Rod Anderson of the Child and Family Unit Red Cross Children's Hospital, Cape Town, reminds us of the basic skills of formal encounters with children
Some thoughts about interviewing the young child
The interview with the young child is often one of the most difficult requirements of our everyday clinical work. We are typically presented with a young boy or girl in trouble or in distress, and we have to find a way of making contact with the child so that we may get some understanding of the nature of their problems in order to help in the way that is most needed. However, we immediately come up against the fact of the child's immaturity which does not allow for ordinary interviewing. Such factors as the child's lack of language skills, their limited capacity for introspection, and their lack of personal motivation for help, make an individual interview with the child very complicated.
Whose version of things?
Given these difficulties we may too readily turn to the more accessible accounts of the child's difficulties given by others who know the child well (parents and teachers for example). The danger here is that we too easily accept their perception of the problem and do not take care to get the child's own version of things: know how they have experienced and interpreted events in their life. We must remember that the child's interview with us often is the first occasion they have had to discuss their difficulties with an interested adult without their parents being present. Having decided to do the interview another obstacle may arise. We may know our interview schedule backwards — all that needs to be covered in a comprehensive mental state examination. The problem here is that, although we may have all the right questions, these may very well prevent us getting the information we need. This is not to say we do not need to know the details of the child's mental status examination. It is just that the question and answer interview tends to have two major drawbacks.
Firstly, such an interview can often be used to protect the interviewer from feeling afraid of not knowing what to do when they are confronted with a child. Secondly, and more importantly, the question and answer interview tends to inhibit freedom of expression. If we are prepared to wait and listen, the child may be able to begin to use the interview setting in a truly spontaneous way, a way which allows us a deeper insight into the child's personal world. We can always ask questions later, and the answers then are more likely to be given willingly and in a fuller, more meaningful way.
The important point is we fail to really get in touch with the child at the deepest most personal level, we may not be able to elicit or hear what the child needs to communicate. The interview as a relationship This brings me to something that is perhaps so obvious that it needs to be stated the fact of the interview being a relationship. A relationship is a two-way process in which both parties affect one another. Similarly, in the child interview there is always a dynamic interaction between the two people present. To my mind what is involved here is more than a meeting of the ego or consciousness of both parties — there are also unspoken aspects which are communicated, aspects which can significantly influence the course of the interview. What I am referring to are hidden aspects of the interviewer and the child which affect each one's ability to really get in touch with or understand the other.
From our side as interviewers there may be all manner of expectations, hopes or fears that we may bring to the situation. These will of course vary according to the interviewer's personality, level of experience, and nature of the problem we are faced with. For instance, we may be so preoccupied by what our supervisor might think or what theory tells us about such cases, or be so intent to show how nice and kind we are, that these considerations overshadow the interview. Let me give an instance where my own need to be helpful nearly got in the way.
From the outset of the interview this little boy seemed unable to do anything for himself. He needed help in thinking about what he should do, and when he eventually decided to paint — he then needed my help to open the tap as well as advice as to how to mix the paint. In my eagerness to show what a nice man I was I soon found myself doing all sorts of things for him — things which he could in all reasonableness do himself. This was precisely not what this boy needed. He did not need me to be helpful because by doing this I was merely repeating a problematic feature in his own family. I was simply perpetuating the way he had been treated in the past, the type of treatment which was the main contributor to the difficulties for which he was referred.
Learning from how I feel
Paradoxically, how the child makes us feel and act in an interview can also be used to deepen our understanding of the child. What 1 am suggesting is that how a child affects us is a form of "communication by impact" (Casement, 1985). To use the above example, my need to be helpful was not only telling me about an aspect in myself but also provided me with a hint as to how this boy had become passively helpless. Perhaps there was someone in his environment who intervened too much in his life in a way that did not allow him to feel confidently able to master the world alone, a fact confirmed over time in my work with this child? It became clear that he had an over-anxious mother who fussed and clucked over everything he did. Returning to the theme of interviewer anxiety, certain other concerns typically arise. For instance, we may worry too much about our level of knowledge, or maybe that we are doing harm by allowing the child's distress to emerge, or by digging into sensitive areas. The possibilities are innumerable and none can be lightly dismissed, nor should they be. They need to be considered seriously as they are ways of telling us about things in ourselves that may obstruct our interview with the child. This is why supervision is so important. We need to have an experienced eye to help us reflect on what transpires between us and the child — to help us discover if and when our own issues may be interfering or distorting our work. Now of course the child will bring his or her own unspoken feelings, expectations and fears to the interview. For instance, the child may come along with the hope or wish that we will take the pain away, that we will change how their parents treat them, or that we will tell them what to do.
For example, a young boy had been brought because of difficult, disobedient behaviour at home. In the interview with him alone, I tried to discuss some of the things his parents had complained of. However he denied these, despite having been present when these were discussed. Instead he wanted to play "cops arresting baddies". These baddies were hunted down, screamed at, imprisoned or beaten. It now became clear why this young boy could not acknowledge and discuss his very obvious difficulties with me. He had brought to the interview the hidden expectation that I was a policeman-like person who punished naughty boys, perhaps by beating them or even sending them away. Of course, if this was the case, he could not — did not dare — talk about his bad behaviour. We had to deal with this anxiety before we could get to anything else. Here is another variation on this theme. I noticed a young girl I was interviewing, often looking at me expectantly as if she was waiting for something to happen. At some point she began talking about being in hospital where a bad cut she suffered had been stitched. As she told me this she began searching my room for something. It became clear she was searching for something she believed I had. I asked what this could be? Her reply was that she imagined I had a machine which I used to fix children's problems, much like the doctors had done with her physical wound.
Discovering what the child brings to the interview
We can see from these examples that the thing we might want to deal with or get from the interview may not coincide at all with what the child needs first to deal with. As you can imagine, the possibilities are innumerable. The important thing for the interviewer to remember is the question: what is it that this particular child may be bringing to the interview, which may help or hinder our attempts to reach the heart of the problem ? Something else which is necessary to help us reach the child is that we provide a suitable setting. The well known British psychoanalyst Donald Winnicott spoke much about the importance of what he called 'the holding environment' (Davis & Wallbridge, 1983). Although he used this term originally to refer to the way the mother held and cared for her baby, he saw that what was involved here clearly had relevance to the relationship between patient and clinician. The 'holding environment' with its atmosphere of care which "supports yet does not dominate" provides the child with "an indispensable sense of being safely held". This holding environment begins with the physical setting in which we attempt our interview. For instance, is it reliably free from disturbances? By this I mean such things as: is there sufficient privacy, do we have sufficient time, is the interviewer liable to come and go unexpectedly, are we continually interrupted by people walking in, or by telephone calls? All of these details will convey to the child a sense of whether they will be attentively listened to or perhaps suddenly (symbolically) dropped or abandoned.
Personal response to settings
From some of the earlier illustrations it may have become clear that young children often communicate more about themselves and their inner world symbolically through play than in any other way. It is vital therefore to have available a range of simple toys that will allow for the broadest possible range of symbolic expression. Equally important is the 'mental setting' we provide. In most cases, the way we can best discover the child's problems and attitudes is to start by allowing the child to make use of the interview in the way they wish. That is, by simply listening and waiting, and not by bombarding the child with questions or getting the child to draw this or do that. If we are prepared to wait a while, the child will be able to use the situation in an entirely 'personal' way.
By doing this we allow the child to express how they see their situation what their thoughts and fantasies are. As we have seen already, these thoughts and fantasies may concern both the interviewer, as well as important people in the child's life and certain experiences they may have had. What is more, we must be sure to take their feelings and fantasies seriously. We too often conclude that what the child is telling us is "just their imagination". For example, the child may talk about how they feel their parents hate them. Through our contact with the parents we cannot see how this is true. We may then be tempted to conclude that these are 'just fantasies'.
What is important is that we realise that the child feels they are true. Fantasies express for them a painful 'internal reality', and this internal reality is just as real as external reality. From the point of view of understanding the child it is their perception of reality which must concern us. For instance, a young boy, who had lost his younger brother 9 months earlier, was presented with complaints that "he lied and made up incredible stories". In my interview with him by himself, he began telling me about a pony which he kept in the park next to his home. This was in fact not true. He was again telling one of his "incredible stories". What struck me though was his need to convince me that this fictional object actually existed despite all evidence to the contrary. I pointed this out to him. He then surprised me (and I think himself) by telling me "something he could not tell anyone" — that his brother was still alive and lived in a shed outside their house! He knew no one would believe it if he told them, but he often saw him and spoke to him. I took all this seriously and did not attempt to point out that this could not be true. Instead I recognised it as an indication of his desperate need to hold onto the belief his brother was still alive. He had to cling on to this fantasy as he was somehow at this moment unable to accept the painful reality of his brother's death. (During therapy it became clear that he could not accept his brother's death because he was convinced it was the extreme unconscious hate he had felt for his brother which had led to his death).
Our interview must go beyond the simple diagnostically oriented or mental status examination. It should reach out to discover the picture of the world the child has in their mind. To this end the interviewer needs to keep in mind that both parties bring aspects of themselves to the interview — aspects which may help or hinder the interview. In the interview we need to provide a setting which conveys to the child a sense of safety which allows the child to use the situation in a uniquely personal way so that we may get to know what is important for them. The child needs to feel that the interviewer is a person who listens and who does not impose their own ideas, a person who does not make the child feel stupid or bad: someone who can accept the child's feelings and ideas as something important, yet who is not overcome by them and is still able to think independently about them. All of these factors contribute towards a feeling in the child that their reality is taken seriously, and that they are being understood in depth.