciplinary team. This service had not only a longstanding tradition of family therapy but has also included a couple therapy service in the past.Hackney Council employs a couple therapist within the clinical service embedded in its Children’s Services. This service is part of the CAMHS alliance, and therefore is linked to Hackney’s NHS CAMH service. The couple therapist, who had applied for the role of Specialist Clinical Practitioner, was employed on account of the particular skills that she could bring to the multidisciplinary team. This service had not only a longstanding tradition of family therapy but has also included a couple therapy service in the past.
The impact of couple relationships is frequently discussed within the service. Indeed, couple therapy is something that is often explored with parents, as an option that might be offered to them. The fact that it can be offered to them allows them to then start to think about their relationship. And even if they don’t all up end in the clinic, the fact that it is there is meaningful.The family therapists and the couple therapist in the service work in different ways. What is unique about couple therapy is the focus upon the couple relationship itself, destructive conflict, repeated negative dynamics etc. What this brings to the CAMHS team is a worker who is trained to understand and has the skills to work directly with high conflict couples.
The couple therapist in this service has found the rest of her team to be interested in her role and what she can bring. While sometimes providing couple therapy directly to couples – mostly working on a six session model in a Couple Therapy Clinic, or for longer in other cases – she will often work in a consultative capacity, with the social workers from across the service often seeking out her advice regarding the couples they are working with.
In many instances, where a couple is unwilling to attend therapy sessions, the couple therapist can advise the social worker on how to address the issue of conflict with parents and suggest ways of approaching it. Social workers have reported that this can be extremely helpful for them as practitioners and the work they can then do with a couple may lead on to them being more willing to engage with therapeutic work at a later date.Were her role not to exist, the couple therapist believes that many children would continue to act out, at home and in school, the parental conflict they experience (whether overt or silent).
Couple work with the parents provides a unique intervention, which couples – many of whom have never had any therapy before – can benefit from, and often find very containing. For rather than being defensive about receiving help, parents often welcome the fact that there are lots of minds on their relationship. Generally, parental wellbeing improves, the couple therapist believes, as a result of couple therapy provision.
We believe that many CAMH service managers, andtheir multi-disciplinary teams, would welcome theaddition of a couple therapists into their services.Indeed, given the survey referred to earlier, in whichclinicians judged that 57% of those children affectedby inter-parental conflict would see their mental health difficulties continue if the conflict were not resolved/improved, it is hard to argue against their inclusion inthe service (Mees, 2017).
Such a view is informed by qualitative research, which Tavistock Relationships has conducted with CAMHS clinicians, CAMHS commissioners and policy-makersin the field. A former Director of the children’s mental health charity YoungMinds, who was interviewed as part of this work, said: “If I were to open a clinic, I’d have acouple therapist in addition to a family therapist. I think the parental couple element in child development, in child psychopathology, is highly significant”; while a CAMHS clinician noted that “most of the time, when clinicians understand that the relationship betweenthe parents is directly affecting the mental health of a child, nothing gets done about it”.
Furthermore, another CAMHS clinician observed that “I would suggest about 90% of the cases I see would require a couple intervention - there’s very few of the kids we see that don’t have some parental aspects that need also to be addressed” (Tavistock Relationships, 2016).
We are therefore calling on the Government to fund pilot projects of couple work in CAMHS in order further explore and develop the potential for this kind ofintervention to alleviate children’s mental health problems.
Bruce, F. (2017) Manifesto to Strengthen Families.Bruce, F. (2017) Manifesto to Strengthen Families.
Casey, P., Cowan, P. A., Cowan, C. P., Draper, L., Mwamba, N. and Hewison, D. (2017) Parents as Partners: A U.K. Trial of a U.S. Couples-Based Parenting Intervention For At-Risk Low-IncomeFamilies, Family Process.
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Hewison, D. (2017) In Encyclopedia of Couple and Family Therapy, edited by Lebow, J.,Chambers, A., Breunlin, D. C. Springer International Publishing Fees, P. (2017) One and One and One is Minus Three: Therapeutic Consultations in Child andAdolescent Mental Health Services with Separated and Conflicted Parents. Journal of Infant, Child and Adolescent Psychotherapy, 16, 3.
NSPCC (2018), The courage to talk: Childline annual review 2017/18. London: NSPCC
Tavistock Relationships (2016) Working with the parental couple in CAMHS – themes emerging from interviews with CAMHS clinicians and commissioners. https://tavistockrelationships.ac.uk/policy-research/reports/1249-working-with-the-parental-couple-in-camhs-themes-emerging-from-interviews-with-camhs-clinicians-and-camhs-commissioners-in-2016
Wolpert, M. (2017) Outcomes for children and young people seen in specialist mental healthservices.